Options before kidney patients

Print edition : December 13, 1997

Kidney patients have to choose between dialysis and kidney grafting. In the absence of a public health service in dialysis, prevention of kidney diseases assumes vital importance.

WHAT is End-Stage Renal Disease (ESRD), or "kidney failure" as it is commonly known? The main function of the kidneys is to cleanse the blood of wastes such as uric acid and other toxic substances. At any point in time, one-fifth of the total blood in the body is filtered by the kidneys. A person suffers from renal disease when, owing to an impairment in their functioning, the kidneys do not cleanse the blood efficiently.

Kidney diseases can be broadly classified as chronic and acute. Chronic kidney diseases may be caused by problems in other parts of the body and can be reversed once the underlying problem is set right. The second is a disease of the kidneys themselves and is not reversible; the condition deteriorates. This is ESRD and there are roughly 100 ESRD patients for every 10 lakh people in the West. Comparable figures for India are not available, and doctors usually apply these statistics in their calculations.

Kidney functioning is affected mainly by diabetes (which is the causative factor in 30 per cent of ESRD cases), chronic glomerulonephritis (20 per cent), chronic intestitial nephritis (20 per cent), hypertension (10 per cent), infections (10 per cent) and other causes (10 per cent). Hypertension accelerates the decline of kidney function in all other diseases. Only when the efficiency of the kidneys is down to 30 per cent or less does the malfunction manifest itself. Typically, ESRD manifests itself not symptomatically but in a blood test. And even where there are symptoms, usually nausea and indigestion, they are mistaken for other problems. When the kidneys function at less than 10 per cent of their capability, a person is said to have ESRD.

There are two treatment options available to a person suffering from ESRD - dialysis and renal transplant. Haemodialysis is a process by which the blood is cleansed by an artificial kidney, a machine that removes the wastes by diffusion. An ESRD patient usually undergoes it thrice a week. Dialysis entails a high recurring expenditure.

In recent years, an excellent but expensive option has become available: Continuous Ambulatory Peritoneal Dialysis (CAPD). CAPD is done inside the patient's body, using his or her own peritoneal membrane (which lines the peritoneal cavity) as a blood filter. A catheter is inserted into the patient's abdominal cavity and is connected to sterilised plastic bags containing the dialysis solution. Through a process of diffusion and osmosis, waste products in the blood are transferred across the membrane into the bag. Typically, this exchange of fluids across the membrane is done three or four times during the day. The CAPD method is a refinement of the peritoneal dialysis technique. Under CAPD, patients are on non-stop dialysis. Baxter, the multinational pharmaceutical company which pioneered the CAPD technique, claims that the method puts less pressure on the patient's heart than haemodialysis does, allows the pace of dialysis to match the patient's metabolic rate, enables mobility and eliminates the need for hospital visits. CAPD also entails less dietary and other intake restriction on patients.

TRANSPLANTS or kidney grafts can be done from a live donor, whether related or unrelated to the ESRD patient, or from a cadaver. The medical challenge in transplantation is that of rejection. The immune system recognises the transplanted organ as not belonging to it and fights the alien as it would fight any hostile organism that enters the body. The success of organ transplantation has greatly improved since the advent of the immunosuppressive drug, cyclosporin. This suppresses the attack of the immune system on the transplanted organ, but there are risks involved as the whole immune system tends to be suppressed, making it vulnerable to infection.

The dialysis ward at CMC, Vellore. Dialysis is one of two treatment options available to a person suffering from ESRD, but in the absence of a public health service in dialysis, it is beyond the means of many.-K. GAJENDRAN

While cyclosporin and the newer drugs have made a huge difference to the organ transplantation programme, the long-term success of a graft depends on the degree of tissue-matching (of the human lucocite antigen, known as HLA matching) between the donor and the recipient. The best results are obtained from kidneys donated by close blood relatives such as siblings, parents or children (among these, siblings give the best results). About 1 in 10,000 has a half-match, which is acceptable. A full-match sibling graft tends to have a life of 25 years; a half-match relation 12 years; and an unrelated donor or cadaver-sourced kidney 6.5 years. According to the Encyclopaedia Britannica: "The best survival rates are between identical twins... Approximately 50 per cent of grafts cease to function after 8 to 11 years, but others last 20 years or more."

According to Dr. J.V. Thachil, Chief Urologist at the Apollo Hospitals, Chennai, the five-year survival rate of a live related tissue-matched transplant is 90 per cent; cyclosporin increases the survival rate substantially. "Before cyclosporin was introduced, the three-year survival rate for an unrelated or cadaveric transplant was dismal, about 38-40 per cent," the surgeon points out. "With cyclosporin, the five-year graft survival rate of a cadaveric transplant patient is 75-80 per cent. We have patients who have survived more than 25 years." This is good news indeed and the trends are getting brighter for ESRD patients.

The live related donor programme is the mainstay of the transplantation programme in India, according to Dr. M.K. Mani, Chief Nephrologist at the Apollo Hospitals, Chennai. Apart from a better graft survival rate, there are measurable advantages that a live related transplant has over live unrelated and cadaveric transplants. The donor and recipient can be investigated in advance and the surgery planned in such a manner as to keep dialysis at a minimum, thereby reducing costs. The need for immunosuppressants is correspondingly lower; this also reduces overall expenses.

A kidney transplant surgery under way at the Apollo Hospitals, Chennai, on November 5. The donor's kidney being isolated for removal.-VINO JOHN

In an article, "The Management of End-Stage Renal Disease in India", which will appear in the March 1998 issue of Artificial Organs, the journal of the International Society for Artificial Organs, Dr. Mani estimates the costs of different treatment options for patients with ESRD. (The figures given below are rupee conversions of Dr. Mani's estimates in U.S. dollars.) Transplantation from a live related donor involves an initial cost of about Rs.2 lakhs and a recurring annual cost on cyclosporin of Rs.1 lakh; haemodialysis at hospital entails an annual expenditure of about Rs.1.75 lakhs; haemodialysis at home requires an initial cost of Rs.4.5 lakhs and a recurring cost of Rs.1 lakh a year; a CAPD home unit entails an initial expenditure of about Rs.10,000, but the annual recurring expenditure varies from Rs. 1.5 lakhs to Rs. 4.5 lakhs depending on the specific unit.

A person who seeks a transplant from an unrelated donor usually incurs an extra expense, that which is paid illegally to the donor. Quite apart from the illegality of the purchase, Dr. Mani says that the long-term results of a well-managed dialysis programme are better than those of an unrelated live transplant, both medically and with respect to costs. He writes: "With the additional burden of paying for the kidney and for cyclosporin, the recipient of an unrelated donor kidney pays approximately Rs.2.5 lakhs for his transplant in the first year. It would cost considerably less to keep him on maintenance dialysis at home" ("Renal Transplantation in India", Transplantation Proceedings, Vol. 24, No. 5, 1992).

A leading Bangalore nephrologist (who requested anonymity) told Frontline that many nephrologists "coax-ed and cajoled" patients into opting for a transplant without really making a case for dialysis as an alternative. "It is only in a badly managed programme that a patient on dialysis becomes weak," he noted. "Abroad, in any nephrology programme, the conversion rate from dialysis to transplant is 30 per cent, that is, more than two-thirds of all renal failure patients prefer to stay on dialysis. Here it is the other way around."

Medical problems in the case of unrelated donors arise because of the limited match between the antigens in the donor and the recipient. Large doses of immunosuppressants are administered to fight rejection, but this makes the recipient susceptible to other infections, such as Hepatitis B.

Finally, the live unrelated donor programme stifles the development of a cadaveric transplant programme, which is really the option of the future.

ACCORDING to Dr. Thachil, "any healthy person can donate a kidney and lead an absolutely normal life." He cautions, however, that the removal of the kidney is a "major muscle-cutting operation" and there are risks involved that must be explained to the donor.

The donor's kidney being kept under ice.-VINO JOHN

Among the donors who come to him for regular check-ups are mothers over the age of 60. Kidney donors at Apollo are typically from the middle class: they include government employees, professionals, Army personnel and persons running small businesses or involved in trade.

What are the precautions that a prospective donor or donor must take? Persons with a family history of ailments such as blood pressure, diabetes or asthma should not donate their kidneys. Blood pressure and diabetes in such persons tend to increase the chances of kidney failure; an asthmatic condition in donors can increase anaesthetic risks during surgery.

Donors have to come back to the hospital for annual medical check-ups for the rest of their lives. Urine, blood and renal function tests and monitoring of blood pressure are "absolute musts". It is important that the donor maintain good health after removal of one kidney, and regular physical examinations are necessary to monitor the health of the donors. Dr. Thachil says that "the risks of kidney failure are greater in cases where a donor does not return for regular medical monitoring."

Transplanting the kidney into the patient.-VINO JOHN

Persons who do hard manual labour such as work at construction sites, or people in professional sports such as boxing or horse-riding cannot get back to the same occupations after donating their kidneys. The donor does not have to change his or her diet after surgery, but has to take care to avoid activities that pose risks of injury to the remaining kidney. Members of the armed forces who donated their kidneys at Apollo had been reassigned to desk-work rather than being sent to the front.

Dr. Thachil notes that the impact of kidney removal on the health of commercial donors has not been adequately studied by the medical profession. A powerloom worker can continue to work normally after the surgery, but malnourishment can significantly "increase risks by delaying recovery of the patient from a major surgery."

GIVEN the high costs of renal transplantation, only a minority of those suffering from ESRD in India can afford it. Dialysis is also beyond the means of many, given the absence of a public health service. Under the circumstances, the prevention of renal disease assumes overriding importance. The Kidney Help Trust in Chennai, set up by Dr. Mani, did a study of the renal disease burden in a rural community of 25,000 persons near the metropolis. The study showed that 5.26 per cent of the population was suffering from hypertension, 3.64 per cent from diabetes mellitus, and 7.50 per cent was at risk of developing renal failure. Dr. Mani concluded in "The Management of End-Stage Renal Disease": "It is clear that if we could control diabetes and hypertension well from their commencement, we would prevent or slow (the) progression in half the patients with chronic renal failure in the country. However, health authorities and the public conspicuously neglect these diseases."

The distinguished nephrologist ar-gues strongly in favour of making treatment programmes for diabetes and hypertension part of a domiciliary treatment programme in the way the treatment for tuberculosis and leprosy are.

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