My day

My teaching topic for the trip has been chronic kidney disease, end stage renal disease and renal replacement therapy in India (likely not a surprise to many of you) and man, today was my day. While Sapna and Christie were off at KIMS with Neena Auntie learning about “the sugars” and women’s health respectively, the rest of us were back at NIMS. Luis, Peter and Shobha had their sight set on a day of microbiology while I would be spending the day with the nephrology department. We met the department head Dr. Dakshinamurty when we arrived; he may rival Dr. Wish for the most smiley nephrologist ever. We sat in his office while I fired questions at him; it bordered on pressured speech, but I really wanted to compare what I had learned in my readings to what was really going on. Dr. Dakshinamurty did confirm that “crash landings”, patients who show up with ESRD secondary to god knows what was still quite common. A lot of the articles that I read while preparing my talk painted a rather dreary picture of renal replacement therapy options in India so I was encouraged when we learned that they did in fact have maintenance hemodialysis available. We discussed access issues and line infections (it seems there is ID everywhere!). Peritoneal dialysis is really much much more common here than hemodialysis here which is a very sharp contrast to the U.S.. The benefit to PD is that people can still work, only need to come into clinic once/month and they don’t take up the very limited number of hemo spots that are available. Doctor visits are a big deal especially if you are a patient living 800 km away in a rural area making the trek to NIMS. Get this, no perma caths only temp lines and fistulas. The fistulas are used after 4-8 weeks. I was unable to figure out what the heck results in the 6 month delay at home.

Their hemodialysis unit has 14 stations with 5 shifts per/day, yes, that is basically 24 hours a day, and yes, some outpatients do come for HD in the middle of the night. Dr. D’s only comment about that was “ya, they hate us sometimes” which he of course said with a smile. The unit itself was really nice and could easily have been found in Cleveland. The exceptions were it was quiet (a pleasant change) and we had to take off our shoes (chappels again), this gave us the opportunity to witness Peter’s pink socks. Later in the morning while team ID was learning about fungus and TB I went on to the outpatient clinic. Dr. Dakshinamurty dropped me off with some of his junior faculty, once they figured out what the heck I was doing there and that I did have some vague knowledge about nephrology they seemed to warm up to me and really tried to explain to me what was going on while they saw a bazillion patients. The clinic set up: a room the size of the DMC, one table, on exam bed, 2 stools, 3 chairs, 1 manual sphygmomanometer and 1 bottle of hand sanitizer (which I am pretty sure was only used by me). I am not kidding; at one time there were 14 people in the room, again making me a little more grateful about my own continuity clinic. We saw one poor young gentleman who was accompanied by his father who looked quite old, and a cousin who looked like he had things somewhat together, who had relapsing MPGN. He was having nose bleeds so his nose was packed, and he looked quite ill and in desperate need of dialysis. Turns out his Cr was 16 and he was uremic as all get out. Plan: intermittent (or temporizing) PD…hmm, well that’s different.

In the afternoon we “rounded”. I use quotes as rounds consisted of the intern (who by the way, looked just as flustered as I felt as an intern) presenting a couple of new patients to the attending at the nurse station while nurses kept handing her labs written on scraps of paper, and patients coming out of their rooms (not in any sort of hospital attire) sometimes with their families asking questions, all at the same the attending was trying to review all the notes that the flustered intern had written that day. Try to picture the secretary’s desk on tower 3 with about 25 people hovering around it and the attending and me sitting in a mountain of charts behind the desk. So, I was encouraged, at least here at NIMS and seems like in Hyderabad in general, l there are treatment options available for patients. There were some discouraging things that were confirmed. The attrition rate from HD is 50% in the first 3 months, if you don’t have a family member to donate a kidney you’re pretty much out of luck (at least at NIMS), there is still no organ procurement program so cadaveric kidneys are not an option, if you do get a transplant the risk of TB or CMV is overwhelmingly high. There are at least options; this is good. What a great day!