END STAGE RENAL FAILURE IN INDIA : Is Cadaver Transplantation The Answer?
The overall picture of ESRF in India today is extremely depressing. To understand where exactly we stand let us look at the available data.
More than 1,00,000 new cases of ESRF present each year. Of these barely 15,000 (15%) manage to reach the stage of receiving dialysis. Rest i.e.85,000 patients die for want of dialysis. This number exceeds the total estimated number of deaths due to road traf.c accidents in the country each year! Of the lucky 15,000 who reach a nephrologist 4000 die as they are critically ill at presentation. Of the 11,000 who manage to survive about 6000 drop out of the dialysis programme at one month to die of uraemia at home. So we are left with 5000 (5%) patients out of the total of 1,00,000. About 3000
transplants are done every year. The rest continue to be on maintanence dialysis. This is indeed a pathetic situation.1,2
Our population has recently surpassed the billion mark. We have only 600 nephrologists to cater this huge population. Almost all practise in the cities. There are about 100 government dialysis centres out of which 20 have a transplantation programme. We have 200 private centres carrying out dialysis and 70 of these carry out transplantation. We all know that nephrology does not get as much attention in the postgraduate training programme as do the other branches like cardiology, neurology and chest medicine. In a progressive state like Maharashtra we have only 2 D.M. seats and 2 DNB nephrology posts for whole of the state! The scene is worse in other states. As a result large streaches of regions and states have no nephrology services.
Apart from inadequate availability of nephrology services. The other major problem is .nance. Our per capita income is Rs. 20,000 p.a., one of the lowest in the world. The average monthly income of a family in Mumbai, India's financial capital is Rs. 4000 pm. The cost of ideal haemodialysis treatment is Rs. 30,000 pm and ideal CAPD treatment is
Rs. 40,000 pm. This includes the cost of medicines and monthly tests. This obviously is out of reach of almost all our patients. Hence we are forced to cut corners and give substandard treatment. We dialyse patients twice or even once a week instead of thrice, reuse the dialysers large number of times, use cheaper dialysers, transfuse blood instead of giving erythropoietin and avoid the mandatory monthly blood tests. The result is far less than adequate dialysis. The patients remain sick while they are on dialysis and the survival is poor - 10 to 15% at 3 years.3 Less than 0.5% of our dialysis patients afford ideal treatment and have a reasonably good quality of life.
Help from the government is lacking. Eradication of communicable diseases, population control, nutrition and family welfare were its priorities for the last 50 years and will continue to be for the next 50 years, looking at the present state of affairs. Even in government hospitals renal replacement therapy is largely self funded. 4% pay from pooled family resources, 63% get help from employers and accept charity, 30% sell property and jewellery and 20% depend on loans.4 Medical insurance is still in its infancy in India.
Let us look at the transplantation scenario. Only about 3% of the new ESRF patients are transplanted each year. Successful transplantation offers a near normal quality of life and is far superior as compared to dialysis. The survival too is better (see Table). Graft survival is improving with the advent of newer immunosuppresants.
TABLE : Patient survival
Gulati S, Gupta S, Kher V CSA/AZA/PRED
Economics too favours transplantation. The initial cost of transplantation surgery is Rs. 2,00,000 in a private hospital and Rs. 80,000 in a government set up. Cost of subsequent treatment is Rs. 8,000 pm for the first year and lesser there after, if standard immunosuppression is used. The cost can be further brought down to Rs. 2,000 pm in well matched related donor grafts. This is far less as compared to Rs. 30,000 pm required for an ideal haemodialysis treatment. Hence live related donor and cadaver kidney transplants must be encouraged. This is the only answer to todays depressing situation.
Only about 25% of the donors are related, rest are unrelated and a miniscule number of grafts come from cadavers.6 Diminishing family size, the break up of joint family system, fear of loss of libido and major surgery and discouragement by spouses are few of the reasons for low related donation. There are other less obvious problems that exist with live related donation. The magnitude of these problems is huge. We and covert .nancial transactions. Patients are asked to give up property rights in favour of the donor. Also, the whole programme is highly biased against women. In Bombay Hospital we had 34 wife to husband transplants but only 2 husband to wife donations.
We have heard of boys marrying for a kidney. In the last 10 years we had 185 female related donors and only 87 male related donors. Whereas we had 213 male recipients and only 59 female recipients or beneficiaries.
Are women more compassionate or emotionally attached than men? We all agree they are. Or is it another social evil like dowry, sati and female infanticide?
Fortunately cadaver transplantation is picking up in Mumbai. Every year the number of cadaver transplants is increasing though still extremely small. There are estimated 60,000 deaths in road traffic accidents per year. If all the cadavers were
salvaged we would have 1,20,000 kidneys, more than enough for the 1,00,000 new ESRF cases. Lot of organs are being wasted in the ICUs every day. Lack of public awareness, ignorance amongst medical professionals, lack of motivation and enthusiasm amongst intensivists, neurophysicians, neurosurgeons and treating physicians and finally, lack of trained and dedicated grief counsellors and transplant coordinators in most centres are few of the reasons. All these can be recti.ed and the callous waste of vital organs can be stopped.
This requires team work and we all should rise to alleviate the suffering of our less fortunate fellow citizens. The following few articles will introduce us to cadaver transplantation.
1. Keshaviah P. Resources limitations and Strategies for the treatment of uraemia. Blood Purif 2001; 19 : 44-52.
2. Chugh KS, Jha V. Commerce in transplantation in 3rd World countries. Kidney Int 1996; 49 : 1181-6.
3. Divaker et al. Transplant Proc 1998; 30 : 3626.
4. Mani MK. The management of end stage renal disease in India. Arif Organs 1998; 22 : 182-6.
5. Gulati S, Gupta S, Kher V. Outcome of live related and live unrelated transplants. Nephrology 1997; 3 : 563-7.