Dr. Jacob George
MBBS, MD, DM (Nephrology), Professor and Head, Department of Nephrology, Medical College Hospital, Trivandrum.
Q: What is your opinion as regards the present scenario of kidney transplantation in India?
A: The wait for a new and matching kidney can be very long. Generally, the transplanted kidneys mostly come from a family member or, at times, from deceased donors. About 2 lakh patients in India are awaiting organ donation with a mere 15,000 donors available. The huge gap between the demand and supply of kidneys has led the government to push for deceased donor transplantation and cadaver donations. According to the Indian Transplant Registry, between 1971 and 2015, out of 21,395 kidneys transplanted, only 783 were from a cadaver or deceased donors and this can be attributed to the lack of awareness and hesitation of the family members. However, post-2012 there has been a significant increase in organ donations. The Live Kidney Transplant Programme in India has evolved in the past 50 years and is currently the second largest program in numbers after the USA. Since 2011, India introduced a provision of “required request” for the Intensive Care doctors to ask for organ donation in the event of brain death and makes it mandatory to register it nationally and counsel relatives for organ donation. While this has put the onus on the hospital, it has also helped in improved rates of deceased donation in India.
Q: How do you foresee this situation in the future?
A: The rising burden of diabetes and hypertension is definitely going to shoot up the number of CKD patients. Many of the patients from the lower socio-economic strata of society still have no access to healthcare facilities. Because of challenges in access to care, over 50% of patients with advanced CKD are first seen when the eGFR is <15 mL/min/1.73m2 . Another challenge is that most of the nephrologists and dialysis centers are concentrated in the urban areas of India. To add to this, costs of medications, transplantation procedures and in hospital care is also on the rise. Putting all these together, the situation is rather grim.
Q: What are the challenges from the treatment perspective?
A: The major issues with the treatment regimens, besides cost, is the risk of infections, bone marrow suppression, especially leukopenia, which can add to the risk of various infections, gastrointestinal toxicity, risk of diabetes, osteoporosis, risk of malignancy including post-transplant lymphoproliferative disorders. The advent of new immunosuppressive agents have not helped diminish the challenge of balancing adequate graft protection with minimizing toxicities. Potent immunosuppression predisposes the patient to risks, and therefore, determining an optimal regimen for a particular patient can be challenging.
Q: Has advent of newer immunosuppressive agents improved the outcome?
A: While there has definitely been a reduction in early acute cell mediated rejections, the long term graft survival has not improved as hoped, In fact, the number of antibody mediated rejections seem to have increased. We are also seeing newer infections including BK virus infections following more potent immunosuppression and also worsening prevalence of other infections, including cytomegalovirus (CMV).
Q: What is the position of renal transplantation in India?
A: Though renal transplantation was started much later in India, the major advantage is that we are able to perform renal transplantations at a fraction of the cost in other countries. With the use of generics, costs can be even reduced. The graft outcome is comparable to that seen in most developed countries. Unfortunately, the risk of infections, especially tuberculosis and gastrointestinal disorders, are more common here.
Q: What, in your opinion, does the future hold in store for us as regards renal transplantation?
A: Well, a lot remains to be seen. Regimens designed to limit or eliminate calcineurin inhibitors and/or corticosteroid therapy continue to be pursued. Considerable headway has been made in renal transplantation, but optimal strategies to prolong patient and graft survival are still needed. In the future, we can expect to witness the development of more effective, less toxic drugs that may displace some of the currently used drugs, and perhaps, in some patients, therapies that approach tolerance so that no maintenance therapy will be necessary. Until then, however, community nephrologists will continue to face the challenges associated with the long-term clinical management of the renal transplant recipient.
