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).

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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.

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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.

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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.

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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).

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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.