Tag Archives: End stage renal failure

Hopeful signs

I began blogging with $100 Dialysis – the vision.  The technical challenge is to develop cheap and perhaps novel  means to filter the blood of nitrogenous waste products.  Below is an example of three approaches, one is a more user-friendly way to use existing technology, another utilizes nanotech, and the third although not aimed at dialysis is an example of new thinking.

Peritoneal dialysis is a form of dialysis whereby the abdomen lining (called the peritoneum) within the body is used to filter the blood.  Simply, the dialysis fluid is pumped into the cavity formed by this natural filter.  Once it has absorbed some of the waste from the blood filtered through the peritoneum it is pumped back out again.  Not everyone is eligible for periotoneal dialysis, but for those who are the concept of a portable dialysis is very welcome.  Progress is definitely being made, have a look here.

Also developing wearable dialysis, but this time using an external device to remove the waste is the Dutch company Nanodialysis.   Rather than simply filter the unwanted particles through small pores they get them to adhere to a surface, a process called adsorption.  From there they get them to decompose to nitrogen, hydrogen, and carbon dioxide.  The company claims that not only will this be cheaper (yeah) and more convenient it will also increase life expectancy 10 to 15 years over standard hemodialysis! This is quite an incredible claim and as they are yet to complete animal trials is premature.  Nevertheless, it is definitely a space worth watching.

Some clever people in MIT and the National University of Singapore have demonstrated that they can remove bacteria from blood making use of a concept from normal biological process called margination in which leukocytes (white blood cells) adhere to blood vessel walls (see here).   Whilst the nitrogenous waste products are much smaller, using fluid flow technology similar to what MIT and NUS have demonstrated may be another way forward.

Getting the users perspective

I can’t possibly expect to be able to comment on what it is like to be on dialysis – I’ve only observed the process.  To try and understand more I have begun to search out some blogs by those on dialysis.  Here are two:

The Facts on The big D. is a blog post by Ellie.  Ellie is a young woman (the same age as my wife) in New York in need of a transplant.  Ellie comes across as a straight shooter.  She’ll tell us when it stinks and she’ll count her blessing aloud.  Sitting in a dialysis centre is the last place she wants to be. Thanks for the honesty Ellie.

D(ialysis) Day   Joe has just begun dialysis for the third time in his life.  This is his first blog post from the chair. He first began dialysis at 15, underwent a transplant from his mother which lasted a couple of years, went back on dialysis for 4 years, underwent a second transplant which lasted 10 years and has now returned to dialysis.  What strikes me is just how long Joe needed to wait for that second transplant.  The same is here in New Zealand.  Folks, it is really very very important that you tell your family if you are prepared to donate your organs – Do not rely on there being something on your driver’s license, this has no legal effect and is often ignored by grieving relatives.  Have that conversation – today.

New visions:

No one will need to wait more than 6 months for a transplant

$100 dialysis will be portable so most will not need to spend 5 hours, 3 days a week, sitting around with tubes in them.

By the way, both these people have End Stage Renal Disease following Chronic Kidney Disease (CKD). Joe’s form of CKD appears to be from a heredity disease.  Ellie does not say.  Neither are overweight or appear to have anything other than a normal life.  CKD affects about 13% of the population (many do not know).  Do not be complacent. If in doubt, get your kidney’s checked.

I am a pee scientist

I’m often asked “What do you do?”   In order to avoid those glazed over looks, and in honor of World Kidney Day, I present to you Dr John’s five minute intro to his study of Acute Kidney Injury (AKI).

What is Acute Kidney Injury and why does it matter?

AKI is the very rapid loss of kidney function.   As the kidney is a big filter designed to clean your blood this means you won’t be able to get rid of the nasties and that ain’t good news (see this previous post for some of the other great things kidneys do).

AKI is not about getting punched in the kidneys.  Lots of things can cause the kidney to fail.  If the blood ceases to run to the kidneys for a short time (e.g. during a heart attack) then no oxygen gets delivered to them.  All cells need oxygen, so lack of it means curtains for some cells.  Other causes are when parts of the kidney get poisoned.  Given that the kidney concentrates the nasties in the blood, it is the first place to get hit by poisons.

About one third of people entering the intensive care have or get AKI.  That’s heaps annually (heaps is a technical term used by scientist to mean “more than we can get funding to count”).  If you have AKI you are more likely to die, need dialysis, get Chronic Kidney Disease and you will spend more time in hospital.  So, it’s kinda important (bean counters – note: it costs billions annually).  These things are all summarised in my latest minfographic below.

Acute Kidney Injury

What do I study?

Most of my work is about how to figure out people have AKI.  The problem is that for the last 70 years or so AKI has been able to be detected only a day or three after it has occurred!  This is too late to do much about it (dialysis only supports the kidney, not cures).  Think about this analogy (remember the kidney is a big filter):  Imagine you a running water in the sink. It goes down the plughole OK.  You are defrosting some meat (the old fashioned way), so you wander away and leave the water running.  Unknown to you, there is some hair stuck down the drain (yuk), which gets shifted around a bit until it largely blocks the drain.  The inevitable happens and the drain and then sink fill up and, of course, overflow.  What my colleagues and I do is to look at the other end of the drain for any tell-tale signs that there is something amiss (yep, we look in the urine.  I guess that makes us pee scientists).   That something amiss is a very small molecule which only the clever scientists in the labs can extract from the urine and quantify.  For the past decade or so there have been many such small molecules discovered (new techniques and technology have helped) which are potential early indicators of AKI.  We call these “biomarkers.”  My job is to analyze the numbers the lab people give me.  I try and see if and when particular biomarkers are in greater concentrations in the urine and try and match this to the clinical outcomes of patients.  The hope is that we will learn enough about these biomarkers to know when and how to use them in clinical practice.  If we can detect AKI when it first occurs, then we should be able to develop new treatments and finally be able to do something about the death rates and other poor outcomes.

A brave beginning

Food depravation, occupation by fascist overlords, and decades before the invention of PCs and the blog are hardly conducive conditions for research, let alone major breakthroughs.  One man thought not.  Willem J Kolff, a physician in Kampden hospital in the Netherlands was perturbed by not being able to do anything for people who went into renal failure.  He knew, if he could just somehow get rid of the toxins for long enough for their kidney’s to recover he may save lives.  In 1943 he built and trailed a dialysis machine(1); – essentially a long tube (30 metres!) of cellophane through which the blood was pumped and what looks like a large washing machine where the urea waste products filtered out of the blood into a rinsing fluid (mainly tap water!).  One important innovation was the use of heparin to prevent blood clotting in the needles.

Miss S with what would now be called End Stage Renal Failure was the first patient.  At just 29 she was dying.   We know nothing more about her, but I salute her and her family for their contribution to science and, ultimately, to the saving of lives.  Miss S would undergo several dialysis sessions which proved that waste products could be removed artificially.  They were successful in preventing further accumulation of waste in her blood for 26 days. Unfortunately, she was terminally ill and died shortly afterwards.  As it turned out the first 15 patients all died.  The sixteenth, though, was the first to undergo dialysis and to live.  She had the acute form of renal failure (now called Acute Kidney Injury, or AKI).  AKI is my area of research and dialysis remains, after nearly 70 years, the only therapy available.

The lessons of the first dialysis machine don’t end at Willem Kolff’s persistence.  It is a wonderful example of cross-fertalisation of ideas.  The second author on the original paper was “H Th J Berk”, director of the Kampden Enamel works.  Berk was responsible for the idea of a horizontal “washing machine.”  Apparently the local Ford dealer provided the ideal pump – from a Model T! The nursing staff and technicians were indispensable.  One, Jan van Noordwijk, at least, found the job kept him out of the hands of the occupiers.

The Kolff Dialysis Machine immortalised in a dutch stamp

1.         Kolff WJ, Berk HT, Welle ter M, van der LEY AJ, van Dijk EC, van Noordwijk J. The artificial kidney: a dialyser with a great area. Acta Medica Scandinavia, vol. 8, p121ff, 1944 .

Kidneys are Kool with a capital K

Minfo: The Kool Kidney

The Kool Kidney

The kidney is still very much a black box to me.  Hence, the box in this mini-infographic (a “minfo”) describing some of the cool stuff our kidneys do.  As you can tell, it is not just a brilliant filter getting rid of waste products but so much more.  Dialysis (with the aid of Nephrologists’ potions) has got to do most of this stuff too.

$100 Dialysis – the vision

$100 dialysis will do for health what the $100 computer did for education.

I have no expertise in dialysis, I’ve only published one paper and a letter that address it directly. What I know is that there are millions the world over with kidney failure whose only hope is transplant or dialysis.  What I see is that dialysis is very expensive – machines and treatments cost tens of thousands of dollars, and that it is only those of us in the so called developed world who have access to them.  This was highlighted by the story of a tongan woman who had come to New Zealand for an eye op (funded from Tonga), who was subsequently found to need life saving dialysis. She was not entitled to it in New Zealand.  There were no dialysis machines in Tonga.  Without a machine she would die.  These people are our neighbours in the pacific, asia, and africa.  Dialysis is conceptually simple, it is a way of filtering waste from the blood. Practically so much waste needs to be filtered, very precisely, whilst maintaining the correct proportions of water and salts, that dialysis is also a substantial challenge.  Extraordinary progress in materials science and the ability to manufacture simple pumps using desktop 3D printers give me hope that $100 Dialysis will be a reality.  Social networking and the internet provide the means by which a vision may be propagated and progressed.  My vision is for a dialysis machine that costs just $100 to manufacture and $100 a year to run, a machine that will save a million lives. I do not see myself as leader of a project, there will need to be dozens of projects led by people far more skilled than I – nephrologists, engineers, nanotechnologists, intellectual property lawyers and the like, simply I hope to light a fire.