Every donor kidney a perfect match: no more transplant drugs!

We all hate rejection.  It hurts us somewhere deep inside.  And those of us who’ve had an organ transplant hate it most of all.  Because the only way to make all that pain go away is by taking a hearty (sometimes heroic) dose of anti-rejection drugs.

Rejection is driven by our body’s immune system, a collection of cells (T cells) that recognise and destroy foreign cells: germs, poisons, other bits that find their way into us. All cells have proteins called antigens on their surface.  As soon as these antigens enter our body, the immune system recognises that they are not from our body and attacks them.

When we receive an organ transplant, our immune system may detect that the antigens on the cells of the organ are not from our body or not “matched.”  Mismatched organs, or organs that are not matched closely enough, can trigger rejection.  To help prevent reaction, doctors type, or match both the organ donor and the person who is receiving the organ.  The closer the match the antigens are between the donor and recipient, the less likely that the organ will be rejected.

Anti-rejection drugs work by slowing down our body’s immune system.  But you can’t let up:  it’s like pressing our foot down on a spring: the moment you take it away, it bounces back to exactly where it was.  So once you have a transplant, you must take the drugs for as long as the transplant lasts (which can be decades).

The trouble is, anti-rejection drugs have side effects:

  • With our immune system supressed, we catch every bug that’s passing by and because we have almost no resistance, the damage it can cause is massively exaggerated (where a person with a normal immune system may get a mild sniffle, we can easily end up with pneumonia)
  • The drugs do things to us (give us moon heads, thin easy-tear skin, bruises from bumps a 90-pound weakling would brush aside, scramble our brains and our emotions and lots more).

But all this may change over the next few years (key dramatic, super up-beat music).

Re-writing the anti-rejection script

Dr Tracy Heng, Monash Immunology & Stem Cell Labs, Faculty of Medicine, Nursing & Health Sciences

Dr Tracy Heng, Monash University Department of Anatomy and Developmental Biology

Last week I had the pleasure of interviewing Melbourne scientist from the Monash University Department of Anatomy and Developmental Biology.  Dr Heng and her colleagues from the Departments of Anatomy and Developmental Biology, and Immunology and the CSIRO are re-writing the anti-rejection script: this time eliminating the cause of rejection rather than stamping on the spring.

Put simply, they have found a way to make every donor kidney a perfect match for the recipient using the body’s own mechanism for teaching the immune system to recognise what is foreign versus local.  Of course it involves the wonder building blocks of all cells, stem cells.

How it works

During the normal course of events our immune system creates the T cells it needs from our bone marrow stem cells.  Dr Heng and her colleagues have found a way to introduce foreign bone marrow stem cells from the donor into the recipient’s bone marrow.  The stem cells mix with the locals and when they are converted into T cells, they have been “educated” to see all donor cells as a perfect match.  When the transplanted organ arrives there are no alarms; no attack; and no rejection.  This technique is called “tolerance induction”, whereby the recipient becomes tolerant to the donor organ.

The technique involves using a small dose of Busulfan (a chemotherapy drug usually given before a stem cell transplant for leukaemia) to slightly reduce the number of the recipient’s bone marrow stem cells, making space for the donor stem cells.  The stem cells are then transplanted into the recipient’s bone marrow combined with a small amount of anti-rejection drug for a few days to stop the donor stem cells being rejected.  The recipient is now ready for the transplant.

Good for the life of the transplant

The technique specifically replaces “long term” stem cells, to generate long lived, educated T cells that they expect to last at least as long as the recipient has their transplant.

Low impact and radiation-free

Dr Heng noted that a variant of this approach has been trialled in the US, using larger doses of chemotherapy drugs or radiation, which may not be suitable for the sick or elderly (both groups are heavily represented on transplant lists).  This new approach is a radiation free, way of producing the educated T cells.

Good for aged transplant recipients

Dr Heng started this research in 2009, and the team has conducted successful pre-clinical trials with both young and aged mice, despite age-related cell degeneration in the aged mice.  From a clinical viewpoint, this is especially important, as the majority of transplant recipients are older patients whose immune recovery might be dangerously slow and would benefit from a radiation-free, low impact conditioning technique that enables organ transplant without compromising their immune system.

The details were published in the 10 July 2014 edition of the American Journal of Transplantation. 

When can we line up?

Not for a few years.  There are many tests and trials to complete before it becomes a standard clinical treatment for transplants.  But the fact that the team is using drugs that are in use worldwide means there are no drug safety hurdles.  I’m betting it will certainly be the norm in my lifetime (I’m 62).

Of course, since the whole objective is to make each donor organ a perfect match for the recipient, this treatment is limited to live donor transplants.  Deceased donor transplants happen within hours of death, so there would (currently) be no time to condition the recipient’s stem cells.

Those who follow this blog know that I’ve had two transplants, one from my wife (bless her) and one from a deceased donor (bless him/her too).  Neither did particularly well, because it seems I can reject almost anything, regardless of the level of performance enhancement provided by anti-rejection drugs.

If this technique was available in 1995, I would now be swanning around with my wife’s kidney tucked safely under my right rib, the world as my oyster.  Sadly it was not to be.  But very soon, a whole new population of donor kidney (/ liver/ lungs/heart and most other body bit) recipients will be doing just that.  All thanks to wonderful, smart people like Tracy Heng and her colleagues.

The Best Dialysis Machine?

I had an interesting email from Lawrence recently, about the pros and cons of the various brands of dialysis machine:

Hi Greg

I’ve been dialysing for a year now on Fresenius machines and in the last few months have been doing home hemo on a Fresenius.  I’ve had constant issues with poor arterial pressures and alarms. The techies have been out to try and sort the problems and eventually decided that it must be my line which was the problem.  

This week I am on holiday and have been dialysing on a Braun machine.  What a difference!! I’ve been attaining pump speeds of 350 (I can barely make 300 on the Fresenius) and the arterial and venous pressures are brilliant! My KTV is 1.5.  

I communicated this to my unit who have been stonily silent on the subject.  Has anyone else come across this kind of difference?  I’d be interested to know.  The Braun seems a much superior machine to me, with far more streamlined tubing.  I’ve tried to research on the internet but can’t find any comparative studies on dialysis machines.

Best wishes, Lawrence

Hi Lawrence.  I don’t have a lot to contribute about various machines.  I dialyse on Gambro, which are fine.  I regularly achieve a pump speed of 370 milliLitres per minute (mL/min).  Gambro have the usual alarms and hassles, but do the job well for me.

On holidays I have dialysed on Fresenius, Braun and Nipro.  I have found that I don’t usually achieve more than about 350 on the Fresenius machines I use on holidays (through the nurses usually say that the Fresenius doesn’t need to go as fast to do a better job!).  Just the same, all seem fine to me, though technicians I have spoken to tend to rate Nipro a little behind all the others.

I have heard the NxStage machines tend to under dialyse because of their portable nature and use of limited water supply.

Regards, Greg

I look forward to hearing the thoughts from other BigD-ers!

Choose your holiday dialysis chair by App

I recently had the privilege of attending a workshop hosted by the Victorian Renal Health Clinical Network at the state Department of Health, and to contribute to the future State-wide Clinical Pathway for Victorians with Chronic Kidney Disease and End Stage Renal Disease.  A bit of a mouthful, but it was a collection of 60 people from all areas of renal services, including head nephrologists from the major state hospitals, private nephrologists, private dialysis service providers, renal nurse practitioners, key clinicians including nurses and allied health, peak bodies and ‘consumers’ like me, looking at our “could be/should be” future.

The aim of the workshop was to imagine a new care pathway covering all aspects of kidney disease, from the initial discovery of a problem, through all the various aspects of the kidney failure journey: pre-diagnosis, diagnosis, preventative action (eg diet), treatment (such as dialysis and transplantation), choosing to end treatment, palliative care, death and bereavement: the whole enchilada.

Clinical pathways are highly detailed flowcharts used to manage the quality of care by standardising all aspects, steps and even outcomes in the care processes.  This new renal disease pathway will set out newly optimal practices for all kidney patients.  It will follow a predictable clinical course, with minor variations, in which the different tasks done by the professionals involved in the patient care are defined, optimized and sequenced through the kidney failure lifecycle (if you can call it that).

The workshop was divided between six working groups covering the four major topics of the pathway:

  1. Chronic Kidney Failure (the start of the cycle)
  2. Dialysis
  3. Transplant
  4. Supportive (including palliative) care.

I was part of a Dialysis Working Group, and here are some of our highlights (I couldn’t take note fast enough to get the lot!).

Questions asked included:

What does a good dialysis service look like? 

Our answers included that it should:

  • Be Geographically accessible
  • Provide quality, evidence-based care
  • Offer flexibility for various patient needs (eg flexible hours for those still working)
  • Be measured on patient-oriented Key Performance Indicators (such as high patient satisfaction scores, ongoing good quality of life, low infection rates)
  • Have a high level of staff retention and satisfaction.

Other elements that contribute to patient satisfaction are the sharing of care initiatives and information between dialysis providers and a strong sense of community with each unit.  It became clear that a great way to promote community is to have a facility for sharing patient stories (maybe in the unit newsletter?).

How to best provide information and education?

Our answers included:

On an individual basis, timed for when the information is important to them.  For example, when a specific problem occurs (eg being itchy, or constantly tired) and the patient is most receptive to information that will help solve the problem.

Education should be available at call, typically in small chunks, ideally in a multimedia format, say on an App.

Peer support.  Another form of education delivery could be provided by peers, which has the credibility of personal experience that other patients can relate to.  It’s also cheap and readily available.  Some private units are already using experienced patients as mentors for new ones to great effect.

One overlooked facility with great potential is the “phone a friend” facility provided by Kidney Health Australia.  More details on their website.

Providing Patient-Centred Care?

Answers put forward included:

Some (blue sky) discussions about changing the care model so that consultations with specialists (eg nephrologist, cardiac, endocrinology, vascular) would be more effective if they took place over a single or a small number of sequential sessions.  This already happens in some outpatient clinics (not for dialysis patients), followed by a joint debrief between all the medicos involved.  So it’s not quite blue sky thinking, especially when combined with the TeleHealth initiative suggested below.)

Other interesting suggestions included:

  • Using TeleHealth systems to bring various services to the patient
  • Having consultations while having dialysis (though I think that should be limited to the first hour, based on how non-sparky I am after that)
  • Using the Australian Government’s E-Health Record for at least recording medications and pathology results
  • Using regular web/App-based surveys to all stakeholders, to identify gaps in care clinical problems, education needs, etc.

From the dialysis perspective, establish protocols (and technology as appropriate) to actively manage appointment times: provide realistic appointments at least a few days before each dialysis session and early warning of unavoidable changes (some units do this well already)

Several allied health participants suggested that it would be useful for patients to have ongoing cognitive assessments, eg for home dialysis patients; to be sure they are coping performing what are quite complex tasks.  (This is probably a good idea, but not for me! I’m not keen to see that particular trend line.)

Technology, sustainability and Innovation?

Ideas suggested include:

  • Opening a proportion of each unit’s dialysis sessions to the Internet so that patients can arrange swaps via App: say for special occasions (like the Melbourne Cup), different cities, etc.
  • Establish an App-based holiday booking service or a timeshare-like arrangement for patients looking to holiday in remote locations (eg the DATA holiday units or the Big Red Kidney Bus)
  • Establish a renal data sharing system for use between units
  • Include a Health Informatics Working Group in designing this pathway
  • Set up a generic system for patients to request prescriptions, referrals, etc (there’s already at least one App for that, which I use: MedAdvisor)
  • Establish a TeleHealth service (including Medicare item numbers) for Renal Psychologists, dieticians, social workers, etc.
  • Introduce defined renal career pathways, including renal university courses to ensure the existing renal professionals will be supported and replaced over coming years.

Mark Twain once said, It is difficult to make predictions, especially about the future.  It was difficult and exhausting, but a great day.  Everyone, from the most sceptical grey-hair to the bright-eyed newbie was energised and enthusiastic.  Thinking outside the square really generated some genuinely innovative ideas for the future.  Many people went away determined to implement some ideas immediately at their local level.

I’m looking forward to the next big steps: the workshop report, the final report and recommendations, then, TA DA: the rubber hitting the road – the a new Pathway for BigD-ers not just in Victoria, or Australia, but for all points north.

With luck, we can check out the new pathway on this blog in the near future, while we book our holiday dialysis chair on the Gold Coast using our smart phone.

Dialysis, viruses and bugs – an unhappy combo

Well, that was quite a break!  After six weeks, two hospitals and too many tests, I’m home, and it’s a great place to be.

The problem began with a particularly aggressive Flu caught while Julie and I were on mini-holiday in Surfers Paradise in Queensland.  The sunshine and beaches were excellent, but the local dialysis unit was full of sickies: staff and patients.  I knew I was in for it as soon as I arrived, and saw all the red faces, coughing and wheezing.  Like all BigD members with compromised immune systems, bugs of any description find me a welcoming host, and settled right in.

By the time I got home, I was really unwell with Julie, Chris and my doctor saying I should go to hospital.  I don’t like hospitals.  Non-BigD-ers don’t understand how stressful it is.  It’s not just being sick.  All of a sudden easy, regular dialysis where your routine keeps you feeling well becomes uncertain, irregular and lumpy.  You just don’t get dialysis when you need it (like when we have overpowering metallic halitosis from just living or from the contrast injected into us for a CT Scan, or the gradual flow of extra fluid settling in from the ankles up).

Sometime the kidney ward is full, so you go to bones or hearts or bums.  Joining a four bed ward where the other patients have bowel problems and I share the toilet makes me want to go home, no matter how sick I am.  And in non-kidney wards, staff don’t know kidney stuff:  like the need to get phosphate binders with meals, or how we manage fluid restrictions: I was once confined to bed and the nurse was told I was on fluid restrictions, so she gave me exactly nil.  After begging and cursing, she relented to let me wet my mouth by sucking on a sponge.  I will never forget how dry I was… never.

And hospitals give you as many bugs as they remove.  I could go on, but you get my drift.

Anyway, I had two visits to two different hospitals.  The Flu is a virus and doesn’t respond to antibiotics, but viruses can open the door to other kinds of bacteria that do respond to antibiotics.  So, after some hefty pre-emptive doses aimed at a range of possible bugs at each hospital, I have now recovered and am thankfully, back home.

The bug I had was by no means limited to me.  When I returned to my unit, I found the many of the staff and patients were also sick with a local variant.  But here it was treated with the respect it deserved. Sickies were separated from the healthy.  All staff wore extra anti infection gowns (a very fetching yellow) and full face shields.  If you saw the photos of the Médecins Sans Frontières (Doctors Without Borders) staff fighting Ebola in West Africa, you will get the picture.

Anyhow, thankfully, much of that drama has passed, as it usually does.

On with the show.

Guest post: The Big Red Kidney Walk

Hi everyone.  Thanks for your messages and good wishes.  I am certainly on the mend, but it is an aggressive little bug(ger), and I think I have another week or so before I’m back to normal.

So, in the interim, a guest post!

The Big Red Kidney Walk is on again on 14 September, around Australia.  Kidney Health Australia put on the Walk every year.  It is designed to help raise awareness and funds for kidney disease across Australia. It is a great event that brings the kidney community together for a family fun day where people can meet, go for a walk or run, enjoy a BBQ and entertainment, and generally catch up.

Tony started dialysis at my unit about 10 months ago.  He is married to Kim, and they have decided to get into the walk in a big way.  Why?  Here’s Kim.

My husband is the Tony in “Team Tony” and he has been diagnosed with kidney cancer twice. Just before Christmas in 2006 he was hit by a car and routine scans at hospital following the accident found cancer in his left kidney. The kidney was removed, there was no need for radiation or chemo and once he recovered from the surgery and a fractured pelvis our lives continued on as normal.

However in September last year he was diagnosed with kidney cancer once again following routine tests for another health issue.  We were devastated. Tony had his right kidney removed and we were plunged immediately into our new life of dialysis, adjusting to a new diet, reduced fluid intake, etc all while he was slowly recovering from surgery and his body was adjusting to suddenly having no kidneys at all.

All of this was made so much easier with the support of the magnificent nurses and staff at Diaverum Diamond Valley Dialysis Clinic especially the wonderful Clinic Manager Chris van Bakel. 

The care Tony receives at Diaverum is incredible and with their support he manages his dialysis and has resumed full time work as a Project Manager. We cannot thank them enough for making this very difficult time for our family so much more bearable.

It is from this exposure to all the kidney related issues and seeing the people both young and old who rely on dialysis to live that has prompted our involvement in the walk.  We want “to give back” and show our support for the carers, nurses and all the other families who on a daily basis support their loved ones who are affected by kidney health issues.

My family wanted to participate in The Big Red Kidney Walk not only to raise money for this wonderful cause but also to raise awareness of kidney health issues. There are so many great causes to support but we believe that kidney disease and other kidney related health issues are “forgotten” when compared to the massive support given to other causes.

So on Sunday 14 September Jack (17), Sarah (13) and I will be pounding the footpaths of Melbourne just happy to be there and have Tony walking along side us.  To be able to fundraise for Kidney Health Australia at the same time is just the icing on the cake!


Kim is giving us a powerful message, one we hear many times on this site: dialysis is not the end of our world.  Our life does change, but with the right dialysis and a good support network, our lives are still our own, and we can still work, play, travel and live it to the full.

Unwell-come break

Julie and I went on a mini-holiday about two weeks ago to sit in the sunshine.  Bad move.  Unfortunately, it was Nasty Bug Central, and we both caught some kind of flu.  My immune system is wimpy at the best of times, so I have been laid low, for the last two weeks, first at home, then in hospital.  I came home yesterday, still not quite right.

Throughout, Julie has also been unwell, so rather than at least being made a fuss of, she has had to look after me, visit the hospital, etc.

More news when we stop coughing and start smiling.

How much is a new kidney worth on the Red Market?

Not feeling all that energetic this week (same as the last couple).  For some reason my haemoglobin is still hanging loose at a miserable 8.2.  That is transfusion level, but because I’m on the transplant list, transfusions are off the agenda.  Someone else’s blood may introduce more antibodies than I can handle, and move me from a 2% likelihood of a transplant to a big fat zero.

So I am biding my time, taking my weekly EPO dose and hoping for a surprise energy burst anytime now…   In the meantime, my gym is sending me “Where are you?” messages and I’m breaking ito a sweat jogging from the kitchen to the bathroom.  Though with the daily HB blood tests removing a little of what blood I have, I may be running in a circle.

Since my creative juices tide is on the ebb, I thought it may be interesting to relay some stuff that you may find interesting that other bloggers have sent me: How Much Is Your Body Worth on the Black Market? (Which is now being called the Red Market for obvious reasons.)  I don’t re-post stuff from people pushing their own agenda (especially not kidney-for-sale posts or subtle/not-so-subtle internet hucksters).  But for some reason this blog gets up to three posts/emails a month from individuals or organisations in easy-going countries offering either to sell kidneys, or to arrange the whole transaction, from finding the donor to the complete transplant.

So this re-post seems appropriate.

Black Market
Source: http://www.financedegreecenter.com/black-market-body/.

Go there for more “pricing” details.  Greg

I’m a HemoDialysis Ghost

Now for something completely different, from googleMWgalaxy42.com, dated 29 June 2019.

I’m a Hemo Dialysis Ghost and I’m OK

A couple of weeks ago the bosses at the HDGhosts.com asked us to write a review of our job for their recruitment website (for money!).  Here’s my review.

I’m getting ready for my fifth session as a HD Ghost.  So far it’s been an OK  job.  Not exactly hard work, though it does take a day or two until you feel well again after each session.  But the pay is pretty good, and since it’s the first real job I’ve ever had, and I’m 28, and my dad has never had a job, I’ll stick at it for a while yet.

I wasn’t sure when I first saw the video calling for HD Ghosts flash up on my YouFacePage.  The money was the thing that got me in: pretty good for just an hour’s work – and more than most people get for a day or two mowing lawns or hitting the phones at the call centre.

There had to be a catch, so I hit the More Details button, and there was.  The girl who told me about the job said that I had to have blood tests to make sure I was compatible, a couple of days training and a small operation, called the Buzz, on my arm.  They would pay me for that too, and give me an allowance for the month I had to wait until I could start.  I also had to stick to a fairly simple diet two days before each session.

I wasn’t sure, but the money looked awfully good…

I hit the Review button and searched GalNet to see what people who were already HD Ghosts said.  Guys and girls all said it was for real, that the money as real and it was a regular job. They said the Buzz was no big deal, they were looked after pretty well, and the people running it were nice.

So I hit the Accept button.

I had the Buzz operation two days later, on my left arm.  I was awake the whole time, with just my arm asleep.  It didn’t hurt at all.  I felt a little strange though.  A little scared and maybe a bit upset with myself.  I don’t know exactly why I felt that way.

I could feel the Buzz as soon as the main bandage came off.  Just touching the spot where the cut was made – a small vibration, that pulsed on and off with my heartbeat.  It was cool and scary at the same time.  The doc who did it said it just meant that the vein was growing bigger, so it could take the needles.  Everyone in the job has the Buzz.

The next month went by fast.  I did pretty-well not much at first.  I had enough money from the Buzz and the allowance, so I ate and drank, hung out, surfed GalNet and watched videos.  In the last week I did my training at the unit, met my HD Body (Marnie, a small, dark haired woman about 60 years old) and thought about my first session as an HD Ghost.  I mostly stuck to my diet.

On the day, I arrived at the unit at 7am wearing my newly provided white tracksuit and joggers.  After a friendly greeting, I had a weighscan and it directed me to room 2.  There was Marnie, now in a pink tracksuit.  There were two reclining chairs in the room, one each side of a blood pump about the size and shape of a big shoebox.  Plastic tubing from the pump lay on each chair.  We both sat and waited.  Soon a nurse put two big needles into my arm, close to the Buzz (they hurt a bit, but not heaps), and connected the tubing.  Then she did the same for Marnie.  At the pump, she turned some dials and it started pumping.  Blood came from me, through the pump and into Marnie, while Marnie’s blood came the other way, from her into me.

As they explained it at training, Marnie’s blood is full of toxins and her body has too much water because her kidneys don’t work, so she has dialysis three times a week to clean her blood and remove the extra water.  The trouble is, dialysis doesn’t take out all the toxins, and over the years they build up and stuff up her joints and bones, so she needs her blood filtered by a real kidney at least once a week.  That’s my job: I’m her HD Ghost, or at least one of them.

Each week for about an hour, a fair bit of her blood and the crap that is in it goes into me and my good clean blood goes into her.  After the hour, I am disconnected from the pump and her second HD Ghost is connected, to get rid of more of her blood and give her more good blood.

It is a funny feeling.  Over the hour, I feel less and less well, weak and tired, because a lot of Marnie’s toxins are now in me.  I usually go home and have a sleep, and over the next few days I just let my kidneys do the work.  At first, I pee more than usual, and sometimes my poo changes color for a while, but gradually I feel better and things return to normal.  By the end of the week, I’m ready for the next session.

I don’t know about other people, but I feel OK about being a HD Ghost.  It’s simple, the bosses look after me, I get regular check-ups, lots of down time and best of all I’m in the money (at last!).  It may not suit everyone, but for me its money for old rope (or old blood!).

Dialysis and the Pill Cam

As discussed a month ago, the top-down and the bottom up searches for a gaping, bleeding, pus-filled wound as the reason for my fall in haemoglobin came up with a fat zero.  So, being nothing if not thorough, my Gastroenterologist ordered one more test to explore where no probe had gone before: the undiscovered country of my small intestine and the upper and lower reaches of my large intestine.

The Pill Cam pack

The Pill Cam pack

Naturally, he ordered the latest no-strings-attached technology – the Pill Cam, or Pill Camera to the uninitiated (are there any uninitiated anymore?).  It’s a simple and painless device that consists of a camera, a flashing light (it’s darker than black inside our guts) and a wireless transmitter, all packed into a capsule about the size of a jumbo jelly bean.  During its journey through me, the Pill sent a constant stream of pictures to a receiver unit strapped to my hip.

Ready to eat!

Ready to eat!

The receiver was a lot like the Sam Browne belt that British officers wore during WW1 and WW2: a thick belt around the waist with a thinner strap across the shoulder.  Rather than a sword, this time the thin strap held the antenna for the wireless signal draped across my chest; the thick strap held the receiver, a nifty unit about the size of a two iPhones taped together, with a screen showing the live feed from the camera.

There was more preparation than I expected, but no great challenge from a dialysis viewpoint.  My small bowel had to be empty so the camera could look at its walls, so no iron supplements five days before; no food except clear fluids after lunch the day before; nothing to eat or drink from 10pm, until I swallowed the pill.  Once swallowed, nothing for two hours after, and then clear fluids only for two hours after that.  By that time the pill would have moved from the small intestine to the large one, and on its journey to a wider world.

Initially, I was fixated on the screen.  I found that if I wriggled and moved my stomach in and out, I could move the camera and the view would change.  Though I really couldn’t interpret what I was seeing very well, and I saw no gaping, bleeding, pus-filled wounds (a good thing).

The Fantastic Voyage view

The Fantastic Voyage view

It reminded me of the movie Fantastic Voyage, where four men and a woman are reduced to microscopic size and sent in a miniaturized atomic sub through a dying man’s carotid artery to destroy a blood clot in his brain.  I remember it starred Raquel Welch (I forget who the guys were).  Isaac Asimov also did great things with the story when he wrote the novel from the movie.  He made sure it was as technically accurate as possible (the body bit, not the microscopic sub).  Somehow what I saw in the movie made a lot more sense to me that what I saw from my Pill Cam, but hey, that’s show biz.

Still, the small intestine was well worth a look.  Its where all the nutrients from the food we eat are absorbed and carried by our blood vessels to different organs, where they are used to build the proteins, etc needed by our body.  The non-nutritious stuff that remains undigested and unabsorbed passes into the large intestine (which contains several body bits most of us have heard of, including the colon, rectum, and anal canal).  Its extracts water and salt from the solid wastes, which then exit the building.  That area was also interesting to look at, though it was filled with stuff so I couldn’t see the walls.

I swallowed the Pill Cam at about 8:30am and returned to the doctor’s surgery at about 5pm to give back the receiver unit and have a quick check.  All was well. I handed over the unit, we had a quick look at the signal to confirm it had reached the bowel and I departed.

I had some vague plan about watching for the pill when it emerged into the light of day.  I looked a couple of times, but either it wasn’t there, or it was hiding.  Either way, I lost interest on the third day and stopped searching.  I don’t know what I would have done if I had found it.  Very limited market for used Pill Cams.  Replacing the battery could be tricky… Anyway, its gone now (or at least I hope is has).

So, all clear on the bleeding front; it must have been holding back the EPO for too long, as I suspected.  A lesson for next time.

Single needle dialysis! – ??

Joe (not his real name) has just been through what we all dread: an infected fistula, with complications.

Most of his fistula is in his upper arm, and over the last couple of weeks it became sore, larger and more difficult and painful to needle.  Joe started antibiotics, but unbeknown to him, it had also developed a clot that grew in size until the blood flow through it was minimal.  So, though he was on the machine for the same time each session, less blood being cleaned meant he was actually getting less and less dialysis and becoming less and less well.  Realising that it was not just because of the infection, he was referred to his kidney specialist for treatment.

The treatment for a fistula blockage can be complex and usually involves several steps:

  1. Joe goes to hospital where they to put in a permcath to replace the fistula.  A permcath is a flexible tube that is connected into a vein in his neck;  it has two inner tubes, one to take blood to the dialysis machine the other to return the blood to Joe
  2. The unit dialyses Joe via the permcath
  3. Once he is healthy enough, Joe returns to the hospital so that the vascular surgeon (the guy who created the fistula) fixes the problem by opening it up, cleaning out the blockage and closing it up again
  4. Joe then returns to the dialysis unit, where they continue using the permcath until his fistula is healed and ready to resume duty
  5. Joe then has the permcath removed.

However, Joe couldn’t get a permcath fitted immediately because his blood chemistry had fallen to a point made that made surgery unsafe (too much potassium, endangering his heart).  The only solution was for Joe to have more dialysis until his blood chemistry was OK to proceed.  Since not being able to dialyse properly was the problem in the first place, it sounds like Joe was caught in the crazy circle of Catch22.

But there was a solution: Joe would dialyse using the Single Needle Dialysis technique (What?  Sounds like a quiz question for medical geeks:  How can you dialyse with only one needle?)

Joe’s arm showing ‘Y’ tubing connected to arterial and venous lines

Joe’s arm showing ‘Y’ tubing connected to arterial and venous lines

The Single Needle Dialysis technique is a fiendishly clever system where only one needle is inserted into the fistula.  The needle is connected to a Y-shaped tube, with the tops of the ‘Y’ outlet connected to the arterial and venous dialysis lines respectively (see the picture of Joe’s arm).

Most of the clever stuff is then done by the Dialysis machine, which uses two pumps (rather than the usual single pump in traditional Two Needle Dialysis) and a holding chamber.  One pump is for the arterial line, the other for the venous line.  They operate in sequence over a cycle (a little like a car engine) this way (see the video):

  • In the first part of the cycle, the venous line is clamped shut and the arterial pump draws blood from the body, passes it through the dialyser cell and into the holding chamber.  It does this for 10 seconds
  • Then the arterial line is clamped shut and the venous pump draws the blood from the chamber and returns it to the body at a slightly faster pump speed, for a little under 10 seconds  (the faster the blood is returned, the less recirculation and the sooner a new arterial phase can begin)

Then the cycle starts again.

Single Needle Dialysis works so well that for many people (especially small people and children) recirculation is less than 10 per cent (the same as traditional dialysis) and there is minimal reduction in dialysis efficiency.  For this reason it is often used for children when they only need dialysis short term.  It reduces the level of invasion into their bodies, as well as the mental trauma.

Not many units around here can do Single Needle Dialysis, but our unit can (it is pretty simple using the new Gambro Artis machines), so Chris arranged for Joe to move to our unit for the treatment (hence the photo and video!).

After about two weeks Joe’s potassium level fell to where it was safe to have the permcath put in and his fistula surgery.  Now, normal dialysis via the permcath is going well and he is slowly recovering his health.  Once the fistula has healed, all will be back to normal.  Not a pleasant experience, but Joe is an upbeat guy the and worst is over.

Single Needle Dialysis is interesting.  It was first attempted 50 years ago, in Holland, using a single pump and a time-activated switch opening and closing a double clamp.  It was complex and difficult to set up and its use was limited to highly trained staff during emergencies.  Then in 1980, a couple of Belgian doctors developed a double pump system, the precursor of the one used for Joe.

In his 2013 paper, Dr Guy Rostoker, MD, PhD wrote that tests using the double pump Single Needle system showed “…that dialysis efficiency was at least as good as with conventional double-needle (DN) hemodialysis.   However Single Needle dialysis has failed to gain popularity, except in Belgium, the Netherlands, Luxembourg and recently Asia, because many nephrologists and dialysis nurses are reluctant to use it, even in cases of difficult fistula access, for fear of incidents or under dialysis.”

With the new generation dialysis machines like the Artis, the potential for Single Needle dialysis incidents is falling rapidly.  However, the potential for under dialysis is still there, since during each dialysis session, the blood is being filtered for only a little more than half the session time, because the arterial line is clamped each time the venous line returns our blood to us.  This implies that to move to a single needle, we would need either longer sessions or a session every day.

So I won’t be pushing to move to Single Needle dialysis any time soon, but I’m very glad to know it exists as a backup during emergencies.  And I think Joe is too.