I was sitting inside the dialysis unit at NephroPlus doing my work at the nursing station desk when the nephrologist from UK I have been talking to came on her daily rounds. She was reviewing all the patients one by one and she came to a young 28 year old guy who has been with us for the past half year or so.

After some discussion, I heard the guy ask, "Can I have one liter of water right now? They can pull it off during dialysis, right?"

All of us including the nephrologist, the other patients on dialysis and I burst out laughing!

In the same breath, he said, "Doctor, I feel like having six liters of water every day!"

No one except a dialysis patient can understand these emotions.

Most people on dialysis have this irresistible urge to pull off more fluid during a dialysis session than is actually required. The reason is very simple. We have to restrict our fluid intake. Most of us are allowed no more than a liter of fluids in 24 hours. And this includes anything that is fluid at room temperature. Curd, ice-cream, tea and of course water among other things all put together should not cross more than a liter.

So, when we get off dialysis, the meter starts ticking and every sip of water we take counts towards the fluid weight gain between two dialysis sessions. All the fluid that is present in our body above the 'dry weight' (weight of the body minus any extra fluid that would have been removed if the kidneys were working) is usually targeted for removal during a session.

If too little is removed, you need to watch your fluid intake very carefully until your next session - when you can pull off the extra fluid. Removing too much can cause your Blood Pressure to fall or can cause muscle cramps. Most people on dialysis prefer the latter! Because we hate, simply hate restricting our fluids! The basic restriction is bad enough. Further restricting because you did not remove enough is simply not acceptable.

This is what happened to me recently. I tried removing too much fluid and this caused the low BP.

Most family members of people on dialysis just cannot understand why we do this. Technicians and nurses rarely even make the effort. They treat it like another problem to deal with during dialysis sessions - one that increases their work.

This can be understood only by someone who goes through this. Someone on dialysis.

Last night I found myself up around 3:30. I was slightly sweaty and felt weird. I tried hard to go back to sleep but couldn't. I waited for a while thinking that I would fall back asleep. No luck. I was feeling strange. I figured that my Blood Pressure (BP) was a little low. My body felt weak and drained.

I then woke up Jairam, the tech who comes to help with my dialysis. It was quite an effort. I told him to check my Blood Pressure and infuse some saline. I also asked him to turn the ultrafiltration (UF - removal of water from the body - an important function of dialysis) down. He did all this. He then checked my BP. The higher one was 60! Which was terribly low. Probably the lowest I have ever had! He infused some more saline. My BP was now 80. I could go back to sleep in a few minutes.

I had had a heavy dinner last night. I had skipped dialysis the previous night. When I checked my weight it was 4 kgs above my dry weight. So, I set the UF target to 4 liters. What I overlooked was that I had just had a heavy meal and 4 kgs was probably only 3 kgs of fluid weight. But I had skipped dialysis the previous night and thought I could not put on anything less than 4 kgs!

The important thing I want to highlight is how my body woke up when the BP went low and I couldn't sleep back. If I would not have woken up, the result could have been disastrous. But despite being very tired, I woke and couldn't sleep back. It was almost like my body realized that something was wrong and something needed to be done.

Isn't this simply amazing? I had written about the human genome and the sheer beauty of it all and this is another example of how fascinating the human body is. It has its own little mechanisms of working. It has its own little sub-systems that are so strikingly complex and yet so strikingly wonderful.

My memories of Sitafal ice cream go back to my childhood when my grandfather (mom's dad) would make it and call my brother Prasan, my cousin Nisha and me to his house to have it (we were his only grandchildren at that time). We absolutely enjoyed this and several other treats he prepared and spoilt us completely with! 'Ferndale' boasted of a garden like few others in the city and he grew amazing sitafal, tamarind, guava and mangoes along with things like curry leaves, limes and badams.

Making sitafal ice cream is definitely not for the lazy. This fruit is, by itself, difficult to eat. Every bit of pulp has a big seed inside and you need to use your teeth dexterously to remove the pulp and throw the seed away. These days, a lot of chemicals are also sprayed on the fruit presumably to prevent pest attacks. This makes it necessary to be careful while eating the fruit so that none of the pesticide gets into your mouth. It can lead to a bad cough. The sitafal itself is often wrongly accused of causing the cough but in reality, I think it has more to do with the pesticide that gets into your mouth in small quantities.


Making sitafal ice cream is an infinitely more arduous endeavor. You don't have the luxury of using your teeth to de-seed the pulp. You have to do it with your bare hands if you're doing it at home. Once you have the pulp, you can use it for ice cream or basundi or whatever other concoction you can come up with. Almost anything with sitafal should taste good!

Mumbaikars were treated to sitafal ice cream at the popular Apsara parlour. Then came Naturals. Naturals came to Hyderabad a year or so back and they already have a few outlets in the city. The sitafal ice cream, like many of the other fruit based ice creams is available only during the sitafal season. The sitafal ice cream from Naturals is truly a boon to mankind! It is so good.


The sitafal bits which are in abundance in the ice cream really enhance the flavor. It is nice and creamy, has the right degree of sweetness and the texture is just right. This is one of the ice creams you want to relish every little bit of. A little creamy flavor here. A little bit of sitafal pulp there. Every spoonful is a delight in itself. You just don't want the bowl to finish. And when it finally does, you are so disappointed and craving for more, it is difficult to resist the temptation of ordering another.

One of our older patients at NephroPlus passed away last night. He would come in twice a week. His son mostly accompanied him. I have rarely seen a son so dutiful and loving. He would bring in his laptop and work from the couch we provide next to the dialysis bed. The patient was getting tired of the disease. A couple of weeks back he had stopped coming. I talked to this son and wife a couple of days back. They said he was not willing to come for dialysis. They were trying hard to convince him but he just wouldn't listen. I talked to them yesterday morning and was planning to go over to their house this morning to try and convince him to come for dialysis. Suddenly last evening he became unconscious and was rushed to a hospital. But I guess it was probably all over.

Dialysis can be mentally draining. Week after week, without any relief, without any end to the suffering in sight, you go on and on. There is no light at the end of the tunnel for many. The lucky few who get a transplant get some respite at the end of it all but for the vast majority, this is a permanent thing, something they have to endure for life.

This has led many to question the necessity of dialyzing people who have 'lived their life'. Dialysis is not going to cure anything. Neither is it going to make their lives more pleasant. Dietary and fluid restrictions can be torturous. But this leads us to the question, "What if you don't intervene? What if you don't dialyze them?"

Dr. John Agar, an Australian nephrologist of international repute, in an answer to a question on a forum, says, "Conservative (non-interventional) care is a real and often advisable course. By intervention here, I mean machine and equipment intervention. Good studies - really sensibly and well done - have come from the UK and elsewhere, showing that CKD patients >80 years of age with more than one comorbidity ... do as well - or better - and certainly maintain an better quality of life if treated conservatively without dialysis. Their survival is a little less than 3 months shorter (on the average) than matched patients who chose dialysis ... but their quality of life, their hospitalisation rates, their last remaining time, is better."

He goes on to add, "The dialysis only adds to the misery, rather then relieving it."

The key here is whether to start dialysis or not? Once you start it is very difficult to withdraw. So, relatives of patients above eighty years of age must weigh the pros and cons carefully before deciding to start dialysis. More importantly, doctors must think hard about the benefits and the difficulties and then together with the family make this decision. I am not, for a moment, suggesting that we should not dialyze anyone over 80. All I am saying is it is not the same as dialyzing someone who is much younger. I am saying weigh the pros and the cons, arrive at a decision after a logical consideration of the facts and if the decision is that the patient is going to benefit with dialysis, then go for it.

Don't do it just because you have to do it.