The Story of Glomerular Injury

This is an extract taken from chapter 92 of "The Conscious Notebook" (full text here and table of contents here

The Story of Glomerular Injury 1-7

Glomerular Injury 1

It has been long since June met Professor Joatmon in his limestone cave of holistic medicine full of stalactites and stalagmites. At present if you move these curtains you can spot June looking smart in that suit, standing on the pulpit with a laser pointer in her hand. From a lecturer she has quickly become an Assistant professor now, teaching in the Macchapucchare College of medical sciences, Nepal. She’s at the moment presenting a paper on preventing and managing glomerular diseases in the community. You can stay on if you’d like to view her presentation.

June starts off with, “May we have the first slide please?”

Slide 1. Macchapucchare teaching hospital, Pokhara, Nepal.

The first slide is a picture of Macchapucchare teaching hospital, Pokhara, Nepal where I live and work. To talk on renal diseases their impact and strategy for long-term solutions I am going to begin by relating a story, which has been synthesized from the stories of a number of our patients and doesn’t necessarily reflect any real life patient. Prem Bahadur Khadka (not his real name) is a 25 year old boy who hails from a remote village near Jumla, Nepal and had never seen a bus or car in his life before he left his village for higher studies.

Slide 2.

This is his village where the only means of travel was an airstrip apart from the other option of a few days of walking.

Slide 3. Professor Joatmon’s village.

Prem was intelligent and soon after he finished his 10^th grade exams he decided to leave his village for higher studies.

Glomerular Injury 2

Slide 4.

He came to Pokhara, enrolled in a good school and saw proper roads and vehicles for the first time.

Slide 5.

As he was a good student he got into engineering and after finishing his degree, arrived in US as a software analyst. However he felt miserable there as he kept missing his relations and his mother’s cooking (among other things). He was actually relieved when he got the pink slip and lost his job after the economic slowdown.

Slide 6.

He came back to his village (and his mothers cooking) but found that by now he couldn’t adjust with his brothers who knew more than him about farming and all his knowledge of software was of no use in the village (which didn’t even have a single computer).

Glomerular injury 3

Slide 7.

While all this was happening to Prem our protagonist in his macrocosm, quite unknown to him or anybody else a major war had already started inside his kidney where his glomeruli were being attacked by a lot of inflammatory cells.

Slide 8. A cell in Prem Bahadur’s glomerulus.

This is a cartoon borrowed from Harrison’s principles of Internal Medicine, which shows in molecular detail the happenings inside a cell in Prem Bahadur’s glomerulus. You can see how the antigens are processed and finally parceled into an endosomal compartment containing the MHC class II molecule .The antigen settles down into the groove of the MHC and sets off a chain reaction stimulating a clonal proliferation of hordes of inflammatory T cells.

Glomerular injury 4

Slide 9.

This is the strong inflammatory response inside Prem Bahadur’s glomerulus as a result of which we expect to see a lot of protein and RBCs in his urine (if only we could have examined it earlier). However Prem Bahadur didn’t notice anything wrong with his urine. His neighbors noticed him growing plump day by day and complimented him on this sign of prosperity. At first Prem Bahadur was also happy that he was getting fat but later noticed that he was unable to enjoy his mother’s cooking due to a feeling of extreme nausea. This too was ignored by him until one day he developed extreme breathlessness and had to be rushed to our hospital in Pokhara.

Slide 10. Our hospital in Pokhara.

This is a picture of our hospital on a stormy night. When I saw him in our casualty (for the first time) I found him gasping for breath, his lungs were full of crepitations which we quickly treated with Lasix and referred him to Katmandu for dialysis. At Katmandu they dialyzed him for fluid overload and a urine analysis subsequently showed 3+ proteins and plenty of RBCs suggesting acute glomerular injury. He was immediately treated with high dose steroids and a renal biopsy was done.

Slide 11. Renal biopsy.

The biopsy showed focal areas of glomeruli that were sclerosed in segments.

Glomerular injury 5

The fire was too severe to be quenched with steroids and it was already too late to prevent Prem Bahadur’s kidney from blowing up in smoke.

Slide 12.

He received a few more dialysis from Kathmandu and spent whatever money he had earned over the past few months. His brothers came forward to donate their kidneys for transplantation but that would mean selling off their land and cattle to go to one of the hospitals in India and Prem Bahadur wasn’t keen on that. The next slide is a Haiku sequence, which was mailed to me by a friend right after 9/11.

Slide 13. Haiku sequence.

Glomerular injury 6

The last I heard of him was through one of our medical students also from the same village. Prem was spending his last days in deathbed with his family praying for him daily and it would be a matter of days or months before death would take him.

Slide 14. Summary of the story of glomerular injury.

This is a summary of the story of glomerular injury taken from Harrison’s principles of Internal Medicine which describes how it’s initiated by breakdown of tolerance leading to reactivity of antibodies with planted glomerular antigens which in turn generates a chemical cytokine mediated response leading to proliferation of inflammatory cells and subsequent irreversible renal damage (in a substantial number of people).

Glomerular injury 7

The key word here is tolerance and (next slide).

Slide 15.

Tolerance is fast becoming popular in transplantation research but we need tolerance urgently before the need for transplantation arises to save our native kidneys (before the inflammatory cells attack them). As much as we need tolerance to save this Earth before a full-fledged war breaks out. That is the problem of glomerular injury for we don’t really know why this breakdown of tolerance occurs. We don’t even know why hypertension or diabetes occur (for that matter). Our present strategy is only to control them in the hope of slowing the progression of renal disease.

The Last Honeymoon with the Mountains

This is an extract taken from "The Conscious Notebook" (full text here and table of contents here

Chapter 104

 

The Last Honeymoon with the Mountains

The honeymoon was to be decided after the official marriage formalities that Abraham found too bothersome now that he couldn’t wait to be alone with his beloved June. He wanted Goa again but June was firm. The mountains it would have to be and that too Macchapucchare for one last time before June packed her bags for Kolkata again. Abraham had got a nursing home attachment there and it would be convenient for him to chop-chop every day whatever appendices, hernias, and hydrocoeles he could lay his hands on. June had once fancied herself as a surgeon but once when she had taken her brother complaining of chronic pain abdomen to a very impressive professor of surgery in her medical school he immediately posted him for an appendicectomy coming morning in his nursing home. Their father, Samsara, wouldn’t have any of it and said the pain was just an irritable bowel and would go away on its own. Dupki did out grow the pain once he went to college but the incident made June think that surgeons needed to be robot-like if they were to be deemed a good hand. To keep their hands in shape, they had to cut as many appendices they could lay their hands on, if not for the money it would bring in. The more the merrier, the faster the better- An intellectual surgeon was a failed surgeon.

June's Diary

26/10/01:  Set out walking to Baglung bus-park with Abraham protesting vehemently (he wanted to cover the city stretch on car) and then after a 2 hour bus ride through hills and valleys finally came to Nayapul ...Verified our permits in Birethanti and took a quick breakfast before we resumed our walk.

Met my old patient of Diabetes suddenly on one of the villages in the trail...

He treated us to the guavas and oranges freshly plucked from his own garden.

However he looked quite bad, much worse than what I had seen him in the hospital .He had already developed End stage kidney failure due to diabetic nephropathy and he looked all bloated. Also what was particularly worrying was his inability to sleep at night due to the shortness of breath he had while lying down. This meant his kidneys were not excreting water properly and that was all clogging his lungs.

The guavas were tasty...and we sat relishing them near the Bhurundi river where we also spotted a white capped redstart wagging its tail. When we decided to halt for the night in Tikedhunga it was already late and Abraham immediately hit his sleeping bag but again had to arise out of politeness for two Israeli girls who had come to inspect our rooms, whether it was as bad as theirs and then we had a lot of interesting discussions on the Gaza strip and the rising US allergy among the Israelis. They liked Abraham's name as it sounded Biblical and they said a Messiah would come as a savior for all of them according to the Bible...I made them a bit uncomfortable by asking them whether they really thought it was true.

Chapter 105

Regardless, We Continue...New or
Renewed Track

June’s Diary

The next day was a steep ascent to Ghorepani with tremendous views of Annapurna from Ulleri. I met an English couple coming down from Ghorepani whose guide's mother had been my patient. The lady introduced herself as a GP practicing in Cambridge and at the same time teaching communication skills to other doctors. Her husband was a dear young old man with a silver beard and a book on birds of Nepal and looked more like a bird man although he was a professor of architectural history. I wanted to talk more with them on communication skills but they were going in the opposite direction.

Whatever communication skills in med I learnt was from my mother (Who isn't a doctor).She told me what they would have expected from their own doctors and never got. She described the number of occasions she had been inadvertently offended by her own doctors. That provided for me an early start in building rapport with patients, right from my third year Med school because in effect I was avenging my mother by being good to my own patients.

The rest of the trek to Ghorepani was steadily uphill but it was made easier by Karen and her husband from California who discussed a variety of things under the sun (from surface topologies to obstetrics).We had lunch interspersed with sessions of bird watching with redstarts, minivets, orioles and kites making their forays into our imaginations if not into the nearby trees. That night in Ghorepani we had a feast of pizzas, rostis, chocolate pudding and cake but that didn't make the next day's job of climbing to Pun hill any easier although the sunrise was breathtaking. Found a few ladies photographing themselves against the background of the Annapurna baring their backs with ANNAPURNA 2003 written on them. Karen and her husband set out in the other direction towards Annapurna base camp after which they would be going to Khumbu to climb Island peak.

We soon set out for Tatopani after a quick breakfast and met Curtis and Jean Viev on the way. Curtis was a web designer but his first love was music and was soon going to bring out his first CD but before that he would be taking a month's course in Tibetan Buddhism in a monastery in Nepal. The climb down to Tatopani was tough and at the same time beautiful with fields of kodo and fapar gleaming in the afternoon sun, which was interspersed with rain that caught us on the final descent from Santosh lodge. The steep stone steps felt very slippery.

Chapter 106

Also Saw a Bit of the Himalayas

`Cheshire Puss,' she began, rather timidly, as she did not at all know whether it would like the name: however, it only grinned a little wider.

`Come, it's pleased so far,' thought Alice, and she went on. `Would you tell me, please, which way I ought to go from here?'  Lewis Carol

June’s Diary

The next day was a quick descent to Beni as I already knew the way from last year's Muktinath visit. On the way I met a Norwegian family who were working in Nepal through generations and it felt really interesting to be able to chat all the while in fluent Nepali with people who looked European. Lunch was dashain ko maasu and kodo ko chang(a millet beer) and after reaching Beni found there were no buses since morning as it was the 10th day of Dashain.

A bus did start at 4:00 PM charging exorbitantly although we had to make do with sitting on the roof- top, which too was crowded. After some time however the roof top was gradually transformed into a place to be especially with the near full moon shining on to it a fair share of its gleaming light. It was cold but then somebody was passing around a bottle of apple brandy fresh from Marpha, Mustang.

I met Soul an Australian medical student who was a year junior to Andy who had been doing his elective with us last year and had done the Annapurna circuit in a fairly short time. Then there was this French painter whose medium was oil on water and I wondered whether it was possible to paint using only words. We lay down on the roof top of the bus watching the moon and the stars and the snow peaks dazzling at a distance while the bus moved at its gentle pace.

I felt as if I had seen the world in these few days, more so through the eyes of its people from various countries and off course I also saw a bit of the Nepal Himalayas.

Conscious Notebook Poetry and those that didn't make it there

The poems below are extracted from the book, "Conscious Notebook" which you can read full text offline here: https://searchworks.stanford.edu/view/7929525 and a few that didn't make it to that book but may exist in other books such as here:Haiku Harvest 2001 – 2006

Dream

You stepped into my dream

Like a whiff of rain swept Earth

A cool breeze blew through the windows

Rain…created music outside

The room bore your silent eyes

And myself lying on the mat

From an unearthly distance you bent down

And breathed softly into me

While I …kept on struggling

To reach you

Through dense jungles, steep slopes

Gradually you receded

into that never ending corridor. 

Grass

To the scorching summer sun

Burnt into an orange evening

You held out a blade of grass.

Back

It was quite sudden

When I noticed her

From the back

Was it somebody I didn’t know?

The next instant I knew it wasn’t true

When she turned momentarily

I continued to stare at her back

Two completely different persons

I never knew the back could have a personality of its own.

Faces                                

You wouldn’t have known

How smoothly I pocketed your face

The other day when we met

For a second time on the lift

Now… I can savor it

In the privacy of my room

Or the silence of the library

In the bustle of a crowd

Or whenever I’ve reason

To be distressed

I’d simply take a look at you

All golden rays of the sun

Shimmering on the waters

Of an unusual calm

As it sets over the horizon

The dark silhouette of a returning sail

Light

Today again…there was this light

After a storm

There were clouds too…but

 In their midst there was this bright

Shining through a huge cumulo nimbus

An orange glow…which

Shone through the cornfields and

Children’s faces that watched

Their paper-boats go in fast rivulets

The light seemed from another time

My yesterday and your tomorrow

Merged in a swirl of river rapids

River

A lot of mosquitoes

In the water

They don’t let her sleep…

River tosses and turns

Through the night

In her bed

Unable to sleep also

Are the fish

Until they decide

To go to the market

Buy a huge mosquito net

At night…inside,

The snake-like long net

River bathes…               

In moonlight streaming

Through the net

Fireflies light up the riverbank

In these early hours

Fishermen start… to row out into the sea

The moon seeps into the dense jungle

Of mangrove filled by the river

There is a gentle breeze

The mosquito net swings lightly

And along with it… the moon

Mountain

1

The day one comes face to face

With a huge mountain

Automatically windows open

Deep down somewhere

Inside the brain

Dark brown clouds atop a black massif

Penetrate your innermost corners

One fine day they suddenly emerge

Barging into a busy office room full of overworked colleagues

2

There are some people who never get to see a mountain

All they can do is simply wait

Any of these days it might just happen

Flapping its wings out of the blue

Would appear a shining desolate golden mountain

And lift them off their park side benches

3

In this extremely plain city

You sometimes wish

The road behind your house

Led to a nearby mountain

Every day on your return

From office

You’d take a walk on its steep slopes

Everyday…in this extremely plain city

One longs for a very own dear mountain

4

The rain stopped for you

To open that window in the bus

For your eyes to feast on those rice fields

Beside the road and at a distance

A shining ivory tearing through the clouds

5

I strongly believe amidst us somewhere

Resides a gigantic mountain

Full of perennial snow

Shining brightly in the afternoon sun

Changing colors with time

Morning…a pinkish white

Evening…a orange hue

We go about all our lives

Trying to scale our individual mountains

Somewhere deep within them

We exist…ourselves

6

Let down your hair in the wind mountain

Let it flow like a torrent through poetry

Swept off false moorings

Your volcanic lips let it burn each syllable

And let it cool with your icy stare

7

This mountain is an institution

One staying here too long tends to gather roots and branches

And finally …one day…becomes a tree which nests

Innumerable eggs of countless dreams

Each day we struggle to hold on to our mountains

Our roots, our dreams, losing our smiles in the process

In the end the institute crumbles and leaves us

To fly on the wings of freedom 

8

You resemble the mountain of my dreams

Is that a running stream or your hair blowing in the wind?

The day our eyes met and clouds burst into rain

I had to carry a wet heart all the way to the top

What are those pock marked scars

Did some one use pitons on your body?

One day I too had longed for a climb atop your majestic tresses

Every day I had been saving a jumar or a carabiner

All is lost today in your flowing hair

A mountain stream that floods my dreams in the plains

9

One day, they show a mountain on the TV screen

Walking towards a lonely traveler

It grew bigger and bigger and the traveler

Smaller and smaller until…

The whole screen was full of the mountain

Snow covered soft powdery white and the traveler…

One of the black dots on the tube…yet

Nobody really ever moved from their individual places

10

Oh no! Mountain she’s not for you

She’s just a bolt from the blue

A thundercloud, which will drench you from head to toe

After a time you’ll notice the smiling sun

Point out to your cloud over another distant mountaintop.

  

11

For me, I am sure await

A few playful mountains

One has to cross them on the way

To the biggest of them all

Its peak…lies invisible amidst clouds

Its surroundings…serene, silent

And yet…there’s this welling of love

Shining mountain…do stay put I pray

For you, I shall come definitely, one day

12

Imperceptible and yet a gradual accumulation

Of hatred, anger and distrust…human relationships

They form a thundercloud of emotions from a wisp of smoke

Far down from the valley…all within seconds

A gigantic mountain of misunderstandings

From mole hills of misconstrued notions

13

In terrible tensions sleep is only possible

On listening…to a far off melody that emanates

From deep within a desolate, distant mountain

There’s a hint of the smiling sun

At the distant mountaintop there exists

None of our dreams and wants

Only sleep…deep and restful

14

On returning from the mountains

One roams in the city…full of visions

Giant skyscrapers resemble Makalu…Lhotse

Vehicles ply on disgruntled streets…remind you

Of hurrying sherpas on the Khumbu ice fall

15

One day…maybe on a trip to the mountains

One might just encounter crumbled rocks and dust

On both sides of a road which extends into a never ending desert

A gradual wear and tear through the ages…play of air wind and water

Cities buried deep within them…houses that twinkled once at night

Atop dense dark mountain shapes.

16

One day just before elections you chance upon

Political workers painting graffiti on the mountain

Slowly and steadily it gets covered in slogans and speeches

As you go near it becomes illegible…childish scribbles

You leave and from a distance… see only a sparkling sun

17

Everyday I return to you

Like you are home waiting

With a sweet smile and a cup of tea

The sea gulls fluttering in your eye lashes

Throw up incredible patterns of white

I am sucked into them in a vortex of river rapids

18

If one can’t go to a mountain

It comes to him

I’ve been waiting for a long time now

Molehills cover my body

The Earth on it sprouts Trees

With the passage of time it seems I have

Become the mountain

Respiratory Care Nights

Breathing machine pumping love

Eyes of dying hens

Pierce to depths of turbulence

Needles, blood gas and movement

Brisk sharp and painful

A cascade of alarms, ventilator settings

Causes and remedies

Eventually dropping off to an unusual silence

Mountain valleys, placid waters

Light of dawn and a distant bird song

Waking up to a humidifier alarm.

Acute inflammatory demyelinating polyneuropathy

One night a black raven swooped down

And carried off all the power in his legs

Next day there were hordes of them

Screeching and perching at his hands and arms

One rude jab and he lost his voice

Another made him choke to swallow

He was brought to the ICU

Breathing slowly turning blue

A large ostrich perched near his head

Delivering mouth to mouth till he turned red

Gradually his power returned

One by one in all his limbs

All birds one by one returned to their nests.

Pulmonary medicine

Take a look at this chest x-ray

Hmm dense forests bordering on green rice fields

A cow munching grass, lazily waving away the flies

The setting sun, one or two clouds interspersed

Hmm looks normal-show the other one

What’s this! a giant jungle mower

Concrete new buildings-all cooped up look alikes.

Hey can you hear the trees crashing!

Can’t make out – over here the mower’s creating a din

Hmm see anything more?

A lot of alveolar opacities

That’s the smoke from our upcoming power plant

Hmm the diagnosis is clear—Lung cancer

Get a bronchoscopy but the prognosis is bleak

At the most 3-6 months.

The battered bronchial tree

Last night I discovered the fruits of bronchogenic carcinoma

Growing on my bronchial tree

Ugly and slimy it tasted of blood and phlegm.

This tree…had long been a source of shade

For travel weary souls amidst sun burnt fields.

Not any more…falling leaves,

Shriveled bark, ugly nodular fruits with a slimy sauce

With each and every cough it shook from its very roots

Caught in a raging storm