Controversies and challenges in renal transplantation

  • Post category:Expert Speak
  • Reading time:6 mins read

Dr. Satish Balan

MD, DM, DNB, Senior Consultant Nephrologist, Kerala Institute of Medical Sciences, Thiruvanantapuram, Kerala.

One of the main issues in the post-transplant period is the analysis of the cause of graft dysfunction if it occurs. A rapid scaling up of technologies to pick up rejection early will lead to a tremendous improvement in graft outcomes.

Many non-invasive screening techniques are now available and could be useful. In addition, measures to improve compliance in taking drugs by patients should be applied as far as possible. With these measures, the success of our programs can be far better.

Q. What is your opinion as regards the present scenario of kidney transplantation in India?

A. It must be remembered, at the outset, that the living kidney transplantation program in India has evolved over the past 45 years and is currently the second largest program after the USA. End-stage renal disease requiring transplantation affects between 151 and 232 individuals per million population in India. Thus, almost 220,000 people require kidney transplantation in India. Against this background, currently, approximately 7500 kidney transplantations are performed at 250 kidney transplant centers in ​India. Of these, 90% come from living donors and 10% from deceased donors. Also, remember, these are estimated figures and are not 100% owing to the absence of a national transplant registry. Well, the deceased donation program has fared comparatively better in southern India states, including Tamil Nadu, Puducherry, Kerala and Andhra Pradesh. Chandigarh, in North India, has done well in terms of donors per million population.

Q. How do you foresee this situation in the future?

A. Well, the rising burden of diabetes and hypertension is definitely, going to shoot up the number of CKD patients in India. Add to this the fact that we have a burgeoning geriatric population. Many of our patients come from the lower socio-economic strata of society and still have no access to basic healthcare facilities. As a consequence, more than half the patients with advanced CKD are first seen when the eGFR is <15mL/min/1.73m2.

To add to this, the costs of medications, transplantation procedures and in-hospital care are also on the rise. Moreover, a large number of renal transplantation facilities are located in the urban areas forcing the rural and peri-urban populace to evict themselves to an urban centre for transplantation and further care. This only serves to add to the costs of patients, treatment as well as caregivers.

Q. What are the challenges from the treatment perspective?

A. The advent of better immunosuppressive medications and induction agents to stop early rejection episodes has brought about a shift from using high-dose steroids to prevent graft rejection and this has resulted in lower incidence of postoperative complications after transplant surgery. Minimally invasive methods for managing transplant surgery complications have been possible due to the advances made in the field of urology over the past few decades.

The primary problems in India are the application of new technologies to the poor. They cannot afford many of the newer treatments and many cannot even afford the cost of immunosuppressive drugs, which are the lowest priced in the world. This calls for massive government support and promotion of

universal health care.

Q. What, in your opinion, does the future hold in store for us as regards renal transplantation?

A. According to the Indian law, there is a provision of “required request” available to the intensive care doctors to ask for organ donation in the event of brain death. It also makes it mandatory to have a national registry to look at outcomes and appointment of a trained transplant coordinator for the purpose of counseling relatives for organ donation with the idea of improving the deceased donation rate in India. However, the key to the success of this program is early identification, followed by certification and maintenance of potential donors in the intensive care units. Currently, most organ donations happen in private sector hospitals with few public hospitals participating in the program. However, the potential of this program is far greater in public sector hospitals as most victims sustaining severe brain injury due to road traffic accidents land up in these public hospitals, as these are medico-legal cases.

One of the main issues in identification of brain death and reporting. Despite mandating reporting of brain death by several state governments, this is still poor. This calls for the universal application of the post of Transplant Procurement Manager who is an intensivist with responsibility of identifying brain death and communication with the family to promote the cause of organ donation. This will cause a major increase in the number of donations.