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Saturday, 14 January 2012 07:45

Chennai Diary

Written by Kamal Shah
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Last minute thingie

It was a last minute trip. Oh, how I hate these last minute trips! You always get high fares and you don't get the timings you want. And you invariably forget something. Honestly, I am quite a fussy guy. I need my stuff around me and feel quite lost without some of my things.

Anyway, I did not have a choice. The meeting had to happen. So, within a few hours of crystallizing the plan in my head, I found myself in a cab driven by an oblivious cabbie on the way to the Shamshabad Airport en route to Chennai.

Chennai

I find that people have extreme feelings for Chennai. Some love the city to the core. I know people who willingly give up high paying jobs just so they can settle down in Chennai. They simply swear by the city! And then there are the rest of them. They loathe the city. Everything about it. The food, the people, the place.

I am neutral. I have no problems with the people or the place. I love the food here (more about this in a bit). I was warned about the airport even though this was not the first time I had been there. I was told that a whole swarm of taxi drivers would accost me and ask me to take their taxi. No such thing happened because I took a pre-paid taxi. I guess it is an unfair bias after all.

Highway Robbery at Lunch

I reached my hotel at around 12 noon and checked in. I had a meeting scheduled at 1:30. That gave me enough time for lunch. I checked with the room boy where I could get a decent South Indian Thali. He told me to go to the Malgudi restaurant on the Ground Floor. I went there with high expectations. This was Chennai after all - the best place for a South Indian Thali. I asked for the menu. This turned out to be a branch of the Malgudi restaurant at Hyderabad - only much pricier. Disappointing! I looked for the Thali. All I got was some platters. Guess how much they were priced at? The cheapest was Rs. 1,300! WTF??? Thirteen hundred bucks for a thali?

I decided to go for a dosa with some Karnataka-origin curry (I forget the name). The dosa was good. I took one spoon of the curry and left the rest. The bill came to Rs. 641 - for a dosa and one spoon of curry!

There are idis and there are idlis

Many people in Andhra Pradesh are used to a variant of the idli rather than the idli itself. Most hotels do not use rice while making the idlis. They use rava. This makes good idlis too but the original is something else. In Chennai and the entire state of Tamil Nadu, the rice idli is the default. There is a difference. The rice idli, though a bit heavier to feel, is much lighter and better to taste.

When I come to Chennai, I always make it a point to visit the Murugan Idli Shop. They started off with one outlet in T Nagar, close to Vani Mahal and have now expanded to 15 outlets including 2 in Singapore! They serve out-of-the-world rice idlis. The other fare is also good. I was told not to miss the uttapam. I tried it. Good. But not as good as the idlis.

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The important thing to know is what the best thing about a place is and then focus only on that. When I go to Poorna Tiffins in Hyderabad, I only eat idlis. Nothing else. So (I must) let it be with Murugan.

On an interesting note, a relative of mine, also an idli aficionado, suggested I try the Idli Vilas, a new joint opened right outside Savera Hotel, where I was staying. I kept space for a plate of idli and checked Idli Vilas on my way back from Murugan. The idli was good. But not as good as Murugan.

All in all, it was a great trip. Thanks in no small measure to the idlis!

... http://www.kamaldshah.com/2012/01/chennai-diary.html


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Friday, 13 January 2012 09:49

The oblivious cabbie

Written by Kamal Shah
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I was on a cab this morning. After a few minutes, the cab driver struck up a conversation. He asked me what I did in Hyderabad. I told him that I work in a dialysis center. (He spoke in Hindi. I am translating here.) "Hmmm, dialysis? Kidney stones related huh?" I explained that kidney stones were different and that dialysis had to be done when someone's kidneys failed. Dialysis was needed to clean the blood and remove excess toxins and water.

I wondered how oblivious this guy was to what his kidneys did. They worked every instant of the day, tirelessly cleaning the blood. And he was not even aware of their existence. Well, to be fair to him, we are all like that. I had no clue that there was a word like 'dialysis' until I had to get onto it.

"There are many dialysis centers in Hyderabad, na?"

"Yes, most big hospitals have one. But ours are different. We do only dialysis."

"How much does it cost?"

"Roughly Rs. 1,500."

"Oh, that's it? Quite cheap!"

That was one thing that dialysis has never been accused of! "Quite cheap"! Everyone complains about the price of dialysis. You have got your frequency wrong, dear, I mentally addressed him.

"Thrice a week"

He turned his head towards me in disbelief. "Thrice a week?"

I gestured to him to turn his head to the front. He was driving, after all!

"So, Rs. 4,500 a week?!"

"Yes"

"I thought it just had to be done once!"

"Oh, how I wish that were true!", I thought to myself!

I refrained from telling him that I was on dialysis. I wanted to get to my destination.

... http://www.kamaldshah.com/2012/01/oblivious-cabbie.html


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Tuesday, 10 January 2012 11:16

PD first

Written by Kamal Shah
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I have a huge bias for PD and my six years on PD were my best among those with CKD. PD, I feel offers the best quality of life among all dialysis modalities.  The few diet and fluid restrictions, the possibility of unhindered travel and not having to go to the hospital thrice a week all make this modality very appealing.

The nephrologist community has historically been step-motherly towards this therapy. There are multiple reasons for this. Some of these are due to the doctors, some due to the patients. From a patient's perspective, introducing PD first rather than hemodialysis allows patients to settle into a therapy that is less violent, offers more independence and fewer problems. The switch to hemodialysis, from then on, would pose the same challenges as does the switch to PD from hemodialysis currently.

Dr. Kenar Jhaveri of the famous Nephron Power blog interviewed Dr. Arshia Ghaffari from the Keck School of Medicine for eAJKD, the oficial blog of AJKD. Dr. Ghaffari recently concluded a study where PD was presented as an 'urgent start' modality - where PD is the dialysis modality used without any prior preparation for dialysis. The results were great.

This initiative is very welcome. PD as a successful first line of therapy and that too without any prior preparation should at the very least, reduce an excuse from the list of excuses for not recommending this modality.

... http://www.kamaldshah.com/2012/01/pd-first.html


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Sunday, 08 January 2012 19:41

Fresenius must explain

Written by Kamal Shah
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In a very concerning post, Dr. Peter Laird says, "The jury is still out on whether FMC bought these companies to expand home dialysis options or instead to stifle competition with their own dialysis oligarchy. The only proof of the former will be the actual release of sorbent technology for clinical testing and rapid penetration of the home dialysis market. Until then, all we can ask is where have they gone for we know that the good, they die young."

'These companies' refers to Renal Solutions and XCorporeal, both of which had portable home hemodialysis machines, one almost ready to market and the other ready for clinical trials. Fresenius Medical Care bought both these companies. We have not heard anything about these machines since the acquisitions.

I will really be happy if Fresenius proves us all wrong and releases home hemodialysis solutions better and more accessible than those available currently. I have been using a Fresenius machine for almost six years now and have received excellent support from the company on everything. So, I really have no personal reason to complain about them.

However, this is a serious concern and it would be great if Fresenius explained where they are with these machines or a suitable portable home hemodialysis solution. I somehow don't believe that home hemodialysis will ever cannibalize in-center dialysis all that much. Very few people will ever switch to home hemo despite all the advantages.

... http://www.kamaldshah.com/2012/01/fresenius-must-explain.html


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Saturday, 07 January 2012 22:46

Why the 'Kt/V deception' is a good start for India

Written by Kamal Shah
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Dr. Peter Laird, in a great post at his blog, "HemoDoc, From Doctor to Patient", says "Each month, dialysis patients anxiously await the results of blood tests. Each month, the renal staff and physicians pronounce their dialysis adequate by a magical wand without dimensions called the Kt/V. Yet, each month, these same patients die at a rate 2.5 times that of patients undergoing chronic hemodialysis in Japan."

Entirely true Dr. Laird. This is entirely true for the United States and countries that are using at least Kt/V to determine adequacy. The main argument against Kt/V is that it uses urea as the molecule to determine clearance and from this, the measure of adequacy.

While urea is one of the molecules being removed by dialysis, it is by no means, a representative molecule that actually determines that the dialysis is adequate. There are a number of other molecules that dialysis removes and which have a different rate of removal than urea. Urea is a much smaller molecule than many other molecules that are being removed and is therefore, removed much more easily than these other molecules. So, to assume that if you've removed enough urea, you have had adequate dialysis is to be too optimistic since dialysis is actually much more than removing only urea.

There are a number of other measures that have been suggested by a number of different experts. Many of them are much better than Kt/V to determine adequacy. These are all excellent alternatives to Kt/V. Not for India however.

Let me explain.

Most of these indices require a host of blood tests to be done every month or every six weeks. Take Dr. John Agar's Good Dialysis Index. It is one of the best that I have seen among the newer adequacy measures. However, it needs the Serum Iron, Transferrin Saturation, Serum Calcium, Serum Phosphorus, Serum PTH Intact, Albumin and C Reactive Protein to be checked every six weeks.

Yes, I can almost hear all Indian readers of this post laugh out loud!

Many patients resist any blood tests to be done every month. Some will agree, but only after a howl of protest. I don't blame them. Most countries that get these kinds of blood tests done are from countries where the patients do not have to pay for them out of pocket. So, they would hardly have a problem with that. In India, where costs are the biggest problem since most patients pay out of pocket, how can we expect patients to get the battery of tests required to be able to calculate these indices?

Coming back to Kt/V. Yes, it is a flawed measure. But it is a measure nevertheless. In fact what the experts ask us to do (including Dr. John Agar) is to not rely only on the Kt/V. But they would never say do not measure the Kt/V.

When I joined the dialysis industry as a professional and started looking at dialysis from the blunt side of the needle rather than the sharp side I was used to all these years, I found a shockingly great apathy for adequacy. No one did Kt/V! It was mostly some theoretical concept in the text books. Of course, the industry had a reasonable argument to back this. Patients did not want to do tests. Patients did not want to increase their monthly financial burden.

But a start must be made somewhere. We need to move towards adequate dialysis for patients. To be able to do that we must, first of all, know for sure,  what kind of dialysis they are getting. I find that Kt/V is a good start. Gradually we must combine it with other measures to come up with our own index. But Kt/V must be measured. It will at least tell us those patients in whom even the urea is not being adequately removed and I suspect that there must be quite a bunch.

... http://www.kamaldshah.com/2012/01/why-ktv-deception-is-good-start-for.html


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Friday, 06 January 2012 02:13

Starting Dialysis

Written by Greg Collette
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Over the Christmas holiday time both Peter and Armand left comments about their nervousness starting the BigD, Peter for his soon-to-be wife and Armand for himself.

They are not alone. Everyone gets nervous about starting something as dramatic and alien as the BigD: the needles, being a patient, the machine, watching your blood go round and round through the dialysis kidney, the time commitment – it is a big life change.  Also, most people feel very unwell by the time the starts dialysis, so unwell that they can no longer work or play.  Things feel bleak.

But after a few weeks on the BigD, they begin to feel well again – often well enough to start taking their life back.  And once you get used to the routine (which takes about a month), you begin to realise that dialysis itself is no big deal:  you arrive with toxins in your blood, you sit there for three to four hours then you leave with nice clean blood.  Some people like to think of it as a four hour pee.

So what is the real BigD life change?  It’s the time it takes to make it all happen – usually about 15 hours a week.

When I started, my doctor suggested that I think of the BigD as my second job and to make allowances for getting there each session.  But I worked out pretty quickly that I really have no choice but to be there, it’s not some optional hobby.  So now I think of it as my main job, and I think of family time, my for-pay job, the gym, hobby time, movies, etc as things I can do because of my main job.

So now that you are joining the BigD club, the question is not How much of my life do I have to forego?  Rather it’s How will I refashion my life around this new BigD “job”?  Because of BigD, you still have a life.  So you can review it: do I want to keep doing what I did before, or is this my chance to reassess and reprioritise?  Should I negotiate to reduce my work hours?  Or should I start BigD early and work later?  Maybe change the focus to family, fitness or a new work/home mix?

Life with BigD will not be worse, just different.  It’s your choice how different.

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... http://bigdandme.wordpress.com/2012/01/06/starting-dialysis/


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Monday, 02 January 2012 20:00

Two nights on, one night off?

Written by Kamal Shah
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That is Bill Peckham's dialysis regimen. What it basically means is you dialyze two nights and then take the next night off. And then you dialyze the next two nights and take the next night off. And so on. This of course applies only to those on nocturnal dialysis.

I started off my nocturnal dialysis by dialyzing six nights a week. Sundays were always off. Those, however, were the days of huge fluid weight gains and there would also be days when I put on 4-5 kgs between two consecutive days - that is 4-5 liters of fluid consumed in less than 16 hours! Sundays would become difficult then since I would have to consciously restrict my fluid intake. And I absolutely loathed that.

So, I decided to do true daily nocturnal dialysis. No Sunday off as well. On Sundays, though, since the technician would not come, I would do everything from start to finish. This got to me quickly and reverted to six nights a week.

Recently, I started getting fed up with dialysis. I decided to take an extra night off. So, I took Thursdays off in addition to Sundays.

Now I find I find it difficult to do more than two nights in a row. The quality of my sleep on dialysis is not great. So, more than two nights on dialysis is a little frustrating. I am thinking I should also switch to Bill's 'two nights on, one night off' regiment. Heck, if it's good enough for Bill, it's good enough for me!

... http://www.kamaldshah.com/2012/01/two-nights-on-one-night-off.html


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Sunday, 01 January 2012 00:00

How Facebook's tagging ruined my new year's eve

Written by Kamal Shah
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So there I was happily partying away last night when something terrible happened.

A friend tagged me on his Facebook picture. This wasn't a real picture as in 'real picture' but a collage of motley pictures which did not even have me in them. But my enterprising friend decide he wanted to show off his artwork (done on Photoshop?) to the rest of the world. So, he uploaded the pic to Facebook and tagged every single friend on his Facebook to it.

Chaos followed.

Now it was New Year's eve. So, many enterprising friends of this friend of mine decided they have to appreciate my friend's creative collaging skills. So, many of them started commenting on them. Now, because I, unfortunately, was also tagged in that pic that did not even have me, started receiving an email every time anyone commented on that picture! And I had my phone with me on which I would get every email and I also had the Facebook app with push notifications enabled on it so every time someone commented on that I got a separate notification as well.

By 11:30 p.m., I had received like a gazillion emails and another gazillion notifications. It was New Year's Eve, after all and the festive spirit was at its peak.

I couldn't take it any longer. I ran to my laptop and launched Facebook on the browser and went to the pic and 'unsubscribed' to the pic. I felt relieved.

But it was not to be. The emails and the notifications continued.

This morning I went back to the pic on Facebook and realized that because I was tagged I would receive the comments irrespective of whether I was subscribed or not. Then I had an aha moment.

I had to remove the tag. 'Na rahega tag, na bajenge comments.'

I went and successfully de-tagged myself from that pic. Peace ensued.

Happy new year to you!

... http://www.kamaldshah.com/2012/01/how-facebooks-tagging-ruined-my-new.html


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Wednesday, 28 December 2011 18:30

Can I please have my news channel back?

Written by Kamal Shah
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I suddenly realized that news channels are not the same any more. Earlier we had news bulletins at 8 p.m. and 9 p.m. that gave you 'news' as in 'news' not 'news' as in discussions to death about every happening of the day!


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Every single bit of news has to have a discussion associated with it. And there always are the so-called resident experts giving their much more than two cents.

When I watch the news, all I want are the headlines and a quick summary of the main news of the day. That's how it used to be. 30 minutes of crisp, objective reporting of the incidents. Not opinions of every party involved and more.

Now suddenly, every channel has a debate after every news item! And some panelists are asked to stay on for all the news stories. Like they are experts on everything. Think Renuka Chowdhary.

I wonder why this change has come about. Is there any English news channel that does news in the good old format?


... http://www.kamaldshah.com/2011/12/can-i-please-have-my-news-channel-back.html

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