The light of rejection-free, healthy kidney transplants has entered the tunnel, and should arrive at our end in just three to five years.

Last month a senior researcher from the Cell and Tissue Therapies WA at the Royal Perth Hospital (CTTWA) presented a paper to the Renal Society of Australia‘s annual conference that has profound implications for us BigDers.  It detailed their early clinical trial successes in using Mesenchymal Stem Cells (MSCs) to stop kidney transplant rejection and to repair acute kidney injury (among many other medical wonders).

Quick MSC primer:

Stem cells in our bodies have the amazing ability to self-renew (make exact copies of themselves) as well transform, or differentiate, into other cell types with specialized functions, such as blood cells, muscle cells, and so on.  They become the various cells throughout our bodies during early development, and help maintain and repair certain tissues during growth and adulthood.

MSC Manufacture

Mesenchymal (“Mezen-kye mel”) Stem Cells are adult stem cells that can give rise to many types of tissue, such as bone, cartilage and fat.  MSCs were originally discovered in bone marrow, but they also exist in other body tissues, including skin, fat, placenta and umbilical cord blood.

In the mid-2000s, early clinical trials found MSCs could suppress inflammation and repair damaged tissue, and might potentially be used to treat diseases like myocardial infarction, liver cirrhosis, Crohn’s disease and amyotrophic lateral sclerosis (ALS).

Then in 2006, researchers found that they could also help repair damaged tissue, suppress immune reactions and even prevent rejection.  Not just for matched donor-recipients, but for universal use: they induce no immune response of their own so they can be manufactured, frozen and provided at call, off the shelf.

Successes with transplants

CTTWA at Royal Perth Hospital, like many others around the world, began working with MSCs around 2005.  Initially, they developed processes and techniques to manufacture them (they are now a licenced MSC manufacturer and provide frozen MSCs for clinical trials evaluation to hospitals around Australia).

Then, following the finding of MSCs capacity to suppress the immune system, they also began clinical studies to evaluate their safety and effectiveness for treating transplant rejection.  Their first trial, in 2007, was as the last resort for a young bone marrow transplant patient who was suffering the final (and usually fatal) stage of Graft vs Host Disease (GVHD).  This may happen after a bone marrow transplant where the donor’s bone marrow attacks the patient’s organs and tissues, in serious cases with horrendous consequences.

Soon after infusion, the MSC’s calmed the immune reaction, reduced the symptoms and began repairing tissue.  Subsequent treatments over the following weeks saw almost complete remission.  Months later, the GVHD returned, but faded again with further MSC treatment.  This cycle of remission and relapse continued for the next few years.  Now in 2015, the patient has been free of GVHD for over three years.

Protocols for treating patients continue to be developed.  For example, there is now a clinical trial with MSCs being administered as soon as the GVHD is detected, rather than waiting until the disease becomes life threatening.  Subsequent GVHD trial patient recovery numbers show that MSCs can significantly reduce and even eliminate rejection (52% recovery vs 10-15% recovery rate before MSCs).

Two years ago the Centre began clinical trials on lung and kidney transplant rejection, and on repairing donor kidneys that have been damaged during removal, between transplants, or when blood supply returns to the kidney when first transplanted.

A typical kidney transplant rejection treatment protocol consists of a series of small infusions (about 40mls) of MSCs into a vein, typically over a 4 week period: the rejection fades away.

While as yet incomplete, all of these trials have provided clear evidence of the effectiveness of MSCs in suppressing rejection and repairing damaged organs.

So what are we waiting for?

The paperwork.  Every new drug treatment needs detailed written clinical trial evidence of safety and efficacy.  In the right format, over an extended period, in triplicate.

Formal clinical trials are longwinded, meticulous beasts (as they should be, we don’t want the cure to be worse than the disease).  They usually go through three phases before release:

• Phase I clinical trials test a small group of people (e.g. 20-80) to evaluate safety (e.g. to determine a safe dosage range and identify side effects). These are cheap to run and are often run in-house
• Phase II clinical trials may test from twenty to several hundred to check that it works as intended and to further evaluate its safety (the number depends on how effective the therapy is: these Phase II studies only need 20-66 patients)
• Phase III studies may test several hundred to several thousand by comparing the therapy to other therapies, monitoring for adverse effects, determining dosing schedules etc, depending on the design of the trial and expected response.

There is also a fourth Phase IV done after the treatment has been released for use.  Where clinicians monitor the effectiveness on the general population and check for adverse effects of widespread use over longer periods of time, etc.

The current MSC kidney transplant rejection trials are in Phase 1.  Phases II and III get progressively more expensive (we are talking several to many $millions) and time-consuming (3-5 years depending on the recruitment numbers).  However, if the early Phase clinical trial outcomes demonstrate high clinical efficacy then it may be possible to fast track release (making it even less than 3 years).

So for those who want to be involved right now, it’s not easy.  Patients may be recruited to a trial if they fit the profile and eligibility criteria (people who are actively rejecting a transplanted kidney and being located in the right city are two big ones) and are prepared to accept the risks.  Some patients may be granted special/compassionate access to a trial, for example if the treatment is their last resort, having exhausted all other avenues.

So, in summary, MSCs look like they can be used to stop rejection in its tracks, but we need to wait for the clinical trial outcomes.  While frustrating, this is a lot better than where we were a few years or two ago, when things looked positive, but unproven.

The light in the tunnel is getting brighter, but there are still a few stops before it arrives.  For a working transplant, I can wait, and maybe even put off any transplant until it does.

In February 2010, I wrote Dialysis: death via a damaged fistula, which was about Maya’s father, who died when his sore and swollen fistula burst in bed and he bled to death.  At the time I asked some of the experts I knew about this and all said it happens, but was very rare.

However, over the following 18 months I had a steady flow of posts about other people who had died or came close to death from a leaking or haemorrhaging fistula, and it started to look a lot less rare.

In August 2011, I wrote: Dialysis, fistulas and fatal haemorrhages setting out some expert opinion on how to spot the danger signs and action to take to prevent a rupture.

Several people wrote back, saying how they had taken action and prevented their loved one’s fistula from rupturing.  But still, the horror stories keep coming, with more than 30 deaths and near misses posted over the last four years.

Most people posting were still unaware that ruptures could happen and had zero training on what to do if a rupture occurred.

This seems like pretty important information, which should be posted in every dialysis unit and office, everywhere.  So in an effort to get the word out, I have done more research on three areas:

• Just how common are fatal haemorrhages?
• The best way to avoid a rupture and
• What to do if one happens.

Until 2013, apart from the odd passing reference, not much had been written about fatal fistula ruptures.  Presumably most people assumed they were a rarity and not worth the effort.  Then Lynda K. Ball, MSN, RN, CNN, the Vascular Access Specialist for Fresenius Medical Care in Washington State published the excellent Fatal Vascular Access Hemorrhage: Reducing the Odds, in the Nephrology Nursing Journal, of the American Nephrology Nurses’ Association.

Though written for nurses rather than for the proud owners of fistulas, it is right on the money: “..how to recognise accesses (fistulas and grafts) at-risk for Fatal Vascular Access Hemorrhage (FVAH) and implement strategies to decrease FVAHs” (you know the problem has gone mainstream when it gets its own acronym).  For good measure, she also throws in the best technique for stopping the bleeding if the worst happens.  It’s a good read (though the pictures are a bit gruesome).

Here are some highlights.

Firstly, two FVAH factors listed in the paper jumped out from the page:

1. Fistula/access-related complications had occurred within six months prior to bleeding deaths.
2. In some states, up to 80 per cent of rupture deaths occurred at home.

We’ll come back to these factors shortly.

How common are fatal haemorrhages?

It seems that no one actually knows for sure, but they are more common than most people imagine.

In the US, End Stage Renal Disease Notification of Death CMS-2746 forms indicated that between the years 2000 and 2006 (the most recent national data available), there were 1654 fatal vascular access hemorrhages.  This represented about 0.4% of deaths of patients on hemodialysis.  However, these are only reported deaths and are considered an underestimate.

It could certainly be double that figure, say 0.8 per cent.  That seems a small number until you realise that there with about 500,000 people on dialysis in the US, 0.8% is 4,000 people.

FVAH deaths don’t seem to be tracked separately in most other countries.  This blog finds out about between five and ten a year from shocked relatives looking for answers, but it is by no means a definitive list.  Posts come from as far apart as the US, Estonia, New Zealand, India and 170-odd other countries around the world.

There does not seem to be a trend by country, rather it is much more local: it seems to depend on the quality of the unit.  In a well-run unit, fistula/graft haemorrhages really are rare.

Which brings us back to the two factors mentioned earlier.

The best way to avoid a rupture

Be fistula fussy

1. Fistula/access-related complications had occurred within six months prior to bleeding deaths.

Fistulas don’t weaken to a point where they haemorrhage overnight.  The fistula slowly becomes weak, fragile and weepy due to infection, stenosis (reducing blood flow and building pressure) or an aneurysm (the fistula wall balloons and becomes thin).  In other words, red and sore fistulas that are infected, blocked or have weak spots that fail to re-seal after needling are warning signs of impending rupture for both dialysis staff and us.

From the stories posted on this blog, in well-run units, fistula/graft haemorrhages are rare.  Staff check everyone’s fistula regularly and if they see a problem, they act: either with antibiotics and treatment, or a referral to a hospital or vascular surgeon, to examine and rebuild the fistula.

That doesn’t make it any less traumatic for the families when it happens, but mostly, unless you have some specific problems with your graft or fistula, it is not something to lose sleep over.  Most fistulas and grafts are solid and robust.  Fistulas grow slowly and are usually quite firm and elastic.

Be fistula fussy: if your fistula has any of these warning signs tell the unit staff and ask for medical attention.  Don’t take no for an answer.  If they are slow to act, tell them that you consider the problem life threatening.  Make sure they do something.  Tell your carers and get them to tell the staff.  Tell your doctor.  Make a fuss, but get it fixed.

What to do if a rupture happens

Finger press; arm lift

1. Approximately three-quarters of the deaths occurred at home, in assisted living, or nursing homes.

You cannot assume that medical care will always be at hand for emergencies.  If your fistula starts to bleed you need to know how to deal with it, even if just for a few minutes.

The easiest and safest way to control the bleeding is to:

• Immediately apply direct pressure over the site of bleeding with a single finger (or more if the rupture is bigger) and
• Raise the ruptured area of the bleeding above the level of your heart, to make it more difficult for the blood flow to reach the ruptured area due to gravity. (To see how effective this is, raise your fistula arm up above your head now – the blood will quickly drain away from your fistula.)

Do not take time to look for gauze or a tourniquet – these can hide the bleeding area and you may press on the wrong spot – put your fingers directly over the ruptured area and apply pressure immediately, then lift your arm.  Hold the pressure on the site for at least 10 minutes without peeking.

Once things are stabilised, call for medical help.

If someone is with you, they can call while you press on the site (or vice-versa).

Pass on this information: print out this or Lynda’s paper and put it on your unit’s noticeboard.  These strategies will help avoid fistula ruptures and save lives – yours and mine.

Two reasons I worked through the eHealth MOOC I wrote about last time were to find out just how big the eHealth movement is and where it was or can be successful in making life easier providing better health outcomes for us BigD-ers.

Firstly, it’s big, very big.  Most countries are setting up or designing an eHealth framework of some kind or other.  They include the usual suspects, like Scandinavia, the UK, most of Europe, Hong Kong, Singapore, Australia and New Zealand, and parts of Canada and the US.  Thankfully much of the rest of the world is also on the job, like Russia, Brazil, India, Pakistan, the Philippines, Mexico, Turkey, Nigeria, Israel, Iran, Saudi Arabia.

There are also at least two eHealth systems developed and run by Non-Government Organisations (NGOs):

• OpenMRS, developed as a collaborative open source project in the US, which is in use in at least 23 developing countries (mostly in Africa), and
• United Nations Relief and Work Agency (UNRWA)’s e-Health system developed in-house in 2011 to address the administrative burden of millions of patient is the Middle East region (Lebanon, Gaza and Westbank, Syria and Jordan).

These two systems are great examples because they were designed and built mostly by volunteers to meet their core need:  a single, comprehensive, mobile medical record that is available wherever the patient goes.

Most eHealth frameworks are based around the World Health Organization’s National eHealth Strategy Toolkit, which is a roadmap and toolkit for developing or revitalizing a country’s eHealth.  The Toolkit has three steps:

1. Develop a national eHealth vision that responds to health and development goals
2. Develop an implementation roadmap that reflects country priorities and the eHealth context.
3. Establish a plan to monitor implementation and manage associated risks

I rather like Israeli definition of national eHealth: To achieve a universal access to health care services leaving no one behind.  Short, sweet and inclusive.

That’s the theory.  So what should/could the ideal national eHealth framework deliver to us BigD-ers?  Well, we are high-maintenance individuals, all with similar healthcare needs.  We use at least one health service at least three times a week, often more.  So as an example, here some of the eHealth services I’d like:

• eDialysis: that provides dialysis performance details after each session, with opportunities for contact with dialysis clinicians for queries and support
• eResults: online access to all my test results, blood and body fluid tests, biopsies, ECGs, MRIs, and all other medical imaging, with facilities to email the associated clinician for advice/discussion or to set up an appointment (for a fee)
• eMedications: a list of all my current and past medications, with side effect details, would be useful
• ePrescriptions: prescriptions generated in the doctor’s electronic prescribing system and then transmitted through a secure network to the national e-prescription database. While only the prescribing physicians and pharmacy personnel have access to the prescription, I can then have my medication dispensed at any convenient time and pharmacy
• eReferrals: especially for renewals, simply going online and requesting a new referral, which would be emailed to my specialist. I’d be happy to pay a small fee for this rather than us both blowing precious time (and money) on a full visit
• eEmergency: An on-my-person record of personal details, next of kin, ailments, medications, prescriptions, health insurance, and emergency contacts
• eHealthInsurance: readily available, electronic proof of health insurance
• eAppointments for dialysis: being able to set up my treatment times online, to swap times and even book times in other dialysis clinics electronically
• eAppointments for other health care services: setting them up online with my nephrologist, general practitioner or family doctor, clinics/hospitals, nurse practitioner, pharmacist, physiotherapist, psychiatrist, clinical psychologists, occupational therapists, dietitian – the lot
• eVaccination: a system that tracks my vaccination history and reminds me when we need another (currently I am more likely to get a vaccination reminder for my dog!)
• eDonor: if there are any useful bits of me left when I go for the big sleep, the fact that I would donate them should be both with me (on my driver’s licence) and online somewhere
• eMyHistory: secure online access, ideally in timeline and calendar formats, to my patient records (about my hospital visits, transplants, infections, heart problems, etc), specialist visits, family doctor visits (in fact, from all the people listed in my eAppointment dream above)
• eDNA: access to my genetic profile, showing my health risks, inherited conditions, drug risks and general traits. I want to know if I have any vulnerabilities or inherited diseases.  This would also be available for the transplant team to help with matching.

Most of these are already available somewhere but in isolation.  I’d like these on my smart phone please, preferably as a single App.

This list (except for the eDNA; it will probably be on next year’s list) is what eHealth is aiming to deliver.  Most countries are starting with the easy stuff (eAppointment and ePrescription are popular) because they can be developed relatively quickly as stand-alone projects.

Other countries (including Australia) decided on the big bang: to develop a national eHealth record system and then convince patients, clinicians, hospitals and health care services generally to use it.  Without exception, this approach has been very expensive and very, very difficult, especially in countries with a mix of public and private healthcare providers; to the point that most have failed on the first try.

The Scandinavian eHealth system is the most advanced because they started earlier (a couple of decades ago) so they have the most scar tissue and the most success.

But whatever the track record, the expected benefits from eHealth keep it firmly on the agenda in every country, including yours.  To find out how it is progressing, just Google: (your country) and eHealth.  You may be surprised; if not now, soon.

ps: I’ve ignored the many concerns about security and potential for misuse of a centralised health record about each one of us.  They certainly exist, but must wait for another day.

I am now in week 5 of the eHealth MOOC I wrote about in my last post.

It has been a revelation.

The most eye-opening subject was covered in week 3: eHealth for patients and citizens: all about e-patients.

Before we go further, meet e-patient Dave deBronkhart.  His story cuts to the chase: it saves me writing and it saves you reading.  It only runs for 16 minutes, and its great!

What’s the key message? If Dave saved his own life after his healthcare community let him down, so can we.

An e-patient is a type of expert patient.  One who uses online resources to get knowledge, to connect and share with other people in the same situation, who is action-oriented; a believer in  self-care and their own abilities to contribute to their health and well-being.

According to Tom Ferguson, an American doctor who coined the expression, an e-patient is equipped, enabled, empowered and engaged.

In short, when we become an e-patient, we become our own guardian angel.

Most of us BigD-ers are well on the way to e-patient-hood.  Already we take the time and make the effort to understand our health problems and we want IN on our healthcare, ideally as collaborating partners.

And we are not alone; we are part of a worldwide movement that is becoming a force for massive change.

But not everyone it there yet.  This blog still receives a steady stream of anguished and angry comments on one of its most disturbing posts: Dialysis, fistulas and fatal haemorrhages.

Since 2011, more than thirty grieving relatives have written about a loved one whose fistula was infected or blocked, or became fragile and weepy, who was ignored and fobbed off by an inadequate health  care service until they died, often in a pool of their own blood when the fistula ruptured.  Here are just two examples so far this month:

Marlene wrote: “My 40 yr son was found on his bathroom floor bled to death from a ruptured and infected fistula, 4 days after a declot procedure. He was trying to tie his tee shirt around his left arm to stop the bleeding. He had a declot procedure done on the 11/28/14. The vascular doctor who performed the procedure contacted my son’s nephrologist at the dialysis center and informed him of the condition of his fistula and that he needed to have it taken care immediately.

My son was discharged home to die. The vascular Doctors should have called the ambulance and sent him to the hospital for immediate surgery. This is a situation you do not put off. This is life and death.

The police found him dead on his bathroom floor, for crying out loud. Mr D where do we go from here. He has small children who need answers.  Some doctors do not listen attentively to their patients. What’s my next step for the sake of my grandchildren?

Juana wrote: “My daughter’s port fell out they put another one in Saturday the 25th 2015 took her to the hospital. One week after they put the new port in they said that she is very sick and she had an infection, She died on the 27th 2015. I want an answer. I don’t understand.  My baby was 23 years of age. Why didn’t they know about the infection at dialysis? I need an answer; what do I do?”

While these dreadful outcomes and the others in the post are mostly the result of healthcare inaction, it could also be because our guardian angel, our one resource that cares for us above all else, our e-patient, was missing.

All BigD patients need to become e-patients.  No more a passive recipient of care, going to dialysis, closing our eyes, putting out our arm and hoping for the best.

Imagine a world where every BigD patient is backed up by their e-patient guardian angel.  How many infected and ruptured fistulas, let alone horrible deaths would happen then?

Most of us have heard of eHealth – short for Electronic Health, and in its simplest form meaning the use of information and communication technologies for health delivery and management.

While that sounds pretty dry and not that interesting, eHealth is a tsunami, riding on databases of health information and innovative, patient-centred, wireless and wearable technologies that are changing health care systems and health services delivery around the world.

• If you wear a FitBit, Jawbone, or other fitness tracker, or know someone who does, that’s eHealth
• If you use an App for tracking your food intake, heart rate, sleep patterns or just about anything else you do, that’s eHealth
• If you have used a health service delivered via broadband or mobile phone (telehealth), had surgery via a robot operated by a local or remote surgeon, or have been diagnosed and treated remotely by phone (telemedicine), that’s eHealth
• If you live in one of the many European, African, Asian, Oceanic (including Australia) or American countries around the world whose government has developed an eHealth strategy and funded projects to create a national database for Electronic Health Records (EHRs), that’s absolutely eHealth
• If, like me, you track your heartbeat for AF on your smart phone and send ECG’s to your cardiologist using AliveCor’s Heart Monitor, that’s eHealth
• If you are using an iPhone with the new iOS 8 operating system, then you already have the HealthKit and Apple Watch Apps, which are the forerunners of Apple’s Ecosystem For Your Body, the latest in a wave of new smart phone based, personal eHealth.

So, what is the objective of eHealth?  At the big picture level, the answer is simple: better healthcare outcomes.

As for the detail, it depends on who you ask.

• For government: a single eHealth record used by all hospitals, health professional and service providers, will save their health system $ billions a year by cutting the diagnosis, treatment and prescription errors that lead to thousands of unnecessary hospital admissions
• For medical organisations, eHealth is delivering new and innovative tools and techniques resulting in more effective and targeted services, accompanied by a reliable and sustained income stream
• But it is for BigD-ers, and every other person on this planet concerned about their health, that the eHealth wonder is delivering the most: new insights, protocols, pathways and tools that are changing the way we think about and look after ourselves: right now, today.

That’s right: we are where the eHealth rubber hits the road.  It’s up to us: the more we know, the more we get engaged, the better we collaborate and control our health care, the healthier we’ll be, the better our quality of life.

So I asked myself:  how can I get more involved?

Luckily, on the Internet, ask and you shall receive: I found a new eHealth MOOC!  Talk about great timing.  (I’ve written about Massive Online Open Courses before, where you can learn about just about anything, expand your mind and pay nothing.)

Called eHealth – Opportunities and Challenges, it is run by the Karolinska Institutet (a very prestigious university in Sweden).  Among other things, it is designed to “… help you to understand the opportunities and challenges of the field”.  Quick check: yes, it’s in English, so I signed up.

It started a week ago (23 April 15), and it’s great!  It is short, only 6 weeks, and involves about 6 hrs per week.  Each session has brief, pithy videos talking to eHealth practitioners and experts from around the world; simple assignments and lots of opportunities to interact with people doing an amazing array of eHealth stuff: things that can benefit you and me.  At last count, 5000 students are registered from just about everywhere (the M in MOOC definitely means massive).

So if you want to tap into the benefits of eHealth (and you obviously do or you wouldn’t be reading this) and want to make your own health care future, check out and register on the MOOC.  It’s not too late, registrations are still open.

Maybe we can meet and solve sort out some of BigD’s big problems together on the forum.  Whatever floats your eHealth boat.