Advertisement
American Journal of Kidney Diseases

Separation

Published:October 18, 2018DOI:https://doi.org/10.1053/j.ajkd.2018.08.012
      The veins in my forearm bulged as I wrapped the tourniquet around my left bicep. I placed the 14-gauge needle in my arm and relaxed.
      As a surgical intern working nights on the trauma service, I expected to feel tired. Sleeping during the day was almost impossible for me. I naturally attributed my exhaustion to the lack of sleep and constant stress. I expected to feel better when my circadian rhythm reset to normal. The day our rotation ended, my chief resident treated the team to a steak dinner. I ordered a ribeye, medium rare. Two bites in, however, the meat just did not taste right. Everyone else polished off the meal in record time, but I couldn’t do it. I still felt tired. Perhaps I was recovering from some sort of infection? Switching back to a day service and getting sleep should help.
      The waste lines were carefully positioned across the hall in the bathtub.
      I was particularly looking forward to the liver and kidney transplant service, my home for the next 5 weeks. On the second day, I had the chance to scrub in on a fistula procedure. Although these are typically short surgeries, the procedure is technically challenging. As an intern, my job was to observe the vascular anastomoses, keep the operating field clean, and close the wound. The operating room had a strong odor that day. Even through my mask, I smelled the ammonia. Someone must have gone above and beyond when cleaning the room earlier that morning.
      This would be the last wound I closed as a surgical intern.
      24 liters of sterile fluid hung in wait to cleanse my body.
      Although I had switched back to a day schedule, I still felt fatigued. About 2 weeks into the new rotation, I woke up early in the morning and vomited. Something was definitely not right. I dragged myself to the hospital and made it through morning rounds. I did not have a primary care doctor, but heard of a good group affiliated with the university. Maybe they were taking new patients? One of the nurses answered the phone. I told her I was not feeling well and needed to make an appointment. Lucky for me, I must have sounded horrible. She interrupted one of the doctors and immediately placed an order for some basic labs. Not a problem. I was at the hospital and could get that done later in the morning.
      The machine began to pump.
      After placing orders for CT scans, complete blood cell counts, and basic metabolic panels, I walked to the lab testing area on the third floor of our outpatient center for my own complete blood cell count and basic metabolic panel. A few patients in the waiting room casually glanced at the doctor dressed in a white coat and scrubs sitting next to them. The blood draw was uneventful. Still feeling tired, I went to the surgery resident break room to lie down. Within 1 hour, my pager went off. Expecting one of the floor nurses, I was surprised to hear from my new primary care physician’s office. They told me some of my labs were very abnormal and instructed me to get to the ER immediately. I called my chief resident to let him know I would need help covering the service that day. He was not happy, but grudgingly agreed to find someone.
      Fluids flowed into my veins and a welcoming cool, salty taste drifted over my tongue.
      Arriving in the ER, I was rapidly escorted to a room. Someone would be here soon to explain these abnormal lab tests. It should only take an hour or so, I calculated, and I would be on my way home to recover. Great! I know this doctor. He taught our second-year renal pathophysiology course. The serious look on his face betrayed his calm demeanor. With a creatinine of 15.4 mg/dL, a potassium of 6.3 mEq/L, and a serum urea nitrogen of 113 mg/dL, I needed to be admitted.
      I dutifully injected the iron and erythropoietin and sat back in an old pink chair that used to belong to my grandmother.
      During the years I had spent completing my MD and PhD before starting my internship, some of my former classmates had now become attendings and were working at the university. I was admitted to a medicine floor and one of my former classmates prescribed Kayexalate (sodium polystyrene) to drop my potassium. I vomited. About 1 AM the on-call renal fellow, also a former classmate, arrived to place a Quinton catheter in my right internal jugular vein. I was so dry he had to push 2 liters of fluids to get it in.
      I was a 31-year-old man on dialysis.
      The separation of toxic molecules from the blood is the fundamental concept of dialysis. As blood filters across a membrane, the toxins are removed and the essential components remain. Dialysis has a similar effect on a person. Dialysis separates a person from their work, their friends, their diet, their activities. This life-saving and life-changing treatment is painful and difficult.
      The truck arrived at my house for the first delivery of sterile fluid in the fall. I could not believe the size of the shipment. The fluid bags arrived in long rectangular boxes. Requiring 24 liters per dialysis session, I got plenty of exercise carrying those boxes up 2 flights of stairs from the basement. Home hemodialysis is not for everyone. But for me, it was a life-saving option. I had a more flexible schedule, more energy, and a more relaxed diet.
      The surgery took place on a Wednesday morning. My father and I arrived at 5:30 AM for check-in. After changing into the mandatory uniform of the hospital gown, we anxiously waited for the surgeons. Both of our surgeons arrived early and spoke with us briefly. They had an air of confidence that was reassuring. My dad was wheeled off into another area where he would be prepped for his surgery. He would undergo a minimally invasive nephrectomy. The approach for such a surgery is from the back and requires removal of part of the twelfth rib, a more painful procedure than the one I would experience. I soon drifted off to sleep. The surgical team worked efficiently and carefully, implanting my father’s kidney into my right pelvis. There was minimal blood loss. Words cannot describe how grateful I am for this gift. My dad is healthy and currently plays golf at least 3 times a week.
      When I walked into the pathology laboratory to review my own kidney biopsy, the attending pathologist was clearly uncomfortable. She carefully placed one of the slides on the microscope stage and motioned for me to look through the eyepieces. Peering into the scope to examine tissue taken from my right kidney 15 months earlier was unnerving, but ultimately irresistible. As we reviewed the biopsy together, she pointed out the numerous fibrous crescents and globally sclerotic glomeruli. I had been told the diagnosis was anti–glomerular basement membrane disease, something I only vaguely remembered from my second year of medical school. As medical students, we get little exposure to pathology as a field of medicine, let alone renal pathology. Since pathology is not a required clinical rotation, a didactic course during the first 2 years of medical school is the total exposure for most physicians’ training. This is despite the fact that approximately 70%-80% of clinical decisions rely on some type of pathology result, whether it is a lab test, a biopsy, or an intraoperative frozen section.
      Renal pathology is more mysterious: even pathology residents get relatively minimal experience with the discipline. Kidney biopsies for medical kidney disease are few in number but highly complex. The field demands additional training, but allows for relatively few pathologists to practice this small subspecialty of medicine.
      My experiences as a patient sparked an intense interest in kidney disease. Coming from a surgical background, I gravitated towards pathology, a field I did not appreciate until I had the chance to explore it the year following my transplant. There were some practical considerations as well. I could not help but wonder what I would do if I had to go back on dialysis. Surgery would be out of the question. However, it seemed possible that I could still review slides if that should occur. Now that I was aware of the field of renal pathology, it appeared to be a perfect match.
      As a renal pathologist, I have the opportunity to work closely with nephrologists as we discuss biopsy findings in the context of the clinical presentation. Examination of kidney biopsies is truly an art as much as it is a science, requiring the pathologist to integrate clinical findings with light, immunofluorescence, and electron microscopic findings, and sometimes, genetics results to arrive at the correct diagnosis.
      When viewed under a light microscope, pathologic glomeruli take on an almost artistic appearance, transforming themselves into crescents, nodules, and spikes. I recall the first time I saw a case of anti–glomerular basement membrane disease as an attending pathologist. Every glomerulus contained cellular crescents punctuated by streaks of fibrin like angry exclamation points accentuating the aggressive nature of the disease. The bright linear staining of the glomerular capillary loops with immunoglobulin G gave away the diagnosis.
      Today, I still think back to my time as a dialysis patient and imagine the person whose tissue now sits on my microscope stage. A person who faces uncertainty. A person who will undergo separation from their current life, hoping to be brought back to health.