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:
Initial setup
PET
Transport
Prescription
Adequacy Test
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.
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.
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.
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.
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.
Yesterday I blogged about my blood pressure being on the low side, that I had informed my dialysis nurse, and that she suggested cutting back on the strength of the dialysis solution I’m using. Subsequently, she suggested it would be a topic at today’s dialysis team meeting about the BP-related medications I’m currently taking. BTW, Thursday morning it was 97/61, within clinical bounds but still towards the lower boundary.
All of this caused me to ponder whether there’s a more homeopathic approach to controlling blood pressure, perhaps through sodium intake. I turned to Poe with the prompt below and the following results. The lead graphic is also from Poe.
Title: The Role of Salt Intake in Blood Pressure and its Application in Managing Low Blood Pressure
Introduction:
Maintaining a healthy blood pressure is crucial for overall well-being. For individuals on peritoneal dialysis, like yourself, encountering low blood pressure can be a concern. One potential avenue for addressing low blood pressure is through the careful management of salt intake. In this blog, we will explore the relationship between salt and blood pressure, and how salt can counteract low blood pressure in the context of peritoneal dialysis.
Understanding Salt and Blood Pressure:
Salt, or more specifically, sodium, plays a vital role in regulating blood pressure. Sodium is an essential electrolyte that helps maintain proper fluid balance within our bodies. However, excessive sodium consumption can lead to increased blood volume and elevated blood pressure.
Salt Intake and High Blood Pressure:
High salt intake has been associated with higher blood pressure levels. When we consume excess sodium, our kidneys struggle to excrete the excess sodium, leading to water retention. The increased fluid volume in our bloodstream puts additional pressure on our blood vessels, resulting in higher blood pressure.
Salt Intake and Low Blood Pressure:
On the other hand, low blood pressure can also be a concern, especially for individuals on peritoneal dialysis. The dialysis process involves removing excess fluid and waste products from the body, which can potentially lead to decreased blood volume and low blood pressure. In such cases, carefully managing salt intake can provide some relief.
Using Salt to Counteract Low Blood Pressure:
While reducing salt intake is generally recommended for individuals with high blood pressure, increasing salt intake can benefit those experiencing low blood pressure, such as peritoneal dialysis patients. However, it is important to note that any adjustments to your salt intake should be made under the guidance of your healthcare provider.
Here are some key points to consider:
Consult Your Healthcare Provider: Before making any changes to your diet or salt intake, it is crucial to consult your healthcare provider. They will be able to assess your specific situation and provide personalized recommendations.
Gradually Increase Salt Intake: If your healthcare provider determines that increasing your salt intake may be beneficial, they will likely suggest a gradual adjustment. This allows your body to adapt to the changes and minimizes the risk of sudden spikes in blood pressure.
Choose Healthy Sources of Sodium: While increasing salt intake, it is important to focus on consuming healthy sources of sodium. Opt for natural and unprocessed foods like lean meats, fish, dairy products, and vegetables. Avoid processed and packaged foods that tend to be high in sodium and can have adverse effects on overall health.
Monitor Blood Pressure Regularly: It is crucial to monitor your blood pressure regularly throughout the adjustment process. This will help you and your healthcare provider assess the effectiveness of the salt intake adjustments and make any necessary modifications.
Conclusion:
Managing blood pressure is essential for individuals on peritoneal dialysis, and salt intake can play a role in maintaining optimal levels. While high salt intake is generally associated with increased blood pressure, carefully adjusting salt intake, under the guidance of a healthcare provider, can help counteract low blood pressure. Remember, personalized recommendations are key, and regular monitoring of blood pressure is crucial to ensure the adjustments are effective and safe. Always consult your healthcare provider before making any dietary changes to ensure the best possible outcomes for your health.
Disclaimer: The information provided in this blog is for educational purposes only and does not substitute professional medical advice. Always consult with your healthcare provider for personalized guidance and recommendations.
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.”
Last week I posted a blog about complications associated with Peritoneal Dialysis which listed what researchers consider to be the top five “problems.” While those listed may be the “top five,” there are several other serious outcomes that readers should understand are possibilities also. This blog addresses a few of those.
Blood Sugar Changes: The dialysate fluid contains glucose, which can be absorbed into the blood and raise blood sugar levels. This can be a problem for diabetics or prediabetics. I am a diabetic and have NOT seen this as a problem, but some have.
Potassium imbalances: The dialysate fluid can also affect the potassium levels in the blood, winch are important for the function of the heart and muscles. Too much or too little potassium can cause irregular heartbeat, muscle weakness, or numbness. I have experienced increased potassium levels while on dialysis which have largely been attributed to diet; causality attributed to dialysis itself has not been mentioned.
Weight gain: The dialysate fluid can also cause weight gain, as it adds extra fluid and calories to the body. This can increase the risk of high blood pressure, heart disease, and other health problems. This is one of the reasons why those of us on PD weigh ourselves as part of “logging out of dialysis” in the morning, along with assuring adequate fluid removal. I have not experienced weight gain but the forums are full of comments from patients who have experienced this.
Now you have eight possible negative outcomes of PD to be aware of. Hopefully, you will not have to cope with any of them.
As an aside note, our Golden Retriever Dickens encountered snow for the first time yesterday, and took to it like fish to water. He played with it, plowed through it with his nose and in general had a grand time. BTW, the lead graphic was generated in Poe with the prompt “picture of golden retriever plowing through snow with his nose having a great time.”
In the USA, today celebrates MLK Day. It is also at record lows for North Texas. We have a light coating of snow. The Cowboys lost-again and are out of the NFL playoffs. Yesterday, when I did our morning walk with our Golden Retriever Dickens, it was 15 F with a gentle wind. It was on the quiet side outdoors. The golf courses that surround our hosing had all the greens covered up and for once golf carts where not flitting about like beetles following Brownian Motion. We did see a pair of Egyptian Geese who noisily scolded us. Yes it was chilly, but worth it.
Had a conversation with my Dialysis Nurse last week about the amount of Heparin I have been injecting into my dialyses bags. Up until then, I had been injecting 16 mL which was appropriate for my old prescription of 8 L per nite. It was thus increased to 10 L but I stayed with 16 mL Heparin and it seemed to work. With my current prescription of 13.5 L, I started getting drain alarms just about every night. The rule of thumb is 2 mL of Heparin per 2L of dialysis fluid, so by this, I should be using 2 mL x 13.5 = 27 mL of Heparin. Since I am arriving at 13.5 L with three 5 L bags, that maps out to roughly 10 mL of Heparin per bag, and for me, every other night. Since a single vial of Heparin holds 30 mL, we are essentially using an entire vial each application. My Dialysis Nurse agreed and that’s what I’m currently using.
In conjunction with the alarms reported above, my Liberty Cycler for two nights went off the rails from its normal month-after-month performance. It stated continuation of the pumping noise it makes on drains even during dwells. In between, it often made grating noises as if it were digesting something it didn’t like. Yes, dialysis patients often are guilty of the personification of their equipment. Last night was normal so hopefully we’re back to some degree of normalcy, whatever that is for those of us on dialysis.
Speaking of dialysis patients, surely there are (or were) hundreds if not thousands of such patients in Gaza, the Ukraine, Yemen, and other hot spots around the globe. On MLK day, we send our hopes that you have sought and found treatment in safe havens.
The lead picture was generated in Poe with the Prompt: “picture of a sailing ship in a safe haven from a raging storm.”
Complications of peritoneal dialysis (PD) can vary depending on individual circumstances. Here are five common complications that can arise:
Peritonitis: Peritonitis is the most significant and frequent complication of peritoneal dialysis. It occurs when bacteria or other microorganisms infect the peritoneal cavity, causing inflammation. Symptoms may include abdominal pain, cloudy dialysis fluid, fever, and general malaise. Prompt medical attention and treatment with antibiotics are crucial to prevent complications and preserve peritoneal membrane function.
Exit Site and Tunnel Infections: The exit site, where the catheter exits the skin, and the tunnel, where the catheter is tunneled under the skin, are susceptible to infection. Signs of infection may include redness, swelling, pain, discharge, or fever. Proper exit site care, hygiene, and regular monitoring can help prevent infections. Prompt treatment with antibiotics is necessary if an infection occurs.
Catheter Dysfunction: Catheter dysfunction refers to issues related to the peritoneal dialysis catheter, such as poor flow, leakage, or blockages. These problems can lead to inadequate dialysis and complications like inadequate fluid removal or fluid buildup. Catheter dysfunction may require interventions such as repositioning, flushing, or even catheter replacement.
Hernias: Over time, the increased intra-abdominal pressure from repeated exchanges of dialysis fluid can contribute to weakened abdominal muscles, leading to hernias. Hernias can cause pain, discomfort, and swelling in the abdomen or around the catheter exit site. Surgical repair may be necessary to address severe or symptomatic hernias.
Metabolic and Nutritional Imbalances: PD can impact the body’s metabolism and nutritional status. Electrolyte imbalances, such as low potassium or high calcium levels, may occur and require adjustment of the dialysis solution or dietary modifications. Additionally, the loss of protein through the dialysis process may necessitate dietary adjustments or supplementation to maintain adequate nutrition.
It’s important to note that while these complications can occur in peritoneal dialysis, they are not experienced by all patients, and many can be managed or prevented with proper care, regular monitoring, and adherence to recommended protocols. Close collaboration with healthcare professionals and regular follow-up visits are essential to mitigate the risk of complications and ensure successful peritoneal dialysis treatment. This is why we have labs once a month and hang close to our dialysis team!
Poe helped writing this blog and in making the lead graphic.
On the order of only 5.5% of males in the USA reach the mature age of 85. I am one of them as I informed readers of this blog early in the week. To celebrate this achievement, dialysis et al aside, I instructed Poe to write a script on the benefits of being 85, and dropped the results into Pictory.ai to construct a video from the text. The results for your viewing pleasure are offered below:
Assistant Poe
