30 July 2009

A tentative borderline curve-ball hiccup (and other mixed metaphors)...

One of the things my doctors and surgeons told me leading in to the transplant, right after the the transplant, and at my 3- and 6-month checkups was that one of the possible side effects of steroids and of my main anti-rejection drug -- Rapamune (sirolimus/rapamycin) -- is Type II diabetes. This is part of the calculus of drug management; often people with chronic diseases have to take medicines to combat the side effects of the other medicines, and then medicines to combat their side effects, ad...um...nauseam. I was aware of this potentiality, but didn't give it heavy weight in my medicinal scales. I've never had even the slightest tendency toward being diabetic. Consider -- I've had my glucose measured at least every month for the past 20 years, and it's always been solidly normal. I had a glucose tolerance test in the run-up to my first transplant and passed it with flying sugars. And indeed, I have always seemed to be quite sensitive to insulin. The night before my second tranplant, I had an issue with potassium in my blood (too much). One of the treatments for that involved injecting a bolus of insulin right into my veins. I discovered I was more sensitive than average when the nurse noticed me rapidly losing consciousness. It's kind of soft, gushy feeling to have a blood glucose of 20.

So in short, it was a surprise when last week my fasting glucose came back at 125.

Now, 125 is high for a fasting blood sugar. It's not technically high enough to diagnose diabetes; that limit is 126. So I was literally on the borderline.

So they ordered a repeat fasting glucose, and a test called HbA1c. HbA1c, in short, measures your average blood sugar over the last 3 or so months. How it does that is by measuring the percentage of your hemoglobin molecules which have become permanently bound to glucose molecules. Red blood cells have a life of about 120 days, so when you measure HbA1c, you get a "sliding window" view of your current population of RBC's. The average HbA1c for a first-time diagnosed diabetic is about 10-11%. Diabetics are often encouraged to have a level of 7% or less in order to avoid the long-term damage from diabetes. Normal HbA1c is in the 5's or less.

So yesterday my fasting glucose was 99: normal, after last week's borderline 125. And my HbA1c was: 6.2%. A number which is also borderline. Which side of the border depends on which analysis method the OSU lab uses (HPLC or immunoassay), as well as the clinic's own guidelines.

So I'm on the border of becoming diabetic, due to the effect of two of my transplant medicines.

I have not yet "officially" heard from my doctor on any official diagnosis or recommended course of action. I don't expect to hear probably until next week: this is not an emergent situation. So right now I'm in limbo (which indeed is Latin for 'border'), but not a bad limbo, actually.

If I am becoming diabetic, it could not possibly have been detected early. In April my fasting glucose was 88 and 91. So the fact that I get my blood tested every week has caught this as early as possible. This also means that it's not likely I'll have any different course of action that I'm already on! To wit:
  • Continue reducing my daily steroids and ideally eliminate steroid drugs altogether. Long-term steroid therapy has serious side effects. In particular they too can cause diabetes, especially in conjunction with rapamune.
  • Continue daily exercise aimed at increasing muscle mass, burning up excess fat stores, and cardiovascular health. My weight is just about fine, so my goal here's not too lose weight per se.
  • Modify my diet by reducing or eliminating simple sugars and "white" foods.
However, based on their own guidelines and patient experiences, they'll let me know exactly what course to follow. It'll be no fun if I eventually turn diabetic, of course. From a management perspective, I'm sure I can work that into my life as I've done countless times before.

What really bothers me? The long run. That's how I always think: the long run. Sometimes people even pay me to think that way :) In this case, I know that the lifetime expectancy for a kidney transplant is significantly reduced in people with any form of diabetes.

To be honest, that makes me indignant. I was initially just out-and-out red-hot call-in-Red-Adair angry, but I've moved on to something akin to righteous indignation. But not quite. While modern Christian thought regards righteous indignation as the only form of anger which is not sinful, Aristotle notes that righteous indignation is the Mean between envy and spite, a virtue based on reaction to others' fortunes, not one's own. So I'm still working through this, but I'm quite familiar with my own emotional response to this kind of news as well, and I'll return soon enough to my shifting status quo.


That's the results, folks. Currently they mean, well, nothing, except for lot of food for thought. Unsweetened, of course.