In yesterday’s blog, I cited in its entirety an article by DavidJ_PLMin in which he cited two new drugs that show promise in the treatment of CKF. In this blog, we will investigate the first of the two cited, namely sodium-glucose cotransporter 2 (SGLT2).To accomplish this I turned to my AI right hand Poe. Poe has a customized bot named DoctorSage that addresses medical questions. I queried the bot with the following prompt and results:

Prompt: There is a new drug used in treating CKD named sodium-glucose cotransporter 2 (SGLT2). Tell me everything there is to know about this treatment.

DoctorSage Poe

Sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors) are a relatively new class of medications used in the treatment of chronic kidney disease (CKD). These medications work by inhibiting the reabsorption of glucose in the kidneys, leading to increased urinary glucose excretion. This mechanism of action not only helps in controlling blood sugar levels but also offers potential benefits in managing CKD. Here’s everything you need to know about SGLT2 inhibitors:

1. Mechanism of action: SGLT2 inhibitors primarily target the SGLT2 transporter located in the proximal tubules of the kidneys. By inhibiting this transporter, they prevent the reabsorption of glucose, resulting in increased glucose excretion in the urine.
2. Glycemic control: SGLT2 inhibitors are primarily used in the management of type 2 diabetes mellitus (T2DM). By reducing renal glucose reabsorption, these medications lower blood glucose levels, leading to improved glycemic control. They can be used as monotherapy or in combination with other antidiabetic medications.
3. Cardiovascular benefits: SGLT2 inhibitors have shown significant cardiovascular benefits in patients with T2DM and established cardiovascular disease (CVD). Studies have demonstrated a reduction in the risk of major adverse cardiovascular events, including heart attack, stroke, and cardiovascular death, with the use of SGLT2 inhibitors.
4. Renal benefits: The use of SGLT2 inhibitors has shown promising results in preserving kidney function and preventing the progression of CKD. These medications have been associated with a reduction in albuminuria (the presence of albumin in the urine) and a decrease in the risk of end-stage renal disease (ESRD) or the need for renal replacement therapy.
5. Blood pressure and weight reduction: SGLT2 inhibitors have been found to have a mild blood pressure-lowering effect. Additionally, they promote weight loss, which can be beneficial in patients with T2DM who are overweight or obese.
6. Adverse effects: The most common side effects of SGLT2 inhibitors include urinary tract infections, genital fungal infections, and increased urination. There have been rare cases of euglycemic diabetic ketoacidosis (DKA), a serious condition characterized by elevated ketone levels in the absence of high blood sugar levels. Therefore, it is essential to monitor for signs of DKA, especially in patients with T1DM or a history of DKA.
7. Contraindications and precautions: SGLT2 inhibitors should be used with caution in patients with impaired renal function, as they may increase the risk of acute kidney injury. They are contraindicated in patients with severe renal impairment or end-stage renal disease. It is important to assess renal function before starting treatment and regularly monitor renal function during therapy.

It’s worth noting that specific SGLT2 inhibitors available in the market may have slight differences in their pharmacokinetics and clinical effects. Therefore, it is crucial to consult the prescribing guidelines and individual drug information for detailed information on specific SGLT2 inhibitors.

A listing of SGLT2 drugs is provided at this link for further information.

Friday is a good day to mentally reflect on the past week and update the blog on some of the more gritty aspects of a dialysis life. So here’s some of the back stories in my life this week:

1. Since reducing one of my blood pressure meds from 10 mg to a 5 mg dose, my blood pressure responded well and the last six mornings have been over the minimum of 90 over 60. Thursday morning it was 110/62, just about perfect. It appears we have this defugality resolved, at least for now.
2. I have been having problems with my Abbott Libre 3 sensor. Recall this sensor provides me with real-time glucose readings to aid my diabetes control. Normally at night, I plug my phone into its AC charger on my desk in our study which is about 15 feet from our bed. Usually, the phone stays connected to the CGM and all is well. On rare occasions, the phone breaks connection, and the glucose reading goes down reaching the alarm stage of about 53. This causes my wife to get up and ascertain what the alarm is all about. She often wants me to chug orange juice to alleviate low glucose when in fact I feel fine and am not experiencing lows – no sweating and feeling it. The only way around this is to turn the phone off. This morning when I turned the phone back on the Libre 3 app informed me that my sensor had crapped out and to install a new one. This is two days before it was up for a normal last two-week replacement. From all of this, I ascertain that potentially there is something amiss with Libre 3 sensors.
3. I fought the VA and I won! I have previously related that I had to travel to the Ft Worth VA audiology clinic to be fitted for new hearing aids. The doctor there stood up for me and as a result, I received notification that a civilian audiologist in Granbury would be providing me hearing aids with an appointment in March. Since one of my hearing aids is in for repair, I desired to move this up if possible. I called the civilian office and got an appointment for 1600 today in Stevensville, some 43 miles away. Although this is roughly the same distance as we are from Ft Worth VA, it is a pleasurable drive through the remote Texas countryside from our digs. What’s not to like?
4. I spent some time last Saturday at our son’s new digs in the Palo Pinto TX area installing a new 5G Tp-Link Deco Mesh network system in his partially completed ICF (insulated concrete forms) home. He and his wife have now completed moved into the first floor/garage area from the trailer they were living in. His wife works from home and uses the internet heavily in her work as a graphic artist. As such, she requires as good an internet connection as she can get; the mesh network in connection with a T-Mobile 5G internet setup provided her on the order of a 150 Mbps down and 30 Mbps up connection which is more than adequate, even through the concrete wall of their digs.

The lead graphic was made using Poe with the prompt: “picture of the English shops selling “bits and bobs.” In England, Bits and Bobs equates to “this and that,” the subject of today’s blog.

Increasingly since I have been on peritoneal dialysis, my wife has advised me of my bad breath. I can temporarily remedy the situation by using mouthwash and brushing my teeth but these are just covering up the root case which I suspect to be my dialysis. I have not been advised of the potential for such a condition by my dialysis team nor was it even hinted at during my PD training. So what.s the deal?

I turned to the AI-driven search engine Perplexity for answers. Recall that Perplexity is a new and improved AI-driven search tool that is the offspring of four former Google nerds. See this link for more about the tool. Here’s what Perplexity had to say about bad breath and its association with PD:

The association between bad breath and peritoneal dialysis is primarily due to reduced salivary flow and high blood urea nitrogen levels in patients with chronic renal failure. Bad breath, or halitosis, can be a common issue for individuals on peritoneal dialysis due to these factors. A review article published in 2022 states that patients with chronic renal failure have high blood urea nitrogen levels and reduced salivary flow, which can lead to uremic-associated odor and dry mouth. However, it also mentions that treatment with peritoneal dialysis can help reduce the problem.1. Another source from homedialysis.org also highlights that less saliva due to peritoneal dialysis can lead to bad breath and other oral health issues2. Additionally, medical conditions such as liver or kidney disease can also affect breath odor5. Therefore, the association between bad breath and peritoneal dialysis is primarily linked to the physiological changes in the body due to chronic renal failure and its treatment.

So there you have it folks, peritoneal dialysis MAY result in bad breath not necessarily in and of itself, but because of the condition(s) leading to its necessity. And that my friends, is the rest of the story.

Once upon a time, in the serene coastal town of Ocean Plantation, there lived a retired US Navy commander named Commander Hank Feeser. Hank had served in Vietnam’s Brown Water Navy, where he had encountered his fair share of memorable moments. But little did he know that his military experience would lead him to a whole new adventure – one involving his health and a rather amusing doctor.

After returning from Vietnam, Hank discovered that he had been exposed to Agent Orange, which unfortunately led to him developing diabetes. Determined not to let this setback define him, Hank faced his condition head-on and adapted to the challenges it presented.

Hank had a knack for finding humor in every situation, and his regular visits to his doctor, Dr. Turner, were no exception. Dr. Turner was a brilliant physician with a warm and caring demeanor. She often referred to Hank as “Functional,” which Hank found both amusing and endearing.

One day, Hank arrived at Dr. Turner’s office for his routine check-up, hooked up to his peritoneal dialysis machine. As Hank entered the examination room, Dr. Turner’s kind smile greeted him.

“Ah, Commander Functional, always ready to brighten up the day,” Dr. Turner said, with a twinkle in her eye. “Let’s see how you’re doing today.”

Hank, always ready with a witty response, replied, “Ah, Dr. Turner, the magician who keeps me in shipshape condition. How are we sailing today, Doc?”

Dr. Turner chuckled, appreciating Hank’s lightheartedness. “Well, Commander, your sense of humor certainly keeps the winds in your sails. You bring laughter to these halls.”

Hank grinned and said, “Well, Doc, laughter is my secret weapon. It helps me keep my blood sugar in line. Who needs insulin when you have jokes, right?”

During their appointments, Hank and Dr. Turner would engage in playful banter, sharing humorous stories and witty remarks. Hank would tease the doctor about her love for nautical-themed decor in the office, while Dr. Turner would playfully compare Hank’s tales of Navy adventures to tall tales. The two had developed a unique camaraderie over the years.

One day, during a routine check-up, Hank decided to surprise Dr. Turner. He walked into the examination room wearing a captain’s hat, complete with a toy periscope strapped to it. Hank saluted dramatically and said, “Permission to bring some laughter aboard, Doctor?”

Dr. Turner couldn’t help but laugh at Hank’s creative display. “Permission granted, Commander Functional. Let’s see what you have in store for me today.”

From that day forward, Hank would arrive at his appointments armed with jokes, funny props, and even a rubber chicken or two. The atmosphere in Dr. Turner’s office transformed into a sea of laughter and good cheer, as Hank’s contagious spirit touched everyone around him.

Hank’s humorous escapades at the doctor’s office became legendary in Ocean Plantation. People would schedule appointments just to witness the comedic exchanges between Commander Functioal and Dr. Turner. Hank had unwittingly turned his health journey into a delightful comedy show, raising the spirits of patients and staff alike.

In the end, Hank’s ability to find humor in even the most challenging situations not only brightened his own life but also those of everyone he encountered. He showed that laughter could be the best medicine, even when facing health issues. And as for Dr. Turner, well, she discovered that sometimes a little laughter could go a long way in healing both body and soul.

So, Commander Hank Feeser, the charismatic and hilarious retired Navy officer, continued to spread laughter and joy wherever he went, proving that a positive outlook and a good sense of humor could turn any situation into a comical adventure.

And that boys and girls, is the rest of the story and almost all true. Or at least partially so. Or it could be. Or it should be? Or you fill in the blanks!

To those new to peritoneal dialysis, things can fly by with those involved wondering what happened. In this blog, I am going to lay out the basic sequences involved in getting set up for, and continuing a peritoneal dialysis routine.

First some terms in the sequence:

1. Initial setup
2. PET
3. Transport
4. Prescription
5. Adequacy Test

1. Initial setup: Let’s assume that a decision you were part of has already been made that you need to go on peritoneal dialysis. Now what? You will need to have a catheter installed in your stomach which was an outpatient procedure for me and relatively painless but did involve an entire day. You need to get in the queue at your dialysis provider, Fresenius for me, for training. Depending on their scheduling, it may take several weeks to schedule your training, and up to two weeks or more to complete the training. During the training, you will be taught how to do both manual and automated peritoneal dialysis. During the manual training, my dialysis team conducted a PET.
2. PET. What is dialysis PET? In the context of ascertaining transport in peritoneal dialysis (PD), the Peritoneal Equilibration Test (PET) is a procedure used to evaluate the peritoneal membrane’s transport characteristics. During a PET, a defined dialysis solution with glucose concentrations of varying strengths is infused into the peritoneal cavity. The solution remains inside the abdomen for a specified dwell time before being drained. The transport status of the peritoneal membrane can be determined by measuring the levels of glucose and other solutes in the drained solution. The results of the PET help classify patients into different transport categories, such as high, high-average, low-average, or low transporters. This information is crucial in tailoring the peritoneal dialysis prescription and optimizing treatment outcomes for individual patients. The mechanics of the test follow: The night before the test I do a mechanical fill of 2000 mL of 2.4 % dialysis fluid which stays in my stomach all night while I sleep. The next morning I go to the clinic where three more manual exchanges are made to accomplish the measurements and sampling outlined previously. A PET is normally conducted annually.
3. Transport: Now that the transport status of the peritoneal membrane is determined, the results of the PET help classify patients into different transport categories, such as high, high-average, low-average, or low transporters. This information is crucial in tailoring the peritoneal dialysis prescription and optimizing treatment outcomes for individual patients. Please note that this “transport” is not a one-and-done procedure as transport may change over time due to changes in the stomach lining to the movement of the catheter within the stomach as was my case.
4. Prescription: Once the transport function has been ascertained, there are research-based tables that suggest what prescription is best fitted for you. The prescription sets forth how much total fluid, how long it will stay in your stomach (dwell), and how often it will be exchanged. These values are embedded on a thumb drive for the Fresenius Liberty Cycler which in turn “programs” it to your prescription. At this point, your cycler is in automatic and you’re good to go.
5. Adequacy Test: Now that we are rolling along on peritoneal dialysis, a question is “How well is our current prescription working?” This is where the adequacy test comes in. Normally conducted quarterly, The peritoneal dialysis adequacy test is a procedure used to assess the effectiveness of peritoneal dialysis (PD) in removing waste products and excess fluids from the body. The test measures the clearance of urea, a waste product that accumulates in the bloodstream when the kidneys fail to function properly. It involves collecting a sample of peritoneal dialysis effluent and measuring the concentration of urea in the sample. By comparing this concentration with the urea levels in the blood, dialysis adequacy can be determined. The test takes into account factors such as the volume and composition of the dialysis solution, the dwell time, and the patient’s body size. Adequacy targets are established based on individual patient characteristics and established guidelines. Regular monitoring of dialysis adequacy is essential to ensure that patients receive optimal treatment and to make any necessary adjustments to the dialysis prescription.

The bottom line of the adequacy test is a lab-provided number of a formula for Kt/V whose target is 2.0 or greater. If it is 1.70 or less, your prescription is not working well enough and must be changed. The variables involved in your prescription, solution strength, solution amount, and dwell times might have to be adjusted to drive Kt/V more positively. I am in this interaction as we speak. I had another PET, and am scheduled for another adequacy test in the near future.

And that boys and girls, is in general, at least for me, been what’s involved in getting set up and conducting peritoneal dialysis in the course of 16 months or so. The Big Picture if you will. Poe provided the lead graphic and aided in writing this blog.

There is a nice little story to relate but first to the outcome of Friday’s meeting with my dialysis team and blood pressure. It was decided to restrict my dialysis fluids to two 1.5 % 5L and one 2.5% 5 L bag each night and do away for now with rotating fluids. This will reduce the amount of fluid we are pulling out (micro filtration.) The second is the reduction of one of my BP meds from 10 mg to a 5 mg tablet. We’ll see how this works. Hopefully, my BP will become more normal.

My renal doctor mentioned in passing that I was “functional.” I responded that I had been called many things in life, but “functional” was not one of them. This resulted in laughter in the entire team. My internalization of the word is the common definition, “practical rather than decorative, utilitarian.” It has a much different meaning in the MD world. I turned to Poe for insight with the following result:

Poe Prompt: In my monthly meeting with my dialysis team, my renal doctor described me as being “functional.” Write a 200 or so-word blog entry in this context on the meaning of the word “functional.” The lead graphic is Poe’s take on “functional.”

Assistant Poe

Title: Embracing “Functional”: A New Perspective on Wellness

Introduction:
In our journey towards personal well-being, we often come across various terms and labels that attempt to define our health status. During a recent monthly meeting with my dialysis team, my renal doctor used the term “functional” to describe me. At first, the word seemed ambiguous, but upon reflection, I realized its profound significance. In this blog entry, let’s delve into the meaning of the word “functional” and its transformative power in perceiving our health.

Unraveling the Meaning:
When we hear the word “functional,” we might associate it with mere adequacy or the ability to perform basic tasks. However, in the context of health, being functional holds a deeper connotation. It implies the ability to engage in daily activities, pursue personal goals, and maintain a fulfilling life despite health challenges. It speaks to our resilience, adaptability, and determination to live life to the fullest, irrespective of our medical conditions.

A Paradigm Shift:
Embracing the term “functional” allows us to shift our perspective and focus on what we can do, rather than what we cannot. It encourages us to acknowledge our strengths, celebrate our achievements, and set realistic goals that align with our capabilities. By recognizing our functional capacity, we can cultivate a sense of empowerment and regain control over our lives.

Finding Balance:
Being functional does not mean dismissing the challenges we face or downplaying the need for medical support. It’s about striking a delicate balance between accepting our limitations and exploring our potential. It involves embracing self-care practices, adhering to treatment plans, and seeking assistance when necessary. By doing so, we optimize our functional abilities and enhance our overall well-being.

Support and Collaboration:
As we navigate our health journeys, it is crucial to build a strong support system and collaborate with healthcare professionals, like my dialysis team. Their guidance, expertise, and insights help us unlock our functional potential and overcome obstacles. Together, we can explore innovative strategies, adapt treatments, and discover new avenues for personal growth.

Conclusion:
Being described as “functional” by my renal doctor provided me with a fresh perspective on my health journey. It reminded me that my worth is not defined solely by my medical condition, but rather by my ability to adapt, thrive, and find joy in life. Embracing the term “functional” empowers us to redefine our own narratives and embrace our unique strengths. Let us embrace this mindset and inspire others to view their health journeys through a lens of functionality, resilience, and endless possibilities.

Around 5:30 AM yesterday, I was awakened from a sound sleep by my wife gently brushing her hand on my cheek. I was buried under a blanket and an electric blanket, warm and comfortable in our cozy bed. The outside temp was a record 11 F. I had been awakened at 2:30 AM by the Liberty Cycler making unusual noises – again, and at that time, I couldn’t get back to sleep.

It seems my Libre 3 CGM was sounding a low glucose alarm. Since my hearing is impaired, I could not hear the alarm, but my wife could and did, thus the awakening. We keep orange juice in the fridge just for such occurrences. She brought me a glass, and soon, my glucose was in the 80 range; we returned to bed and went back to sleep. While she was up for me, she also let our Golden Retriever out to whittle.

So, what’s to be learned from this mini-saga? Having a continuous glucose monitor to warn you of aberrant glucose readings is a must. Equally, a must is having a dialysis partner by your side who has your six.

Poe made the lead graphic. In World War I, American fighter pilots covering a plane’s rear position coined the phrase “I’ve Got Your 6.” This enduring message of support meant, “I’ve got your back.”