That the kidney plays an important, vital role in the human body is beyond doubt. We all know this, and we will have seen close family members or extended friends trying to cope with kidney failure and dialysis.
The 2015 Global Burden of Diseases (GBD) ranked kidney diseases as the 17th leading cause of death around the world. But in India, it is even bleaker, with GBD saying that kidney diseases are the 8th leading cause of death in the country.
The most important contributing factors are diabetes and hypertension. A study showed that adults in south and the east of India are at highest risk of death due to renal failures, and significantly, poorly treated diabetes is the most important factor for this.
A study estimated that about 8000 persons per million could be at risk of kidney failure, in India.
Any way you look at it, Kidney diseases are a huge national priority, and governments - both at the state and centre - and institutions, must gear up to face the challenge. At Apollo Hospitals in Chennai, Dr. Anil Vaidya, a Transplant Surgeon specialising in Kidney, Pancreas, and Multivisceral Transplant surgery, perhaps is better prepared than most others.
Transplant Surgery from a different angle
Dr. Vaidya, who is also a Professor of Transplant Surgery at Oxford University, says he “looks at transplant in a different angle”, and has brought with him several techniques and processes that were not practiced in India before. His work, and his research interests in both the UK and in India, has a real, measureable impact on the quality of lives of people, and provides effective ways to treat illnesses. This is especially seen in organ transplantation for diseases affecting the kidney, the pancreas, and the intestines.
“There is a published estimate that 250 per million Indians require dialysis,” says Dr. Anil Vaidya. That translates to a whopping total of over 3 lakh patients requiring dialysis every year. Hospitals and dialysis centres will be overburdened with the task, and the numbers will only grow every year.
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For these 3 lakh Indians, kidney transplants are the best available option. There are two sources for donor kidneys - a live, willing donor, or a deceased or cadaveric donor.
“Deceased organ transplantation as such has been a bit late to pick up in India,” says Dr. Vaidya.
Dr. Pratap Reddy, founder of Apollo Hospitals, was the moving force behind the 1994 Transplantation of Human Organs Act, which for the first time, governed and regulated transplantation and organ donation in the country. The act also defined and recognized brain death as a factor, for the first time in India, and allowed for cadaveric organ donation.
“There was an onus on live donor kidneys earlier,” says Dr. Vaidya. “But since that act in 1994, it’s opened the doors to cadaveric donors, and to understand what brain death was. It has taken a long time to percolate to the grassroots. It’s one thing for a physician to identify brain death, but there’s a cultural thing on the other side, with relatives not believing that a person is dead, they can see their loved ones with a heartbeat. So, I guess there’s a lot more education that needs to be done to let the general population understand the process."
Since then, laws enacted by the State of Tamil Nadu, and measures taken by Apollo Hospitals and other partnering hospitals, Non-Governmental and Quasi-Governmental organisations and bodies, have worked together to create a transparent, effective system to enable cadaveric organ donation and transplant to happen, without adverse outcomes such as commerce and unethical trade in human organs. The kidney especially has been vulnerable for exploitation and illegal trade.
However, these risks can be mitigated.
What cadaveric donor kidneys have done, is help offset some of the burden on those 3 lakh patients every year going into dialysis. However, Dr. Vaidya says there are other issues and factors to consider.
He introduces the concept of half-life of the kidney.
‘Half-life’ estimates the number of years it will take for 50% of the patients transplanted in a given year to come back for dialysis. The longer, the better. Many factors come into play here, but significant among those, is where the organ has been sourced from: A live donor or a cadaver donor.
In the UK, the half-life of a live donor kidney, is 25 years. That is, a patient receiving a live-donor kidney transplant has a 50% chance that the kidney will work for at least 25 years, before going back for dialysis. The half-life of a cadaver donor, in the UK, is 12 years. Clearly then, live-donor kidneys translate to longer lives and better-quality lives.
In India, the half-life of a cadaver donor kidney is unknown, but, Dr. Vaidya spoke to many physicians around the country, and believes that it may be about 7 years.
So, for Dr. Vaidya’s patients, the choice is clear. “If you can talk to a family member or relative, and identify a willing donor, do it now,” advises Dr. Vaidya. It is better to ask within members of family because there’s a greater chance of organ matches, and the risk of rejection is lower. Further, for a patient on dialysis, every passing month and year exposes them to further risks and complications, so the sooner one can identify a donor, the better.
Systems of care for the donors, and the patients
Live donors require more care than the patient that they are donating to because they have no prior disease process and cannot afford to have any complications from the donation process, immediate or long-term. Some donors may feel that donating one kidney may put them at risk of developing kidney failure and other complications later. For them, Dr. Vaidya has special tests and procedures to estimate risks.
GFR - or Glomerular Filtration Rate - is a test that measures how well a kidney is able to filter toxins from blood, and how effective it is in pushing the toxins out through the urine. Using blood markers, urine markers, and radiological markers, as well as the GFR, Dr. Vaidya is able to determine each kidney’s capacity, and thus allow the donor to make an informed choice.
More needs to be done, says Dr. Vaidya. Legal education for donations is a top priority. Additionally, hospitals and doctors must have programmes for donor management - especially pre and post donation care. At Apollo, live donors are given full explanations of what the transplant procedure involves, and are put in touch with psychologists and therapists before and after donation. Some donors are afraid of pain, and may have reservations about surgery. For such donors, and for their patients, Dr. Vaidya has special pain-killing protocols involving the use of epidural anaesthesia.
Given the scale of the disease in India, and given that a large section of the country lacks access to big, multispeciality hospitals, kidney transplant programmes have to be streamlined, processes and pathways have to be evaluated and legal frameworks will have to be established.
This streamlining process is performed by organisations such as the Zonal Transplant Coordination Committee, the MOHAN Foundation, and the National Organ and Tissue Transplant Organisation.
Apollo is one of the coordinators at the southern region, and is part of the MOHAN Foundation, as well as links with the ZTCC.
These systems and protocols have made all the difference for many of Dr. Vaidya’s patients. As processes and systems evolve, and as more and more people become aware of both the risks of kidney diseases and the benefits of transplantation, a significant number of that 250/million, or 3,00,000 patients, can be cured, effectively. Long term benefits to a healthy, happy society will only increase.
This article has been produced by TNM Marquee in association with Apollo Hospitals.