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Sunday, 06 November 2011 20:06

Moving from a jugular to a fistula: mixed feelings

Written by Kamal Shah
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When I was put on dialysis way back in 1997, I was given an AV Shunt. It was a small surgery, done in an Operation Theater. Dialysis was totally painless. The arterial and venous lines were connected to the two ends of the shunt and dialysis would be done.

Shunts are outdated these days with the preferred mode of a temporary access for dialysis being a jugular catheter. The insertion of a jugular catheter is a more simple process than a shunt. It is mostly done outside an Operation Theater, often on a dialysis bed.

Dialysis using a jugular catheter is also painless. The two ends of the bloodlines are connected to the two ends of the catheter lines and the dialysis is started.

When I eventually got my fistula in 1997, I remember every one around me was excited. "The fistula is working!" "Here, feel the thrill, the bruit", the doctor would say offering me the stethoscope to hear the whoosh sound inside.

Dialysis, however, became horrible. There would be four needle pricks every time. Two to inject local anesthetic and two more for the actual fistula needles which were monstrously huge. I started dreading the whole thing.

So, what is it about the fistula that has medical professionals so excited?

For one, accesses like shunts and jugular catheters are temporary. They last for at most, a few months. And the number of such accesses you can have is limited. A fistula, on the other hand can last for decades. The main reason for this is that while temporary accesses are external accesses (there is something coming out of the body and this 'exit site' is highly susceptible to infection), a fistula is an internal access (the vein and the artery are connected inside the body, under the skin - so there is very little chance of infection).

However, the start of a dialysis session and at times, the entire session becomes a painful experience. The needles are by no means pleasant. So, while everyone around you is happy that you have finally got a fistula, you start wondering what the excitement is all about?! Days with the jugular were so much more pleasant!

One thing positive about the fistula from our perspective is that we can finally take a complete shower. With a shunt or a jugular catheter, you had to always be careful that you did not wet the site. With a fistula however, once the surgery site has healed, you can take a full blown shower, for hours even, without having to bother about wetting the site!

... http://www.kamaldshah.com/2011/11/moving-from-jugular-to-fistula-mixed.html

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Recently someone on dialysis who had a low hemoglobin was advised by his doctor to take a blood transfusion. Innocently he asked me if he could get a donor and we could take the blood from the donor and transfuse it immediately to him?

The scene from the Bollywood classic Amar Akbar Anthony came instantly to my mind where Amitabh Bachchan, Vinod Khanna and Rishi Kapoor, lying on three beds are donating blood. Blood from the three cannulas is flowing into one bottle and from that bottle, the blood flows through a line to Nirupa Roy's veins - all inline!

Makes for some excellent cinema. Unfortunately, blood transfusions are not so simple and straightforward in real life!

In real life, blood is never directly transferred directly from donor to recipient. It is first collected from the donor, then screened for viruses such as HIV, Hepatitis B and Hepatitis C and then a cross matching sample is taken from the recipient and another test is performed to certify that the donor's blood is suitable for the recipient.

Also, often, the recipient is advised some subset of the whole blood that is drawn. It could be packed cells, platelets etc. Sometimes, whole blood is also infused.

Also, blood transfusions are not a very healthy thing to do too often. There is always a risk of catching viral infections that have not been detected due to the virus being in the incubation period. Even inherently, blood transfusions are unhealthy because they prevent the body from producing antibodies.

This means that we should be constantly monitoring our hemoglobin levels and take the dose of erythropoietin necessary to avoid blood transfusions. The guidelines for the dosage of erythropoietin varies from country to country but the guideline that I have been recommended is to make sure the hemoglobin is between 10.5 and 11.5. Anything less than that and you don't feel as well and is risky in other ways. Anything more than that and you could risk clotting your fistula. Again, you should check with your nephrologist about what hemoglobin range you should target.

... http://www.kamaldshah.com/2011/11/blood-transfusions-very-different-from.html

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Thursday, 27 October 2011 20:20

Dialysis: overcoming Buttonholing’s obstacles

Written by Greg Collette
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Buttonholing is great: less pain, easy insertion, less chance of a blowout, less time holding the needles after removal – what’s not to like about it?

Well there are a couple of obstacles, at least for me.  Both can slow you down, but both can be overcome.

First the scab plays hard to get.  If I push the needle all the way in, so that the hole is sealed by the barrel of the needle (which is the intuitive thing to do) the hole eventually forms an indentation.  Scabs being what they are grow over the indented hole rather than flush with the surface and can be  quite difficult to remove next time.  Difficult equals time consuming.

One way around this is to leave a small part of the needle exposed (say width of a couple of hairs) at the hole.  Tape the needle so that the needle stays in that position, rather than being pushed into the hole.  This takes a little practice, but can be quite effective.

Second, my fistula moves like Harry Potter’s staircase.  I find that after about three months the easy-open hole in my fistula moves away from the needle track.  Fistulas are always growing, even if only a tiny amount a week, and eventually the hole wanders away from the business end of the buttonhole track.  As a result, it becomes progressively more difficult to find and needling takes longer.  You can of course ‘chase the hole’ by moving the tip of the needle in various directions until you find it, but this only works for so long.

I still hold the needle by the plastic tubing below the barrel use a gentle twirling motion to search for that easy entry.  Pushing the needle hard into the fistula wall just causes trauma.

But eventually I need to make new holes.

I spent more than 10 minutes searching for the holes for last time a week ago and decided to create some new buttonhole tracks, with sharp needles.  Because my fistula is pretty scarred and calloused, it takes quite a push to start a new hole, and it can be a little messy (blood wise) until the hole forms.  However after about 5 sessions, the hole starts to form a pathway.  Within a further 5 sessions, the track should be sufficiently established to switch to blunt needles.

In choosing the new buttonhole locations, I look for three things:

  1. Ease of access (no strange angles or half-obscured entry points)
  2. A short path between the entry hole and the fistula wall (less chance of creating multiple tracks)
  3. Sufficient needle space to accommodate the entire needle in the fistula (so I don’t risk going through to the other side).

These requirements often mean revisiting old locations.  (Or perhaps I am a chicken about attacking half hidden virgin real estate.)

Once the track is formed, you can feel it.  If you press down gently on the area around the hole you’ll feel a hard, oblong mass (a bit like a cyst) starting at the hole and ending inside the fistula.  It’s actually a callous tunnel.

Once you abandon a buttonhole location, the hole itself heals fairly quickly, but it takes months for the tunnel to disappear.

I should say that this 3 month buttonhole life span is not everyone’s experience.  I have heard of many buttonholes lasting at least twice as long – and sometimes for years.

For me, it may be that the gym has something to do with it.  Apart from a break of about 4 months, I have gone to a gym for about the last 5 years.  During this time I have used weights to try to keep fit, including on my forearms and biceps.  While I have only registered miniscule growth (small children still kick sand in my face), maybe it has been enough to cause my fistula to wander.

Perhaps this is a lesser-known example of Newton’s First Law:  for every action there is an unwanted side effect.

... http://bigdandme.wordpress.com/2011/10/28/dialysis-overcoming-buttonholing%E2%80%99s-obstacles/

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Wednesday, 26 October 2011 20:40


Written by Kamal Shah
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I have not posted for really long now. I have been down with a bad bout of cough, cold and fever. I was given some very strong anti-biotics which had their own side-effects. Looks like things are turning around now. I should be back pretty soon. I hope you had a great Diwali!

... http://www.kamaldshah.com/2011/10/update.html

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Friday, 21 October 2011 13:28

New PureFlow Saks

Written by Steve Bone
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I received a set of instructions through the post today for the new Saks for the Pureflow. They seem to have dealt with some issues in the new design of connections etc, so good to see that the work continues to constantly review and improve. How about the next improvement to reduce the batch creation time? :-)

The Saks apparently arrived at Kimal this week, but the plan is to use up the supplies of current Saks before making the settings changes to the PureFlow and making use of the new ones. This only applies to PureFlow machines running PureFlow SL software release 1.13 or higher. The new ones are designated 300 series.

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... http://mydialysis.co.uk/blog/2011/10/21/new-pureflow-saks/

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Many drugs that are prescribed for people with healthy kidneys have dosing adjustments for those with impaired renal function. This is mainly because the kidneys that usually clear these out from the body are not effective and giving the normal dose can cause unsafe levels of the drug to build up within the body.

So, for example, though the recommended dosage of the drug Levofloxacin, a potent antibiotic for people with normal renal function with certain kinds of bacterial infection is 500 mg every day, those on maintenance dialysis are advised to take only 250 mg every other day after the initial dose of 500 mg. This is simply to prevent the drug from accumulating in the body because the kidneys are not causing the drug to be excreted out of the body.

Dialysis does remove some drugs but only to a certain extent given the short nature of the treatments and the relatively infrequent sessions.

With me? Great! All good so far.

Now, what about people on nocturnal dialysis - those that are getting much longer, better and frequent treatments? One would expect that the dosage for them (rather, us) would be close to those with healthy kidneys.

Not so simple!

There are a lot of factors that come into play here. The molecular weight of the drug is one of them. The ease with which substances are dialyzed out during dialysis is inversely proportional to their size or molecular weight. The protein binding of a drug is also important. The greater the protein binding of a drug, the lesser the tendency for it to dialyze out during a dialysis session.

It is therefore very difficult to come to any conclusion about the dose in those on nocturnal dialysis simply because there just haven't been enough studies on this subject. Well, you would expect that, wouldn't you? There are such small numbers of people doing this therapy that researchers probably feel that it is not worth the effort!

This whole question came up when I was advised by my family doctor to take the regular dose of Levofloxacin along with a cough syrup to battle my horrible cough. As is my habit, I looked it up on the internet and sure enough found that there was an altered dosage recommended for those on dialysis.

I posted this question to the good Dr. John Agar of Australia on the Home Dialysis Central forums. He said the same thing. We don't know for sure but he would recommend going with the hemodialysis dosage.

But in a theoretical sense, it is still an open question!

There is a great article for the medically inclined available here on the subject.

... http://www.kamaldshah.com/2011/10/adjusted-dosage-of-drugs-for-those-on_19.html

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Tuesday, 18 October 2011 09:58

There are cough syrups and there are cough syrups

Written by Kamal Shah
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I have been down with a bad throat infection and congested nose along with fever for the last few days. As usual, I tried some home remedies but did not get better. I then started an antibiotic and a cough syrup. Two more days. No luck.

One evening, my temperature touched 102 degrees Fahrenheit. I then decided it was time to see a doctor. I went over to Sunshine Hospital to meet our family physician, Dr. Kirit Parekh. Dr. Parekh was the one who diagnosed my kidney disease in 1997 and I have been a huge fan since.

Dr. Parekh examined my throat and lungs and asked me to cough. One sound of the cough and he said, "Azethromycin is not going to work for this!" He then went on to prescribe another more potent antibiotic. He also prescribed a cough syrup. Once I was done with the doctor, I rested on a chair in the waiting lounge and asked my mother to pick up the medicines from the pharmacy. She did. I opened the packet just to see what she bought. I realized that the cough syrup that the pharmacist gave was not right.

There are two types of cough syrups. Cough suppressants and expectorants. Suppressants are used in dry coughs and they suppress the urge to cough. Expectorants, on the other hand are used in coughs where you bring out phlegm and they attempt to loosen up the respiratory tract to make it easy for you to bring out all the phlegm.

What I was prescribed was an expectorant. What I was given was a suppressant. Under normal circumstances, I would not have checked. I would have taken the syrup and my cough would have actually got worse because the phlegm would be suppressed inside. Of course, this would be discounting the action of the more important drug under the circumstances - the antibiotic. But you get the drift right?

When I returned the syrup to the pharmacy, the lady at the counter said that there was no expectorant available under that name. I asked for another expectorant that I had used in the past and she gave me that and I started using it.

This is why it is so important for all of us to be proactive when it comes to our health. These days you can never be sure. I believe a degree in pharmacy is required to run a pharmacy. But who cares about what is required? Whenever you buy some medicines, make sure that the name is exactly what is there in the prescription. There are tons of medicines with similar names with an extra suffix. For example you have Norflox and Norflox - TZ. Both are antibiotics but can have different actions. You have Becosules and Becosules - Z. You have many medicines that have a "plus" added. It is easy for the pharmacist to pass off one for the other because he does not want to lose the sale just because he does not have the correct drug. It is entirely up to you to make sure you have been given what you have been prescribed.

... http://www.kamaldshah.com/2011/10/there-are-cough-syrups-and-there-are.html

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Monday, 17 October 2011 15:50

Chugging along

Written by Steve Bone
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Been a while since I posted to the blog – work has been ‘voluminous’ to say the least, but taking a few days off. The NxStage (where’s the wood to touch?) has been behaving – but then the machine always seemed to – it’s been the PureFlow that was the issue, in the main. But that too has behaved – still high usage of Paks, but that aside, all good.

My blood results are now becoming more consistent and as a result of low potassium, I have to ‘gorge’ myself on this – so chocolate, tomatoes, bananas – you name it, I need to eat it. Put on a kilo or so, so need to watch the chocolate! Phosphates are down, PTH down and if this continues, then good signs all round. Dialysis time now averages about 3 hours 40 on a shorter session, although have been down to 3hrs 20, and for longer sessions up to about 4 hours. I have two doses of Tinzaparin to accommodate whether I am on a shorter session or a longer one, as I noted that my dialyser was remaining dirty on wash back, with some clotting, all on the lower dose of 2500units, so have 3500 also now for the longer 4 hours sessions.

Kimal took back a couple of the troublesome cartridges for analysis – not heard anything back, but had noted on some cartridges that the dialysate line at the lower left does not always sit in the channel in the plastic framework, and as such could become occluded. Needs a bit more tape to hold it in place.

With renewed confidence in the machine, contemplating a holiday with it in tow next year, rather than booking into a local unit. Want to go to France for a first hit as I can drive and take the machine with me. If that all works out ok then might work out doing this with flights.

I need to chase up my Kimal nurse as he did suggest I could attach my machine to the network so that both Kimal and NxStage could get data direct on the performance of the machine. I have a spare port on my router, and its about 4 feet from my machine, so will be easy to set up.

Onward and upward!

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... http://mydialysis.co.uk/blog/2011/10/17/chugging-along/

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Monday, 17 October 2011 09:29

Yours truly on Nephron Power!

Written by Kamal Shah
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Nephron Power is a popular nephrology blog authored by Dr. Kenar Jhaveri, nephrologist from New York. It is an academic blog for nephrologists.

I wrote an article, "Give us the choice" on Dr. Jhaveri's invitation and I am so happy to report, it has been published today on the blog. You can find the post here.

At the end of the post, Dr. Jhaveri comments:

"What Kamal is saying is not only true likely in India but in USA as well. This is an ongoing problem as more and more Younger Nephrologists don't feel well trained or comfortable in taking care of PD.  Meanwhile countries like Japan, have majority of their dialysis patients getting PD.  Economics or patient preferences - both might be playing a role in this sad state of affairs."

Thanks Dr. Jhaveri for keeping the patient's perspective in mind and for giving me a chance to write for your blog!

... http://www.kamaldshah.com/2011/10/yours-truly-on-nephron-power.html

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