Fatal Failure

Every year nearly two lakh patients die due to kidney-related diseases in India, waiting for an organ transplant
By Amresh Kumar Tiwary

Kidney disease is emerging as a major, though silent killer. Most people are not aware of the fact that kidney disease may not show any symptoms for a long time till the situation becomes critical. The first symptom of kidney disease is changes in the amount and frequency of your urination. There may be an increase or decrease in amount and/or its frequency, especially at night. It may also look more dark coloured. You may feel the urge to urinate but are unable to relieve yourself when you get to the restroom.
According to a study, two persons every five minutes or roughly two lakh people die due to kidney-related diseases in India every year. There is an acute shortage of organs, and the gap between the number of organs donated and the number of people waiting for a kidney transplant is getting larger. The need of the hour is to establish more detection clinics and take steps to arrest deaths due to kidney failure.

Increasing Incidence of Kidney Disease in India
With the number of kidney transplants in India averaging in the range of 3,000-3,500 per year whereas about 150,000 patients require kidney replacement. Transplant of one organ from one human being to another has always been a rigorous process which needs a lot of care.
According to a recent study, India sees more kidney transplants than any other country in the world barring the US. Under the Transplant of Human Organs Act, 1994, there is permission of organ retrieval from the brain-dead patients, though kidney donations by live donors remain very much in vogue. The country, however, has slipped to the 40th rank in the study of 69 countries in terms of number of transplants per million population, with only three in a million getting the kidney in case of a renal failure.

How does Kidney Disease Occur?
The kidneys are two bean-shaped organs located on either side of the spine just below the rib cage. Each one is about the size of a fist. Their main function is to filter and remove excess waste, minerals and fluid from the blood by producing urine.
When your kidneys lose this filtering ability, harmful levels of fluid and waste accumulate in your body, which can raise your blood pressure and result in kidney failure (end-stage renal disease, which is also known as end-stage kidney disease). End-stage renal disease occurs when the kidneys have lost about 90 percent of their ability to function normally.

Diseases Aggravating Kidney Problem
Common causes of end-stage renal disease include diabetes, chronic, uncontrolled high blood pressure, obesity, Chronic glomerulonephritis — an inflammation and eventual scarring of the tiny filters within your kidneys (glomeruli). Obesity is a major contributor to kidney disease. As per a report, India ranks 3rd (first is USA and the second China) as a most obese country in the world. About 220 to 40 percent people in India are obese. Out of this, 5 percent have morbid obesity. Through BMI (Body Mass Index) you can measure your level of obesity. BMI of 23 to 25 is considered as normal, while 25 to 29 is considered to be overweight and obese respectively.
Increasing occurrence of diabetes especially type2 is a major risk of kidney problem. If not controlled, India will be world the capital of diabetes by 2040. This is because people with diabetes tend to have other long-standing medical conditions, like high blood pressure, high cholesterol, and blood vessel disease (atherosclerosis). People with diabetes also are more likely to have other kidney-related problems, such as bladder infections and nerve damage to the bladder.

The State of Kidney Transplants in India
Kidney transplant takes place generally at the end-stage of renal-disease. The donor in kidney transplant can either be a living person or a deceased person. According to the statistics, the most frequent organ transplant is the kidney transplant. Kidney transplant is not an emergency surgery and patients can be managed with dialysis. So, no patient should die because of non-availability of organs. The success rate is very high in this type of transplant as there are many ways in which a human body can be supported through dialysis in order to purify the blood. Therefore, we can say that the criticality of kidney transplant is comparatively less.
Transplant, as an option, has successful outcomes, and the number of people needing a transplant is expected to rise steeply due to an ageing population and an increase in organ failure.
A kidney transplant costs about Rs 3-4 lakh depending on nature of cases and facilities being provided by hospitals with a lifetime monthly post-operative care costing at least Rs 10,000.Tracking the rate of LKD is important as the worldwide prevalence of end-stage renal disease is increasing and a global trend can help countries evaluate their performance. India is in an unenviable position when it comes to the disease burden, implementation of the Organs Act and preventing kidney rackets that frequently rock the nation. If pushed further to two per million population, then 4,400 kidneys could be retrieved, dramatically reducing the burden on living donors.
Although there is no national registry so that one can know about how many kidney transplants occur in India, Multi Organ Harvesting Aid Network Foundation in Chennai estimates the number of transplants per year to be in the range of 3,000-3,500, with barely 5 per cent coming from the brain-dead. The annual requirement is about 150,000.The LKD rates in two-thirds of the 69 nations surveyed have been growing at 50 per cent over the last decade, but India remains stuck at the same level due to lack of health insurance, and institutional and financial support.

Kidney donation in India
However, the organ donation process is marred in India due to the stigma attached to kidney donation. The law prohibits any commercial dealing in organs such as purchase of kidney from a donor from economically weaker section, but because the demand is so high, the law is difficult to implement and kidney scandals continue to haunt the country where a donor is not adequately compensated.
There have been several news reports about organ trafficking in India, putting the spotlight on the shortage of donors. Against the global requirement of about 600,000 each year, only 60,000 kidney transplants are done in India. And, of the 150, 000 to 200,000 people who need transplant, only 3,500 get it.This scarcity will grow rapidly in the coming years because of an increasing lifespan, rising incidence of end-stage kidney disease, and wrong legislative policies.

Dr Rajesh Agarwal, Nephrologist, Sri Balaji Action Cancer Hospital, said, “Kidney transplant in India faces great challenges in the wake of acute organ shortage and difficulty to optimise transplant outcomes. Though the advancement in immunosuppression and clinical care has resulted in positive short and long-term outcomes, with overall one-year graft survival of 95 percent, kidney transplant suffers from many bottlenecks, beginning with the ever-growing waiting list. Then there are fraudulent practices giving a fillip to the growing market in illegal organ transplant.”
“Under Transplant of Human Organs Act, 1994, the Union health ministry has come up with a composite set of guidelines to deal with such issues. But it needs to develop a number of government healthcare institutions in India where legal issues and cost factors should be negligible for kidney transplant,” Dr Rajesh Agarwal, said.“It’s not easy to find donors in the case of kidney transplant. The aim of the facility should be to serve the poorest of the poor, build proper medical expertise and build the system’s capacity. The number of candidates waiting for a kidney transplant has increased day by day. Over the past few years, several proposals have been designed to increase overall transplant benefit by incorporating a measure of transplant outcome, while maintaining access to transplant for all candidates, have been considered,” said Dr S P Yadav, Senior Urologist and Member, Medical Council of India, New Delhi.

Based on the Kidney Donor Profile Index (KDPI), kidney allocation in the right direction allows longest expected survival of both donors and recipients. It depends on a clinical formula that classifies donor kidneys based on how long they are likely to function once transplant is done. The access to transplant is enhanced for certain populations by calculating waiting time from the dialysis start date. This should successfully address two major problems in kidney allocation: allocation of kidneys from ideal donors to recipients with short expected survival and the use of kidney from less than ideal donors to those expected to live for a long time.
’There should be a uniform legislative policy to augment organ donations and enforce regulatory mechanisms. Kidney transplant is different from other healthcare activities and the law on this subject should be enacted by the Centre. Also, needed is a centralised regulatory authority to monitor the transplant procedures, inspect hospitals, and summon the concerned managerial and medical, paramedical staff involved in the procedure,” added Dr S P Yadav.
He feels that the authority constituted under the Transplant of Human Organs Act 1994 doesn’t have pan-Indian jurisdiction. It should be mandatory to report all transplants to the central organ donation authority, with details of the donor and the recipient, members of the authorisation committee and the transplant team. All transplants must be registered, which should allot a wait-listed number to each registrant’.
Dr Ravi Bansal, Senior Consultant Nephrologist, PSRI Hospital Delhi, said, “International organ donation policy is well established. More than 80% of transplants are cadaveric. In Netherlands, organ donation is included in curriculum of school students. They have an option of taking the pledge to donate organs before they exit from school and join higher education. In India laws are adequate but awareness is less; there is a need to make medical doctors and general public more aware of these laws.”

Causes of Kidney Disease
The most common causes of kidney disease include diabetes, high blood pressure, and hardening of the arteries (which damages the blood vessels in the kidney). Some kidney diseases are caused by an inflammation of the kidneys, called nephritis. This may be due to an infection or to an autoimmune reaction where the body’s immune or defence system attacks and damages the kidneys. Other kidney diseases like polycystic kidney disease are caused by problems with the shape or size of the kidneys (anatomic disorders), while other kidney diseases interfere with the inner workings of the kidneys (metabolic disorders). Metabolic kidney disorders are inherited from both parents, consequently, they are rare.
The two bean-shaped kidneys are located on either side of the body, just underneath the ribcage. The main role of the kidneys is to filter out waste products from the blood before converting it into urine. Kidneys play one of the most vital functions in our body. Sometimes, the kidney may lose its ability to function properly. In extreme cases, they may cease to work. Such a condition is called kidney failure. In such extreme cases, kidney transplant is believed to be the most viable option in the long run.

Need for Kidney Transplant
Kidney transplant is something that is needed for a patient with renal failure. Other than dialysis, a transplant is the only way for someone with advanced renal failure to survive. A transplant must come from a healthy donor who is a match, and even after a transplant, the patient has to take medication and be under a doctor’s supervision for the rest of his life.
A kidney transplant may be performed regardless of age of the recipient (patient who requires the kidney) provided he/she has a general health status that can withstand the major operation. The person should be aware and willing to comply with taking immunosuppressant medications after the transplant to prevent rejection of the new organ by the body’s immune system.
According to Dr N P Singh, Senior Nephrologist, Max Superspecialty Hospital, Vaishali, Ghaziabad, “Patients usually require dialysis when the waste products in their body become so high that they start to become sick from them. The level of the waste products usually builds up slowly. Doctors measure several blood chemical levels to help decide when dialysis is necessary. The two major blood chemical levels that are measured are the “creatinine level” and the “blood urea nitrogen” (BUN) level. As these two levels rise, they are indicators of the decreasing ability of the kidneys to cleanse the body of waste products.”
Dr Rajesh Aggarwal, said, “We use a urine test, the creatinine clearance to measure the level of kidney function. The patient saves urine in a special container for one full day. The waste products in the urine and in the blood are estimated by measuring the creatinine. By comparing the blood and urine level of this substance, the doctor has an accurate idea of how well the kidneys are working. This result is called the creatinine clearance. Usually, when the creatinine clearance falls to 10-12 cc/minute, the patient needs dialysis.”
Dr Rajesh Aggarwal added, “We also use other indicators of the patient’s status to decide about the need for dialysis. If the patient is experiencing a major inability to rid the body of excess water, or is complaining of problems with the heart, lungs, or stomach, or difficulties with taste or sensation in their legs, dialysis may be indicated even though the creatinine clearance has not fallen to the 10-12 cc/minute level.”

Dr N P Singh added, “With a view to create more awareness, Max Superspecialty Hospital, in association with Indian Medical Association, recently organised a conference which focused on issues like the role of dialysis services and sensitisation of cadaver kidney transplant which has still not picked up due to lack of public awareness and the people’s unwillingness to become organ donors.”
Procedure of Kidney Transplant Surgery
As per a report, about 800 million chronic kidney patients are detected in India per year. About 3000 kidney transplants are performed every year and many more could be performed if more kidneys were available. The success rate for kidney transplants is excellent and higher than for other kinds of organ transplants at affordable cost. The transplanted kidney provides enough kidney function. After a successful transplant, there is no need for dialysis, provided the transplant continues to work well. The patients who have a successful transplant should feel better and have more energy. There may, however, be a need to watch their diet to protect the kidney.
Said Dr N P Singh, “In most cases, the barely functioning existing kidneys are not removed, as this has been shown to increase the rates of surgical morbidities. Therefore the kidney is usually placed in a location different from the original kidney, often in the iliac fossa, so it is often necessary to use a different blood supply. The renal artery of the kidney, previously branching from the abdominal aorta in the donor, is often connected to the external iliac artery in the recipient. The renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is often connected to the external iliac vein in the recipient.”
The transplant surgery lasts five hours on average. The donor kidney will be placed in the lower abdomen and its blood vessels connected to arteries and veins in the recipient’s body. When this is complete, blood will be allowed to flow through the kidney again. The final step is connecting the ureter from the donor kidney to the bladder. In most cases, the kidney will soon start producing urine. Depending on its quality, the new kidney usually begins functioning immediately. Living donor kidneys normally require 3–5 days to reach normal functioning levels, while cadaveric donations stretch that interval to 7–15 days. Hospital stay is typically for 4–7 days. If complications arise, additional medications (diuretics) may be administered to help the kidney produce urine.
The immunosuppressant drugs are used to suppress the immune system from rejecting the donor kidney. These medicines must be taken for the rest of the patient’s life. Blood levels must be monitored closely and if the patient seems to have declining renal function, a biopsy may be necessary to determine whether this is due to rejection or cyclosporine intoxication. Grapefruit can decrease the proper metabolism of many drugs, and therefore decrease/or almost cancel out the effect of many critical drugs given after kidney transplants. Therefore, grapefruit products and certain other citrus products must be avoided.
Acute rejection occurs in 10–25 per cent of people after transplant during the first sixty days. The rejection does not necessarily mean loss of the organ, but may require additional treatment and medication adjustments. The problems after a transplant may include transplant rejection (hyper acute, acute or chronic), infections and sepsis due to the immunosuppressant drugs that are required to decrease risk of rejection, post-transplant lymphoproliferative disorder (a form of lymphoma due to the immune suppressants), imbalances in electrolytes including calcium and phosphate which can lead to bone problems amongst other things and other side effects of medications including gastrointestinal inflammation and ulceration of the stomach and esophagus, hirsutism (excessive hair growth in a male-pattern distribution), hair loss, obesity, acne, diabetes mellitus type 2, hypercholesterolemia, and others.

Elaborated Dr Rajesh Aggarwal, “The average lifetime for a donated kidney is ten to fifteen years. When a transplant fails, a patient may opt for a second transplant, and may have to return to dialysis for some intermediary time. The government and private hospitals won’t be able to provide you a living donor for transplant. Donor should be arranged as the human organs transplant law is very strict. In the entire process of donation of kidney, monetary exchanges are not at all accepted and are illegal. So, it’s a patient’s responsibility to arrange a donor for the transplant within your relations.”

Ethical Angle to Kidney Transplant
One of the effects of contemporary medicine, from a sociopolitical point of view, is to place death within a framework of ethical decision-making that emphasises the fight against specific mortal diseases and conditions. In the case of kidney transplant for older adults, longevity at older ages becomes an object of intervention and apparent choice.
Dr Rajesh Aggarwal explained, “The materiality of the body and its relationship to notions of health has become an important frame for ethical judgments. We explore here the kinds of social obligations and moral order at stake when the age for transplant moves beyond 70 and, especially, when living donors come from the succeeding generation. The routineness of transplant procedures extends moral awareness and action to the body itself via the ever-present potentiality of being a donor or recipient.”