Monthly Archives: April 2013

The Face of Kidney Attack Part III

He didn’t die, quite.  But later thought he may well of.  Steve Gurney’s episode of Acute Kidney Injury (see Part II) didn’t finish him after he was discharged from his third hospital (one each in Malaysia, Singapore and New Zealand) – 4 weeks after the event. While media outlets clamoured to hear the story of this amazing athlete’s brush with death, he had a $92,000 medical bill and was so weak he could barely walk.  He couldn’t return to his own home because it was on a hill and he couldn’t make it up the steep track.

Steve did all the right things.  He began exercising by walking to the letterbox and gradually increased it from there.  He lived on fruit, vegetables, nuts, legumes and meat – nothing pre-processed.  While his body began to be restored, it was the mental anguish – so often hidden from others – that really shook him up.  This from his book “Lucky Legs”:

“I’d gone from top dog in my sport to lowly turtle.  My aim to compete as a mountain biker in the Olympics had disappeared down a mud puddle.  I’d lost 15 kilograms, mostly muscle, there was a possibility of permanent kidney damage and my career as a pro athlete was in question.  My fuzzy mind reasoned that the ‘mat of my expertise’ had been jerked from under my feet now that I had been robbed of my fitness, too.  It was like the bottom had fallen out of my world and I was falling, out of control, with nothing to ground me.  ….The depression went on for six months … death seemed like a realistic solution  … But there was a tiny spark that said, ‘Don’t jump. … hang in there … like a long endurance race …”

Steve’s story of recovery is one of endurance and it is one of reaching out for help.  Some of the help Steve got was from practices which scientifically speaking don’t have a leg to stand on, yet the process of reaching out and talking with people concerned and willing to help was, and is to anyone in similar situations, so very important.  Steve didn’t go for homeopathy, but I’ve been told be someone who acknowledges it is a load of nonsense that they think it valuable to have in the community because of the power of the placebo affect.  She may well be right (needs a study).

Steve wins again

Steve wins again

The story continues and is one of anguish and triumph.  The two time winner of the Coast to Coast returned to it three years after his brush with death and won again, and then won another six years in a row.  Steve’s experiences had strengthened him mentally and focussed him on the things that mattered most to him.  As he said, “Contracting leptospirosis … was a good thing.”

There is an ancient Hebrew concept of health called “shalom.”  Often translated simply as “peace” it is actually much broader than that.  Unlike the common idea of health being merely an absence of illness, it encompasses the notion of being in right relationships – spiritually, physically, environmentally, and communally.  Those of us working in medical science do well to be reminded of shalom.

Cooking up a new kidney

The Boston Kidney Recipe

  1. Take an unwanted kidney.
  2. Disconnect from plumbing.
  3. Wash away cells (use plenty of detergent).
  4. Take resultant scaffold and reseed with a few cells obtained from someone needing the kidney.
  5. Place in bioreactor and “cook” for 3 to 5d (or until done)
  6. Place regenerated kidneys into the transplant recipient and connect to plumbing.
  7. Pee.

In Nature Medicine today Massachusetts General Hospital based researchers have announced the successful removal of an unwanted kidney from one rat, the removal of cells from that kidney, regeneration with stem cells from another rat, transplantation into that animal and the observation of  urine production*.  A  small step for a rat, a giant leap for anyone waiting for a transplant.  Why is this so important?  As the authors’ state:

“A bioengineered kidney derived from patient-derived cells and regenerated ‘on demand’ for transplantation could provide an alternative treatment for patients suffering from renal failure.”

While this study is “proof of context”, it is a beautiful proof and one which should bring hope to millions. There are many more people with End Stage Renal Disease than kidneys available for transplant.  Some donated kidneys currently considered not good for transplant may become viable in the future if the cells are stripped off and the patient’s own stem cells can be used to grow a new kidney over the scaffold of the old one.  By using the patient’s own cells the immune response may be reduced.  This will mean less dependence of immunosuppressant drugs and therefore fewer side effects, including  cancer, and less transplant rejection. This is the vision and one that can not come soon enough.  Have a look at the video and if you want to get into details, check out the paper* .

*Regeneration and experimental orthotopic transplantation of a bioengineered kidney. Jeremy J Song, Jacques P Guyette, Sarah E Gilpin, Gabriel Gonzalez, Joseph P Vacanti & Harald C Ott1. Nature Medicine. Advance Publication Online. http://dx.doi.org/10.1038/nm.3154

Spin Doctors go to work on PBRF

University of Taihape:  Doctor Doctor I’ve got a 1.7 on my PBRF

Doctor Spin: Never mind son, your Gumbootlogy results make you the healthiest tertiary education provider in the country.  Let’s talk about that, shall we?

Scoop.co.nz has all the spin from the universities and polytechnics this morning as they try and give the impression that they are the best.  At times like this I am ashamed to be an academic.  One of the worst of sins is to cherry pick data to make your self look good.  We are used to this from certain sectors of society, but we should expect better from our educational institutions. Unfortunately, the culture of self promotion above all else has taken hold in our hallowed halls.

For those who are unaware of what I am talking about, around 18 months or so ago all academics in the country had to put forward a “portfolio” to demonstrate just how research active they were.  This is the Performance Based Research Fund (PBRF) exercise held every 6 or so years. Groups of academics under government oversight then went about scoring each academic in a process that has taken 15 months.  The result is that every academic has been given a grade A , B, C or not research active.  The grades of academics in each institution are then thrown into four different formula – each has additional information about different aspects of the institution (eg numbers of postgrad students).  Four numbers result.  This gives Doctor Spin plenty to play with. The numbers are also what are used to allocate hundreds of millions of dollars of research funds – here in lies the importance of PBRF to the institutions. A number is also provided for each of the self selected academic units that the institutions provided to the Tertiary Eduction Commission.  If they don’t score well in any of the four overall grades (comparative to other institutions their own size), then they can pick a favourable number from one of their academic units and talk about that. More grist for the spin mill.

Academics are notoriously competitive – obviously a good trait when it drives them to produce better and better research. I certainly have some of that streak in me. However, it is not  helpful when it results in attempting to pull the wool over the eyes of the public as happened yesterday.  The PBRF is a complex system designed to find a way to allocate research funds and hopefully improve research quality.  Academics will argue until the cows come home if it does this fairly. It certainly is a very expensive exercise. It certainly focusses institutions on the importance of research, which is a good thing.  Remember, the teaching in our universities (not polytechnics) is required by law to derive from research.  However, as a small country where the combined size of all our universities is only that of some of the larger overseas universities I wonder if such a inter – institution competitive model is the best for the country?  Perhaps the story should be an evaluation of cost benefits of the exercise. Is this the best method of allocating funds? Such a story should also consider if the competition is enhancing or detracting from the quality of research – after all in almost any field experts are spread across institutions.  Collegiality is a major driver of good research – does PBRF hinder that?

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If you want to check out the PBRF results in detail your self you can download a PDF from the Tertiary Education Commission here.

Disclaimer:  If you think my skepticism about PBRF is sour grapes because of a “poor” grade, then you’d be wrong.

The Face of Kidney Attack Part II

This guy crawls through bat dung for fun.  He also runs incredibly long distances and then cycles or kayaks more.  If you’ve not guessed already, our Face of Kidney Attack is multisport and adventure racer Sir Steve Gurney (He’s not really “Sir” but anyone who does what he does deserves some sort of honorific and all other honorifics he’s been called are not printable).

For those of you who are not New Zealanders or who were asleep the last couple of decades, Steve made his name in the incredible Coast-to-Coast race which involves cycling, kayaking and mountain running from the West to East coast of the South Island of New Zealand through the Southern Alps.  Arduous does not begin to describe this race – that Steve does it in under 12 hours and has won the race 9 times are mere numbers which can not possibly describe the punishment he put his body through and the mental toughness he developed.  However, in 1990 a Kidney Attack almost halted the adventure and very nearly killed Steve.

In the 90s Raid Gauloises were the toughest races of them all. Now known as Adventure races they involve hiking, mountain biking, canoeing, and scrabbling across the toughest terrain for days on end.  The first race in 1989 had been the NZ Grand Traverse. The lure of such a race in Borneo with Christchurch adventure race guru John Howard was too much for Steve in 1994 – a prize of $55,000 was a pretty good incentive as well.  John and Steve arrived in Borneo where John had arranged for three Malaysian athletes to join them (all adventure race novices).  The race was expected to take 10 days.  The race was famous for four things, first John organised the team to take minimal equipment and supplies – previously heavily laden backpacks had been the order of the days, second John and Steve became the first athletes to win two such races, third they did the race in 5 days not the expected 10, and fourth, is what happened to Steve.

Early in the race Steve suffered heat stroke having mountain biked up a steep hill (just to show he could, the others walked their bikes!).  He vomited and was quite sick.  Water was in short supply (remember they took minimum supplies) and it was very humid “jungle” weather.   This was the first “hit” his kidneys took – dehydration is not good.  One of the primary roles of the kidney is to regulate body water so as to keep the right balance between water and salts.  This process was obviously under stress as Steve lost water through vomiting and sweat and may not have replaced enough.

Later in the race the racers had to crawl through the Mulu caves.  This was an 8 hour trek that involved getting down on hands and knees and squeezing through gaps in the rock.  The caves were home to bats and the floor was covered in bat dung.  By the time they finished the trek Steve, wearing shorts at the time, was covered in scratches.  It is likely that here he picked up the bacteria  that causes leptospirosis from the bat dung. “Hit” number two. This is an infectious bacterial disease which grows great in neutral or acidic pH as found in renal tissue.  The body’s response is inflammation, hypotension (low blood pressure), decrease blood flow to the kidneys (low oxygen to the tissue, therefore death to cells), and decrease in renal filtration.  There can also be direct invasion of renal cells causing necrosis. The severity of disease determines severity of the kidney attack.

Hospital2 Hospital3While the Kidney Attack began during the race, it was not until a few days later Steve got real sick.  As the team waited for the other teams to finish, he began to feel unwell – fever and headaches.  He was determined to enjoy the post race party on Saturday 29th October, so took a couple of aspirin (!).  He made it to the party, but only just. By Sunday afternoon his friends were in emergency mode organising for him to get on a flight to reach the nearest hospital in Kuching.  Steve quite literally crawled off the plane and waited for an ambulance to take him to hospital.  It was a small hospital and after 5 days, most of it sedated, without improvement, Steve was evacuated to Mt Sinai Hospital in Singapore.  There leptospirosis was diagnosed (it’s difficult to diagnose because of similarity of symptoms with other diseases of the tropics like typhus, dengue fever, Hanta virus infection).  Steve spent 10 days in ICU undergoing regular dialysis to support his kidneys and nearly all the time under sedation.  He was very lucky to survive.  His story of leaving Singapore, a $91,000 medical bill*, and continued hospitalisation in Christchurch with further dialysis is a harrowing one and can be found in his autobiography, “Lucky Legs.”

In the next instalment of the Face of Kidney Attack I will look at life after Kidney Attack.

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*Steve had insurance provided by the race organisers, but it was woefully inadequate.  Only with the support of friends, family, and a public appeal did he avoid loosing his house.  I’ve considerable experience in assessing medical and travel insurances (long story why).  Never travel without at least $500,000 medical cover and preferably unlimited!  I choose myself to use Uni-Care outbound (http://www.uni-care.org)

The Face of Kidney Attack

The Face of Acute Kidney Injury.  (Published with permission).

The Face of Acute Kidney Injury. (Published with permission).

It ain’t pretty, it’s Acute Kidney Injury.  This case was probably brought on by leptospirosis.  This is the face of a well known New Zealander.  Do you recognise him?  He’s kindly lent his name to my research on AKI.  I will reveal that name in future posts as I tell his remarkable story.