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By Dr. Khurshid Ghani
The blank stare from the passport photo of the young lady has stayed with me and I don’t know when it will leave. The unfortunate woman was a foreigner working in India who caught an infection out of the blue that eventually made her kidneys useless. She was now on dialysis and was hoping to have a kidney transplant; the kidney had been donated by a relative who had come to India especially for this purpose.
I was in the weekly transplant meeting of a hospital in North India, listening to the strong Indian accent of the junior doctor recount in minutiae what this poor lady’s T or B cell or some other cell count was. The meeting was the final process in the pathway before the decision was made as to whether the transplant could proceed. It was approved.
As a urologist, my exposure to renal transplantation had until then been minimal. In the US and UK, transplant surgery is its own discipline, and as result the number of urologists performing kidney transplants is low. I recall assisting at a renal transplant very early on in my training as a senior house officer in the Edinburgh Royal Infirmary. Then, towards the end of my urology residency I remember agonizing over the ridiculous sounding names of the newer generation transplant drugs which are essential knowledge for passing the UK board exams. But I didn’t really understand the heartache of this condition until I had the opportunity to visit three of India’s premier transplant units.
The incidence of kidney failure in India is difficult to define, but estimates range from 186 to 7,800 persons per million. What is known is that 30-40% of diabetics in India have chronic kidney disease. In the West, we tend to encounter predominantly older patients with kidney failure as a consequence of diabetes or hypertension. I was therefore surprised to see so many young patients in India with kidney failure. I had been expecting the fat Indian patient with badly controlled diabetes. In my mind these patients are easier for a doctor to deal with emotionally. What do you expect? If you don’t look after your body, it won’t look after you. But what about that cough you had last month or the fever you could get tomorrow that we think will be a mild flu or respiratory infection that should go away after a few days? What if it turns out to have devastating consequences on your kidney function?
You can get all sorts of bizarre illnesses in India. My brother-in-law in the U.S. got ill with a mysterious fever associated with vague joint symptoms. All the best doctors in Minneapolis, using the most sophisticated diagnostic tools were unable to diagnose the condition. My father-in-law, an experienced and wise physician practicing in India, told him to get on a plane to India. He said the doctors there would figure it out. He was right. They did diagnose it and he got better. The Indian doctors succeeded where the Mayo Clinic failed.
Some of these illnesses, like nephritis, end up causing kidney failure. As a result, the only way to survive is to be close to a dialysis machine that has to be visited at least three times a week, with up to 6 hours during each visit chained to this ingenuity of modern medicine. Can you imagine what that does to your life or your work? How can you raise a family? What if you are a poor farmer in rural India, where the nearest dialysis machine is a day’s journey away?
The practicalities of getting onto a dialysis machine are compounded by the awful statistics of survival once dialysis has begun. Multiple studies have shown that patients have an increased risk of cardiovascular death as a result of being on dialysis. The difficulty of life on dialysis forces these patients to search for their only way out – a new kidney. The reality of the ethics of transplantation in India is heartbreaking, and I will discuss this in my next blog.
(Dr. Khurshid Ghani, is a Fellow at the Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, with interests in Robotic Surgery and Endourology. A UK Board qualified Urologist, he was awarded The Urology Foundation Robotic Surgery Fellowship from the British Association of Urological Surgeons. He is the co-author of the textbook, Endourology: A Practical Handbook.)
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