Empowering dialysis users and caregivers
Hello, I'm Kamal from Hyderabad, India. I have been on dialysis for the last 13 years, six of them on PD, the rest on hemo. I have been on daily nocturnal home hemodialysis for the last four and half years. I can do pretty much everything myself. I love to travel and do short weekend trips or longer trips to places which have dialysis centers. Goa in India is a personal favorite. It is a great holiday destination and has two very good dialysis centers.
As a senior nephrologist once commented, Mineral and Bone Disorders are the one thing in dialysis patients that doctors haven't really been able to get a firm grip over.
I have still not been able to arrive at the 'steady state' with respect to the balance between Calcium, Phosphorus, PTH and Vitamin D. We have played with the dose of Calcitriol, Cinacalcet, Phosphate solution addition to the dialysate and the dialysate Calcium level that would result in my levels being in the good range - and more importantly, staying there.
I haven't helped my cause by neglecting this in the current episode. I should have been much more proactive. I feel like an idiot now. Of what consequence is anything else in the world if I don't take care of my health?
I, the self-acclaimed 'savvy, proactive patient'!
I have reached a stage where I walk with a limp and almost every turn or twist of my body causes pain. Just what was I thinking?
Yesterday, finally, we have started Trial 1 - stopping of Calcitriol. I say Trial 1 because the frustrating part about this is that no one is really sure of anything. We will try this for a month and if it does not work begin Trial 2. And if that does not work either, begin Trial 3. Its so fucking ridiculous. In the meantime, if we do not get on the right track, continue to bloody suffer.
I'm sorry for the rant but it just feels so frustrating. Let's hope Trial 1 works.
Look at this from a doctor's perspective. A regular nephrologist would hardly see a handful of cases in his or her entire career! What is point in spending time in learning about this disease when there would be such little impact? The chances of anything new being learned to be actually put into practice would be almost zero! Why, then, must he or she not spend time on something that yields more 'bang for the buck'?
What about the pharmaceutical companies? When the total target population is a few hundred across the world, what incentive would be there for them to spend huge sums of money on research for drugs that could treat this disease? Its not like all the other possible work is exhausted and this is the only disease left, right?!
Where does this leave the Atypical HUS patient?
With little information forthcoming from doctors, not much advancement from pharmaceutical companies, we are left languishing, struggling to get back to 'normal'.
The situation is much worse in countries like India. While patients in some countries have access to Eculizumab, the one drug that could change their lives, India is not even on the radar for Alexion Pharmaceuticals to launch this drug in.
Why can't the drug be brought to India by patients who need them? It costs about Rs. 3.5 crore for a year's treatment and it could potentially be needed life-long. If there was a God, I would say, he has a sick sense of humour.
In all this gloom, it is important to find support. To reach out to people who are going through this hell just like you. That is why I started the Atypical HUS India Foundation. We have a website, a Facebook group and a Twitter account as well.
Chances are that you have nothing to do with aHUS. Chances are that the only place you've heard about this dirty disease is from me. But I would be really happy if you would take a minute, visit the website, like the FB page and follow the Twitter account (you can disable notifications if you like). The number of posts will anyway be very few. What worries me is when someone new is diagnosed with the disease, they would not find all this and that would rob them of a chance to get some support in dealing with this.
I plan to slowly add a forum and a latest news section in the website. I want to let Atypical HUS patients in India and their families know: You are not alone!
When I contacted Alexion Pharmaceuticals, the sole company in the world that manufactures Eculizumab, the only drug with which I can have a successful transplant, they said they had no plans to bring the drug to India. Their chief concern was India's weak IP protection laws.
In effect, they were worried that a local company could easily reverse engineer the drug and sell it at a fraction of the price. I was quite surprised that Indian laws would allow that. For a while, I assumed that they were referring to the illegal drug market where the drug would be copied in highly questionable conditions and sold illegally.
I was wrong. Indian patent laws allow reputed Indian manufacturers to reverse engineer drugs and sell them at a fraction of the price at which the original drug is sold by the company that actually invented the drug.
I read up a little on this recently. This issue was in the news after two significant rulings - on Novartis' Gleevec and Bayer's Nexavar, both cancer drugs. The rulings rejected the requests of these companies to prevent Indian companies from selling reverse engineered versions of the drugs at a fraction of the cost at which the originals were being sold.
There are a few things we must know. India used to provide only for process patents and not product patents. So, you could get a patent only for the way you produce a certain drug, not the drug itself. This changed in 2005, when due to India signing the WTO treaty required it to become TRIPS compliant which provided for product patents. However, some safeguards were provided which prevented MNCs from monopolising their products often to the detriment of the general public. It is often the interpretation of the safeguards that come up for litigation.
For example, there is a provision called Compulsory License where the country can allow a company to manufacture a generic version of a patented drug without the consent of the patent holder and sell it in the country by paying a certain royalty to the patent holder. Under what circumstances this can be done and what is the royalty that would be paid are all not specified clearly.
Look at all this from a big pharma company's point of view. They would believe that since they have the patent to the drug, no one must be allowed to sell it. In fact, the price at which Indian companies sell the drug is often a miniscule fraction of the manufacturer's price. Further, the cheaper version could also be exported to other countries and this could be disastrous for the patent holder! The pharma companies spend a lot of money on research and actually bringing the drug to the market. They believe that it is unfair to them to allow generic versions to be sold by someone else, at such low prices!
Now, look at this from a patient's point of view. There is a drug that is available in the market. The drug could save his life. But is priced so high that he cannot afford it. Or it is priced so high, his insurance / government will not pay for it. He would say this is completely unfair! He would argue that in the case of life saving drugs, commercial exploitation must not be allowed. When someone else is able to produce the drug and sell it much lower prices, this should definitely be allowed!
Again, fair point!
What is the way out?
I have been having recurrent diarrhea for the past month or so. I am on my third antibiotic course. Everything seems to be ok for a few days and then it starts again. The day before yesterday, the gastroenterologist suggested that we do an endoscopy and a biopsy of the duodenum.
This sounded scary. Biopsy of the duodenum? Whatever did that entail?!
I have become an endoscopy veteran by now and have had more than I care to count. In fact, I stumbled upon this post where I actually compare how endoscopies have changed over the years! Just imagine! So, I wasn't in the least worried about the endoscopy. It was the other beast I was worried about. How can something called 'biopsy of the duodenum' be anything pleasant?!
Anyway, these days I have stopped thinking about all this, stopped applying my mind to my treatment and surrendered completely to the doctors. Its become a pointless exercise. So much of it is just trial and error!
So, I went ahead and got the endoscopy and the duodenum biopsy done. I was advised to do a heparin-free dialysis that night. A biopsy involved cutting off a tiny little piece of the tissue in the duodenum and examining it under the microscope. So, there was a small chance of bleeding. Heparin is the drug that is used for almost all dialysis patients to prevent the blood from clotting when it is outside the body getting purified in the artificial kidney. So, if you used heparin after a biopsy (and even a surgery), chances are that the site of injury will start bleeding.
It is normally fairly straightforward to do a heparin-free dialysis in-centre during the day. All that is needed is to flush the lines with saline every 30 minutes. At night, it can be quite a bother. Giving a saline flush every 30 minutes means someone needs to stay up the whole night. Guru, the tech who dialyzes me was, as usual, very co-operative. He stayed up the whole night and religiously flushed my bloodlines with saline every 30 minutes.
All in all, everything went off well. The biopsy report is expected in 4-5 days. Let us hope we get some clue on what the issue is.
However, I am not sure if that is entirely accurate. Dialysis, however much you get, can never replace all the functions of the kidney. There are some functions that it does not even attempt to replace. That is left to the medicines to manage. We unfortunately know so little about the human body that it is always an uphill task to manage such intricate mechanisms within the body with a bunch of tablets.
Only a transplanted kidney can give you close to normal body functioning. Things like Mineral and Bone Disorders (MBD) are very difficult to get a handle of. I have experienced this first hand. I am struggling with severe, debilitating bone pain from the past month or so, something which has been getting worse and we were not able to do anything to arrest it. Even seasoned nephrologists agree that MBD is something that they are just not on control of yet.
The trouble with me is my primary disease - Atypical Hemolytic Uremic Syndrome (aHUS). With this disease, the chances of recurrence after a kidney transplant are more than 90%! Which pretty much rules me out from getting one unless I get access to a drug that will prevent recurrence of the HUS.
There is a drug Eculizumab that is available in many countries that has been shown to prevent recurrence of HUS in transplanted kidneys. There is one more drug (Omeros 721) in clinical trials stage. Both these drugs are not available in India yet.
I just hope they become available before my MBD gets out of hand.