End-stage kidney disease: The scenario in India

Kidney failure occurs due to a variety of reasons and can largely be grouped into two types — the completely reversible (acute) and the one that is not (chronic). The chronic type progresses to end stage when the only treatment options are dialysis or kidney transplantation, the latter being the preferred one. Both types of treatment are expensive and, hence, prevention is of utmost importance.

Efforts to prevent kidney disease include early detection and treatment. This has to be done on a mass scale involving the community at large — just a simple urine test and BP measurement done annually can detect not just kidney disease in the very early stage, but also its two main causes, namely diabetes and high blood pressure. Also, educating the public about early reporting of symptoms — appearance of blood in urine and swelling of feet — is vital. This is the only and most cost effective way of winning over this 'epidemic', which is already reaching gigantic proportions, drawing the attention of policymakers as is reflected in the recent central government Budget.

In India, more than 2 lakh new cases of end-stage kidney disease are present each year. Of these, about 70% manage to get access to dialysis, but almost two-thirds of these give up because of non-affordability and non-availability of treatment. So, one-and-a-half lakh patients just perish while the rest continue dialysis awaiting transplant. Chronic dialysis is virtually nonexistent in government-run hospitals and is unaffordable in the private sector (Rs15,000-20,000 per month).

The government has taken steps to alleviate this problem to some extent. The Rajiv Gandhi Aryogya Yojana provides free dialysis in designated private and charitable hospitals to patients who are below poverty line. A few states, notably Andhra Pradesh and Telangana, provide dialysis in government hospitals under the PPP model.

The Centre has revoked the custom duty and other taxes on dialysis equipment and components. This is a great decision for which the nephrology community had been lobbying for almost a decade. The government has also announced a 'National Dialysis Services Programme' to be started under the National Health Mission through the PPP model. This is a giant step. To get access to these funds, the state governments are expected to follow a few stringent policies in the tendering process. These policies are made mandatory to guard against any financial irregularities and to ensure that the funds reach the patients. Insurance industry and various reimbursement schemes are also helping patients get access to dialysis.

The quality of dialysis is another issue. Unlike most other treatments, it needs intense efforts to maintain quality of care, including infection control. Many dialysis centres are ill-equipped to ensure this, particularly in smaller cities and towns. Fortunately, the dialysis industry is changing fast. The entry of dialysis chains Apex Kidney Care, Davita and B Braun has brought in protocol-driven practices and accountability, thus improving the standard of treatment. These chains have the potential to make quality dialysis available in small towns across the country.

All said and done, the best treatment is kidney transplant. Not all are fortunate to have a fit and willing kidney donor in the family, leaving most to stay on dialysis and await their turn for a deceased donor kidney. There are 1,800 patients on the waiting list in Mumbai alone. Most die as only 50-60 deceased donor transplants are performed annually.

A big effort is being done to increase the donor pool by innovations, such as swap transplant and domino transplants by ASTRA and other registries. Thanks to the great efforts of the media, awareness about organ donation and transplant is increasing fast.

The situation is much better than what it used to be a decade ago. A large planned effort is needed towards early detection and prevention of kidney disease as our country cannot afford its treatment costs.