Thursday, October 27, 2011

Update

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!

Wednesday, October 19, 2011

Adjusted dosage of drugs for those on nocturnal dialysis?


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.

Tuesday, October 18, 2011

There are cough syrups and there are cough syrups

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.

Monday, October 17, 2011

Yours truly on Nephron Power!

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!

Saturday, October 8, 2011

Six times, Seven times, Five times

When I started daily nocturnal home hemodialysis in May 2006, I dialyzed six times a week and took Sundays off. It was that way for a long, long time. However those were the days of huge fluid weight gains. Sometimes even 5 kgs in one day! So, my Mondays would be pretty uncomfortable. Heavy chest and all. There were two main reasons I was doing this. Most of my mentors in the US (Bill Peckham, Rich Berkowitz and Pierre Lachan) were doing six nights a week. So, I did too. And Jairam, the guy who did the dialysis for me would take Sundays off.

Then somewhere down the line, I learnt the ropes and could do everything on my own - from start to finish. So, I thought why not make my Mondays comfortable? And I switched to seven times a week! Six nights Jairam would do most of it and Sundays I would do everything. I would be alone in my room and I would do everything from start to finish on my own. My parents would be in the house though and I always had my cell phone next to me to call them should I need help.

Earlier this year, however, my parents went on a holiday to the US. I was home alone. Before going, they extracted a promise from me never to dialyze alone. They shuddered at the thought of a blood leak and no one in the house to help me. So, I switched back to six nights a week when Jairam would come and took Sundays off from dialysis.

Recently, involuntarily, my fluid intake has reduced. I put on, on an average, only about 2 to 2.5 kgs of fluid weight between sessions. Also, to be honest with you, I have started to tire of dialysis. Fourteen years are taking their toll. Needles are not pleasant. It is very difficult to get used to them. I was also 'inspired' by Bill Peckham's "two nights on, one night off" regimen! So, I decided to take Thursdays off as well. So, these days, I dialyze Monday, Tuesday, Wednesday, take Thursday off, then dialyze Friday, Saturday and take Sundays off.

Thursday, October 6, 2011

Farewell Steve Jobs


"Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma - which is living with the results of other people's thinking. Don't let the noise of other's opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary."

Steve Jobs, 1955 - 2011

Tuesday, October 4, 2011

Spare a thought for the caregiver

Being on dialysis is difficult. Being a caregiver for someone on dialysis can be difficult too. Seeing a loved one being diagnosed with a life-threatening disease can be emotionally very stressful. Every individual reacts differently.

I have seen my family over the years. And now, because of NephroPlus, I have seen and interacted with a whole lot of caregivers. Sons, daughters, wives, husbands, fathers, mothers. Almost every possible relationship.

Everyone starts off with shock and extreme feelings of love and sympathy for the affected person. How that holds differs from person to person. Some maintain the same level of love and affection over the years. In some, it slowly starts to wear off. In some, it turns into total apathy; in some even hate.

The patient also changes mentally. And this causes the family to change as well. I have seen people who were executives at good companies being reduced to simply names who occupy beds at the dialysis units during their allotted shifts. This can be quite humbling for the patients. They, who used to command the  respect of dozens of their subordinates, earned huge salaries, enjoyed the best comforts, always flew business class are now at the mercy of unethical technicians and nurses who sometimes even scold them. Yes, this can be humbling indeed.

I often see caregivers being severely burdened with guilt. Guilt for not doing enough. Guilt for not being there throughout. The whole problem with kidney disease is the continuity, there not being light at the end of the tunnel, it being a week after week thing, in perpetuity. Unlike cardiac disease where a surgery ends the problem (at least for the most part) or cancer where the problem often ends with the person (and the attempt here is not to lessen, in any way, the enormity of the suffering of the patient or the hurt in the family of these two health conditions), the fight with kidney disease is often drawn out over years causing a huge impact on an entire family's finances apart from the mental trauma.

Caregivers often realize that they need to get back to work! And to get on with their life. Sometimes patients make it easy by co-operating and being practical. However, sometimes, due to genuine reasons or otherwise, patients see this as being a crime. "He does not care for me any more!" Or worse, go into bouts of depression.

So, here's my advice to patients: Yes, we have the disease. We suffer the most. No two ways about that. However, let us understand that our family is also affected. In ways that we do not realize. Spare a thought for them. They have their own life. Let us not make our life theirs. Give them space. Let them live their life. If we do that, they will be recharged to help us with our problems.




Sunday, October 2, 2011

The software world loses a great programmer...

... to the healthcare world!

I recently switched to a full time role with NephroPlus. These have been very exciting times. Throughout my working life, the only thing I have ever done was software. Development, testing, managing. Years full of deadlines, requirements, design documents and code reviews. It has been a very rewarding experience.

When I started off in late 1999 at Summa Computers, the company belonging to my mother's friend, it was my first job. I was part time. I had just settled down into CAPD after the extremely tumultuous two-odd years with kidney disease and the unsuccessful transplant. I was itching to do something useful and my mother's friend agreed to take me on. I started learning Visual Basic and MS SQL Server.

A few months later, Obul, my uncle Paul's friend was looking to start a software company around web applications using Apple's WebObjects and he was in India and we met up and Effigent was born. Effigent took up the next eight years of my life. I worked on WebObjects apart from doing a lot of management. Effigent was definitely the most significant part of my career till now. I learnt a lot during these years both in terms of software and general stuff as well.

Somewhere in the middle, the tsunami happened and I had to eventually move from PD to home hemo.

I then joined Grene in November 2008 and worked on WebObjects, Cocoa and Cocoa Touch. This were probably my best two years as a pure programmer with no management distraction. I did some great work on home automation.

Software was my first love. It will always hold a special place in my heart.

I have been involved with NephroPlus since Day 1. There is no doubt in my mind that the work I do at NephroPlus is my 'calling'. I have struggled for years to find it. I am glad that I have. Many people don't. So, that way I am fortunate.

Life is very different from that in the software world. When you develop software, you basically enable people to do things. Outside it, you actually do those things! I am now on the other side of the fence where I am looking after the implementation of software prepared by someone else at NephroPlus.

I am very excited about the work at NephroPlus. I hope the years to come are productive, fruitful and intellectually satisfying!

Saturday, October 1, 2011

Birthday Videos

Here are the two videos done for my birthday, the first one by the NephroPlus folks and the second one by my Engineering College friends.