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Winter 2013

Fresenius Medical Care informs

Different countries – different habits

Back to the roots

The first Kidney Options Forum in Barcelona

Surprising Slovenia Paving the way for transplants

NephroCare

Dear Readers,

In the Northern Hemisphere, the months from November to February can challenge even the sunniest optimist. Winter brings the year’s coldest temperatures and shortest days, but there’s an easy way to treat a mild case of the “winter blues” – simply spend time out of doors. Try taking a thirty-minute walk outside each day, especially around noon, when the sun is at its highest. A good dose of sunlight can make a world of dif-ference to your mood.

In this issue of NephroCare for me, we’ll take a look at some other things that can make this frosty season more enjoyable – and healthier, too. So curl up in your favourite chair, maybe with a hot water bottle or an extra blanket for warmth, and dive in…

Many of our patients have surprising stories to tell: Jasna Trbuha from Croatia and Rui Mira from Portugal have overcome tremendous adversity and now share their gifts and wisdom with others. You’ll meet both of them in this issue.

When the weather turns grey and chilly, it can be nice to daydream. It’s certainly the quickest way to travel! Let us take you to the largest country in the EU and to one of the smallest – at opposite ends of the Alps. And while we’re “travelling”, we’ll also discover some international Christmas dishes as well as healthy habits for the festive season.

Our history series “Back to the roots” takes a break from the dialysis timeline to intro-duce two physicians, Joseph E. Murray and Jon van Rood, who pioneered another life-saving treatment option: kidney transplantation.

Speaking of physicians, have you ever met a clown doctor? Dialysis patients in Venezuela recently did – they experienced first-hand how laughter can reduce stress, foster a positive outlook and even boost the immune system.

Have a great winter – and happy reading!

Your NephroCare Team

Welcome!

“We are nearer to SpringThan we were in September,

I heard a bird singIn the dark of December.”

Oliver Herford

NephroCare for me Winter 2013

Fresenius Medical Care informs. 4HighVolumeHDF – helping you to make the most of your life 4 The first Kidney Options Forum in Barcelona 6

NephroNumber. 8Schweinfurt – serving kidney patients with state-of-the-art technology 8

News from around the world. 12First NephroCare centre opened in Peru 12Clowning around in Valencia, Venezuela 14

Worth knowing in renal. 16Vitamins – essential to your health 16

Different countries – different habits. 20France – land of sensual delights 20 Rising like a phoenix 24Surprising Slovenia 28Haemodialysis forced me to slow downand helped me to study 32

NephroCare people. 36Dedicated to comprehensive care 36

Back to the roots! 40Paving the way for transplants 40

Here’s to your health! 44Holiday flavours to savour 44Recipes 46

Inspiring. 50Brain calisthenics 50Announcements 52Questionnaire 53

Content

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Standard haemodialysis (HD) is the most common form of dialysis. During treatment, the patient’s blood is passed through a membrane called a dialyser which removes excess water and waste products by diffusion. Only mole-cules smaller than the membrane’s pore size can cross into the dialysate.

In haemodiafiltration (HDF), excess fluid and waste products are removed from the patient’s body through both diffusion and convection. A pressure gradient is applied, causing water to move quickly through the highly permeable membrane, “dragging” along with it many dissolved substances, in-cluding large molecules which haemodialysis does not clear well.

HighVolumeHDF achieves high substitution volumes in HDF and removes a broad range of waste products – especially large mole-cules – more effectively. It also contributes to the protection of the heart and cardiovascular system to a greater degree. The latest studies have shown that using a large substitution

volume significantly improves treatment results. As such, HighVolumeHDF is the most effective dialysis treatment available today. It lowers the risk of inflammation, anaemia, muscle cramps, hypotension, and complica-tions in general, greatly reducing the likelihood of hospitalisation.

HighVolumeHDF – helping you to make the most of your lifeThe most advanced and efficient form of haemodialysis available, high-volume haemodiafiltration (HighVolumeHDF) has a whole range of positive effects on dialysis-related cardiovascular risk factors. This treatment resembles the normal physiological function of the human kidney more closely than any other dialysis method1. Not only that, it’s also more tolerable for patients. As such, Fresenius Medical Care has made it its goal to allow every one of its patients the chance tobenefit from this therapeutic approach, which can greatly improve quality of life, as part of its ongoing dedication to improving patient outcomes.

“... thanks to HighVolumeHDF,the quality of my life

has greatly improved!”Maria Rosaria Tammaro, NephroCare patient, Italy

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Fresenius Medical Care has been developing products in this area for a long time, and our new 5008 CorDiax and 5008S CorDiax dialysis machines are the most advanced systems available for High VolumeHDF. In combination with our FX CorDiax haemodiafilters, which perfectly support the removal of larger mole-cules (with its unique membrane), HighVol-umeHDF can be applied as simply and safe-ly as HD. This means more patients will have the possibility to benefit from the outcomes of HighVolumeHDF.

Study results from SpainA recent study in Catalonia, Spain, has pro-vided clear evidence for the benefits of the

HighVolumeHDF. In the words of Prof. Bernard Canaud, Chairman of the EMEALA Medical Board, “HighVolumeHDF significantly im-proves quality of life in comparison to stand-ard haemodialysis and should therefore be the standard in cardioprotective haemodialysis therapy for all patients”.

906 patients from 27 dialysis centres across Catalonia took part in the study, making it the largest trial of haemodiafiltration to date. The results showed that dialysis patients treated with large volumes of exchange substitution fluid (HighVolumeHDF) had 28% less hypo-tensive episodes during dialysis. The likeli-hood of hospitalisation was also 22% lower than for patients receiving haemo dialysis. These results demonstrate how HighVolume-HDF contributes to better patient well-being and ensures that patients enjoy greater quality of life and benefit from our excellent therapy.

• Lower risk of hypotension (drop in blood pressure) during dialysis2

• Less medication needed due to reduction of EPO3 and phosphate binders4

• Less fatigue, headache, nausea, and weakness due to improved anaemia control5

• Fewer days in hospital2

• Less risk of inflammation4

The benefits of HighVolumeHDF

1 KrickG.,RoncoC.(eds):On-LineHemodiafiltration:TheJourneyand theVision.ContribNephrol.Basel,Karger,2011,vol175,pp93-109.2 MaduellF.etal.,JAmSocNephrol(2013);24:487-497.3 OkE.,etal.,NephrolDialTransplant(2013);28:192-202.4 Pedrini,L.etal.,NephrolDialTransplant(2011);26:2617-2624.5 BonforteG.etal.,BloodPurif(2002);20:357–363.

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This May in Barcelona, the Nephrology Departments of two Spanish hospitals – Fun-dació Puigvert and Hospital del Mar – joined forces with the Kidney Patients’ Association of Catalonia (ADER) and Fresenius Medical Care to host the first Kidney Options Forum. The evening event was attended by more than 80 pre-dialysis patients and their relatives.

Exploring three treatment pathsDr. José Ballarín, Head of the Nephrology Department at Fundació Puigvert, started off by talking about healthy kidney functions as well as the causes and distribution of chronic kidney disease (CKD) before spotlighting the importance of early diagnosis and describing the measures used to slow down the progres-sion of CKD. Next, Dr. Julio Pascual, Head of the Nephrology department at Hospital del Mar, spoke about one specific option for kidney replacement therapy: kidney transplantation. In fact Cata-lonia has one of the highest rates of trans-plants in Spain. He succinctly explained what a kidney transplant is and what leads to its success. Some patients are not suitable candidates for kidney transplantation, but for those patients there are other possible

treatment options, each offering an enjoyable quality of life. Dr. Rosa Ramos from the Medical Depart-ment of Fresenius Medical Care Spain briefly introduced the basic principles of dialysis, and then focussed on one of these “other” options: peritoneal dialysis (PD). The process uses the patient’s peritoneum as the membrane to remove fluids and waste substances from the blood. Dr. Ramos explained the advantages and disadvantages of this technique, empha-sizing the freedom of movement it provides.

During a short break the participants had the opportunity to ask questions, request infor-mation, and express their concerns and worries. After the break, Dr. Laura Ribera, Medical Director of Fresenius Medical Care Glories Dialysis Centre, presented another treatment option: haemodialysis (HD), which can be done at home or in-centre. After illus-trating the importance of a well functioning vascular access and how blood is purified by means of a dialysis filter, Dr. Ribera pointed out what patients should consider when choosing to have dialysis in a centre or at home.

A local patient shares his storyThe forum concluded with a presentation by

The first Kidney Options Forum in BarcelonaKnowledge is the key – this rings especially true if you’ve been diagnosed with kidney disease. Future patients want to understand their illness better, ask questions, compare options and share experiences. Spending an evening together with experts in a welcoming atmosphere can be very reassuring.

Foro Opción RenalTome una decisión informada

30 de mayo de 201316:00 – 19:30Novotel Barcelona City

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Antoni Tombas, President of ADER. He shared his experience as a renal patient, describing the phases of his long journey. In a very descriptive way, Antoni recalled his experi-ence with dialysis and how it has effected his life. He reported that he is very happy with his current state of health – a renal transplant from a living donor allows him to live a full and active life. Antoni stressed the importance of family ties during the entire process, thanking medical staff, family and friends and of course, all the anonymous donors who helped pave the way for him and other patients.

Visiting a NephroCare dialysis centreThe event itself was over, but there was more to come! About 30 patients, accompanied by staff from Fresenius Medical Care, opted to take a guided tour of the nearby Glories Dialysis Centre. Time to ask more questions: What happens to my blood in the filter? Does it mix with the water? How does tap water become pure water? Can all patients choose haemodiafiltration (HDF)? The visitors ex-plored the clinic’s treatment options and re-ceived first-hand advice, e.g. on eating well. And all the nice little “extras” – like having an individual television or Internet connection during dialysis – were a positive surprise.

This is just the beginningThe Kidney Options Forum is designed to help clear up fears and questions about the various treatment options for renal failure. That way, renal patients and their families are reminded that they are not alone, that hospitals, clinics and patient associations will provide all the vital informa-tion and accompany them on the journey they have begun. This first event was a success – we hope there will be many more!

“Whensomeonewhohasbeenthrough whatyou’regoingthrough,tellsyou hislifeexperience,youseethisprob- lemwithdifferenteyes.Youdon’tfeel solostoralone.”

“InabouttwomonthsI’llhavetostart dialysis,andthisforumtellsmewhatto expectandhowtoprepareforit.”

“Thesemeetingsareessentialforus. Itisveryimportanttohaveallthe informationbeforetakingsuchabig decision.”

Feedback from participants:

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Focus on supporting renal patientsFresenius Medical Care has been manufac-turing dialysis machines in Schweinfurt for 34 years, dedicated to improving the quality of life for patients with kidney disease. But the roots of this commitment go back nearly five decades. To support kidney patients in Ger-

many, Fresenius had started to import and distribute dialysis machines from the United States in the 1960s. By maintaining these machines and continuously exchanging ideas with medical staff, Fresenius employees developed a high degree of technical exper-tise in dialysis technology.

Schweinfurt – serving kidney patients with state-of-the-art technologyLocated in a Southern German region known as Franconian Tuscany, Schweinfurt and nearby towns along the River Main are famous for delicious wines such as Silvaner and Spätburgunder. But wine is just a small part of the story. Franconia provides excellent “growing conditions” for technology, too! The high-tech companies who call Schweinfurt home manufacture airplane components, innovative bicycle parts – and, in the case of Fresenius Medical Care, world-class dialysis machines for patients around the globe.

ProductionoftheA2008Cdialysismachinemorethan30yearsago.

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By the 1970s, Fresenius was developing its own dialysis machine. In Schweinfurt, Germany, a plant was built precisely for this purpose, and serial production of the first Fresenius dialysis machine began in 1979: the A 2008 C was born.

Schweinfurt was the first plant to be estab-lished, but Fresenius Medical Care now oper-ates more than 40 production sites on all continents. Its largest plants in terms of production output are in the USA, Germany (Schweinfurt and St. Wendel), and Japan

(Buzen). Around the world, twenty-five large facilities and 15 smaller ones cater to local demand for dialysis products. All with a view to improving patients’ lives and providing highest quality dialysis.

Bold beginnings and strong growthBack in 1979, the Schweinfurt workforce was fairly small – only 40 employees – and the plant produced exactly 36 machines that year. The original plant has increased nearly sevenfold in size, and now employs over a thousand people.

• In 1999, the employees won second prize in the international “Industrial Excellence Award” competition which is open to all industries, and is awarded by the German business magazine “Wirtschaftswoche” and the French management school INSEAD. • In another competition of similar scope in 2000, the plant received the German GEO Award (GEO = Global Excellence in Operations) for its particularly efficient organisation of dialysis machine development and production.

• In 2005, the employees once again won second prize in the international “Indus- trial Excellence Award” compe tition. • In 2006, Fresenius Medical Care received the 26th German Business Innovation Award in the category “Large Companies” for its new 5008 dialysis machine, developed and produced in Schweinfurt. • In 2010, Fresenius Medical Care’s Schweinfurt plant earned the Bavarian Quality Award for outstanding quality management in the “Industrial Manu- facturing” category.

In everything we do, we focus on providing renal patients with the highest quality dialysis products. The best “prize” is knowing we’ve helped improve your daily life!

Employees at Fresenius Medical Care’s Schweinfurt plant aim for the highest possible product quality and durability, continuously improving processes to further enhance the quality of life for kidney patients. This commitment has been honoured with many awards:

Prizewinning patient care

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The Schweinfurt factory now manufactures approximately 46,000 dialysis machines annually – thanks to many fully-automated production steps, such as for the highly sensitive valves in the hydraulic circuit. Last year, Schweinfurt’s 500,000th dialysis machine rolled off the production line!

Talented teams, own equipment, strict testingThousands of parts must be assembled and tested so that a dialysis machine can deliver top-quality therapy to patients consistently, even after the millionth treatment. After all, some machines are in operation for more than a decade. First-class manufacturing starts with well-educated, talented staff. On aver-age, 50 employees are involved in the pro-duction of each dialysis machine. The plant has its own injection moulding and machining

equipment to manufacture components in-house, as well as a range of circuit board mounting equipment to fit the boards with the electronics and software needed to operate the machine. Lastly, before being shipped to customers, each dialysis machine must pass a rigorous series of stress tests. During the first stage, called “burn-in”, it is operated under adverse conditions to see how it copes with temperatures up to 60°C and extreme

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pressure on the tube lines. After passing this stage, the machine is subjected to “extended burn-in” where it runs non-stop for two days and undergoes detailed inspections by electronics specialists looking for weaknesses or signs of malfunction. Only machines that reliably pass every test are released for ship-ment, carefully packaged, delivered to dialysis centres, and put into service. Reliability is crucial to treating patients with chronic kidney disease, because it guarantees a high level of patient safety and an enhanced quality of life.

In Schweinfurt, everything is done with renal patients in mind. Throughout the plant, you can see posters of patients receiving dialysis. These portraits of dialysis sessions serve to remind everyone of their number-one goal: improving patients’ lives by manufacturing state-of-the-art dialysis machines.

46,000200,000,000

500,000


70,000

Nephro numbers – neat to knowChronic kidney disease is enough of a challenge – we want to make its treatment as reli-

able and accessible as possible. Many patients and doctors trust the high quality and

reliability of our products. In fact, more than 50% of the dialysis machines in operation

around the world come from a Fresenius Medical Care factory.

• The size of the Schweinfurt plant has increased from 10,000 m2 to 70,000 m2

since 1979.

• 2012 was a significant year for Schweinfurt: The 500,000th dialysis machine

rolled off the production line, and more than 46,000 dialysis machines were

produced at the plant during the year.

• Worldwide, Fresenius Medical Care dialysis machines provide 200,000,000

treatments to patients every year.

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Peru’s healthcare landscapePeru has one of the fastest-growing econo-mies in the world. The government invest-ment in healthcare has increased significantly in the past few years and remains a priority in the future also.One important aim of imple-mented widespread reforms is to give health care services to the nation´s poor. Aside from the expensive health insurance system, Peru-vian hospitals have good standards, and there are numerous private health clinics in Peru’s larger cities, such as Lima and Arequipa.

Peru is home to a small number of dialysis patients, almost all of whom have their treat-ment covered by the national social security system. The Clerdisur clinic now offers renal patients haemodialysis treatment in a friendly, welcoming atmosphere.

Clerdisur: setting new standards“At Clerdisur, we use our medical expertise to help our patients so they can achieve a better standard of living,” explains nephrologist Dr. Socorro Carreón, the clinic’s medical director. “We do this by providing them with personalised treatment characterised by kind-ness, care and patience.” Carreón is sup-ported by her team of expert staff led by head nurse Jacqueline Guillén. Since the take over, Fresenius Medical Care has adapted both the architecture and the treatment standards for patients’ comfort and safety, which always comes first. A stand-alone dialysis centre fully equipped with Fresenius Medical Care 4008S haemodialysis machines, Clerdisur currently treats about 100 patients, all referred by Arequipa’s main public hospital.

Four types of hospitalsEsSalud, Peru’s employer-funded social

First NephroCare centre opens in Peru

FreseniusMedicalCare'sClerdisurDialysisCentre,Peru

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In February 2013, Fresenius Medical Care took over its first haemodialysis clinic in Peru. The Clerdisur clinic is located in Peru’s second city, Arequipa, in the far south of the country. As a fully-fledged member of the NephroCare network, Clerdisur focuses on making a positive difference in patients’ lives – one treatment at a time.

News from around the world


security system, runs a large network of hospitals and clinics open to EsSalud mem-bers and their families. Those who do not qualify for EsSalud coverage are catered for by MINSA-SIS, a national insurance system run and financed by the ministry of health. MINSA-SIS was created to bring people in social need into the system and provide them with healthcare coverage. There is still a lot of work to be done. At present, almost 40% of the country’s population still has no health insurance. This is partly due to administrative barriers, as well as the fact that many people are unaware of the programme and its benefits.

The third pillar of the Peruvian healthcare system is the country’s network of police and armed forces hospitals, which treat only members of those forces and their families. Finally, expensive private clinics cater to the elite; although they are open to all, only 10% of the population can afford to use them.

Fresenius in Peru – 13 years and countingFresenius Medical Care entered Peru in 2000 as a provider of dialysis products. Since then, it has grown to occupy a leading position in the Peruvian dialysis market – thanks to excellent product quality and outstanding

staff performance. Now, Fresenius Medical Care Peru is looking to expand the local NephroCare network, so more Peruvian kid-ney disease patients throughout the country can have access to NephroCare´s first rate treatment.

“All of us at Fresenius Medical Care Peru are very proud to have Clerdisur as our first NephroCare clinic,” explains Gustavo Ambro-sini, General Manager of Fresenius Medical Care Peru. “The Clerdisur team has already demonstrated superb professionalism and a very sensitive touch when taking care of patients.”

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Fresenius Medical Care Centre Peru

Clown Care is a global scheme in which spe-cially trained clowns visit hospitals and medi-cal centres. These clowns are also colloqui-ally termed “clown doctors”, and this name is trademarked in a number of countries. Visits to hospitals by teams of clowns have been shown to aid patients’ coping ability, as they create humour and positivity and provide a sense of hope and connection with society. Staff and patients’ families also benefit.

The “clown doctor” idea began in New York in 1986, when Michael Christensen created the Big Apple Circus Clown Care Unit. Today,

clown doctor programmes are active in all kinds of medical environments around the world. And clown doctors aren’t just for kids – while they’re trained to attend to children’s needs in particular, they’re also happy to visit adults. Clown doctors provide an entertaining distraction and help patients adapt to new

Clowning around in Valencia, Venezuela

“What soap is to the body, laughter is to the soul.” Yiddish proverb

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Cultivating a positive attitude towards life, maintaining good humour and staying enthusiastic can help us cope with the difficulties life presents – especially in the case of illness or disability. With this in mind, the NephroCare team at Centro Nefrológico Valencia Sur, in Venezuela’s Carabobo State, arranged for some “clown doctors” from a local organisation to visit and talk with patients.

News from around the world


surroundings. Being in a jovial space filled with laughter encourages people of all ages to relax and have fun. The goal: to bring smiles to patients’ faces.

Clown doctors use magic, music, storytelling and other clowning techniques to enliven clinic situations and make patients feel at ease. Studies have shown that humour and laughter have many positive effects – as well as combating stress, they can even play a role in reducing pain and boosting the immune system. Bringing humour into the clinic set-ting can make a tremendous difference for patients: helping them foster a positive out-look, creating a pleasant atmosphere, and promoting bonding and support. All of this supports the patient’s ability to cope, and helps make dialysis sessions as relaxed as possible.

Dr. Yaso Hospital Clowns is a non-profit foun-dation active in Venezuela since 2005. Its mission is to help alleviate the suffering of people with diseases – especially children, adolescents and the elderly – through imagi-nation, play, love and respect. When contact-ed by NephroCare, the clowns dropped every thing, heading to Valencia to pay the

centre a visit and bring smiles to the faces of patients, their families and NephroCare staff.

The Dr. Yaso clowns helped explain kidney disease and its implications to patients and their families, briefly but comprehensively and in their own inimitable way. Instead of a public performance, the clowns worked with patients individually, moving from chair to chair. While some patients were positively surprised and happy to engage with the unusual visitors, others were reluctant or nervous at first, but soon opened up – thanks to the clowns’ friendly and caring approach.

The Valencia team hopes that this initiative will become a recurring event. The trained clowns inject colour and variety into patients’ every-day routine, help meet their emotional needs and boost their quality of life. Many of the patients expressed their appreciation for the clowns’ visit, and the centre’s staff were pleased the event went so well. The Nephro-Care team at Centro Nefrológico Valencia Sur hopes to inspire other Fresenius Medical Carecentres to hold similar events in the future. More smiles for everyone!

“Laughter is the shortest distance between two people.” Victor Borge

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Vitamins – essential to your health, but only in the right amountVitamins – so named because they are vital to health – are organic nutrients that help your body use the food you eat. They’re absolutely essential for functions such as energy, growth, and repair. As most of them cannot be manufactured in sufficient quantity by the body itself, they must be obtained from food or through supple-mentation. Vitamins are an important part of everyone’s diet, but especially so for kidney patients, who are particularly susceptible to deficiencies.

How vitamins were discoveredIn the late 1800s, Dutch physician Christiaan Eijkman discovered that substituting unpol-ished rice for polished rice would prevent beriberi, a disease causing anaemia and pa-ralysis among the very poor. But it wasn’t until 1911 that a Polish chemist discovered what exact component of unpolished rice was

preventing the disease. Casimir Funk realized that it was an amine, a type of compound containing nitrogen. Because it was vital to health, he named it “vital amine” or “vitamin” from the latin word vita, which means life, combined with amine.

What’s key for renal patientsVitamin deficiencies develop slowly over time and can occur due to abnormal renal meta-bolism, inadequate gastrointestinal absorp-tion, and loss of vitamins as they are “washed out” during dialysis. Deficiencies also depend on factors such as your diet, your body’s existing vitamin stores, your age and gender, time spent on dialysis, the type of dialyser used, and how well your metabolism is func-tioning. As such, vitamin supplements must always be prescribed by your doctor and tailoured to your specific, individual needs.

Signs of deficiencyIf you have a vitamin deficiency, you may experience a depressed immune system, peripheral neuropathy (a loss of sensation), impaired amino acid and lipid metabolism, mild scurvy, or other abnormalities in bodily functions. Deficiencies in water-soluble vita-mins such as the B vitamins and vitamin C are

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Worth knowing in renal.

most common. Nevertheless, it’s important that renal patients do not take over-the-counter vitamin supplements designed for people with healthy kidneys. Chronic kidney disease changes your body’s need for certain nutri-ents, and as the kidneys stop functioning, some vitamins can accumulate in harmful amounts. This means you need to limit or even avoid certain vitamins; commercially-available vitamin supplements are not recom-mended for dialysis patients

Which supplements are safe?Most people can ensure they get all the vita-mins and minerals they need by following a balanced diet – but for kidney patients, this is usually not enough. Dietary restrictions, poor appetite, side effects of medications, vitamin losses during dialysis, and missed mealtimes due to appointments or illness can make healthy eating quite challenging at times. You may be not be able to obtain all the vitamins you need from dietary sources, because you have to limit specific food groups. And renal disease affects the body’s ability to manufacture or even use some nutrients, such as vitamin D.

If your doctor identifies a vitamin deficiency, he will prescribe a supplement tailoured to

your individual needs, that you should take daily or after each of your dialysis sessions.

Vitamins to avoidThere are two types of vitamins: fat-soluble and water-soluble. The fat-soluble vitamins A, D, E and K are stored by your body and have a tendency to build up, so please avoid taking them unless prescribed by your nephrologist. Vitamin A in particular can accumulate to a toxic level if taken as a daily supplement.

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Vitamins you needWater-soluble vitamins are not stored by the body and need to be supplemented. To provide you with the extra water-soluble vitamins needed, a special renal supplement is usually prescribed, containing the full set of B vitamins – B1, B2, B6, B12, folic acid, niacin, pantothenic acid and biotin – plus a small dose of vitamin C. While some claim that large “megadoses” of vitamin C are beneficial to health, dialysis patients should avoid a large vitamin C intake at all costs. Your body breaks it down into oxalate, which may accumulate and deposit in bones and joints and cause pain.

How vitamins help your bodyThere are 13 human vitamins: vitamins A, C, D, E, K and the eight B vitamins. All were identified by science in the first half of the twentieth century.

The B vitamins help your body’s cells produce energy, and also have a variety of other essential functions. Thiamine (vitamin B1) helps your nervous system function correctly, riboflavin (vitamin B2) keeps your skin and eyes healthy, and niacin (vitamin B3) ensures your body’s enzymes work correctly and

helps your body use sugars and fatty acids. Pantothenic acid (vitamin B5) and biotin (vitamin B8) play a role in metabolising protein, fat and carbohydrates from food, while vitamin B6 is involved in making new red blood cells.

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Worth knowing in renal.


Finally, folic acid (vitamin B9) and vitamin B12 help make DNA, new cells and red blood cells, and keep your nerve cells healthy.Though excessive uptake should be avoided, Vitamin C is a very important vitamin with many roles. It keeps your gums and immune system healthy, protects against bruising, and helps to heal cuts and wounds. Not only that, it’s involved in the production of collagen, bone, red blood cells and other tissues, and keeps the walls of blood vessels and capillar-ies firm. It also helps the body absorb iron.

Vitamin A helps your cells and tissues grow, and protects against infection. Vitamin D helps your body absorb calcium and phos-phorus, needed for healthy bones and teeth.

Vitamin E acts as an antioxidant and protects cells from oxidation and free radicals. It also protects against heart disease and some types of cancer. Lastly, vitamin K is respon-sible for blood clotting and healthy bones.

If your doctor has not placed you on a special vitamin supplement, ask him whether you could benefit by taking one. Please do not take any other supplements, herbal or folk remedies or over-the-counter medicines not approved by your nephrologist. Your body will thank you!

Fat or water?Remember: There are two types of vitamins: fat-soluble and water-soluble. Fat-soluble ones tend to accumulate in your body, water-soluble ones must be replenished. But kidney patients need to take special precautions – please talk to your nephrologist before taking any type of supplement.

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France – land of sensual delights

A history of revolutionFrance has a rich history and a tremendous amount to see and do. The country’s national motto of “Liberté, égalité, fraternité” (Liberty, equality, fraternity) traces its origins back to the French Revolution, when the monarchy was overthrown and the population rose up against the power of aristocrats, landowners and the Catholic Church. This was followed a decade later by the Napoleonic Wars, which saw Napoleonic France conquer much of Eu-rope, only to be driven back and defeated in 1815. Today, France is proud of its status as a republic, and in the 20th century the country played a major role in the creation of the UN and EU.

Paris – city of dreamsWithout doubt one of the world’s most stun-ning cities, Paris is almost like a giant, bustling open-air museum – one that has to be seen to be believed. Whereas many cities are archi-tecturally chaotic, Paris is remarkably uniform thanks to its complete redesign by Hauss-mann in the 19th century, which transformed a medieval city of winding roads and narrow alleys into a grand modern one of spacious squares and broad boulevards. Paris is the world’s number-one tourist destination and

most of the city’s major tourist attractions, such as the Eiffel Tower, the Trocadero, the Louvre art museum (home to Leonardo da Vinci’s Mona Lisa), the Arc de Triomphe and the striking Pompidou Centre are north of the Seine, on La Rive Droite. For shopping – and to see and be seen – there’s no better place to head for than the legendary Avenue des Champs-Élysées, home to upmarket brands (Chanel, Dior, Yves Saint Laurent, Louis Vuit-ton, Cartier, …). Or for the latest in French fashion, head for the historic department stores Galeries Lafayette and Printemps on Boulevard Haussmann in the 9th arrondisse-ment.

Live like a ParisianSouth of the Seine, on La Rive Gauche, is where Paris’s true, unique character really shines through. There is perhaps no location more archetypically Parisian than Rue Mouf-

World-renowned for its food and wine, culture and lifestyle, it’s no wonder that France is the world’s most-visited country. Every year, around 80 million tourists head for La République to indulge in some Gallic joie de vivre. Mainland France offers a gorgeous array of sights, sounds and smells for visitors to soak up in all parts of the country – from the Pyrénées and Côte d’Azur in the south to the Breton coast and the urban flair of the Île-de-France region in the north. Not forgetting the French Alps!

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Different countries – different habits.

fetard, a long, narrow cobbled pedestrian street in the city’s Latin Quarter, lined with a seemingly infinite selection of bakeries, confi-series, cafes, restaurants, delicatessens, mar-ket stalls, and highly specialised independent food shops. One of the city’s best kept se-crets and surprisingly easy to overlook, it’s here that Parisians come day in day out to meet all their culinary needs, from the most elaborate and expensive gateau to a simple punnet of juicy French raspberries. Quaint yet bustling and almost impossibly picturesque, it’s no surprise the street has been used as a location in French films such as Trois Cou-leurs: Bleu starring Juliette Binoche.

Historic treasures nearbyJust outside of Paris is the Château de Ver-sailles, a grand palace that testifies to the pre-Revolutionary power of France’s monarchy. Even more historic is the Basilica of Saint Denis to the north of Paris, where the coun-try’s patron saint is buried.

Rural and rusticFrance’s northern coast may be less explored than its Mediterranean counterpart, but boasts delights all of its own – like the fairy-tale castle of Mont St. Michel, built on a prom-

ontory and regularly cut off from the mainland by high tide. It’s located in the region of Nor-mandy, the closest part of France to the UK, and known for its characteristic half-timbered houses and cider production. The region also includes a number of historic abbeys such as Jumièges, Gruchet-le-Valasse and Bec Abbey.Further west lies Brittany, the scenery of which is strikingly different from the rest of

France, being more similar to that of south-west England. The Breton coast features dra-matic cliffs as well as marshes and forests and over 800 islands. Locals speak the Celtic language of Breton, closely related to Welsh. Brittany is also peppered with dramatic chateaux and beautiful Gothic and Roman-esque cathedrals, and many towns in the region still retain their full medieval fortifica-tions. Neolithic sites testify to the region’s early settlement.

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Scenic mountainsFrance is renowned for its countryside. The French Alps are popular among skiers and snowboarders in winter and hikers in summer, many of whom stay in the beautiful city of Grenoble or in resorts like Chamonix, site of the first ever Winter Olympics, and Annecy, on the northern shore of Lac Annecy. Here you will find some of the highest peaks in the Alps, such as the impressive Mont Blanc, the high-est mountain in Europe. Forming the border with Spain, the Pyrénées mountain chain also provides ample hiking opportunities. The Pyrénéan town of Lourdes in southern France is visited by millions of pilgrims a year, as the water is believed to have healing properties.

Mediterranean coastIn summer, the most-visited part of France is the Mediterranean coast or Côte d’Azur, so named for its turquoise waters. Part of the Provence region, it’s the playground of the rich and famous and a major yachting desti-nation. Cities on the Côte d’Azur include Nice, Cannes – which hosts the annual film festival – and Monaco, a tiny principality and one of the world’s smallest countries, home to the Monte Carlo casino and prestigious Monaco

Grand Prix. Nearby Corsica, an island in the Mediterranean Sea, boasts more than 200 beaches and its own language. Further inland in the Provence region, the city of Avignon has a beautifully preserved historic centre and medieval ramparts, and is a UNESCO World Heritage Site.

Tasty treatsFood is an incredibly important part of French culture. The country’s cuisine is based around multiple small courses – the French love noth-ing more than savouring rich meats, decadent desserts and pungent cheeses. Meals typi-cally begin with an amuse-bouche (taster) and hors d’oeuvre (starter) – perhaps escargots (snails) – before moving on to a soup.Then it’s time for the plats principaux or main course, commonly a meat or vegetable dish such as coq au vin (chicken braised in wine) or rata-touille (a vegetable stew from Provence). Be-fore moving on to dessert, tasting some French cheese is a must. Desserts are small and calorie-rich, and include crème brûlée, éclairs, madeleines, profiteroles and crepes.

NephroCare in FranceFresenius Medical Care began its activities in France in 1997 as the country’s first private dialysis provider. Since then, evolution has been constant and we are currently the only dialysis provider with nationwide coverage. At our 38 centres throughout the country, all with free Wi-Fi, over 700 employees – including 60 nephrologists – currently treat more than 2,150 patients, mostly with haemodialysis. All of our patients are provided with access to dieticians, social workers and psychologists.

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4 surprising facts about France• The most famous landmark in all of France, the Eiffel Tower was never intended to be permanent and only had a 20-year permit. It was even supposed to be moved to Montreal, Canada in 1967. Thankfully, this didn’t happen, and today it is the world’s most-visited paid monument. • Bastille Day (14 July) is France’s main national holiday. It celebrates the event that started the French Revolu- tion: the storming of Paris’s Bastille Saint-Antoine prison on 14 July 1789. Ordinary French people had had enough of vast social inequality

and a decadent, indifferent aristo- cracy, and made their voices heard. Today on Bastille Day, a parade is held in Paris. • Hitler ordered Paris’s complete destruction in 1944. It was only thanks to the actions of the German governor of Paris, that the city did not meet the same fate as Warsaw. • French inventions include the hot air balloon and the submarine. French pioneers also played major roles in the development of photography, cinematography, animation, and vaccines …

Muret Béziers

NîmesLunel

Maubeuge

FourmiesPont sur Sambre

Champigny sur Marne

BièvresSuresnes

Coulommiers

ÉtampesVillejuif

GennevilliersMarne-la-Vallée

MontfermeilLe Raincy

Créteil

Chelles

Pontault-Combault

Bagnols sur Cèze

Castelnau-le-Lez

Castelnau Le RochetCornebarrieu

Rieux-Volvestre

Fontenay sous Bois

Rillieux-la-Pape

Belley

Helfaut

Aulnay sous Bois

Tassin – Charcot

Béziers la Colline

Maubeuge Crosseurs

Aire-sur-l’AdourOrthez

Oloron-Sainte-Marie Pau

FreseniusMedicalCaredialysiscentresinFrance

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Rising like a phoenix – on the wings of creativity

She wheels her chair into the room, with her hands wrapped up in bandages, but her face shows no signs of pain and hardship, rather, she seems to radiate inner strength and hap-piness. Jasna Trbuha is 40 years old. Her journey with dialysis began in 2008, and she admits that it took her quite a while to accept her diagnosis: “When I found out I would need haemodialysis, I was in shock and denial. My mind simply refused to accept it.” Gradually,

the news sank in, and Jasna felt incredibly angry towards the world of medicine, her diseases and life in general. “It was like I’d been sentenced to life in prison.” But after facing other health complications – including amputation of her right leg caused by severe carcinoma on her ankle – she wanted to avoid further problems and decided to start dialysis.

Jasna was born with a rare genetic skin disease called epidermolysis bullosa, also known as EB. People with this hereditary disease have extremely thin, fragile skin – blis-ters or “bullae” form continuously. This causes open wounds that are as painful as burns and heal very slowly. Jasna’s damaged skin and mucous membranes have caused deforma-tion of her feet, hands and ankles, along with other problems. Although her hands and feet

Receiving a diagnosis of renal failure is never easy. But if you are already severely ill with another condition, this news can feel like the last straw. Jasna Trbuha, a Croatian kidney patient with a rare skin disease, told us how she found a way to accept haemodialysis treatment as ‘technical support’ for her creative life – and how she found a new occupation as an artist.

“Painting is a world of freedom with all

the possibilities imagination can offer.”

Jasna Trbuha

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are deformed, she can still feed and clean herself – by putting in a lot of time and effort.

Due to EB, Jasna has no functional fingers, since they’ve fused with her palms. Her fists are wrapped in bandages. Babies born with EB are called “cotton-wool” or “butterfly” children since their skin is as soft as cotton wool and as fragile as a butterfly’s wings. Having such a severe skin disease and also having to undergo haemodialysis treatments isn’t easy at all.

Still, as Jasna says, there’s something inside her, a “formidable life instinct”, which won’t let her give up. And she also has a strong support team: “My brothers, nephews, nieces and my recently deceased mother were and are a

great help to me. Through her care and devo-tion, my mother gave me the energy and love to fight in life.” Jasna also mentions that the challenges of haemodialysis are much more manageable because of the friendly, caring relationship between patients and personnel at the Vita Clinic in Krapinske Toplice.

When people hear that Jasna is a painter, they can’t quite believe it. The first question is usually how she holds a brush with no fingers. Jasna laughs and answers “I manage.” She experiences her extremities and body simply as tools. “Through the strength of creativity and intellect, you can master various ways of bringing ideas to life on paper.” With a twinkle in her eye, she jokingly adds, “This is my little secret on how to be a great artist.”

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“I’m just like the famous French painter Renoir. His hands were destroyed by arthritis, so he tied a brush to his hands and worked. And that’s just what I do too - I attach the brush to my bandaged hands.” Painting gives Jasna psychological relief, as well as helping her re-generate and heal. “I’ve been painting and drawing my whole life,” Jasna continues. “Painting gives me a world of my own. A world of freedom with all the possibilities imagination can offer. In this world, I’m the master of my own life.”

Jasna explores different motifs with a variety of techniques. She likes acrylic and pencil be-cause of their simplicity, and also works in oil. “ Water colours are beautiful, but they require the most effort,” she says. With the help of others Jasna can paint great volumes of work with surprising speed, skill and ease.

Understandably, Jasna is proud of her artistic achievements. “Through painting I’ve gained recognition, a sense of competence and self-confidence. I’ve had a lot of exhibitions and have received critical acclaim from profession-als. The audience always senses my fighting spirit in the paintings and responds to it.”

As a young woman, Jasna trained as an administrative clerk, but her severe condition has prevented her from finding employment in that field. Today, many people want to own her works, so she sells her paintings. Jasna explains that being a paid artist gives her additional support – both financially and emo-tionally. “It is proof to me and others that any seemingly hopeless situation can be mas-tered, or at least improved, through willpower.”

“Any seemingly hopeless situation can be mastered,

or at least improved,

through willpower.”

Jasna Trbuha

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“My work has helped me to accept life on haemodialysis treatment as ‘technical sup-port’ so that I may use my life for creativity,” Jasna summarises. But she doesn’t paint all day – she also enjoys going on nature walks with her four-legged friends: a Labrador named Akela, and Tina, a Pekingese mix. And Jasna is sharing her love of art with the next generation. “I make picture books with my niece Laura – she writes the text and verses, I illustrate them. My nephew Mihael is an inspiration in my life, as all children are. Watch-ing him play, I learn about the essence of life. He invents games limited only by his imagina-tion.”

“Yes, life is amazing,” Jasna summarises. “I’ve even surprised myself by overcoming all of the

pain and suffering with the help of that ‘some-thing’ inside of me. It gives me peace in every situation because inspiration and creativity pushes me forward. Each time my haemodi-alysis session is over, I rise like a phoenix from the ashes and continue the game of life.”

“People say I’m brave and optimistic. But I don’t see myself like that – to me, it’s nothing more than a life instinct, the power of love and creativity that soothes every misfortune and mends every broken heart and spirit.”

“The power of love and

creativity soothes every misfortune and mends

every broken heart.” Jasna Trbuha

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Surprising Slovenia: from Alpine atmosphere to Mediterranean flair

Over a million tourists visit Slovenia every year, mostly from Austria, Italy, Germany, the UK, and the other countries of the former Yugo-slavia. Due to the country’s international orientation, almost every Slovenian speaks English. The national currency is the Euro. As the capital, Ljubljana, is located right in the centre of the country, all points can be reached from it within a couple of hours.

A charming capitalThe capital of the historic region of Carniola, Ljubljana is one of Europe’s smallest capital cities and can easily be seen in a day. Many of the city’s most beautiful buildings were designed by architect Jože Plečnik, who gave the city its modern look, and also worked on

Prague Castle and buildings in Vienna and Belgrade. The central point of the city is Prešeren Square, a large public square over-looked by the Baroque Franciscan Church of the Annunciation and renovated in 2007. On the south side of Prešeren Square is the fa-mous Triple Bridge, the city’s main landmark, also designed by Plečnik. This set of three ornate pedestrian bridges over the River Ljubljanica joins Prešeren Square to the city’s Old Town on the south side of the river. As well as the many traditional restaurants, at-tractions here include Ljubljana Castle, perched on a hill overlooking the city, and the charming, bustling Central Market – a must-see on any visit.

Lakes and mountains in the northwestLeaving Ljubljana and heading northwest, the terrain rapidly becomes mountainous – this part of Slovenia is characterized by the Julian Alps. The region’s main tourist destination, Bled, boasts striking scenery. Bled Castle, Slovenia’s oldest medieval castle, sits high on a precipice, overlooking the vibrant blue wa-ters of Lake Bled below. At the centre of the lake is Bled Island (Blejski otok), Slovenia’s

With a population of just 2 million, Slovenia is one of Europe’s smallest countries, yet also one of its most beautiful and diverse. The former Yugoslav republic borders Austria, Italy, Hungary and Croatia, and thus sits at the crossroads of Germanic, Latin, Hungarian and Slavic culture. The country’s scenery is incredibly varied and spans the Alps, the Mediterranean Sea, the Pannonian Plain and the Dinaric Mountains. And the best thing about travelling to Slovenia? Thanks to its compact size, the whole country can be explored in a single holiday.

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only natural island and home to a 17th cen-tury baroque church dedicated to the Assumption of Mary. The island church is a popular destination for weddings. Bled has many hotels and is popular for its hot springs and spas, swimming pools, sports facilities, and of course its casino.

Not far from Lake Bled is Slovenia’s largest lake, Lake Bohinj, which is located at the end of a deep valley and surrounded by moun-tains on three sides. Music and fireworks fes-tivals take place here in summer, and the val-ley is popular with tourists from neighbouring countries. Northwest Slovenia’s main towns, Kranj and Škofja Loka, have well-preserved historic centres, while the resort town of Kran-jska Gora in the heart of the Julian Alps is a popular tourist destination for skiers in winter and hikers in summer. It’s a great starting

point for hiking in the Triglav National Park, home to Triglav, the country’s highest moun-tain. Northwest Slovenia is also the location of Čedca, the country’s highest, 130 metre waterfall.

Cliffs, caves and a beautiful coastPostojna Cave is one of Slovenia’s top tourist attractions. Over five kilometres of the cave system are open to the public, making Pos-tojna the world’s longest publicly accessible cave system – it even has its own electric train. The caves have their own ecosystem and are famously home to an endemic

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species of salamander native to southeast Europe, the olm or “human fish”, so named for its light-coloured skin. Local legend held that the salamanders were baby dragons, but in fact, their closest relatives are the mudpup-pies of North America. Adapted to life in dark-ness, the olm is blind and lacks any pigment, but its senses of smell and hearing are highly developed. No visit to Postojna is complete without also exploring the nearby Škocjan Caves, a UNESCO World Heritage Site.

Slovenia’s short Adriatic coastline is charac-terized by Italian flair, and indeed the city of Trieste is not far away and Italian is spoken throughout the region. The main coastal towns are Piran, Portorož and Koper, a typical medieval Mediterranean architectural style. Scenery in the Piran area includes the striking

Strunjan cliffs and Strunjan Nature Reserve. Further inland, a main tourist attraction in the area is Lipica Stud Farm, where the famous white Lipizzaner horses of the Vienna Riding School are bred. Visitors can tour the museum, enjoy carriage rides, take part in riding courses, and watch the horses perform and be trained.

4 surprising Slovenian facts• Although the countries do not border each other or share a common history, Slovenia and Slovakia are often confused with each other. In Brussels, EU representatives from the two countries meet up once a month to swap incorrectly delivered mail!• Slovenia is a largely forested country, so much of its cuisine uses nuts, berries and wild plants. Dandelion is grown and eaten in spring, often prepared as dandelion-and-potato salad. Chestnuts and wild mush- rooms play a leading role in main courses, while walnuts and hazelnuts

feature heavily in local desserts – together with wild strawberries, logan berries, blackberries and blue- berries.• Old Vine in Maribor, the oldest vine in the world, is the oldest living speci- men on our planet of a noble grape vine that still bears grapes! With an age of over 400 years it is registered in the Guinness Book of Records as the oldest vine in the world. • Communication is also a strong point in Slovenia: especially near the borders Italian, German, Hungarian, Croatian and English are widely spoken.

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Wine and Austro-Hungarian flairMuch of northeast Slovenia lies in the historic region of Styria and shares a common history with Austria. The area is home to the coun-try’s second-largest city, Maribor, which is just an hour away from the Austrian city of Graz by car or train. Ptuj, Slovenia’s oldest town, is also nearby. Further north and east, the Prek-murje region on the Hungarian border is cul-turally very different to the rest of the country and much more Hungarian in character. Part of the Pannonian Plain, Prekmurje has a number of spa resorts and springs and is Slovenia’s largest agricultural region, with sunny hills covered in vines in summer. The dialect spoken here features Hungarian influences and is very difficult for Slovenians from the rest of the country to understand. Castles worth visiting in this part of the country include Sobota Castle and Grad Castle.

Hills and castlesRolling countryside covered in forest and vineyards is what defines southeast Slovenia.

It’s here that the Dinaric Mountains begin, which continue into neighbouring Croatia. The landscape is ideal for cycling and hiking, and there are many castles and spa towns, as well as more caves to explore in the an-cient forest of Kočevski Rog. The region is home to Slovenia’s only island castle, Otočec castle, as well as the picturesque Žužemberk Castle and Ribnica Castle. Day trips to his-toric cities in Croatia such as Zagreb, Sombor and Varaždin are also possible from this part of the country.

NephroCare in SloveniaFresenius Medical Care began its activities in Slovenia in 1992. We have 5 NephroCare centres – two in Ljubljana, one in Naklo in the northwest of the country, one in Celje in the northeast, and one in Krško in the southeast – and currently treat more than 300 patients. If you’re planning a holiday in Slovenia contact your NephroCare team! We´d be happy to schedule dialysis sessions for you in our centres – wherever in the country you decide to go!


Ljubljana Črnuče

Ljubljana Dragomer

Slovenia

Croatia

AustriaHungary

ItalyNaklo Celje

Krško

FreseniusMedicalCaredialysiscentresinSlovenia

Naklo Celje

KrškoLjubljana Dragomer

Ljubljana Crnuče

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“Haemodialysis forced me to slow down and helped me to study”

When Rui was seriously injured in a motorcy-cle accident at the age of 23, the prognosis was bleak. He was in a coma, with a punc-tured lung and spleen and 22 broken ribs. As-suming he awoke, which wasn’t a given, he was expected to be wheelchair-bound for the rest of his life. “But just 15 days later, I was sitting up in my bed and eating snails!” Rui recalls with mirth. His carers were astonished. Rui was making a good recovery, one slow

step at a time. Soon afterwards, Rui decided to undergo voluntary hippotherapy – therapy assisted by horses – in addition to conven-tional treatments. “My family has always had horses, so I was used to them – in fact, I learned a lot from them,” comments Rui, ex-plaining the decision. He organised the therapy himself until the positive results proved to the hospital that it was worth supporting it further.

46-year-old Rui Mira has two roles at the NephroCare Clinic in Barreiro, Portugal. Out of his white coat, he’s a patient. But in his white coat, he’s an intern in the clinic’s social welfare service team. We met Rui to learn more about his remarkable life story, one which is marked by courage and initiative.

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Born in the southern Portuguese town of Moita, where he still resides, Rui grew up sur-rounded by horses. His childhood and youth were characterised by equestrian activities, from races to carriage-driving contests. So after his accident, he chose to explore hip-potherapy first in the Algarve, then in São Paulo, Brazil, where he found the best experts in the field. “I travelled to Brazil by myself and stayed there for four months, to learn from the best,” he recalls proudly. When he returned, there were a lot of opportunities to put his new-found expertise into practice: Rui taught hippotherapy techniques to members of Portugal’s National Republican Guard and joined the polytrauma rehabilitation team at the Alcoitão Medical Centre. He had crossed

the divide from being a patient to helping patients, something he appreciated tremen-dously.

“It was the biggest shock of my life” Alongside his equestrian activities, Rui was still working as an assistant social worker for Moita municipality at the time of his second serious accident, when he fell from a truck and required immediate emergency treat-ment. “The doctor told me ‘Your kidneys stopped working’ in such a blunt way that it is still etched in my memory,” Rui reminisces. As Rui was far from a layman, he immedi-ately understood the potential consequences of life without functioning kidneys. “It was the biggest shock of my life,” he sighs, expressing what he felt at the time. “After my recovery

33

from the motorcycle accident, it came as a terrible blow, and at first I didn’t know how to face it head on.”

But there was some positive news: at around the same time, Rui was accepted onto a so-cial welfare course at Unigran, a Brazilian uni-versity that offers distance learning courses through various local centres, including one in Lisbon. While this gave him something to focus on, Rui was at first unsure of how to fit his work and studies around his haemodialy-sis. But over time, the puzzle pieces started falling into place and making sense. “The haemodialysis forced me to slow down and study – in fact, it gave me more time for my university work. I started to take advantage of the clinic hours to read and do research. If it were not for the haemodialysis, maybe I would

not have devoted so much time to studying.”

Patient in a white coat Rui believes that without the haemodialysis treatments, he wouldn’t be standing here today in a white coat as a member of the social welfare service department at the NephroCare clinic in Barreiro, the same clinic where he receives haemodialysis. After completing the two-year course, the Univer-sity suggested following it up with a two-year internship, an opportunity Rui embraced. Management at the Barreiro clinic supported his proposal to complete his internship there, and he is now a major asset, greatly valued by fellow team members. Colleague Inês Fern-andes works alongside Rui and says he is a tremendously positive example to patients – one that gives them hope and shows them

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that life need not come to a halt after kidney failure and can still be full of joy and achieve-ments.

Rui is a rare example of someone who can approach the world of dialysis from two perspectives, that of a patient and a caregiver, and he uses these insights to improve patients’ well-being. On the surface, though, Rui makes a point of keeping the two roles separate. “When I am not wearing the white coat, I’m the patient. When I’m wearing my white coat, I’m the clinic’s intern, available to support those in need and help come up with solutions,” he says. It’s the everyday moments that allow him to make a real difference to people’s lives – and that brings him joy.

Something else that brings him joy is his family – despite being told by doctors that he could never become a father, in 2012 Rui welcomed his daughter Filipa Maria into the world.

Rui Mira was transplanted on May 2nd, 2013 in the Coimbra University Hospital. As soon as he recovers from the surgery is going to return to work as a social as-sistant at NephroCare Restelo to com-plete the last six months of his Social Assistant training.

Rui Mira

Age: 46A haemodialysis patient and trainee in social-welfare service at the Nephro-Care Barreiro Clinic

His passion: Horses

His motivation: To help others

His favourite film: Braveheart, be-cause it’s all about the desire to achieve freedom

His future plans: To finish the course and get a job in the field of social wel-fare.

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A day in the life of …Thomas Raphael, Nephrologist at NephroCare Marne la Vallée, Chairman of NephroCare Marne la Vallée Medical Committee and NephroCare Marne la Vallée Medical Coordinator

Forty-two-year-old Thomas Raphael joined NephroCare in 2004, when Lagny Private Hospital, where he had worked as a neph-rologist since 2001, was acquired by Fresenius Medical Care. In May 2013, Dr. Raphael and his team were relocated to the new site at Lagny Marne la Vallée hospital and the centre adopted the new name of NephroCare Marne la Vallée.

A childhood calling Medicine has always been Dr. Raphael’s call-ing. “I grew up in a medical household,” he tells us. “My father was a professor of inten-sive care medicine. My whole life, I wanted to follow in his footsteps. So after finishing

school, I studied at the medical faculty of the Pitié Salpêtrière teaching hospital in Paris, and graduated in 1996. My father was and is my role model – I’ve always tried to live up to his sense of integrity and ethics.”

Even before qualifying, Dr. Raphael says he quickly realised that monitoring patients on a long-term basis was what he really wanted to do. “One of the main motivators in my career has always been my desire to help patients become strong individuals. I strive to do this by providing them with expert support, and by accompanying them and their families on the dialysis journey to become more involved and active. During my research year, I spent

Dedicated to comprehensive care

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NephroCare people.

Marne la Vallée


time covering shifts at Lagny polyclinic, spe-cialising in nephrology. I was immediately struck by the caring, professional, and highly responsible approach of the nephrology team. So I returned to Lagny and joined the team in January 2001, with the specific aim of working on illness prevention in nephrology.”

Now, a decade later, Dr. Raphael has a wealth of experience under his belt and is the hospi-tal’s medical coordinator and president of its medical committee. “Our main objective at NephroCare Marne la Vallée dialysis centre is to develop strong relations with all of the hos-pital’s departments, especially internal medi-cine and cardiology. We also provide nephrology consultations to the rest of the hospital.”

Designed with patients in mind Opened in May, NephroCare Marne la Vallée was designed as a pleasant and welcoming treatment environment. The purpose-built facility aims to ensure maximum patient safety and well-being. “Our new institution focuses on preventing renal failure, and treating and monitoring chronic kidney disease patients in the best possible way,” continues Dr. Rap-hael. “As a result, doctors and hospital physi-cians consider us the preferred local partner

for the early screening of renal failure and subsequent monitoring.”

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A typical day Dr. Raphael’s day starts early. “I wake up at 5 a.m., drink a coffee, check my e-mails, then commute,” he explains. “When I get to the dialysis centre at about 6:30, I spend the next hour or two reading the day’s reports and preparing for consultations. The rest of the day is taken up with a mix of activities. In the morning and afternoon, I visit the patients undergoing dialysis, monitor their dialysis sessions and provide support to the medical staff. I also review patients’ files and update their prescriptions, and provide external nephrology consultations offsite. The most important parts of my everyday work are contact with patients and collaboration with my team. It’s about more than just dialysis – it’s about providing all-round care.”

Helping patients be proactive “Patient participation is tremendously important and a subject close to my heart,” Dr. Raphael enthuses. “Putting patients back at the centre of the healthcare system, letting them play an active role in their treatment, and helping them become stronger is the core of our work. We take this approach with each and every patient.”

As such, the centre runs a programme of pre-dialysis nursing consultations and therapeutic education in which all patients participate. Personalised therapeutic support is given and meetings with other medical staff such as dieticians, psychologists, and pre-transplant advisors are initiated. “We offer our patients educational workshops appropriate to their needs,” continues Dr. Raphael. “Our workshops and training

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NephroCare people.

sessions cover all kinds of topics – how to apply an anaesthetic patch, monitor your blood sugar levels, take medication correctly, and so on. We plan to expand this scheme by providing patients with even more ways to increase their involvement and take control of their treatment on a made-to-measure basis.”

In Dr. Raphael’s view, soft factors count for a huge amount too. “Having chronic kidney

disease is a bumpy psychological, social and emotional journey, both for patients and their families. So good communication between staff and patients is paramount. Patients can only play a more active role in their own care if they’re well-informed and trust their care-givers. At the end of the day, there’s nothing I find more motivating – or more rewarding – than seeing patients and staff satisfied and happy.”

6 questions – 6 answers

1. A good working day starts … withaverystrongcoffeeandsmiles frommyteam.

2. I celebrate success with … aglassofwinewithfriends,family ormyteam.

3. I don’t like it when ... Idonothaveenoughtimetospend withmypatients.

4. My mottos are… Intelligenceisknowinghow toadapt.

5. My friends appreciate my... listeningskills,uncomplicated nature,loyalty,andwillingness tohelp.

6. In my free time … Iread,mainlydetectivenovels. Ilovegoingtothecinema.Itake partinseveralsports(running, cycling,tennis,skiingetc.).And ofcourse,Ispendtimewithmy family,mysonClémentandmy friends.Whenevermyschedule allows,IvisittheÎledeRé[aholiday islandoffthewestcoastofFrance] torechargemybatteries.

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An extra-special Christmas giftFifty-nine years ago, on 23 December 1954, 24-year-old Ronald Lee Herrick made medi-cal history by donating a kidney to his identi-cal twin brother, Richard. The operation kept Richard – who had been diagnosed with end-stage kidney failure – alive for eight more years. He was able to marry a nurse he had met in hospital and have two children.

Ronald’s selfless gift is considered the world’s first successful organ transplant. The opera-tion was performed at the Peter Bent Brigham Hospital (now Brigham and Women’s Hospital) in Boston. Lead surgeon Dr. Joseph E. Murray went on to win the 1990 Nobel Prize in Med-icine for discoveries “concerning organ and cell transplantation in the treatment of human disease”. “Kidney transplants seem so routine now,” Dr. Murray once shared in an interview, “but the first one was like Lindbergh’s flight across the ocean.” A 1943 graduate of Harvard Med-ical School, Murray’s interest in transplants began during World War II when he performed reconstructive surgery on injured troops. Burn patients were often treated with skin grafts from other people. “The slow rejection of the

foreign skin grafts fascinated me,” Murray recalled in his short autobiography for the Nobel Prize ceremony. What was the mecha-nism of transplant rejection? Why did a patient distinguish another person’s skin from their own? The hospital’s chief of plastic surgery had performed skin grafts on civilians and noticed that the closer the donor and recipi-ent were related, the slower the tissue was rejected. A skin graft between identical twins

Paving the way for transplantsIn the Summer 2013 edition of NephroCare for me, we saw how innovators like Kiil and Scribner developed dialysis into a life-saving treatment for millions of patients. In this issue, we’ll take a slightly different angle and explore another historical break-through – kidney transplants – and meet two pioneering physicians.

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Back to the roots!


had been permanently successful. Murray said that this inspired him to study organ transplantation.

Jon van Rood – decoding the HLA systemJohannes Joseph (Jon) van Rood was born in the Netherlands in 1926. After experiencing the German occupation as a teenager, he studied medicine at Leiden University. There

he was influenced by Piet Gaillard, professor of histology, who may well have performed the first successful human transplant from a genetically non-identical donor. Gaillard trans-planted cultured parathyroid gland tissue into a patient whose parathyroid gland had been accidentally removed. His student Jon van Rood went on to make major contributions to the fields of transfusion medicine as well as organ and stem cell transplantation.

Thefirstidentical-twinkidneytransplantationoperation,performedonDecember23,1954.

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In 1958 Jean Dausset, a French scientist, had discovered genetic characteristics of leuko-cytes on cell walls that differ for each individ-ual human being. In 1965, he described what is now known as the human leukocyte antigen (HLA) system. Dr. van Rood’s group was the first to start unravelling the complexity of the HLA system through collaborative studies. Van Rood was also a pioneer of kidney trans-plantation, founding the Eurotransplant consortium in 1967.

Eurotransplant – a new approach to matchingUntil the mid-1960s, transplant surgeons matched donor and patient mainly by blood type. Patients had to wait until a matching donor was found in the centre where they were being treated. Dr. van Rood chose a new approach, using the HLA-type of donor and recipients to achieve better transplantation results. But finding a donor with a matching tissue type was a huge challenge. To find the

best possible match, he needed a list of all patients waiting for a donor kidney. So, in 1967, van Rood founded the Eurotransplant database. Twelve transplant centres in three countries signed on to register their transplant candidates with Eurotransplant. Each centre also reported donors, and Eurotransplant made the best possible match. The outcome of kidney transplants improved by leaps and bounds.

What started as a scientific experiment soon became an international non-profit foundation whose services were in demand throughout Europe. A period of rapid growth followed. Only three years later, in 1970, Eurotransplant involved 68 centres in six countries: Austria, Belgium, Luxembourg, West Germany, the Netherlands and Switzerland. Switzerland withdrew from Eurotransplant, but in 1991 East Germany joined, followed by Slovenia in 1999 and Croatia in 2007. On July 1, 2013, Euro transplant welcomed its newest member: Hungary.

Eurotransplant region

Austria

Hungary

Croatia

Germany

Slovenia

Belgium

Luxembourg

Netherlands

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Back to the roots!

To date, Eurotransplant has allocated donor organs for 125,000 transplants. Constant improvement was the focus right from the start, and continues to be a priority. In 1996, the Eurotransplant Kidney Allocation System (ETKAS) was launched, seeking to promote a more patient-oriented approach to kidney allocation by balancing medical and ethical principles.Then as now, the Eurotransplant mission is to offer “life-saving and quality-of-life enhancing treatment options to patients with end-stage organ failure”.

Future of transplantationAlmost all religious denominations approve of organ and tissue donation as the ultimate charitable act – the gift of life. However, potential recipients still far outnumber donors. A possible solution to the global shortage of transplantable organs is to develop artificial ones: At the University of California in San Francisco, a research project is underway to create a small, surgically-implanted bioartifi-cial kidney to treat end-stage renal disease (ESRD). All interested NephroCare patients who are suitable for transplantation should be on the transplantation list. It is our duty to give our patients the best options to maximise their suitability for transplant.

It is now history

1967: First successful liver transplant by Dr. Thomas Starzl (Denver, Colorado, USA)

1967: First successful heart transplant by Dr. Christiaan Barnard (Cape Town, South Africa)

1998: First successful hand transplant by Dr. Jean-Michel Dubernard (Lyon, France)

2008: First baby born from a whole ovary transplanted by Dr. Sherman Silber (Infertility Centre of St Louis, Missouri, USA)

2010: First full facial transplant, by Dr. Joan Pere Barret and team (Hospital Universitari Vall d’Hebron in Barcelona, Spain.)

2011: First double leg transplant, by Dr. Cavadas and team (Hospital La Fe in Valencia, Spain)

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Healthy festive fun – eat well, live well

The Christmas holidays are generally filled with parties, celebrations and food galore. As a dialysis patient, you’ll know that you can eat only a small amount of traditional foods like sweet potatoes, eggnog, chocolate and nuts. But with a little careful planning you can still tuck in to delicious food and enjoy social events to the full!

Party planningIf you’re invited to a party or dinner, make a point to eat smaller meals during the day so you can eat a little bit more in the evening. But don’t arrive at the party famished either – when we’re hungry we tend to eat too much, and too quickly. If possible, find out in advance which foods will be served. When you arrive at the gathering, see which dishes there are and choose what to eat based on what you enjoy most and the provisions of your renal diet.

Savvy shopping A little planning can go a long way – this ap-plies to Christmas shopping as well as your diet. If you know you’ll still be out shopping when it’s time for your regular meal, plan in advance where and what to eat, or take a packed meal with you – and remember to carry some phosphate binders. Avoid the temptation to buy “fast food” or chocolate by taking along some snacks: sliced apples, a sandwich, unsalted pretzels, pasta salad or a slice of sponge cake.

Making wise choicesKnowing your renal diet well also allows you to make wise food choices. Go easy with sauces and gravy which are often high in fat and salt. On the other hand, foods such as turkey, chicken, fish, lean beef and fresh pork are great protein-rich choices which will meet your nutritional needs. Resist the temptation of fried foods, creamy dishes and casseroles which can have high levels of potassium and sodium. And remember to remove the skin and trim any excess fat from poultry and meat.

Did you know that an average Christmas dinner contains more than 2,000 calories?

We all know how busy the festive season can be! All the shopping, decorating and special events can be quite stressful at times. And with all the parties and festive dinners, there’s also the extra challenge of sticking to our healthy and safe eating habits.

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Here’s to your health!


That’s equivalent to the amount of calories you’d normally consume over an entire day. If you’re curious to try the great variety of dishes on offer, try taking just a spoonful of each, that way you can taste many different ones. And chew slowly, that way you’ll enjoy the taste longer! As always, moderation is the key.

Focusing on what matters mostSometimes those festive treats simply look

too good to resist. If you do overindulge at one meal, remember to make amends the next day! But don’t forget that what makes the festive season so special is spending time with family and friends, and not the food we eat. Some families have the tradition of taking a walk during the afternoon, or be-tween the main course and dessert. Focus-ing on nature and on each other is a great way to celebrate, too.Season’s Greetings to you and yours!

Cooking tipsAs the majority of processed foods and frozen meals are high in phosphorus, potassium and sodium, it’s a great idea to prepare your own food. You can put together a delicious festive feast with foods that are kidney-friendly. Here’s how: 1. Use herbs and spices to flavour your food instead of salt. 2. Try making your own stuffing and gravy. They taste great and this helps reduce or eliminate high sodium ingredients like salt and stock cubes. 3. You can lower the potassium content of potatoes by leaching them before

cooking. Peel the raw potatoes, cut into small pieces and soak in a large bowl of water (I0 parts water for 1 part potatoes) for at least four hours. Drain off the water and rinse. Cook in a large pan of water and prepare as usual.4. Use olive oil or vegetable oils as heart healthy alternatives to replace butter.5. Remember that gelatin, sauces and gravy count as part of your daily fluid intake.6. A festive sponge cake or carrot cake can make an excellent dessert and fits well in your renal diet!

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When winter winds blow, preparing and sharing a relaxed meal is one of the nicest ways to stay warm. In this issue, we travel the world to bring festive recipes to your table. Happy holidays!

Holiday flavours to savour

Tomato stuffed with aubergine puree – from Romania (serves 2)

Ingredients: 2 medium aubergines (300 g each)4 tablespoons sunflower oil1 teaspoon finely chopped onion (optional) 4 – 6 large tomatoes

Preparation: Grill the aubergines until soft, in a tray in your oven at the highest temperature or on a barbecue grill, turning them over once if necessary. Peel the aubergines while still hot or cut them in half and use a tablespoon to scoop out the pulp. Leave to drain for at least 30 minutes. Chop up the aubergine pulp using a wooden knife, not a blender, because you want a creamy texture. Stir in the oil and the onions (if desired). Cut a cap off each tomato, preserving the green stem if possible, and remove the seeds using a teaspoon. Take care not to pierce the skin. Fill the tomatoes with the aubergine puree, put the cap back on and serve.

Tip: For a richer taste, add one tea-spoon of homemade mayonnaise to the aubergine puree.

Per recommended portion:Calories 285 kcal

Protein 2 gCarbohydrates 11 gFat 25 gPotassium 45 mg

Phosphorus 550 mg

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Preparation:Heat the oil in a pan and sauté the onion until soft. Add the cabbage and fry while stirring. Add the flour and fry for 2-3 minutes more.Remove the pan from the stove and add the paprika. Add 300 ml water and stir until smooth and free of lumps. Add 800 ml water and cook for 15-20 minutes on low heat with the lid on.Next, add the sausage slices and bay leaves and cook until the cabbage is soft. Add 200 ml soup to the sour cream, mix it, pour it into the soup and let it boil. Add pepper and salt to taste, as well as a pinch of sugar if you like.

As with all soups, please eat it during the short interdialytic period or on the day of dialysis, before the treatment.

Smoked sausage contains a lot of salt – you may not need to add more salt at all!

Sauerkraut soup – from Hungary (serves 6)

Ingredients: 400 g sauerkraut (pickled cabbage), drained and cut into 2-3 cm pieces 150 g smoked sausage, sliced into rounds1 onion, diced 2 tablespoons olive oil2 tablespoons flour1 tablespoon sweet paprika powder2 bay leaves200 ml sour cream

Tip: If you like intense flavours, try adding a pinch of savoury, e.g. coriander and/or mustard seeds.



Phosphorus 123 mg

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Grilling the pumpkin Preheat the oven to 180-190 °C (gas mark 6-7). Brush an ovenproof dish with oil. Peel the pumpkin and remove the seeds, then cut it into slices approx. 1 cm thick. Put the slices into the ovenproof dish. Sprinkle the pumpkin with oil, chopped herbs and a pinch of grated nutmeg. Bake in the oven for about 30 minutes. Turn the pumpkin slices gently halfway through cooking time.

Preparing the guinea fowl Put the guinea fowl pieces under the grill or into a non-stick frying pan for 6 minutes each side. The skin must be well done. Mix the mustard, zest and lemon juice and season it with pepper. Take the guinea fowl out of the pan and put it onto a baking dish brushed with a teaspoon of oil. Brush the guinea fowl with the mustard mix and bake for 20 minutes. Pierce a skewer into the thickest piece of meat. If clear juice runs out, the meat is done. Serve at once with grilled pumpkin pieces.

Roasted guinea fowl with pumpkin – from France(serves 6)

Ingredients: 1 guinea fowl weighing about 2 kg, cut into 8 pieces 800 g fresh pumpkin2 tablespoons Dijon mustardGrated zest and juice of 2 lemons2 tablespoons olive oilPepper, oregano, rosemary, nutmeg



Phosphorus 309 mg

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Light glace fruit cake – from the United Kingdom (serves 24)

Ingredients: 225 g sultanas2 tablespoons brandy110 g pecan nuts (or walnuts)110 g glace pineapple, roughly chopped175 g red, green and yellow glace cherries, roughly chopped110 g candied peel50 g angelica, chopped small50 g crystallised ginger, chopped smallThe grated zest of 1 medium orange and the grated zest of 1 medium lemon225 g margarine225 g caster sugar4 medium eggs280 g plain flour, sifted

Grease a 20 cm round cake tin or an 18 cm square tin and line with a double thickness of greaseproof paper. Begin the night before by placing the sultanas and brandy in a large mixing bowl. Cover and leave overnight. Next day, pre-heat the oven to 170 °C. Add the rest of the nuts, fruit and peels to the sultanas. In a separate large bowl, whisk the margarine and sugar until pale and fluffy. Beat the eggs in another bowl and gradually add them to the sugar mixture, whisking well after each addition. Then lightly fold in the sifted flour, fruit, nuts etc. Now transfer the mixture to the tin, levelling it off with the back of a spoon and place the tin in the oven so the top of it is more or less in the centre.

Bake the cake for one hour at 170 °C. Then place a double sheet of greaseproof paper over the top of the tin and turn the heat down to 150 °C for a further 2 hours. When it’s done it will shrink away from the sides of the tin and be springy in the centre.

Tip: Add 1 teaspoon mixed spice to the batter, and/or a layer of icing when cool.You can leave this cake in the tin till it’s absolutely cold then peel off the papers and wrap it in double greaseproof paper before storing in an airtight tin.This cake contains half the potassium of a traditional fruit cake.



Phosphorus 68 mg

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Brain calisthenics

You can find the solutions on page 54.

Labyrinth Three people are racing to find the cup, but only one will find their way out of the maze. Who is the lucky one?

?

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Magic How many shelves can you see in this picture? Can you even count them?

Mystery close-upSomebody has been using the microscope. But what were they looking at? Can you tell? The devil is in the details …


Inspiring.

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Labyrith MagicThe yellow person is the winner. It is really a magic, no logical solution!

Mystery close-up1. Pumpkin from Page 48. 2. Postojna Cave from Page 29.

Announcements

XXth birthday celebrations!On May 16th, Luise Murphy will celebrate a very special birthday indeed. It will be her 100th! We would like to take this opportunity to send her our congratulations for her birthday and to wish her all the best as a newly crowned centenarian!

Every day is a new day to be celebrated in many ways!On this note, here are some special announcements for the birthdays and anniversaries of friends and loved ones. If you have a special an-nouncement you would like to make, please get in touch with us.

Brain calisthenics solutions

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The examples shown here areplaceholders.


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Fresenius Medical Care informs.HighVolumeHDF – helping you to make the most of your life The first Kidney Options Forum in Barcelona

NephroNumber.Schweinfurt – serving kidney patients with state-of-the-art technology

News from around the word.First NephroCare centre opened in Peru Clowning around in Valencia, Venezuela

Different countries – different habits.France – land of sensual delights Rising like a phoenix Surprising Slovenia Haemodialysis forced me to slow down

NephroCare people.Dedicated to comprehensive care

Back to the roots!Paving the way for transplants

Here’s to your health!Holiday flavours to savour Recipes

This is us in...Introduction of dialysis centres

Inspiring.Brain calisthenics Announcements Questionnaire

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Fresenius Medical Care Deutschland GmbH · 61346 Bad Homburg · Germany · Phone: +49 (0) 6172-609-0 · Fax: +49 (0) 6172-609-2191Head office: Else-Kröner-Straße 1 · 61352 Bad Homburg v. d. H.www.fmc-ag.com www. nephrocare.com

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