The Burden of Chemicals and Sudden Dizziness For Mr. Ahmet, life sometimes felt like a storm of chemicals. His morning routine was dominated by a daunting array of pill bottles, each representing a different part of his treatment plan. The anxiety of missing a dose often led him to take everything at once, early in the morning. But on dialysis days, his routine could be more complicated. During one session, he suddenly felt dizzy and lightheaded. A painful cramp developed in his calf, leaving him worried and uncomfortable. Nurse Elif noticed his distress and immediately assessed him. “Mr. Ahmet, dizziness and cramps during dialysis can have different causes. We need to look at your blood pressure, fluid removal, medications, and overall condition before deciding what is happening.” She explained that intradialytic hypotension can occur when blood pressure falls during dialysis and may be associated with symptoms such as dizziness, weakness, or muscle cramps. “Your medication schedule is important, but there is no single medication schedule that is correct for every dialysis patient. Some medications may need to be adjusted around dialysis, while others may not. The decision depends on the medication you take, your blood pressure pattern, your risk of low blood pressure during dialysis, and your individual treatment plan.” Mr. Ahmet looked relieved. “So I shouldn't decide on my own whether to take or skip a medicine before dialysis?” “Exactly,” Nurse Elif replied. “Never change the timing of your prescribed medicines on your own. Your dialysis and medical team should make that decision with you.” Page 25

The Science of Dialyzability When the session finished, Nurse Elif pulled up a chair. “Mr. Ahmet, there is another important concept you should understand,” she explained. “Some medicines can be removed from the blood during dialysis. This is called dialyzability.” She showed him a simple illustration of the dialysis filter. “The amount of a medicine removed during dialysis depends on several characteristics of the drug and the dialysis treatment. Not every medicine is removed to the same extent.” Mr. Ahmet looked at the collection of medications on his chart. “So if a medicine can be removed by dialysis, should I always take it after dialysis?” “Not necessarily,” Elif explained. “The timing depends on the specific medication and why you are taking it. For some medicines, taking the dose after dialysis may be appropriate. For others, the treatment schedule may be different.” She pointed to his medication chart. “That is why medication timing should be determined medication by medication—not by one rule for all medicines.” Mr. Ahmet nodded. “So ‘dialyzable’ doesn't automatically mean ‘always take it after dialysis.’” “Exactly. That is an important distinction.” Page 26Page 26

Tailoring the Dose and Preventing Cramps Nurse Elif helped Mr. Ahmet review his medication chart. “Your medication plan should fit your dialysis schedule, your blood pressure pattern, and your clinical condition,” she explained. “Some medicines may be removed by dialysis, while others are not. Some medications may contribute to low blood pressure during dialysis in certain patients. The decision about whether a medicine should be taken before, during, or after dialysis should therefore be made according to the specific medication and your individual treatment plan.” She then returned to his painful calf. “Your cramps and dizziness also need attention. Fluid removal during dialysis can contribute to these symptoms, particularly when the rate of fluid removal is difficult for the body to tolerate.” She pointed to his fluid record. “Controlling excessive fluid gain between dialysis sessions can help make fluid removal easier, but symptoms during dialysis should always be assessed rather than automatically attributed to one cause.” Mr. Ahmet asked, “What should I do if this happens again?” “Tell the dialysis team immediately. They can assess your blood pressure, fluid status, target weight, ultrafiltration, medications, and other possible causes.” Page 27Page 27 KEY SELF-CARE MESSAGE “Medication timing should be individualized according to the specific medication, blood pressure pattern, risk of intradialytic hypotension, dialyzability, and the patient's treatment plan.” “Excessive fluid gain and excessive ultrafiltration rates should be avoided. Dizziness or muscle cramps during dialysis should be reported promptly and clinically assessed.”

Mastering the Rhythm of Health Equipped with his personalized medication plan, Mr. Ahmet’s experience began to change. He no longer tried to take all of his medicines at the same time simply because it was easier. He followed the schedule developed with his healthcare team and understood that the timing of a medication could depend on the medicine itself and on his dialysis treatment. He also became more attentive to his fluid intake between dialysis sessions. Instead of trying to solve everything with a single rule, he learned to work with his dialysis team to understand his target weight, fluid gain, blood pressure, and tolerance of fluid removal. When dizziness or cramps occurred during dialysis, he reported them rather than assuming they were normal. He also learned that symptoms such as itching or restless legs should not automatically be interpreted as proof of a specific laboratory abnormality. These symptoms can have different causes and should be assessed by the healthcare team. Nurse Elif reminded him: “Symptoms are messages, not diagnoses. Don't stop or change your medicines because of a symptom. Tell us what you are experiencing, and we will help you understand what it means.” Mr. Ahmet smiled. He finally understood that the true “Key to Life” was not memorizing a list of medication rules. It was knowing his treatment plan, following it consistently, recognizing changes in his condition, and communicating with his healthcare team. He no longer felt overwhelmed by his medicines. He felt involved in his own care. Page 28Page 28 KEY SELF-CARE MESSAGE “Know your medicines. Follow your individualized schedule. Never change your medication on your own. Report new or worsening symptoms to your dialysis team.”