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Saturday, 11 December 2010 23:34

Can a blocked fistula cause chest pain?

Written by Greg Collette
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I had some interesting comments and email this week, well worth sharing.  The first is from Balasaravanan:

Can a blocked fistula cause chest pain?

my mom is having the av fistula in the hand for 8 months since we have not used before 8 months due to some reasons that the creatinine was not so high it was 3 so we didn’t use that now the thing is that now we are going for a dialysis in the neck we asked to put in the hand the doctors said that the fistula is not working so leave it no problem will come some doctors  that heart attack will come due to the fistula just leaving in the hand now my mom is having a pain in the chest when my mom gets to sleep and wakes up…….she gets the pain…….! so tell me is that true? reply to me………..

As I understand it, your mom had a fistula put in 8 months ago but it was never used. Now that she needs dialysis, it is not working (maybe blocked?). So they are using some kind of line inserted into her neck.  This is a normal routine for people starting dialysis without a working fistula.  It does not usually represent a danger for people with heart problems.  I know several people who have quite severe heart conditions who have been dialysing for many years.

In fact, dialysis is a key treatment: kidney failure results in fluid build up, since the fluid cannot be removed.  This excess fluid puts great pressure on the heart, and dialysis acts to relieve this pressure by removing the fluid.

With regard to the blocked fistula causing heart problems, it is unlikely.  Fistulas can become blocked when they are not in use, especially if you have some residual kidney function.  For example, many people who have transplants find that their fistula blocks up.  Rather than being soft and spongy, it becomes quite hard, with clotted blood.

If it needs to be unblocked (like your mom’s), there are typically two ways to do it:

  1. If there are small clots, they can be softened and eliminated by inserting a balloon into the blood vessel
  2. If the clot(s) is large, they bring out the big guns: either a specially designed device called a Percutaneous Thrombolytic Device that uses small wires to gently break up the clot, or an Angiojet, which sprays a saline solution directly at the blood clot breaking it up, and vacuuming out the bits.

Both procedures are done in radiology, typically via ultrasound, while you are awake, with a local anaesthetic.  The balloon or other devices are inserted into the fistula via a needle not much thicker than a dialysis needle.  I have had the balloon treatment.  It is not painful, but it feels strange, with all that pumping and prodding going on while you watch.  I must admit that I was nervous of the balloon bursting the fistula wall as the pressure grew, but they were very careful and all was well.

With regard to your mom’s chest pain, I don’t know enough to say anything but the most general comments.  Heart pain is not usually related to dialysis or a blocked fistula, but you should ask your mom’s cardiologist as soon as you can.

My BigD Experience, by David in Malaysia

David dropped me an email through the week, and I am delighted to reproduce it here.  His experience has been like most people once they decide to get started – health giving and not the drama they expected.

He also gives us the address of his dialysis unit, recommended for travellers to Malaysia.  Thanks David, it was great to hear from you.

Hi Greg,

Came across your blog recently from a search on Google. I’ve recently started dialysis and just turned 41 years old. Like you said, kidneys have let us down. Initially I was very depressed knowing that I have to depend on the “Big D” :) to live, but after the first few times and my health had improved a great deal, I was glad and thankful that I started dialysis. It was no fun though and I don’t like the needles. I keep telling my doc that I still have hope that God can do a miracle on my kidneys, he just smiled.

Anyway, I thought I’d like to share with you that if you are planning to visit Malaysia, Kuala Lumpur in particular, you can visit the place that I am doing my dialysis, it is a cool place :) The nurses are friendly and funny, joking with the patients, and the Medical Centre is modern and well equipped, and the costs are not expensive.

Here are the details:

It is great of you to start your blog site, very encouraging to me.

Take care. Warm regards,


More answers to questions next post.


... http://bigdandme.wordpress.com/2010/12/12/can-a-blocked-fistula-cause-chest-pain/

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Saturday, 11 December 2010 08:36

Figuring out my dry weight

Written by Kamal Shah
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Yesterday, as I was on my way from Grene to NephroPlus, I felt a familiar sensation. My head suddenly felt cold and I could feel tiny droplets of sweat on my head. I felt slightly giddy and weak. It wasn't very bad. But I knew it could get worse if I didn't do anything about it.

I asked my driver to go to a snack center nearby. I rushed in and ordered an Idli. It came pretty fast. I quickly ate the Idli and could immediately feel better. Not totally normal, but definitely better.

I then got dropped at NephroPlus and sent my driver to bring me a soft drink. I then sat down in a chair, set the air-conditioner to a comfortable temperature and took a few deep breaths.

Slowly, I regained composure and felt normal.

What was this? It could have been one of two things - hypoglycemia or hypotension. I cannot say for sure which.

Hypoglycemia is a condition where the sugars in the blood go down suddenly and you have exactly these symptoms. Diabetics experience this sometimes if they have taken too much of the sugar-lowering drugs.

Hypotension, on the other hand, is something which people lucky enough to be on dialysis sometimes have. Let's say you have been eating well and eating healthy food like sweets and fried food. Your weight increases. Now, when you go for your next dialysis session, this can be misconstrued as fluid weight and the good folks (aren't they all?) at the dialysis unit try to pull it off. Now, this results in the amount of water in the blood actually going below what it should be. This causes thickening of the blood and reduces its pressure.

This can result in the symptoms I had, as well.

So, knowing your 'dry weight' is key. I knew my dry weight had gone up a little but I was in a little bit of denial. I somehow wanted to convince myself that my daily swim is helping me reduce weight. What I did not realize is that my regular cola binges are not helping matters. Hence, the hypotension.

But then, if it was truly hypotension, maybe, I shouldn't have felt better with the Idli. But then, I did have cramps in the last hour of my dialysis and I also had a little bit of a cramp in my hand that afternoon.

So, I am really not sure what it was. All I can say is I really enjoyed the full bottle of Thums Up that morning!

... http://www.kamaldshah.com/2010/12/figuring-out-my-dry-weight.html

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Tuesday, 07 December 2010 21:37

The evolution of the humble khakhra

Written by Kamal Shah
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The khakhra is a Gujarati snack. It is probably one of the simplest foods ever. It is basically a chapati that is roasted as crisp as a papad. It is typically made of wheat flour, a little salt and a little oil. A dough is made with these ingredients and then made very similar to a chapati. This is then roasted in a tava by applying pressure with a wooden utensil. Ghee can also be used while roasting the khakhra to make it a little tastier.

The most a good cook would experiment with the khakhra would be by adding a little jeera to the dough to add a touch of flavor to the otherwise bland recipe. A few years back, however, people started experimenting a lot with the khakhra. They started making masala khakhras - basically adding turmeric, chilli and other masalas to make the khakhra quite tasty.

Most people would have the khakhra for breakfast with milk, tea or curd. Some people would also have it as a tea time snack, sometimes with a little pickle. But due to the plain nature of the snack, it would always need an accompaniment like curd or tea. With the masala-isation, however, the khakhra took on an independent identity and people started relishing masala khakhras plain.

Recently, people have started taking experiments with the humble khakhra to another level. You now have a large variety of khakhras. The mangroli khakhra, tomato khakhra, bajra khakhra, bajri-methi to even pani puri and pav bhaji khakhras! You also get a dosa khakhra which actually is dosa batter made into a khakhra!

As people started becoming more and more watchful about what they ate and how healthy it was, the khakhra adopted too. So, you now had seven-grain khakhras and khakhras without ghee!

There are entire stores in Mumbai and Ahmedabad that are devoted to khakhras and allied items.

Take a look at this picture of a variety that I recently saw:


The khakhra is shaped like a mobile phone, complete with a keypad on the packing and is called SMS khakhra! It is ideal for people like me for whom the khakhra forms a great 5 p.m. snack at work. Easy to carry as well. The interesting thing about this khakhra is it is labeled 'whole wheat bran diet and health' but at the bottom says 'Ghee sada'! Pray, how can a khakhra that has ghee be branded as a 'diet' khakhra??

... http://www.kamaldshah.com/2010/12/evolution-of-humble-khakhra.html

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Monday, 06 December 2010 18:57

The Dialysis Community

Written by Steve Bone
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Hi all, my first blog post here on Global Dialysis. I have my own blog elsewhere, and since starting that, and now being involved with this one, it strikes me that when you survey the totality of content, groups, blogs and other great items on the web, there is a huge community with a vast array of voices all pulling in one general direction to support the dialysis community, transplant community and others. If we take this further, it suggests that the coming together of a number of these communities and voices into one cohesive group would become (collectively) more powerful, and the volume of the voices would be ramped up to considerably more than the sound emanating from the individuals. There are many good causes on the go most of thr time in our area of interest, but how much more effective would we be if we were able to mobilise a large and effective group. ··Let me cite one example. The law on organ donation. Check out the No10 web site and you will see a large number of (failed) petitions each attracting a relatively small number of signatories. Work together on this type of subject, develop a rational argument and mobilise the enlarged group to have the impact, and draw REAL attention to issue by the benefits of scale. Not saying this should be the primary argument, but hopefully you get my 'drift' on the benefits of working together. Happy Monday evening all. Steve

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Sunday, 05 December 2010 08:06

New Peterborough Dialysis Unit

Written by Steve Bone
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Well, we are finally dialysing at the new Peterborough unit. First class facility and a huge improvement on the old one. A few niggles though. It’s blooming cold! Even the nurses are wandering around with blankets over their shoulders to keep warm. For the patients who will all feel the cold more for their 4 hours stint, it has become very uncomfortable. The building managers have been around with their thermometers and judged things to be fine – but they have not consulted the nursing staff or the patients. Also, they’ve not issued barrier cards, so patients have to ask nurses to sort out their car parking on each visit – not their role really.

Updated - we've got access cards to the car park - with thanks - shame the car park for the unit is now so full there are no spaces for the dialysis patients. Down to the building managers to sort this out - it can't be that difficult! Can it......? Oh, and it's still cold on the unit. Lovely and warm around the rest of the hospital so this does suggest some 'climate' adjustment is required for our little corner!

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... http://mydialysis.co.uk/blog/2010/12/05/new-peterborough-dialysis-unit/

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Saturday, 04 December 2010 03:39

Does this ad inspire any confidence?

Written by Kamal Shah
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Recently, a new hospital opened in the city. They've probably got a really bad PR agency! Look at this ad that they have in many prominent places in the city.


Who is the guy in the ad? Is he a doctor? Why is he wearing a sherwani? I read somewhere that he is a ghazal singer. Hmmm. An unknown ghazal singer on the ad for a hospital! It's not even as if he is handsome or something. Seriously, what were they thinking? This is even more silly than the dick who had his pictures all over the city for a famous club in Begumpet.

They have also flooded radio channels with ads with some guy talking about the hospital. The voice is so sick and he talks like he is being very gentle and caring. This may serve to drive patients away from the hospital rather than to it!

A good PR agency is so key!

... http://www.kamaldshah.com/2010/12/does-this-ad-inspire-any-confidence.html

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Monday, 29 November 2010 14:55

NxStage – a solution?

Written by Steve Bone
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I learnt to selfcare on hemo over 20 years ago, and have dialysed at home in two houses in the past. At present though I live in a rented property and I have never pursued the idea of home hemo again as the work involved in installing the RO and machine etc would never be agreed to by my landlord, or any other landlord faced with this prospect – and I don’t blame them either! (and my landlord is a GP and would be better placed to understand)

So, when it was recently suggested that the local renal unit could obtain a NxStage machine for me, I jumped at the chance. This will be far easier for the landlord to accept as the work is minimal, and the changes, if any, can be reversed quickly and easily.
And the real big plus is that I can now face the prospect of daily dialysis and all the benefits that brings, not least that I can work while dialysing so gain back some 16+ hours a week travelling and dialysing at the local unit in Peterborough.
So, in the new year, all systems go, and I can look forward to a positive change in my life thanks to innovative technology.
How things have changed since I started dialysing in 1990 – we even used to recycle dialysers back then! Ugh!

Update: Well, have to wait at least three month while the NxStage is 'tested' on one patient - and assuming that is ok, then I can out my hand up for one.

The interesting issue here is that other renal units are using the NxStage and have been for some time, yet we are 'testing'? One would think that this should be handled centrally rather than devolved to local decisions. Makes me think there would be some buying clout for centrally sourced supply of the machines? Fingers crossed, eh?

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... http://mydialysis.co.uk/blog/2010/11/29/nxstage-a-solution/

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Monday, 29 November 2010 04:42

Fistula pain

Written by Kamal Shah
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For the last couple of days I have been having some pain in the venous site of my AV Fistula. I changed the location of the cannulation. I am actually at Care Hospital, waiting outside Dr. P. C. Gupta's OP room for my turn. Dr. P. C. Gupta is a vascular surgeon.

I suspect that there is an infection at that site. There was a similar pain a couple of months back and I had shown it to him. He put me on an antibiotic and asked me to give the site some rest. I haven't used that site since then. Now, a site close to that is paining.

I am a little worried about this. This is the second time in the recent past that this has happened.

A fistula is basically an access to your body's blood for dialysis. During dialysis, blood is continuously drawn from an artery and then passed through an artificial kidney - a dialyser - and then sent back into the body through a vein. Veins are generally small and cannot handle the flows typical during the dialysis process. For this reason, the artery and the vein are connected so that over time, the vein becomes large enough to be able to handle these flows.

Over the last thirteen years, I have had a number of surgeries that involved making accesses, most of them fistulae, in my arms. Once a site has been used or attempted to be used, it cannot be used later. So, except for my right upper arm, all potential fistula sites have been used up. The current fistula is in my left upper arm.

For this reason, I must do all it takes to preserve the current fistula because I do not have too many options left in terms of access.

... http://www.kamaldshah.com/2010/11/fistula-pain.html

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Friday, 26 November 2010 03:18

Dialysis Buttons for your buttonhole

Written by Greg Collette
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In my last post I mentioned that it is becoming more common for units to get people started with buttonholing by inserting a plug into each needle hole for a couple of weeks, so that buttonhole and tunnel formation are accelerated.  I met with Anna Flynn a very experienced practitioner of this technique last week to get the whole story.

As you know, I am a big proponent of buttonholing (using the same needle holes for each dialysis session) for several reasons.  On a day-to-day basis, you get less pain when the needles go in, less lumps and bumps develop on your arm and bleeding times is reduced to a few minutes once the needles have been removed.  In the longer term, it is pretty clear that fistulas last and stay functional for a longer time.

Just a quick recap on what buttonholing is:

  • Using the same hole, inserting at the same angle and depth eventually creates a tunnel down to the fistula vessel for each needle.
  • At the start of the next session, each site is cleaned and sanitised, the scab that forms after the last session is lifted off, the sites are cleaned again and the needles inserted to puncture the fistula at the same place each time
  • After a few weeks of this, a tunnel forms to guide each needle and a flap or “trap door” is created in the fistula wall
  • At this point, you can switch to blunt needles, since there is no longer much resistance when the needle is inserted: it flows down the tunnel, opens the flap, and Robert’s your father’s brother!
  • When you remove the needle, the flap closes over and the after a few minutes pressure, the bleeding stops, you put on a light dressing and go home.

That’s buttonholing.

Now, about the plugs.  Called Bioholes® (manufactured only by Nipro in Japan) they are very small, sterile, polycarbonate, thumbtack-shaped pegs, used to prop the needle tracks open between cannulations.

This is Biohole® plug. The shaft is about as thick as a BigD needle.

Once inserted, scar tissue forms quickly around the peg as the body tries to heal itself in just the same that a newly pierced ear does, when a sleeper stud is left in place to preserve the new hole.  This scar tissue helps form the tunnel track and can be felt as a small lump over the needle site as the track develops.  Typically you need only 6 or 7 sessions to create fully developed buttonhole.

Here's what Biohole® plugs look like in place.

Bioholes® were developed in Japan in 2003 (yes, things move slowly in medical world), to speed the buttonhole development cycle and the enable the buttonholing to be introduced to dialysis units on a large scale.  The problem with the buttonhole approach is that it requires that the same person to insert the needle each time.  This is not possible in most dialysis units with many staff on various rosters.  Using these plugs and a customised protocol, these problems can be minimised.  Bioholes® are being trialled in Europe (see this paper); they  used Asia and the pacific (including Australia) now, and are probably coming to a BigD unit near you sooner rather than later.

Here’s how it’s done:

1.       At the end of dialysis, remove the needles as usual, and apply pressure to stop bleeding the needle sites.

Inserting a Biohole® plug after the needle has been removed

Closeup of Biohole® inserting

2.       Once bleeding has stopped, ideally wait for five minutes, then insert the Biohole pegs can be inserted into the holes, using an aseptic technique.

3.       Cover the pegs with at least two plasters to avoid the accidental dislodgement.  Keep them in place until the next dialysis session.

The hole that's left after the Biohole® is removed. Thanks to Nipro for the photo.

4.       At the next dialysis session, the nurse and or the patient removes the pegs.

5.       After the patient has washed their hands and fistula arm with antibacterial soap and water, sharp needles are inserted as normal into the sites recently vacated by the Biohole peg.

While we are on buttonholing, there are a couple tricks to know:

  • Getting the scab off before inserting the blunt needle: I use a sharp needle, so I can get under the scab and lift it off.  Most use blunt Drawing-Up needles.  Both are effective; the sharp are quicker, but you can do a bit of damage if you are not careful (especially if like me, your eyesight is a bit iffy).
  • If you are having trouble getting the scab off, put some saline or skin disinfectant on some gauze for 5 minutes, to soften it up.
  • Recent finding indicate the buttonholing can increase the potential for infection, so swab before and after removing the scab and if you need to fully withdraw the needle while you are hunting for the flap, start again with a new needle.
  • Sometimes, with the best technique, the needle can’t find the entry flap (my fistula seems to be always on the move, and the entry point seems to wander).  Don’t force it: you can tear and scrape tissue which is both painful and ineffective.
  • Insert the blunt needle by holding the tubing part of the needle just behind the wings and with a gentle twisting and rotating motion, allow it to seek out the tunnel.  It can be helped along by gently stretching the skin to open the tunnel.

For more details, check out Anna’s presentation:

Many thanks to Anna Flynn for the pics and the extensive advice.

... http://bigdandme.wordpress.com/2010/11/26/dialysis-buttons-for-your-buttonhole/

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