Diabetes is a particularly troubling disease for Indians.
It is an epigenetic disease - in which environmental factors, lifestyle and diet choices, trigger and compound genetic factors that puts people at greater risk of contracting the disease.
About 20% of urban populations, and about 10% of the rural population in south India are at risk of contracting diabetes, and some research says that there is prevalence of insulin resistance in Indian populations. These, combined with the high-sugar, high-fat food we eat, could trigger a large-scale epidemic. A World Health Organisation report says that about 7.8% of all Indian populations have diabetes, with associated risk factors - such as obesity, physical inactivity - at about 12% of the population.
For a country of 1.3 billion people, thatās at least 150 million (about 15 crores) people at potential risk of the disease.
Diabetes could also be a gateway for other health risk conditions. Type 2 Diabetes - which is more common across the world, and especially in India - could lead to kidney failure, blindness, among other complications.
Further statistics are even more disconcerting. A study estimated that about 8000 persons per million could be at risk of kidney failure, in India. Dr. Anil Vaidya, a Transplant Surgeon in Apollo Hospitals in Chennai, estimates that about 250 per million Indians require dialysis. Of which, he says, about 44% - or approximately 100 persons per million, have both kidney failure and diabetes.
However, there is hope.
Simultaneous Pancreas and Kidney Transplant.
āCan you cure a person with Type 2 Diabetes through transplantation? And the answer is yes! However you got to select your patient correctly,ā says Dr. Anil Vaidya. Dr. Vaidya - who is also a Professor of Transplant Surgery in Oxford University, focuses on Pancreas and Kidney transplant in Apollo, although he also does other abdominal and intestinal organ transplant, and in his own words, ālook at transplantation in a different angle, try to introduce new procedures, which were not available in India prior to my arrival here.ā One of the new procedures he brought to India, was to include the pancreas as part of the āpackageā when doing kidney transplant for diabetic patients.
There are two major types of diabetes: Type 1, and Type 2.
Type 1 diabetes - or Insulin dependent diabetes - usually is an auto-immune condition in which the body detects its own insulin-secreting cells in the pancreas, and attacks it. This auto-immune disease usually affects children and young adults and is managed with regular injection of exogenous insulin.
Type 2 Diabetes - also sometimes known as Adult Onset diabetes, is where the pancreas produces Insulin, but it is either insufficient for the body to regulate sugar level, or the body has developed a resistance to Insulin. The former (with no resistance) can be cured by āaddingā an insulin secreting unit (transplanted pancreas) - allowing more insulin to be produced in the body.
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Simultaneous Pancreas and Kidney (SPK) Transplant is the current Gold Standard of therapy for diabetics on dialysis, says Dr. Vaidya. Those diabetics already requiring a kidney transplant - could easily get a pancreas transplant during the same procedure, under the same immunosuppression medication (which allows the body to āacceptā this new organ) - giving them a greater chance of fighting both diseases and living a better, longer life.
The first such procedure was performed in 1966, and about 55000 simultaneous Pancreas and Kidney transplants have been done worldwide since then. India has the most number of diabetic+dialysis patients, but a dual transplant is not the first line of defense against the disease, as doctors may not have the expertise to perform it.
But, āthere is no doubt about it!ā says Dr. Vaidya. World-wide data suggests that the treatment of diabetics who fulfil the selection criteria for transplantation and are on dialysis, is better with a simultaneous pancreas and kidney transplant as opposed to a cadaver kidney alone.
The advantage: longevity of the Transplanted organ
To understand longevity better, we must look at something called the āHalf-Lifeā of an organ.
āHalf-lifeā of an organ is a concept especially in kidney transplantation. This roughly estimates the number of years it will take for 50% of the patients transplanted in any given year to be put on dialysis again. The longer, the better.
Many factors come into play here, but significant among those, is whether the organ has been sourced from a live donor or a cadaver donor.
In the UK, the half-life of a live-donor kidney transplant is 25 years, while the half-life of a cadaveric-donor kidney transplant is 12 years.
In other words, 50% of patients who underwent a kidney transplant using a live donor, went for 25 years without needing additional procedures or medication, and lived a much better life.
In India, the half-life of a cadaveric-donor kidney transplant, is unknown as data collection is poor. However, evidence from some centres suggest that it may be as low as 7 years.
For a middle-senior level professional - of about 40-45 years of age - who is prone to diabetes, and at risk of kidney failure, 7 years is too short a time. The actual cost of treatment, and the opportunity cost - in terms of lost time, lost opportunities for career development, is too high.
But, with Simultaneous Pancreas and Kidney Transplant, Dr. Vaidya says, the half-life, even with a cadaver donor, is 25 years. āSo that is the advantage for a diabetic!ā
Survival graphs of those receiving live donor kidney alone, and those receiving cadaveric kidney and pancreas, are similar. However, after 25 years, the patient who received only the kidney, is at greater risk now. The diabetes which had been under control simply with medication or with insulin injections, will have caught up with the personās heart function and coronaries. Survival rates after 25 years, are higher for those with simultaneous pancreas and kidney transplant.
So a patient with Type 2 Diabetes has more than 25 years of a healthy, diabetes and dialysis free life to look forward to. Thus for a patient at 45 years of age, this means their quality of life is assured well past their prime, working life, and significantly into their retirement age. Combined with a healthy lifestyle, and good diet, this translates to a long, happy life. That promise - for 1,32,000 Indians - is worth every bit of effort and research into medical sciences, that Apollo, and Dr. Anil Vaidya, are currently doing.
A Structural Change
But this promise, to actually materialise for Indian patients, needs a larger, systemic effort.
The Transplantation (Human Organs and Tissues) Act of 1994, created the first nation-wide law to govern how and when transplantations can be performed. Dr. Pratap Reddy, founder and chairman of Apollo Hospitals, was the moving force behind the act. Since then, organisations such as the Mohan Foundation in Chennai, the Zonal Transplant Co-ordination Committee in Karnataka and Maharashtra, the National Organ and Tissue Transplant Organisation (NOTTO), have created a network of hospitals, research organisations, and coordination agencies that facilitate transplantation. These organisations and partnering hospitals have programmes to share organs - and to match patients needing transplants, with live and cadaver donors.
But, this is complex, and complicated. While Tamil Nadu leads the country in terms of organ donations and transplantation surgeries performed, the waiting list is long, the process to source the donor organs difficult, and the cost of the entire process is often prohibitive to a large percentage of our population.
When it comes to Simultaneous Pancreas and Kidney transplant, this is further complicated because there are two organs involved. A bottleneck is created where if the donor is in another hospital, it is likely, that the pancreas is available but kidneys from the same donor may be allocated locally to the hospitalās waiting list and may not come with the pancreas.
For Dr. Vaidya, who has 60 plus patients on his waiting list, this is a tough task. To manage expectations, to assure and comfort patients, and to co-ordinate with the various systems and procedures that govern transplantation and organ donation, takes up a lot of time. The waiting period could range anywhere between a couple of months, to up to a year and half or more.
That is a huge risk.
Diabetes and Dialysis is a dangerous combination.
The median patient survival in this case - when you do nothing, is 8 years.
A live donor kidney-alone transplant increases life expectancy to 25 years, and a kidney+pancreas transplant, is more than 25. However, for a patient on the waiting list, there is a 12% chance of dying every year, and this probability goes higher every year, and with more complications developing over time.
āSo, we come back to the same question. I have this young person, sitting in front of me. I know Kidney-Pancreas is the best option for him, but he might have to wait for it. Heās on dialysis, so his clock is ticking - the 8 year clock is ticking. How much should I wait? When do I say, āListen get a live donor kidney, get off dialysis. Get one āDā out of the wayā?ā wonders Dr. Vaidya.
Pancreas are readily available in India. The question is the kidney.
Hospitals that remove organs from registered donors - cadavers, will need to send the organs to the Government pool of available organs. A hospital may remove two kidneys from a donor, in which case they can keep one for their own patients, and send the other kidney to the government pool. Given that most hospitals that share organs and perform transplant surgeries have their own waiting list, this creates an imbalance between demand and supply.
Dr. Vaidya says, āI need the kidneys to follow the pancreas. That regulation is still not in place in India.ā
āTo have the awareness, in the structure of transplantation, that anyone with a dual organ requirement, has priority.ā This structural change, is the key to treating diabetes and dialysis in one effective procedure.
This might be perceived as an advantage for those with diabetes. Could this mean that a seriously unwell patient on dialysis, who is not a diabetic, does not get priority?
Hospitals in the West, have handled it by a system of repayment. When one hospital receives a kidney from the other, they will repay the donor hospital, at a later time, with another kidney from their pool. Other systems are being evolved to handle the mismatch between the requirements of organs, and the availability of donors. A similar system must be created and enforced in India, to benefit a larger number of patients in the country.
At Apollo, Dr. Vaidya, and the rest of the medical team, is trying to address this question. In the process, he is also creating more effective ways to identify and treat diabetes and kidney failure, and has pioneered a technique that allows him to monitor the long-term āacceptanceā of the donor organ, and therefore the long term health, and quality of life, of his patients.