KIDNEY DISEASE IN DIABETICS

 

I have been practicing Plastic & Reconstructive Surgery for 40 years now and over the years if ignorance has constantly plagued my patient population it is their understanding of Diabetes. I still see patients who are known diabetic for the last twenty years, walking in with two recent investigations, often totally unrelated to their disease. They know they are diabetic, but they have no idea how diabetes is harming them. They have no information about diabetic endarteritis, and how it affects their target organs – kidneys, heart, eyes and feet, and so naturally they are taking no notice of it. Their constant lament is that no doctor can control their blood sugar levels and the latter keeps on fluctuating constantly! I have in my previous blogs on Diabetes often mentioned about this problem. If you want to read them please click:

https://surajitbrainwaves.blogspot.com/2023/02/diabetes-myths-and-facts.html

https://surajitbrainwaves.blogspot.com/2025/05/are-you-diabetic-let-me-help.html

 

 

In this blog I would like to emphasize how kidneys are at risk in diabetics. For millions of people living with diabetes, the kidneys are quietly working overtime — and often, by the time something feels wrong, significant damage has already been done, because 75% of healthy kidney tissue is reserve, and not needed if the remaining 25% are fully functional. Diabetic nephropathy, or kidney disease caused by diabetes, is one of the most serious complications of diabetes. It can creep up on you almost silently and by the time the patient shows symptoms, the kidneys are significantly damaged.

 

What Is Diabetic Nephropathy?

When blood sugar levels stay high over time, they can gradually damage the tiny blood vessels inside our kidneys — the ones responsible for filtering waste from your blood. The result is diabetic nephropathy: a progressive form of kidney disease that affects a significant portion of people with both type 1 and type 2 diabetes. The condition is more common than many people realize. Roughly 1 in 3 adults with diabetes will develop some degree of kidney disease over the course of their lifetime. It's also one of the leading causes of kidney failure worldwide, making early awareness genuinely life-saving.

 

The condition unfolds in five stages, each measured by something called the Glomerular Filtration Rate (GFR) — essentially a score for how well our kidneys are doing their job.

• Stage 1: Mildly increased GFR, no clinical signs of disease.
• Stage 2: Elevated GFR, significant micro-albuminuria,  potential progression to end-stage renal disease. (Albumin in urine in microscopic amount)
• Stage 3: Overt diabetes, clinical albuminuria, and increasing proteinuria (Significant protein loss in urine)
• Stage 4: Severe loss of kidney function, GFR <15 mL/min/1.73m², requiring  renal replacement  therapy.
• Stage 5: End stage renal disease , GFR <10mL/min, requiring dialysis or kidney transplantation

 

In stage 1, the kidneys are damaged but still functioning well. By stage 5, the kidneys have failed entirely and dialysis or a transplant becomes necessary. What makes this progression so dangerous is that the kidneys are remarkably resilient organs — they can continue working even when significantly damaged, masking the problem until it becomes serious. This is why diabetic nephropathy is sometimes called a "silent disease."

 

The Earliest Warning Signs

Most people feel nothing in stage 1. It's only around stage 2 — when the GFR drops below 89 — that the first, often subtle, symptoms begin to surface. And subtle they are. Patients often dismiss them and attribute them to a bad week or a busy lifestyle. I usually try to look for:

·        Fatigue that doesn't match your activity level

·        Loss of appetite with no obvious reason

·        Persistent headaches

·        Dry or itchy skin unrelated to the weather

·        Nausea or vomiting with no clear cause

·        Mild swelling in the arms and legs

 

I always tell my patients that if any of these sound familiar — especially if they have diabetes they shouldn't brush them off. One particularly telling symptom worth mentioning is foamy or bubbly urine. This occurs when the kidneys begin leaking protein — something healthy kidneys are designed to retain. While it can be easy to overlook, it's one of the more distinctive early signals that something may be wrong.

 

Why should the patients visit their doctors?

A doctor – a physician, an endocrinologist, can detect diabetic nephropathy even before patients feel a thing. Routine blood and urine tests can reveal early red flags, including:

·        Elevated creatinine levels — creatinine is a waste product that healthy kidneys filter out efficiently. When it builds up in the blood, it suggests the kidneys are struggling.

·        Protein in the urine (proteinuria) — specifically a protein called albumin. Its presence in urine is one of the earliest and most reliable indicators of kidney damage.

·        Low albumin levels in the blood — as the kidneys leak protein, blood albumin levels drop, which can eventually affect everything from immune function to fluid balance in the body.

 

In some patients, a doctor may also order a renal biopsy — a minor procedure where a tiny sample of kidney tissue is examined under a microscope to assess the extent of damage. This is typically reserved for more complex or uncertain cases.

 

This is exactly why regular check-ups are so important for anyone living with diabetes. Current medical guidelines recommend that people with type 2 diabetes get screened for kidney disease annually from the time of diagnosis, and those with type 1 diabetes from around five years after diagnosis. My follow up schedule of investigations for my diabetic patients is:

1.      Physician’s consultation (MD Medicine / DM Endocrinology)          – monthly

2.      Blood Urea and Serum Creatnine                                                        - 2 monthly

3.      Blood Sugar – Fasting & PP                                                                - monthly

4.      HbA1C                                                                                                - 6 monthly

5.      Ultrasound of Kidneys, Ureters and Bladder                                       - 2 yearly

6.      Serum Lipid profile                                                                              - 6 monthly

7.      E.C.G                                                                                                  -6 monthly

8.      Fundus examination by Ophthalmologist                                            - 6 monthly

9.      X.Ray Chest                                                                                        - 2 yearly

 

Why is prompt diagnosis and treatment of Nephropathy important?

 If diabetic nephropathy is left undetected or untreated, the symptoms become harder to ignore. These include:

·        Constant fatigue

·        A persistent sense of feeling unwell

·        Shortness of breath

·        Difficulty concentrating

·        Foamy urine

·        Swelling in the hands, feet, and around the eyes

·        Blood pressure tends to climb and this accelerates the damage.

 

 In later stages other kidney functions too get affected:

1.      They struggle to regulate important minerals like potassium and phosphorus. This can lead to muscle cramps, bone weakening, and dangerous changes in heart rhythm.

2.       Anemia — a shortage of red blood cells — is also common, as the kidneys produce a hormone called erythropoietin that signals the body to make red blood cells. When kidney function declines, so does this signal, resulting in anaemia. This leaves many patients feeling persistently exhausted regardless of how much they rest.

 

Who is Most at Risk?

Beyond having diabetes itself, certain factors raise the odds of developing diabetic nephropathy:

·        A family history of kidney disease

·        High blood pressure

·        Obesity

·        Smoking

·        Type 1 diabetes diagnosed before age 20

·        Indians as a race are prone to diabetic nephropathy more than Caucacians

·        Existing eye or nerve damage from diabetes

 

A Vicious Cycle

High blood pressure and diabetic nephropathy form a particularly vicious cycle — kidney damage raises blood pressure, and high blood pressure in turn accelerates kidney damage. So, the real challenge is to break this cycle early, often with medication. This is one of the most important steps in managing the condition.

 

Prevention

While we can't undo damage that's already been done, there's a great deal we can do to slow it down — or prevent it from starting in the first place.

1.      Keep blood sugar in check. This is the single most important thing a diabetic patient can do for their kidneys. Consistently high glucose levels are the root cause of the damage, and studies show that tight blood sugar control can significantly reduce the risk of developing nephropathy.

2.      Manage your blood pressure. Target blood pressure for people with diabetes and kidney disease is generally below 130/80 mmHg. Medications called ACE inhibitors or ARBs are often prescribed specifically because they protect the kidneys beyond their blood pressure-lowering effects.

3.      Watch what you eat. A kidney-friendly diet typically means reducing sodium, limiting protein intake (which reduces the workload on the kidneys), and cutting back on potassium and phosphorus in later stages. Working with a dietitian can make this much more manageable.

4.      Quit smoking. Smoking narrows blood vessels and reduces blood flow to the kidneys, directly worsening their function. It also raises blood pressure and interferes with diabetes medications.

5.      Stay active. Regular moderate exercise helps control blood sugar, lower blood pressure, and maintain a healthy weight — all of which take pressure off the kidneys. A daily walk 4 Km in 40 minutes is ideal.

6.       Avoid NSAIDs. Common over-the-counter pain relievers like ibuprofen and Brufen can be hard on the kidneys. They are called nephro-toxic drugs. People with diabetic nephropathy are generally advised to use alternatives under medical guidance.

 

Kidney damage from diabetes cannot be reversed — but it absolutely can be slowed down, especially when caught early. Treatment options range from diabetes medications and dietary changes to dialysis and kidney transplants in advanced cases. Newer classes of diabetes medications, including SGLT2 inhibitors, have also shown promising results in protecting kidney function and are increasingly being prescribed for this purpose specifically. The most powerful thing you can do? Don't wait for symptoms. If you have diabetes, make kidney health part of your regular medical conversations. A simple blood or urine test and the habit of visiting the doctor every month, even when seemingly in good health could make all the difference — and in this case, catching something early isn't just good news, it's a genuine lifeline.

 

REMEMBERING PROF. K. D. VERMA AND PROF. N. S. BHATNAGAR - AN IDEAL SURGEON - ANAESTHETIST RELATIONSHIP

 

These two friends were inseparable and there is no way I can remember one without the other. Prof. K. D. Verma was a Reader in the Department of Surgeryand Prof. N.S. Bhatnagar was a Reader in the Department of Anaesthesia  in King George's Medical College,  Lucknow when we were doing our MBBS and MS. They offered the perfect example of cordiality that should exist between a surgeon and an anesthetist. I have learned this from these two teachers and have discussed it in great details in one of my previous blogs. If you want to read it, please click: https://surajitbrainwaves.blogspot.com/2019/12/never-argue-with-anaesthetiest.html

 

Prof. Verma was tall, dark and handsome, extremely helpful and always smiling and an very good teacher. His lectures were carefully designed and always to the point. He knew exactly how long to spend on a given point, and he never seemed to rush to the conclusion.  Yet he always had ample time to finish and then ask a few pertinent questions, just to ensure that the subject was clear in our minds.

 

Dr. Verma was trained in Endocrine Surgery from U.K. and was a pioneer thyroid surgeon of our State of Uttar Pradesh, a state which always had a population greater than Europe! So, not only was his Medical College OPD always overflowing with cases of goitre and thyroid cancer, but even his private practice was very busy, predominantly with Thyroid patients. Lucknow being close to the Tarai region of the Himalayas, where iodine deficiency was an endemic then, there was no dearth of goiter patients during our training days.

 

I never had an opportunity to work in Prof. K. D. Verma's unit and so naturally I had not seen and assisted so many thyroid cases as my friends who had worked with him had. But, all that was about to change.

 

After completing my M.Ch in Plastic Surgery and overseas training in four continents, when I returned to Lucknow to start my own practice, I did so in Neera Hospital where Prof. K. D. Verma would regularly operate most of his private cases. He was usually assisted by my two very respected seniors, Dr. Ramakant, who later retired as the Professor and HOD of Surgery and became the President of Association of Surgeons of India and Dr. Ajit Jafa, a senior surgeon doing exclusive private practice in Lucknow then. 

 

One day Prof. Ramakant was held up and Dr. Jafa was out of town. I had just finished my Cleft Palate repair and I did not realize that Prof. Verma was standing behind me, watching me operate. He was very kind with his words of appreciation for my surgery, but little did I know that my luck had struck gold! He asked me if I was free and would I help him with his sub-total thyroidectomy!

 

This started a beautiful relationship of the true Guru-Shishya parampara, and after that I had the privilege of assisting him countless times. What this meant was that an umbra region in my surgical training was suddenly and unexpectedly illuminated by the best guiding light in the world!

 

Right from anaesthesia after seeing the vocal cord movements and documenting it, to positioning the patient's head, neck and shoulders to marking the incision along a horizontal skin crease in the neck with a thread every step was meticulously done in every thyroid surgery.

 

I learned the steps by seeing him methodically follow them again and again. With his original assistants he would never be so verbose, but with me the teacher in him realized that this surgical field was not the one I would often visit. So, he made it a point to explain every step and show every structure.

 

A typical thyroid surgery, a sub-total thyroidectomy will go thus:

• Incision and Exposure: A transverse incision was made in a lower neck skin crease, followed by raising subplatysmal flaps to access the strap muscles.
• Accessing the Thyroid: The strap muscles (sternohyoid/sternothyroid) were separated at the midline and retracted to expose the thyroid gland.
• Ligation of Vessels: The superior pole vessels were ligated first, close to the gland, followed by the middle thyroid vein and then branches of the inferior thyroid artery, often using energy devices or sutures, away from the gland.
• Identification of Structures: The recurrent laryngeal nerve (for voice) and parathyroid glands (for calcium regulation) were carefully identified and preserved.
• Subtotal Excision: Removal of majority of the lobes, leaving a small remnant of tissue on the posterior aspect of the gland to avoid damaging the nerves and parathyroids.
• Closure: Hemostasis was confirmed, and the incision was closed in two lavers with sutures, sometimes placing a surgical drain temporarily, to be removed after 48 hours.

Post operatively the anesthetist, Prof. Narayan Swaroop Bhatnagar would once again confirm the movements of the vocal cords and then the patient was wheeled out.

 

Near the superior pole of thyroid, Prof. Verma would caution me that the Superior Thyroid artery and the external branch of Superior Laryngeal Nerve (EBSLN) travel close together but diverge as they approach the thyroid. So, this artery should be ligated close to the gland, almost abutting it as ligating higher up may damage the EBSLN. This will result in inability to reach high pitched notes.

 

Again, Prof. Verma was most careful while ligating the Inferior Thyroid Artery because of the close approximity of Recurrent Laryngeal Nerve (RLN) and the anatomical variations that can be in their relationship. He would follow the artery to its intersection with the nerve, identify and preserve the latter, and ligate individual arterial branches directly on thyroid capsule, away from the gland. This protected both the RLN and the blood supply to parathyroids that prevented ischemia of parathyroid and resultant hypocalcaemia.  

Once, when I asked how we can diagnose hypocalcaemia he explained:

Low calcium levels cause neuromuscular excitability, leading to:

• Early Signs: Paresthesia (numbness and tingling) in the fingertips and around the mouth.
• Progressive Signs: Muscle cramps, stiffness, and irritability.
• Severe Symptoms: Tetany (sustained muscle contraction), seizures, laryngospasm, and life-threatening cardiac arrhythmias.  

He then went on to explain two tests of hypocalcaemia

- Chvostek’s sign (facial twitching) 

- Trousseau’s sign (hand spasm with blood pressure cuff inflation).

 

Assisting Prof. K. D. Verma was fun. After every surgery there used to be a party, and Dr. N.K. Gupta, who was the owner of Neera Hospital, ensured that food and beverages were never in short supply! Tea, coffee, jalzeera, samosa, bun-makkhan, French toast, cake, pastries, ice-cream, all we had to do was name it……and it was there!

 

Prof. Verma and his anesthetist, Prof. N. S. Bhatnagar shared a unique bond of camaraderie. Their friendship was from their student days and they would unhesitatingly divulge each other's darkest secrets. There are countless stories that come to my mind. The most interesting story, narrated by Prof. Bhatnagar surely was the story of Prof. K. D. Verma's wedding.

 

He was married in a village in Madhya Pradesh, in the once notorious Chambal ravines, famous for dacoits, where no state police ever dared to enter. After the marriage, when he was returning with his newly wedded wife and the baratis, Prof. Bhatnagar being one of them, suddenly they saw a pile of dust in the horizon and heard the hooves of countless horses, getting louder and louder with every passing second. Soon from every direction masked horsemen were descending down the hill and appearing through the ravines. They surrounded the baratis and the newly weds. Everyone was convinced that this was a dacoity and not only will they lose everything, but would be distinctly lucky to escape alive from this mess.

The leader of the pack roared loudly and wanted to know who they were, who was the groom and who the bride's father was? Once he had all the answers he said that they can't go any further and have to accompany them to their Sardar's abode. Left with no choice they all agreed and their convoy was surrounded by all sides by masked horsemen as they made their way through the ravines. At one point they were asked to leave their vehicle, and around 20 horses were provided to them. Needless to say that most of them were on a horseback for the first time, but they were so scared that no one complained. Mercifully the animals did not gallop, they gently trotted and after some time, which seemed to be an eternity, they reached a beautifully decorated house, nestled in the ravines.

 

A huge man, with bushy handle bar moustache was waiting for them at the floral gate. He introduced himself as Malkhan Singh and took them all inside his house where his wife was waiting with an Aarti thali, flowers, sandalwood paste, dhoob and sweets. The bride and the groom were given new clothes to wear. The bride was decorated with sandalwood paste and new set of gold ornaments and the marriage ceremony was again performed. Gifts were showered not only on the groom but on every barati. Gun salutes were given to them and all the masked men danced in gay abandon. Later they were escorted back to their vehicles on horseback. The hosts had refilled their fuel tanks and they came all the way to the national highway to bid farewell to their daughter.

 

Dr. Bhatnagar in his inimitable style said, this was the famous Dacoit of Chambal, Daku Malkhan Singh, who was the bride's tau or bare papa (father's elder brother, not necessarily real brother but even a village elder is tau), and the message to the groom was loud and clear "you are taking my daughter with you, I must never hear any complaints from her!" Then with a triumphant smile he said "Now you know why K.D is so henpecked!" Prof. Verma, to his credit, was a perfect sport and would hit back with an equally interesting story of his own!

 

Dr. Bhatnagar was full of stories, one for almost every occasion and every surgeon. He could keep the atmosphere lively. He was my father's friend but that didn't spare me too. Once he told Prof. I. D. Sharma, with whom I often did breast surgeries, "Let him only reconstruct. Do the mastectomy yourself, don't leave it to him. His 'safe margins' will extend to your next patient." 

 

Prof. Bhatnagar belonged to Banda in Uttar Pradesh and his father was a doctor. My father worked for the Life Insurance Corporation of India, and was posted in Banda. Prof. Bhatnagar's father, Dr. Subbasi Lal, was our family physician and he and his wife treated my parents like their own children. That made me their favorite grandchild, and I remember milking a cow for the first time with Dadi, Prof. Bhatnagar’s mother! Prof. N. S. Bhatnagar and his brother Dr. I. S. Bhatnagar were very friendly with my father and they would often tease me "How will you do plastic surgery, you don't even know how to milk a cow properly. Most of the milk will be all over your face, instead of the bucket!" Prof. Bhatnagar stayed in Mahanagar on Mandir Marg next to the Mayor of Lucknow, Dr. S,C. Rai, a surgeon with whom he regularly operated.

 

Dr. K. D. Verma belonged to a very illustrious academic family. His sister, Prof. Roop Rekha Verma taught Philosophy in Lucknow University for four decades and became the Vice Chancellor of Lucknow University. Prof. K.D. Verma used to stay in Bishop Rocky Street and his house was home to many pet animals and birds. He was a true animal lover and dogs, cats, rabbits, ducks, birds of many variety, roosters and hens and even a pair deer were there.  He was a wonderful host during Holi and he and Mrs. Verma were present in all social gatherings. The couple graced both my wedding and my son's wedding. 

 

Later in life he developed vitiligo and the supremely confident role model that he was, he neither complained nor bothered. After his retirement from this teaching job in KGMC, his practice accelerated. His patients and his students loved him. His seniors too respected his knowledge and skill, and when Prof. P. C. Dubey wanted to get his thyroid cancer operated, he chose Prof. K. D. Verma as his surgeon.

 

We lost Prof. K. D. Verma to COVID. This was an irreparable loss to us, his students and most certainly to his patients. I, being a Plastic Surgeon, never operate on thyroid but because of the blessings of Prof. K. D. Verma, have helped many of my junior colleagues when they needed help in their thyroid surgeries.

A PLAN TO AVOID REGRETS IN LIFE

 

If you knew that your life will end tomorrow, then are you satisfied with the way you lived? Have you done everything you wanted to do? Have you achiever all that you set out for? Have you checked most of the boxes of your /to do’ list? If not, then you are left with a bag of regrets! The commonest regrets – wasted time, missed opportunities, unaccomplished goals, words left unsaid, choosing work over family, not being true to oneself, getting involved with the wrong people and ignoring personal health and happiness are there with almost every person to a lesser or greater extent. You have always known them, but now that I am bringing them to your notice, why not have a plan to avoid them?

 

Regrets can hurt our mental and physical health if we don't accept them. Reflecting on regrets helps us learn from mistakes and become a better person. The biggest regrets often come from not taking action in life. The phrase “if only…” is normally one associated with deep regret, and that’s why it’s incredibly sad when we feel compelled to say it. To avoid having to utter those fateful words, I’ve made a conschious effort and chalked out a plan.

 

1. Always being yourself, and not what others expect you to be.

 It’s a big mistake to always think about other people’s perceptions of you and trying to play up to them, as opposed to just being yourself. If you continuously focus on this, rather than being who you really are, the end result will be that one fine day, you will forget who you are beneath the mask you always try to uphold. Forget about who people want you to be, or how they see you – impress them and inspire them with how you deal with your imperfections instead.

 

2. Never letting others create your dreams

Although the greatest life challenge is the sound discovery of who you really are, the second greatest is finding happiness and peace with yourself. You should always stay true to your own goals and dreams to find happiness and peace. If people disagree with you, it isn’t necessarily a bad thing – it just means you’re standing your own ground and finding your own way. Don’t worry about whether people think you’re doing something crazy. When you find yourself excitedly losing track of time, you’ll know in your heart that you’re on the right path.

 

3. Avoiding the company of negative people

Negative people are best avoided, because they can foist their bad attitudes on you, and even get to you. Remember that keeping the company of negative people is a choice, not an obligation. Once you realize this and begin to keep it in mind, you will open up your world to compassion over anger, generosity over greed, and patience over anxiety. Negative people will sap your energy by their negativism, while a positive circle of genius around you will boost you, improve your performance and bring enjoyment and fulfillment.

 

4. Never falling into selfishness and egotism

A life that revolves around selfish pursuits and egotism is not a life well-lived. You will be remembered by what you have done for others and the world at large, rather than what you have done for yourself. Be selfless, compassionate and try and give back whenever and wherever you can. Our profession gives us an unique opportunity to spread happiness. If we can bring a smile in one face every day, we are touching 365 lives positively every year! And if this becomes our life’s mission, there can never be room for regrets.

 

5. Never fighting change and growth

Change, death and taxes are the only three constant things in life you cannot change. So, don’t fight them as you will surely lose. If you want to know why your life is the way it is, take a look at your past. If you want to know how your future’s going to be, take a look at your actions in the present. You should always leave room in your life for the old to make way for the new. As much as we all like to hold on to that which we know, the truth is that the old is gone, and isn’t coming back. Accepting this fundamental reality and embracing change as it comes will set you up for lasting success.

 

6. Never giving up during tough times

Whenever we fail in life, we should take it as a blessing. This is because failures act as indicators that we need to try something else. Failure is nothing more than a stepping stone towards success. What failures do not indicate is the necessity to give up on what we’re setting out to achieve. Learn what you can from a failure and move on. One baby step at a time is what will get you ahead in life. Eventually, these baby steps build on top of each other and lead to our most glorious and defining moments.

 

7. Never trying to micro-manage everything in life                       

There’s plenty of truth to the notion of creating your own destiny, however this doesn’t mean that you incessantly have to worry about and control everything. Letting go a little will allow you to gain perspective. Once you can see the forest for the trees again, it’s time to take the next step forward. Remember that you don’t always have to be certain that you’re headed somewhere great. Occurrences in life happen in perfect order, regardless of whether you understand that or not. As time goes by in our lives, we all come to understand this principle and see how all the dots are connected. I am not at all suggesting that do not plan in life, those who fail to plan actually plan to fail. What I am suggesting is don’t go into finer details and nitty gritties – they take your time, cause anxiety and in an ever changing world, may eventually turn out to be totally unnecessary.

 

8. Never settling for less than what you deserve

You should always make it a priority in life to let go of what no longer serves you. Sometimes we need to be floored by a bad relationship or other situation, as hitting rock bottom can actually be the springboard we need for us to stand taller than we ever did before. The tears we cry can sometimes clear our eyes so we can see the possibilities that lie in front of us. Remember not to settle for anything less than you deserve.

 

9. Just doing it! Not endlessly procrastinating

We all know life is short, but it’s actually even shorter than you think. If you’re forever waiting for tomorrow, the window for you to do all the things you’ve always wanted to do will silently close, and by the time you realize it has, it will be too late. The choice is yours – do you want to look back on what you’ve achieved with pride, or do you want to make a whole myriad of excuses for the things you haven’t?

                         

10. Being assertive and no just waiting for things to happen

For whatever reason, you may feel hard done by due to the hand of cards that life has dealt you, but that doesn’t mean that you are owed anything – by anyone. Focus on developing a backbone, rather than a wishbone. It’s up to you to take responsibility for what transpires in your life. You are equally important to and just as needed as everyone else in this world. Don’t sit around waiting for things to happen, because they just won’t. Your day is now, it’s here. Seize it and go and create the world you want for yourself.

Life is fragile and unpredictable, and can change petty quickly. To avoid looking back, and wishing that you had done things differently, you need a plan. This blog is that plan.

REMEMBERING PROF. B.K. KHANNA BY HIS CASE DISCUSSION – EMPYEMA THORACIS AND HALITOSIS

 

Prof. Bal Krishna Khanna was the Professor and Head of the Department of Tuberculosis and Chest Diseases in King George’s Medical College when we were doing our M.B.B.S. He was a very strict disciplinarian and a very hard task master. We students were mortally afraid of him. He would never start teaching a fresh chapter or discussing a new case until he had thoroughly quizzed the entire class, starting from the back benchers, about the last taught chapter or about the patient discussed the day before. The rules were petty simple, correct answer, which was an answer that could satisfy him, which in turn was very rare, would mean that the student can sit or he or she would remain standing for the rest of the class. An exceptionally stupid answer would result in standing of the chair. So, it was not at all uncommon to find majority of the students standing in his class.

Prof Khanna was an exceptionally good teacher, and reputed, even long after his retirement, as the last word in pulmonary medicine. He was M.D in three subjects - Pharmacology, Medicine and Pulmonary Medicine & Tuberculosis. His understanding of the diseases of the lungs was outstanding and thorough and Prof. O.P. Tandon of Medicine would invite him to every Postgraduate Clinic in which a patient with pulmonary disease was being presented and discussed. His would teach eliciting of physical signs of pulmonary diseases with great care and the details he could pick up in auscultation with his stethoscope were simply unbelievable. Different types of crepitations, ronchis at different stages of the respiratory cycle, broncheal breathing over the smallest area of consolidation, could never escape his stethoscope. He, Dr. M.S. Agnihotri, Dr. P.K. Mukherjee and Dr. Zafar Zameel formed a formidable quartet of all exceptionally good teachers, but Prof. Khanna was the most feared and still the most sought after. 

He was a visionary academician and an inspiring guide and had a profound influence on generations of students.  He had a gentle squint, and that made him a dangerous invigilator during our written examinations. His gaze would be very deceptive and many students got caught while attempting to pass a chit or prompt a friend, because we thought he was not looking towards us!

He went on to become the Principal of our Medical College when I was doing my M.Ch in Plastic Surgery. He was always just, and always guided by the merit of the student while making key decisions. In March 1998, my one year Pool Job in Plastic Surgery department was coming to an end, and my then Head of the Department was not inclined to give me an extension. During this year long tenure I had participated in undergraduate and postgraduate teachings, conducted elective and emergency surgeries, published 6 papers in indexed journals and was awarded the prestigious Peet Prize by the Association of Plastic Surgeons of India. So, my mentor, Prof. S.K. Bhatnagar asked me to write to the Principal pleading my case and asked me to annex the photocopies of all 6 papers and the certificate of the Peet Prize and my log book. Within 24 hours I got the recommendation for extension for one more year!  

When one becomes the Principal, one often acquires a fan club of teachers around, but Prof. Khanna had none. He once famously asked a senior teacher, who was visiting his office a bit too often, "Don't you have some work to do in your department, because I have a lot!" He was a true Guru of the guru–shishya tradition, where knowledge, discipline, and values were passed on for a lifetime to enrich the students. His students have become pioneers in the field of Pulmonary Medicine, and headed departments and institutions all over the world, and one of them, my senior Prof. Rajendra Prasad, was recently decorated with Padmashree!.

I am today sharing with you a case discussion in which he patiently listened to the history and clinical examination of a patient of Tubercular Empyema Thoracis. Then he started teaching:

Types of Empyema Thoracis

Empyema thoracis can be classified into different types based on the stage and characteristics of the condition. The stages of empyema include exudative, fibrinopurulent, and organizing stages.

·        The exudative stage is characterized by the presence of fluid in the pleural space.

·        In the fibrinopurulent stage, there is an accumulation of pus and fibrin within the pleural cavity.

·        The organizing stage of empyema involves the formation of a thick pleural peel.

Other categorizations of empyema may include acute, chronic, loculated, or complicated empyema.

Acute empyema develops rapidly and may be associated with an infection.

Risk Factors

·       Chronic respiratory conditions like COPD can increase the risk of developing empyema thoracis due to compromised lung function.

• Smoking tobacco is a significant risk factor for empyema thoracis, as it weakens the immune system and damages lung tissues.
• Having a history of pneumonia can predispose individuals to developing empyema thoracis by increasing the likelihood of bacterial invasion in the pleural space.
• Immunocompromised individuals, such as those on cortisone or undergoing chemotherapy, are at higher risk of empyema thoracis due to weakened immune responses.
• Conditions that impair normal swallowing reflexes, like neurological disorders or structural abnormalities, can lead to aspiration pneumonia and subsequent empyema thoracis.

Investigations

     ·        Hematocrit
·        Blood Sugar Fasting and Post prandial
·        Blood urea & Serum Creatnine
·        X-rays Chest PA
·        Examination of Pleural fluid for bacterial culture
·        Pleural biopsy

 

Treatment

     ·        Anti tubercular treatment
·        Inter costal drainage (ICD) with under water seal
·        Atibiotics to treat super added infection
·        Decortication - Chronic empyema is often characterized by thickened visceral and parietal peels which hamper the ability of the affected lung to re-expand and requires this definitive surgical intervention. Open thoracotomy is followed by removal of thickeded and calcified visceral pleura followed by ICD. The lung expands and recreates its pleura
·        Plombage – This is an ancient technique, mentioned only to be ridiculed. After cleaning the pleural cavity of pus, it is washed with antibiotic solution and filled with ping pong balls to fill the dead space. Foreign body infection is a big problem.

Now he turned to the backbenchers and asked them to approach the patient one by one and say what the person presenting the case had missed. After 5 people had returned to their back benches to remain standing for the rest of the class, the 6^th student said “foul smelling breath Sir, halitosis”

Good! He exclaimed, and then started his teaching. 

Halitosis is persistent bad breath. Smoking, eating food with onion and garlic can also cause bad breath but that is transient. Chronic smokers can have halitosis too. Poor oral hygiene is a very common cause of halitosis but bad breath doesn’t necessary mean poor hygiene, but it could be the symptom of an untreated disease. The smell of your patient's breath can tell you an awful lot about different health issues he/she might have and which type of specialist would help him/her most.

1. Acid Reflux or Heartburn – Sour Smell

If your breath smells sour, then there is a condition associated with it – acid reflux. In order to control this smell and make it disappear, you’ll have to take control of your condition first. Also, changing your diet and excluding trigger foods such as garlic, alcohol, spicy food, and coffee may help.

2. Gum Disease – Rotting Teeth Smell

If you have a rotten tooth, then your breath will certainly be letting you know that something is wrong. If this is the case, then you need to make an appointment with the dentist. Gingivitis and periodontitis are the two main conditions associated with rotting teeth and bad odor from your mouth.

3. Stomach Cancer – Metallic Taste and Smell

A metallic taste in your mouth with a similar breath odor is a typical sign of advanced stomach cancer. However, it must be noted that certain medications can sometimes give similar smelling breath.

4. Diabetes – Fruity Smell

A fruity smell from your mouth wouldn’t be considered much of a problem if it weren’t for the fact that it’s a symptom of a much more serious issue. Such an odor only appears when a person is about to develop a diabetic ketoacidosis. Make an appointment with an endocrinologist if you notice that you have fruity breath.

5. Lung Cancer – Rotting Smell

Lung cancer is known to produce a certain odor in the breath that is often described as a rotting smell. Therefore, if your breath has changed and is smelling of something rotten, it’s time to visit the doctor.

6. Kidney Failure – A Fishy Smell

If you have a fishy smell when you exhale then it might mean that you have kidney failure. This disease is very serious, so putting off visiting the doctor is out of the question.

7. Lactose Intolerance – Sour Milk Smell

A sour milk smell is a definite sign of lactose intolerance, meaning your body can’t break down the protein in milk. Other symptoms include cramping and diarrhea.

8. Liver Failure – Moldy and Sweet Smell

A sweet mold-like smell means that your liver is not working well. Another symptom of this condition is the yellowing of your skin and the whites of your eyes. If you notice this, schedule an appointment with your doctor immediately.

9. Tonsil Stones – Dirty Diaper Smell

Tonsil stones accumulate in your throat on the tonsils, giving you breath that some people described as smelling like dirty diapers. One way to treat this condition is to visit a doctor – they’ll use a special medical instrument to get rid of the calcium and bacteria that has accumulated in your tonsils.

10. Head & Neck cancer

Cancer tongue, floor of mouth, alveolus, oro-pharynx all produce halitosis.

The fact that he would surely ask the causes of halitosis in his next class compelled us to learn them by heart, and be ready for his interrogation.