Friday, April 24, 2015

How much fluid weight do I gain between two dialysis sessions?



A great thinker had once said, “Never ask a lady her age and a dialysis patient his weight gain.”

I often get asked this question. Especially when people get to know that I dialyse every day. People who ask this are either nephrologists or people on dialysis themselves. You can’t blame them. Fluid weight gain is one of the biggest problems for people on dialysis and for people who treat people on dialysis.

My guess is people who dialyse thrice weekly and have no urine output would gain on an average two to three kgs between sessions. Unless they are very compliant - the ‘good boys’ in which case they would gain between 1 to 2 kgs or extremely non-compliant - the ‘bad boys’ in which case they would gain about 4-5 kgs.

I dialyse every day (pretty much) and I typically put on 3 kgs between sessions unless it is my day off, after which I am about 5-6 kgs above my dry weight. If I am travelling and have a day off, it could touch as much as 7 kgs.

There, I have said it. No, no, please don’t berate me. Don’t tell me about the dangers of the high gains. Don’t even ask me how I manage to put on so much.

I look at it this way. I take all the trouble of doing daily dialysis. I spend all the money on doing daily dialysis. I bear two big pricks on my arm almost every day of the week. All this for what? To deprive myself of the cola? To restrict myself from having the chilled aam panna? Why even bother with so much dialysis if I had to restrict myself so much?

Make no mistake, the biggest problem I have with kidney failure is the fluid restriction. If I did not have to restrict my fluid, I would not have any problems with kidney failure! Seriously!


So, now that I have answered the question, please don’t ask me this again and more importantly, those who deal with me on a daily basis, please, never ever, ever ever say something so ridiculous like “such a high weight gain” again.

Sunday, April 12, 2015

Ooty diary

Coimbattooor-Coimbattooor...

The NephroPlus founding team was to be honoured with the "Dynamic Indian of the Millenium" Award by K. G. Foundation Coimbatore! So, the three of us, Vikram, Sandeep and I planned to go to Coimbatore for the event on the 5th of April. We also thought a celebratory break of a day would be just right in the cool climes of Ooty after the event!

Ever had a song stick in your head with no hope of letting it go for many hours? Well, I had that happen to me many-a-time and a few days before the event, the song from the movie Padosan, Bhai baddur was stuck in my head except that my head, all excited about the trip, conveniently replaced the first two words with Coimbattooor-Coimbattooor! Here's the original for those inclined:



Dynamic Indian of the Millenium

The K. G. Foundation awards distinguished Indians who have made some impact on society every year with these awards and we were quite surprised that we were picked for the award this year! The foundation is headed by the dynamic Dr. G. Bhaktavatsalam, an extremely active doctor, who heads the K. G. Hospital of Coimbatore and is a Padma Shri himself. The organisation of the awards event was really amazing. All the finer details were taken care of. The award itself was a plaque, a shawl and a memento. After the awards were given to us, they were collected back and were sent to our car. By the next day, an album with pictures from the event that featured each of us separately was delivered to us! Truly remarkable!




Ooty -  a day in the hills

We had rooms booked in Club Mahindra Derby Green at Ooty. As soon as the K G Foundation event completed, we headed out in a cab for Ooty. The three and half hour drive that culminated at around 11 p.m. was quite tiring. As soon as we reached, we checked into our rooms. The resort was a three hundred year old property. The rooms were made out of fine wood and had an old-world charm about them.

The next morning we got up late and headed for the restaurant for breakfast. We had a Maruti van come and pick us up to take us to the restaurant. The resort is so vast that for people with creaky bones like me, just going about from place to place would be an arduous task!

We then got ready and decided to go around Ooty. We first went to the Ooty lake. Just outside the boat house, I chanced upon some lovely Tota-kairis and passion fruit. We had our fill of these fruits which were really delicious. We then took a pedal boat and took a half hour boat ride in the lake.



How not to market Tea!

We then went to the Government Tea Factory where they show you how tea is processed from the leaf that is picked from the gardens to the Cut-Tear-Curl process and the roasting to eventually give you the tea that you actually brew. There's a rather sad sampling that you are offered after which you could buy what you liked. To put it mildly, a much better job could have been done.

To me, tea is something that is almost divine. I enjoy my three cups of Darjeeling Orange Pekoe over my day with such relish that this came as quite a letdown. I was looking forward to an hour of fondness, it turned out to be an hour of disappointment!

Doddabetta Peak

The driver then told us about the Doddabetta Peak which was supposedly the highest peak of the Nilgiris. We drove down to the point where there is an entrance to the place. You had to walk about half a kilometer to the point where you could get a great view of the valley. I, with my creaking bones and Vikram and Manju with their year old daughter decided to give this a miss. The drive to the place however was truly amazing. The road to the point is quiet and quaint, with eucalyptus and teak trees on both sides growing wildly. We were quite happy to take the drive back to our hotel for a nice, short nap.



Winding up

The evening saw us getting massages at the hotel spa which relaxed and rejuvenated us. I went to the local market and bought some passion fruit and mangoes for my parents. We had dinner and turned in. We were back home the next afternoon.

Though this was a small trip, it served the purpose - that of a short break and an opportunity to recharge our batteries. In the modern day and age, where you get so tied down with your daily work, even a short trip like this can really help. Especially with work like ours in NephroPlus, where every day can bring on a new challenge, where every decision we take is critical and affects a lot of people, it is essential for our minds to be refreshed once in a way.

Sunday, March 29, 2015

Depression in Indian Dialysis Patients: a problem begging to be addressed



This morning, as I browsed through my Facebook wall, I was alarmed to see a friend's post that he was trying to enjoy the last few days of his life! This guy is on dialysis and has been on dialysis for a year. I was wondering what could have happened that he thought these were the last few days of his life?

I called him immediately and realised that he was thoroughly depressed. I tried to cheer him up and realised that many people on dialysis are very depressed.

Unfortunately, in a country like India, where there are hardly a thousand nephrologists for a population of more than a billion, doctors do not have enough time to spend with their patients and give them 'all-round' care. A dialysis patient has multiple problems - the basic issues around dialysis itself, diet problems, co-morbidities, psychological issues. There is just not enough bandwidth for a doctor to attempt to address all these problems!

The patients themselves find it hard to grapple with a multitude of problems. Add to that the horrible problem of paying for treating all this.

"Its all in the mind", goes the adage. Now, there's proof to back this. A paper in Nephrology, Dialysis, Transplantation states, "scores on the emotional components of (Quality of Life) questionnaires are in fact strong predictors of patient outcome." A study quoted in this paper actually found that "patients with scores of 0–37 have twice the relative risk of death than those patients with scores of 51 or higher".

In India, what can we do to address this very significant cause of patient mortality among the dialysis population?

First, we need to acknowledge that this problem exists. We need to at least start tracking depression among our patients. It is not very difficult. Standard questionnaires are available. A beginning can be made by administering this questionnaire to our patients and then figuring out the magnitude of the problem at hand in our country.

Subsequently, steps can be taken as arranging support systems for those affected. We, as a country, may not have the resources to treat every patient who is depressed. Let us at least make a beginning. Rome was not built in a day. Treating dialysis patients is honestly, a more arduous task.

The medical community owes this to the patients. Dr. Victor Gura said, in response to a question on how working on the WAK helps him:

"Why would somebody go to medical school for any reason except because you want to alleviate pain and suffering or save lives. If you go to medical school that's what you want. And I would be basically fulfilling my endeavors and my hopes of becoming a physician. Alleviate suffering, make life better and hopefully save a few lives."

Saturday, March 14, 2015

Improving outcomes and QoL in patients on long term dialysis: what is the secret?

I was recently a panelist on a discussion at the Indian Society of Hemodialysis Conference on the topic, "Improving outcomes and Quality of Life in patients on long term dialysis".



I have been on dialysis for almost eighteen years now. I lead an almost normal life. I swim every morning. I work full time. I travel regularly. If you asked me what the secret ingredient in this recipe is, I would unhesitatingly say, "hours, hours, hours". The number of hours you spend on the machine, in my mind, is the most important factor.

I could not make that point as forcefully as I would have liked to in the discussion. In any panel discussion, even without Arnab Goswami as the moderator, there is a limited amount of time that each panelist gets to make his or her point. With Arnab, you have a second or two before he would interject and then make your point for you even if it is not really your point!

But, I digress.

There are two things dialysis removes - fluid and toxins. You can use a better dialyzer to remove toxins in a better manner. However, for fluid removal, even the best dialyzer in the world is restricted by the physiology of the body. The human body can only handle about 400 ml/hour without any complications. Stretch this limit and you are setting yourself up for a variety of problems like cramps, low blood pressure and some heart issues like Myocardial Stunning.

More hours on the machine also means you have less time between treatments. This means lower inter-dialytic weight gains. The normal human body has about 5-6 liters of blood. When someone consumes about 2 liters of fluid without removing it, it means almost 40% extra fluid for the heart to pump. This puts a lot of load on the heart causing it to expand (Left Ventricular Hypertrophy) and eventually fail. That is why most dialysis patients die of Cardiac issues and many of them die during the 'long-gap' between sessions. For patients on thrice a week dialysis, this typically is the 'killer weekend' - the Sunday-Monday gap or the Saturday-Sunday gap.

So, how much dialysis should one get?

I would say, "however much you can practically get!" I get about seven hours each night, six nights a week. That's at least 42 hours per week! Compare this to those who get five hours, twice weekly or four hours, thrice weekly. I get a lot more. Yes, there are a large number of people who have survived for a lot longer than I have on these modalities. But we must not get swayed by a few odd cases. The vast majority of patients who get low hours per week have poor survivals and quality of life.

Even when it comes to toxins, middle molecules can only be removed by more hours on the machine. These are the silent killers when it comes to long term dialysis.

I strongly believe a lot more effort needs to be made by the Indian dialysis community in getting patients more hours on the machine. Yes, patients here have financial constraints. Yes, we have a resource crunch. But if we honestly ask ourselves the question, "Are we giving optimal (not just adequate) dialysis to every patient who can afford it?", I am sure the answer is a big "No".

Are we giving enough hours to patients covered by private insurance? No!

Are we giving enough hours to patients covered by Government reimbursement schemes? No!

Are we giving enough hours to patients to patients who can afford them? No!

Where is the financial constraint for patients here?

I rest my case.

Sunday, February 22, 2015

My take on the AIB roast



A lot of water has flown down the Ganga since the AIB Roast first hit the headlines. People praised it to begin with and called it "Indian stand-up comedy finally coming of age". Most people found it funny and bold. Then someone decided it was indecent and actually filed an FIR against those who produced it and participated in it. Since then, every few days we find someone or the other voicing their opinion on this. We have had Aamir Khan, Twinkle Khanna, Shah Rukh Khan, Varun Dhawan and many others give their two cents on this.

I have actually seen the entire Roast on YouTube before it was pulled off. So, unlike many others, I at the very least have the legal sanction to comment on it!

For me, it worked only in parts. I honestly don't find abuse funny. Merely mouthing expletives just doesn't cut it for me. No, I am not against using expletives but I don't find them funny by themselves. The Roast depended a lot on people finding expletives funny by themselves.

To be fair, there were some really good jokes. But all in all I found it pretty average in terms of humour content. I don't think this was 'Indian stand-up comedy coming of age'. If anything, it served to highlight that Indian stand-up comedy still relies heavily on expletives that appeal only to immature imbeciles who have had a less-than-perfect schooling.

Almost all the jokes that targeted Karan Johar were about him being gay. To be fair to him, he took these jokes very sportingly and what was probably the worst-kept secret of Bollywood is now completely out in the open. Then there were jibes galore at skin colour, religion and relationships.

This brings me to the reaction to the Roast. All I can say is that it was wholly unnecessary. It was on YouTube. There's much worse on YouTube and this elicited the kind of response it did only because of the names involved. Poor Karan Johar had to have the High Court restrain the police from arresting him for this! Please give the poor guy a break!

If you get offended by such jokes and language, you have a very simple choice: click on Stop!

Friday, February 20, 2015

A productivity hack that is really working well for me



As an organisation grows, individuals who have started it have to take on additional responsibilities. As a result, the number of things on your to-do list grows significantly. You often have multiple urgent things that you need to do NOW. You are always picking one over the other saying you will come back to the other. Your list of things left undone grows.

The number of emails you need to attend to also keeps growing tremendously. You are away from your computer for a few hours and by the time you get back to your computer, you find 50-60 emails that have hit your inbox and need to be responded to.

I have this policy of 'Inbox 0'. This means that I always need to have no emails in my Inbox. When an email comes, I need to read it and do one of four things:

- Delete it if it is not needed at all (promotions, alerts etc.)
- Just move it to an appropriate folder if I don't need to do anything about it
- Respond immediately and move it to an appropriate folder
- Add an item to my to-do list and move it to an appropriate folder

This adds stuff to my to-do list and I was looking for a way to optimise how I manage my to-do list which was getting just too long and unmanageable. I use Wunderlist for managing my to-dos (and might I add, evangelised many of my colleagues at work to use this great tool as well - it syncs your to-dos among your phones and computers, has multiple lists and easy prioritising).

Then, one day, on Quora, I got this article in my email alert: As a startup CEO, what is your favorite productivity hack?

Now, now, Vikram, I can see you raising your eyebrows! I am not CEO of a startup, but I am a co-founder of a startup. So, I thought might as well read it as I was looking for ways I could be more productive.

Here is what I have started doing after reading the article. The article recommends other tools but conceptually what I am doing with Wunderlist is the same. It is not rocket science and after reading this, you might say: Much ado about nothing! But then, most great ideas seem simple. The fact is I was not doing it until I read this and after beginning to do this, it has helped a lot!

So, I have an "Inbox" list on Wunderlist. Here is where all new to-dos go to. Every week, on Monday morning, I go through this list and move to-dos to my "This week" list. These are things I would really like to get done this week. Then, every morning, I go through my "This week" list and move to-dos to my "Today" list. Then I take up things from my "Today" list and then actually do them. At the end of the day, it feels really nice to see that most of your to-dos are done.

I have tried this for a couple of weeks. It has worked really well. Yes, it might be early days yet but I am going to persist and continue this. Many things that were pending for a long time have got done. Earlier, all I was doing was responding to email. This meant OTHERS were dictating what I did in my day. With this method, I am dictating what I do with my day! This is really important!

There are many productivity hacks that people use. It is important that you pick something to make sure you get things done which are important to you. Many of us end up doing things that are unimportant to us and just react to emails and things others want us to do. That is not what we are meant to do!

A stupendous success!

The First ever Dialysis Olympiad in India organised by NephroPlus was a huge success. Almost 350 patients and their attendants participated in the event this Sunday, the 15th of February in Hyderabad. Right from the morning, patients started participating in the various events that were conducted with great enthusiasm and a 'will to win' which was the theme of the event. Here are some pictures from the event:












For more pictures, click here.