New Zealand: Dr Kannaiyan Rabindranath - Hamilton nephrologist

Hutan

Hutan

Moderator
Staff member
https://www.healthpoint.co.nz/private/specialist/dr-kannaiyan-rabindranath/
Nephrologist welcoming referrals for patients with ME/CFS.

I am an UK (Oxford) trained nephrologist (kidney) and general internal medicine specialist.

I completed my MBBS in India in January 1997 and my renal and internal medicine registrar training programme in Oxford, UK. During my 15 years in the UK NHS, I worked in various regions including the West Midlands (Wolverhampton, Dudley and Shrewsbury), Mersey (Liverpool), Scotland (Aberdeen-where I was a PhD research fellow), and the South (Oxford and Reading). I worked for about two years as a consultant in the UK prior to moving to New Zealand in 2012 with my family, attracted by the better work-life balance in this country.

I am currently working as a consultant nephrologist at Waikato Hospital and have recently established the Waikato Kidney Clinic in Hamilton East for private referrals. I have an interest in all aspects of renal and internal medicine and I am excited to bring a new skill-set to the existing pool of private physicians in the Waikato region.
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Interests
Renal: Hypertension, Glomerulonephritis, Acute Kidney Injury, Chronic Kidney Disease, Diabetic Kidney Disease, Urinary Abnormalities, Haematuria or Proteinuria, Renovascular Disease, Kidney Stone Disease, Transplantation. Nephrology insurance work & immigration medicals.

General Internal Medicine: I have a keen interest in the management of patients with multiple complex general medical problems. I am developing a special interest in patients with Chronic Fatigue Syndrome. I welcome referrals for patients with general medical problems & those with ME/chronic fatigue syndrome.
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I think this is the first specialist in New Zealand I have heard of with an interest in ME/CFS. It's not clear what his approach to ME/CFS is. 'multiple complex general medical problems' doesn't sound great, and Liverpool, Oxford and Reading have been BPS hotspots. However, I haven't found anything worrying on line so far.

I doubt that there are many nephrologist consultants actively seeing ME/CFS patients in the world, so, so long as he isn't caught up with BPS ideas, he could offer some significant expertise and new perspectives to the world, as well as to New Zealand.

I found a presentation he did on virtual medicine (telehealth). He seemed concerned about patient welfare and of course virtual consults could be very useful for ME/CFS patients.
 
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According to ORCID his only activity is as a peer reviewer on The effects of cognitive behavioural therapy on depression and quality of life in patients with maintenance haemodialysis: a systematic review (2020, BMC Psychiatry)

Peer review records are here. His review is —

Could the author's please include the Cochrane Review on Psychosocial Interventions for depression in dialysis patients in their article? It is a comprehensive and up-to-date review that needs to be alluded to.
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I first heard of him about 3 years ago, I think I read something online at the time, that he has a close relative ?wife with ME/CFS - could be wrong, can't find the reference at the moment. It would be great if he could join this forum and tell us himself.

It was about the time Dr Vallings retired and started mentoring Dr. Judikje Scheffer, a GP who had been working for Cycling NZ in Cambridge but had started up Jusc Medical specialising in CFS/ME. I think Dr Vallings was also mentoring him.

I presume if he is in private practice in Hamilton and Tauranga, as per his Healthpoint Page, there would be an opportunity for people outside Waikato/Bay of Plenty to be able to arrange a consultation with him.

@SNT Gatchaman I think it is difficult to characterise a clinician's "BPS status" on the basis of what you have presented.

I searched through another forum I am on and a patient that had seen him said he diagnosed her with ME following covid infection, he was caring, considerate, knowledgeable about ME, very thorough and explained tests required to rule out other conditions. She was recommending him to the group. Have not found any mention of him being BPS.
 
It was a bit late last night, but despite the ORCID record paucity, looking at the Cochrane review, I see he was the first author on the 2005 review (and its 2003 protocol) and a senior author on the 2019 revision.

The 2005 review stated —

No RCTs were identified comparing psychosocial interventions with control or no intervention for the treatment of depression in the dialysis population.
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The 2019 review opened with —

People with end‐stage kidney disease (ESKD) treated with dialysis are frequently affected by major depression. Dialysis patients have prioritised depression as a critically important clinical outcome in nephrology trials. Psychological and social support are potential treatments for depression, although a Cochrane review in 2005 identified zero eligible studies. This is an update of the Cochrane review first published in 2005.
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and concluded —

Cognitive behavioural therapy, exercise or relaxation techniques probably reduce depressive symptoms (moderate‐certainty evidence) for adults with ESKD treated with dialysis. Cognitive behavioural therapy probably increases health‐related quality of life. Evidence for spiritual practices, acupressure, telephone support, and meditation is of low certainty. Similarly, evidence for effects of psychosocial interventions on suicide risk, major depression, hospitalisation, withdrawal from dialysis, and adverse events is of low or very low certainty.
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So I think we can at least say he has an established interest in psychosocial interventions as possible treatments in the chronic dialysis context.
 
hibiscuswahine said:
I think Dr Vallings was also mentoring him.
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Not ideal. Dr Vallings has of course been the source of a lot of unevidenced if not outright weird ideas about ME/CFS treatment.

hibiscuswahine said:
I think I read something online at the time, that he has a close relative .. with ME/CFS
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That's a good sign though.

I've sent an email to Dr Rabindranath, thanking him for his interest in ME/CFS and alerting him to the existence of the forum.
 
SNT Gatchaman said:
It was a bit late last night, but despite the ORCID record paucity, looking at the Cochrane review, I see he was the first author on the 2005 review (and its 2003 protocol) and a senior author on the 2019 revision.

The 2005 review stated —



The 2019 review opened with —



and concluded —



So I think we can at least say he has an established interest in psychosocial interventions as possible treatments in the chronic dialysis context.
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I don't agree, I have no problem with his paper. He appears to be looking at the level of evidence for various interventions. I have not read the full paper but for a nephrologist to be concerned about the mental health of his dialysis patients, I think is a good thing. I am retired psychiatrist with ME who treated clients with ME with co-morbid mental health conditions, so does that make me BPS? I know many clinicians within my local mental health practitioner community (psychiatrists, psychologists, occupational therapists) who see ME as a biological illness (some are part of active ME advocacy) who are not BPS. I do not think it is within our capacity to remove "psychosocial" from psychiatry/psychology.

@Hutan, yes, Dr Vallings definitely had a lot of ideas I didn't agree with, I don't agree with everything ANZMES does either, but I would like to keep an open mind on Dr Rabindranath, having consultant physicians with a special interest in ME/CFS are rare, in my experience. The one we had locally for 30 years has now retired. Consultants often have mentors and supervisors, doesn't mean they agree with everything that they say.
 
For sure @hibiscuswahine, we don't yet know what Dr Rabindranath's views about ME/CFS are, and I am still hopeful. Having a well-informed specialist doctor regularly seeing many people with ME/CFS would be a big deal for New Zealand, and I guess, given how often we have found doctors harbouring BPS ideas, we are just trying to manage our expectations.

hibiscuswahine said:
The one we had locally for 30 years has now retired.
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Who was that? I wasn't aware that we had had a consultant physician with a special interest in ME/CFS (other than yourself treating people with conditions co-morbid to ME/CFS of course).

CBT may in fact help reduce depression/sadness in people undergoing dialysis. Certainly I can imagine chatting with someone who understands the process and the demands on people and their families would be helpful for making people feel more in control and happier about things. I guess there is the concern though that the review did not properly consider the problems with subjective outcomes combined with unblinded treatments, potentially overstating the benefits of the treatments reported to have helped with moderate certainty (CBT, exercise and relaxation techniques).

Just looking at the abstract, it is noted that objective outcomes like suicide attempts and withdrawal from care in the studies included have low certainty of evidence and no outcomes for these are presented in the abstract. But there is no statement saying that this is not good enough, that the research needs to be better. Outcomes reported were subjective quality of life assessments. Neither was there mention of the potential confounding of mood with exercise - people well enough to exercise probably feel better in all sorts of ways compared with people who are not well enough to exercise. Overall wellness will affect the ability of a person to participate in a trial of exercise. So, there should be a lot of caution around the idea that exercise cures depression in people undergoing dialysis. There is the concern that if someone does not see the problems in that review, they may not see the problems with similar evaluations in ME/CFS.

But yes, perhaps the review did cover those issues in the text, perhaps Dr Rabindranath is very aware of the problems with assessing non-drug interventions and perhaps he holds evidence-based views about ME/CFS. I hope so, and regardless, I very much hope he joins us here.
 
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@Hutan
https://www.ccdhb.org.nz/about-us/h...-clinical-support-services/icu/roberts-peter/

I was diagnosed by him in 1996 and never needed to see him again. I heard several doctors talk of his special interest in this field but I don't think he had any research outputs. GP's would refer to him to get a diagnosis of post infectious syndromes including ME.

I can't speak to his BPS beliefs. I had a very thorough examination and he commented "well you don't look depressed" which could be BPS if you want to interpret it that way, but having been a clinician it is important to make sure the client does not also have moderate to severe clinical depression which might require mental health treatment and support.

Often physicians would refer to psychiatry when they were concerned about major mental health disorders but that has changed due to high demand for mental health services, whereby the specialist physician would note any concerns in the consult letter to the GP and the GP would then discuss this concern with their patient and then decide if a referral should be made to specialist mental health services, with their patient's consent. Often mild (and some moderate ) mental health problems, where the patient did not have significant risks of harm to self or others are treated within primary care.

I know people were being referred to CL psychiatry in the next few years during my training but not all people diagnosed with ME were referred there. That department definitely was BPS. Though there have been changes in psychiatry since then, there are still local psychiatrists who think LC and ME are psychosomatic.

I didn't even know CCDHB had a Post-infectious Clinic until a few years ago when I was referred to it but the lead consultant retired and it closed permanently and I never got seen. It was at the same time, Dr Roberts retired so I guessed he was still running it or perhaps being such a senior doctor at the hospital - supervising the physicians that were now running it. Could be wrong. I have been retired for 11 years.
 
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hibiscuswahine said:
for a nephrologist to be concerned about the mental health of his dialysis patients, I think is a good thing.
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Definitely.

We've posted at least one paper relating to fatigue in patients on long-term dialysis. Chronic pain is also a common issue. We also know there are significant cardiovascular risks, with increased mortality. I think it's long been generally held that dialysis is associated with increased prevalence of depression. As a junior, working briefly in an HD unit, I recall this was said to be due to (paraphrasing from distant memory) "being chained to a machine for three afternoons a week, unable to do anything else". I don't know if that's still thought to be the explanation. If so, I would suggest that pwS/VSME might welcome such an intermittent scenario and yet I don't think they are found to have unduly high rates of depression, so I'm not sure that could be a good explanation.

However, maybe that constant taste of freedom/rescinded, is even more psychologically damaging. From someone with much more experience —

shak8 said:
I spent 20 years as a dialysis nurse and saw the fatigue every day, post dialysis. Big shift of fluid and electrolytes removed during the 3-4 hr. treatment, most patients ending up with low blood pressure/volume due to all the retained fluid removed.

Dizzy and staggering out of the clinic, home to bed, feel a bit better the next day. Repeat 3x a week. Not fun.
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However, as Dr Rabindranath said in the original 2005 review —

Depression is the most common psychological problem in the dialysis population. The diagnosis of depression in dialysis patients is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression.
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It's a trope that seniors will tell their trainees: "the kidney knows more physiology than you ever will" (probably said by House, certainly said to me IRL!). Perhaps the profound metabolic, biochemical and immune dysregulation associated with the failed kidney has more yet to teach us.

From Asymmetric ADMA and Symmetric SDMA Dimethylarginines in Chronic Kidney Disease: A Clinical Approach (2019, International Journal of Molecular Sciences) —

ADMA is the most potent endogenous inhibitor of nitric oxide synthase (NOS), with higher levels in patients with end-stage renal disease (ESRD). ADMA has shown to be a significant predictor of cardiovascular outcome and mortality among dialysis patients. On the other hand, although initially SDMA was thought to be an innocuous molecule, we now know that it is an outstanding marker of renal function both in human and in animal models, with ESRD patients on dialysis showing the highest SDMA levels. Today, we know that ADMA and SDMA are not only uremic toxins but also independent risk markers for mortality and cardiovascular disease (CVD). In this review, we summarize the role of both ADMA and SDMA in chronic kidney disease along with other cardiovascular risk factors.
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From Urine Metabolomics Exposes Anomalous Recovery after Maximal Exertion in Female ME/CFS Patients (2023, International Journal of Molecular Sciences) —

Four compounds in the urea cycle; arginine and proline metabolism subpathway are changing differently after exercise in the ME/CFS patients and controls: carboxy-methylarginine, proline, symmetric dimethylarginine (SDMA), and dimethylarginine (ADMA). Proline is a building block of collagen and is therefore a key component of connective tissues. SDMA and ADMA are both regulators and competitive inhibitors of nitric oxide (NO) production. NO aids in vascular maintenance in healthy individuals, and decreased NO production is associated with endothelial dysfunction and cardiovascular disease. ADMA can be removed through urinary excretion or it can be degraded in the liver. The increased excretion of SDMA and ADMA in controls but not in patients after exercise implies that controls may be removing excess NO synthase inhibitors in order to maintain vascular homeostasis and that this beneficial adaptation to exertion may not be occurring in patients. The relationship of NO and ME/CFS is unclear; plasma from ME/CFS subjects at baseline was found to induce less NO production by endothelial cells in vitro, but it is unknown whether or not that was due to higher levels of ADMA or SDMA in ME/CFS plasma, as they were not measured in that study and NO regulation is complex.
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And from Chronic Viral Reactivation and Associated Host Immune Response and Clinical Outcomes in Acute COVID-19 and Post-Acute Sequelae of COVID-19 (2024, Preprint: BioRxiv) —

Additionally, detection of CMV and Anelloviridae transcripts were both associated with increases in several long chain fatty acids such as erucate, arachidate, and docosadienoate and regulators of nitric oxide synthesis, dimethylarginine (SDMA + ADMA)
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@SNT Gatchaman. I also worked in nephrology as a "junior" on the nephrology ward and the renal transplant unit in Auckland and saw many dialysis clients coming in. Maybe we had different consultants but I didn't see a lot of BPS. I think it is worth noting we were both "juniors' about 30+ years ago? I am quite aware of end stage renal failure - dialysis patient's suffering. It is not easy.

Clinical Depression is common in all chronic illnesses, many chronic illnesses have a degree of pain or people have comorbid pain conditions and this group does have (to be even more specific - men) have a higher risk of suicide in this patient population.

My point is for a consultant to recognise that a person may be depressed is a good thing as it gives them an opportunity to check what their patient's supports and home environment is like, has there been a change in them?, do they need to arrange more support from family, carers, nursing staff, do they need better housing/transport /funding etc it has nothing to do with BPS, i.e getting them to exercise, meditate and do more "wellbeing" activities. Most consultants, I know, do accept they are unable to change the miserableness of their patient's condition and can only acknowledge and validate their patient' s lived experience.
 
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So is this excitable "pathology" the same as, or similar to lability, that symptom long said to be to be common or characteristic in M.E, though it seems to have been dropped from the array some time ago

I was first given to understand its an emotional reactivity, not quite emoting, and found in alcoholism, so may be its maudlin I was never sure what was being observed and labelled emotionally labile

Its such a shame that the distinct disturbance of neuro-transmitters was not tracked for our benefit all these years, while people who are not biologically competent preferred to latch on and be shoddy

A kidney specialist could help a lot since the kidney and some hormones are regulating the electrifying metal salts on which the neurons operate, and the RAAS system is so inexplicaby anomalous in ME / CFS according to some article I read and now can't find

I read it in Breakthorugh, the magazine produced by ME Research UK who might fund Dr Rabindranath to run some preliminary analysis of any casework in his clinic relating to ME / CFS :

Tracking changes
in the structure
and function
of the brain
over time
in ME/CFS

Current projects: Project grants

I understand some people, whether or not academically trained, like to make out others are aberrant and this adds an encyclopaedia to the actal aberrations, as people are so very diverse

Its one thing to work at the cliff-face helping people who are too disrupted and disorderly to engage themselves with their own world, its another to see it everywhere. I would hate to be in a personal relationship with such a pontificator.

Surely Dr Rabindranath has been exposed to the best and worst of the UK health services and should be able to see it coming when on common ground with the ME /CFS community in NZ encountering the local tug of war over narratives and all that follows

As he moved to NZ for the benefit of his family, he might well like to endow his client community also with his perspicacious presence and so slowly over the years to come he might be establishing a new network of doctors in associated fields with interest in learning evermore how to differentiate between the categories and between the conventions
 
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