The stats helper monkeys at WordPress.com mulled over how this blog did in 2010, and here’s a high level summary of its overall blog health:

The Blog-Health-o-Meter™ reads Wow.

Crunchy numbers

About 3 million people visit the Taj Mahal every year. This blog was viewed about 27,000 times in 2010. If it were the Taj Mahal, it would take about 3 days for that many people to see it.

In 2010, there were 39 new posts, growing the total archive of this blog to 80 posts. There were 26 pictures uploaded, taking up a total of 19mb. That’s about 2 pictures per month.

The busiest day of the year was November 13th with 181 views. The most popular post that day was Typical hemodialysis Fistula.

Where did they come from?

The top referring sites in 2010 were search.aol.com, righthealth.com, blogsurfer.us, davita.com, and search.conduit.com.

Some visitors came searching, mostly for dialysis fistula, fistula dialysis, fistula for dialysis, fistula, and hemodialysis fistula.

Attractions in 2010

These are the posts and pages that got the most views in 2010.

What does a Healthy Dialysis Fistula Look Like? October 2009
9 comments

How many people are on Dialysis? September 2009

What does dialysis and a kidney transplant cost? September 2009
2 comments

What to expect when you start Dialysis August 2009
12 comments

Hello and welcome to my first post for the New Year.  I hope you had a good Christmas and celebrated the arrival of 2011 in a style that set the tone for the year ahead.  My New Year was easy-going: we went to see The King’s Speech at the movies on New Year’s Eve, followed by a drive to Falls Creek, Victoria’s biggest alpine resort on New Year’s Day.  We stayed overnight and I was back in time for the BigD the next day.

The King’s Speech was a great movie: fabulous acting by Colin Firth and Geoffrey Rush and an inspiring message about how persistence and courage can win you back your life (a familiar theme, and not just for stammerers).

The Bogong high country. There are millions of dead trees from the 2003 bushfire. It will take a generation for them to regrow.

Spring wild Daisies on the High Country above Falls Creek.

There was no snow at Falls Creek (it is early summer in Australia) but walking among the wild flowers and taking in the mountain views in the high country was a real tonic.

We stayed in a lodge, which was much more interesting than a motel. It was an instant community, with group meals and lots of talk about where to go and what to see.

So, what’s the first story of 2011?  Hot on the heels of my Future Dialysis post late last year, comes the first blossom of that new BigD reality: an implantable artificial kidney that could be with us within 5-7 years.

It’s happening at the University of California San Francisco, where researchers recently unveiled a prototype model of the first implantable artificial kidney, in a development that one day could end the need for dialysis.

The device, which would include thousands of microscopic filters as well as a bioreactor to mimic the metabolic and water-balancing roles of a real kidney, is being developed in a collaborative effort by engineers, biologists and physicians, led by Shuvo Roy, PhD, in the UCSF Department of Bioengineering and Therapeutic Sciences.

The prototype has two parts: First, thousands of nanoscale filters take out toxins from the blood. Then, a BioCartridge of kidney cells act like a real human kidney.  The kidney cells are a result of recent advances in tissue engineering to grow renal tubule cells to provide other biological functions of a healthy kidney (remember the mouse with the ear on its back?).

A model of the implantable bioartificial kidney shows the two-stage system. Thousands of nanoscale filters remove toxins from the blood, while a BioCartridge of renal tubule cells mimics the metabolic and water-balance roles of the human kidney.

Unlike dialysis machines, the system runs on the body’s blood pressure — eliminating the need for pumps or an electrical power supply to filter the blood.

What is more, it has been shown to work: a Michigan collaborator proved it worked after hooking patients up to a similar external model of the system. However, the implantable prototype isn’t going to be put into a human anytime soon.

After animal model experiments, the researchers expect to have this artificial kidney in clinical trials in 5-7 years.

Eventually, Roy plans to unveil a coffee cup-sized device made with silicon fabrication technology, which is fitted with kidney cells, ready for implantation into patients. There will be no need for immune-suppressant medications. Check out his video:

There is still a way to go: for example, how to back-flush the filter and change the kidney cells when they wear out without operating?  Maybe it will be worn outside the body until the flushing problem can be solved (see my post on the wearable kidney).

The interesting thing about this project is that it is one of a growing number of collaborations across scientific disciplines that accelerate the translation of academic research into real solutions for patients, according to Mary Anne Koda-Kimble, PharmD, Dean of the UCSF School of Pharmacy.

“This project shows what can be accomplished by teams of scientists with diverse expertise, collaborating to profoundly and more quickly improve the lives of patients worldwide.”  You can find the most recent press release about the system here.

That’s the way the end of dialysis will come: through collaboration and insights across disciplines.

So the way I see it, we need to hang around until about 2016.  It may not be exactly like the system shown here, but the days of dialysis are numbered.

In the meantime, stay healthy.  Then when the time is right, get in the queue and take a number!

I had some interesting comments and email this week, well worth sharing.  The first is from Balasaravanan:

Can a blocked fistula cause chest pain?

my mom is having the av fistula in the hand for 8 months since we have not used before 8 months due to some reasons that the creatinine was not so high it was 3 so we didn’t use that now the thing is that now we are going for a dialysis in the neck we asked to put in the hand the doctors said that the fistula is not working so leave it no problem will come some doctors  that heart attack will come due to the fistula just leaving in the hand now my mom is having a pain in the chest when my mom gets to sleep and wakes up…….she gets the pain…….! so tell me is that true? reply to me………..

As I understand it, your mom had a fistula put in 8 months ago but it was never used. Now that she needs dialysis, it is not working (maybe blocked?). So they are using some kind of line inserted into her neck.  This is a normal routine for people starting dialysis without a working fistula.  It does not usually represent a danger for people with heart problems.  I know several people who have quite severe heart conditions who have been dialysing for many years.

In fact, dialysis is a key treatment: kidney failure results in fluid build up, since the fluid cannot be removed.  This excess fluid puts great pressure on the heart, and dialysis acts to relieve this pressure by removing the fluid.

With regard to the blocked fistula causing heart problems, it is unlikely.  Fistulas can become blocked when they are not in use, especially if you have some residual kidney function.  For example, many people who have transplants find that their fistula blocks up.  Rather than being soft and spongy, it becomes quite hard, with clotted blood.

If it needs to be unblocked (like your mom’s), there are typically two ways to do it:

1. If there are small clots, they can be softened and eliminated by inserting a balloon into the blood vessel
2. If the clot(s) is large, they bring out the big guns: either a specially designed device called a Percutaneous Thrombolytic Device that uses small wires to gently break up the clot, or an Angiojet, which sprays a saline solution directly at the blood clot breaking it up, and vacuuming out the bits.

Both procedures are done in radiology, typically via ultrasound, while you are awake, with a local anaesthetic.  The balloon or other devices are inserted into the fistula via a needle not much thicker than a dialysis needle.  I have had the balloon treatment.  It is not painful, but it feels strange, with all that pumping and prodding going on while you watch.  I must admit that I was nervous of the balloon bursting the fistula wall as the pressure grew, but they were very careful and all was well.

With regard to your mom’s chest pain, I don’t know enough to say anything but the most general comments.  Heart pain is not usually related to dialysis or a blocked fistula, but you should ask your mom’s cardiologist as soon as you can.

My BigD Experience, by David in Malaysia

David dropped me an email through the week, and I am delighted to reproduce it here.  His experience has been like most people once they decide to get started – health giving and not the drama they expected.

He also gives us the address of his dialysis unit, recommended for travellers to Malaysia.  Thanks David, it was great to hear from you.

Hi Greg,

Came across your blog recently from a search on Google. I’ve recently started dialysis and just turned 41 years old. Like you said, kidneys have let us down. Initially I was very depressed knowing that I have to depend on the “Big D” to live, but after the first few times and my health had improved a great deal, I was glad and thankful that I started dialysis. It was no fun though and I don’t like the needles. I keep telling my doc that I still have hope that God can do a miracle on my kidneys, he just smiled.

Anyway, I thought I’d like to share with you that if you are planning to visit Malaysia, Kuala Lumpur in particular, you can visit the place that I am doing my dialysis, it is a cool place The nurses are friendly and funny, joking with the patients, and the Medical Centre is modern and well equipped, and the costs are not expensive.

Here are the details:

• Name: Sunway Medical Centre
  
• Its Dialysis Unit (currently has 21 day machines):
  
• Its in-house Nephrologists

It is great of you to start your blog site, very encouraging to me.

Take care. Warm regards,

David

More answers to questions next post.

Greg

In my last post I mentioned that it is becoming more common for units to get people started with buttonholing by inserting a plug into each needle hole for a couple of weeks, so that buttonhole and tunnel formation are accelerated.  I met with Anna Flynn, a very experienced practitioner of this technique last week to get the whole story.

As you know, I am a big proponent of buttonholing (using the same needle holes for each dialysis session) for several reasons.  On a day-to-day basis, you get less pain when the needles go in, less lumps and bumps develop on your arm and bleeding times is reduced to a few minutes once the needles have been removed.  In the longer term, it is pretty clear that fistulas last and stay functional for a longer time.

Just a quick recap on what buttonholing is:

• Using the same hole, inserting at the same angle and depth eventually creates a tunnel down to the fistula vessel for each needle.
• At the start of the next session, each site is cleaned and sanitised, the scab that forms after the last session is lifted off, the sites are cleaned again and the needles inserted to puncture the fistula at the same place each time
• After a few weeks of this, a tunnel forms to guide each needle and a flap or “trap door” is created in the fistula wall
• At this point, you can switch to blunt needles, since there is no longer much resistance when the needle is inserted: it flows down the tunnel, opens the flap, and Robert’s your father’s brother!
• When you remove the needle, the flap closes over and the after a few minutes pressure, the bleeding stops, you put on a light dressing and go home.

That’s buttonholing.

Now, about the plugs.  Called Bioholes^® (manufactured only by Nipro in Japan) they are very small, sterile, polycarbonate, thumbtack-shaped pegs, used to prop the needle tracks open between cannulations.

This is Biohole® plug. The shaft is about as thick as a BigD needle.

Once inserted, scar tissue forms quickly around the peg as the body tries to heal itself in just the same that a newly pierced ear does, when a sleeper stud is left in place to preserve the new hole.  This scar tissue helps form the tunnel track and can be felt as a small lump over the needle site as the track develops.  Typically you need only 6 or 7 sessions to create fully developed buttonhole.

Here's what Biohole® plugs look like in place.

Bioholes^® were developed in Japan in 2003 (yes, things move slowly in medical world), to speed the buttonhole development cycle and the enable the buttonholing to be introduced to dialysis units on a large scale.  The problem with the buttonhole approach is that it requires that the same person to insert the needle each time.  This is not possible in most dialysis units with many staff on various rosters.  Using these plugs and a customised protocol, these problems can be minimised.  Bioholes^® are being trialled in Europe (see this paper); they  used Asia and the pacific (including Australia) now, and are probably coming to a BigD unit near you sooner rather than later.

Here’s how it’s done:

1.       At the end of dialysis, remove the needles as usual, and apply pressure to stop bleeding the needle sites.

Inserting a Biohole® plug after the needle has been removed

Closeup of Biohole® inserting

2.       Once bleeding has stopped, ideally wait for five minutes, then insert the Biohole pegs can be inserted into the holes, using an aseptic technique.

3.       Cover the pegs with at least two plasters to avoid the accidental dislodgement.  Keep them in place until the next dialysis session.

The hole that's left after the Biohole® is removed. Thanks to Nipro for the photo.

4.       At the next dialysis session, the nurse and or the patient removes the pegs.

5.       After the patient has washed their hands and fistula arm with antibacterial soap and water, sharp needles are inserted as normal into the sites recently vacated by the Biohole peg.

While we are on buttonholing, there are a couple tricks to know:

• Getting the scab off before inserting the blunt needle: I use a sharp needle, so I can get under the scab and lift it off.  Most use blunt Drawing-Up needles.  Both are effective; the sharp are quicker, but you can do a bit of damage if you are not careful (especially if like me, your eyesight is a bit iffy).
• If you are having trouble getting the scab off, put some saline or skin disinfectant on some gauze for 5 minutes, to soften it up.
• Recent finding indicate the buttonholing can increase the potential for infection, so swab before and after removing the scab and if you need to fully withdraw the needle while you are hunting for the flap, start again with a new needle.
• Sometimes, with the best technique, the needle can’t find the entry flap (my fistula seems to be always on the move, and the entry point seems to wander).  Don’t force it: you can tear and scrape tissue which is both painful and ineffective.
• Insert the blunt needle by holding the tubing part of the needle just behind the wings and with a gentle twisting and rotating motion, allow it to seek out the tunnel.  It can be helped along by gently stretching the skin to open the tunnel.

For more details, check out Anna’s presentation:

Many thanks to Anna Flynn for the pics and the extensive advice.

In my last post I mentioned that it is becoming more common for units to get people started with buttonholing by inserting a plug into each needle hole for a couple of weeks, so that buttonhole and tunnel formation are accelerated.  I met with Anna Flynn a very experienced practitioner of this technique last week to get the whole story.

As you know, I am a big proponent of buttonholing (using the same needle holes for each dialysis session) for several reasons.  On a day-to-day basis, you get less pain when the needles go in, less lumps and bumps develop on your arm and bleeding times is reduced to a few minutes once the needles have been removed.  In the longer term, it is pretty clear that fistulas last and stay functional for a longer time.

Just a quick recap on what buttonholing is:

• Using the same hole, inserting at the same angle and depth eventually creates a tunnel down to the fistula vessel for each needle.
• At the start of the next session, each site is cleaned and sanitised, the scab that forms after the last session is lifted off, the sites are cleaned again and the needles inserted to puncture the fistula at the same place each time
• After a few weeks of this, a tunnel forms to guide each needle and a flap or “trap door” is created in the fistula wall
• At this point, you can switch to blunt needles, since there is no longer much resistance when the needle is inserted: it flows down the tunnel, opens the flap, and Robert’s your father’s brother!
• When you remove the needle, the flap closes over and the after a few minutes pressure, the bleeding stops, you put on a light dressing and go home.

That’s buttonholing.

Now, about the plugs.  Called Bioholes^® (manufactured only by Nipro in Japan) they are very small, sterile, polycarbonate, thumbtack-shaped pegs, used to prop the needle tracks open between cannulations.

This is Biohole® plug. The shaft is about as thick as a BigD needle.

Once inserted, scar tissue forms quickly around the peg as the body tries to heal itself in just the same that a newly pierced ear does, when a sleeper stud is left in place to preserve the new hole.  This scar tissue helps form the tunnel track and can be felt as a small lump over the needle site as the track develops.  Typically you need only 6 or 7 sessions to create fully developed buttonhole.

Here's what Biohole® plugs look like in place.

Bioholes^® were developed in Japan in 2003 (yes, things move slowly in medical world), to speed the buttonhole development cycle and the enable the buttonholing to be introduced to dialysis units on a large scale.  The problem with the buttonhole approach is that it requires that the same person to insert the needle each time.  This is not possible in most dialysis units with many staff on various rosters.  Using these plugs and a customised protocol, these problems can be minimised.  Bioholes^® are being trialled in Europe (see this paper); they  used Asia and the pacific (including Australia) now, and are probably coming to a BigD unit near you sooner rather than later.

Here’s how it’s done:

1.       At the end of dialysis, remove the needles as usual, and apply pressure to stop bleeding the needle sites.

Inserting a Biohole® plug after the needle has been removed

Closeup of Biohole® inserting

2.       Once bleeding has stopped, ideally wait for five minutes, then insert the Biohole pegs can be inserted into the holes, using an aseptic technique.

3.       Cover the pegs with at least two plasters to avoid the accidental dislodgement.  Keep them in place until the next dialysis session.

The hole that's left after the Biohole® is removed. Thanks to Nipro for the photo.

4.       At the next dialysis session, the nurse and or the patient removes the pegs.

5.       After the patient has washed their hands and fistula arm with antibacterial soap and water, sharp needles are inserted as normal into the sites recently vacated by the Biohole peg.

While we are on buttonholing, there are a couple tricks to know:

• Getting the scab off before inserting the blunt needle: I use a sharp needle, so I can get under the scab and lift it off.  Most use blunt Drawing-Up needles.  Both are effective; the sharp are quicker, but you can do a bit of damage if you are not careful (especially if like me, your eyesight is a bit iffy).
• If you are having trouble getting the scab off, put some saline or skin disinfectant on some gauze for 5 minutes, to soften it up.
• Recent finding indicate the buttonholing can increase the potential for infection, so swab before and after removing the scab and if you need to fully withdraw the needle while you are hunting for the flap, start again with a new needle.
• Sometimes, with the best technique, the needle can’t find the entry flap (my fistula seems to be always on the move, and the entry point seems to wander).  Don’t force it: you can tear and scrape tissue which is both painful and ineffective.
• Insert the blunt needle by holding the tubing part of the needle just behind the wings and with a gentle twisting and rotating motion, allow it to seek out the tunnel.  It can be helped along by gently stretching the skin to open the tunnel.

For more details, check out Anna’s presentation:

Many thanks to Anna Flynn for the pics and the extensive advice.