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Renal replacement therapy options from an Indian perspective: Dialysis versus transplantation
Renal Replacement Therapy Options From an Indian Perspective: Dialysis Versus Transplantation P. Singh and M. Bhandari ABSTRACT In developing countries such as India, the management of end-stage renal disease (ESRD) is largely guided by economic considerations. In the absence of health insurance plans, fewer than 10% of all patients receive renal replacement therapy (RRT). Hemodialysis (HD) is mainly a short-term measure to support ESRD patients prior to transplant. Infections are common in dialysis patients. The majority of patients starting HD die or are forced to abandon treatment because of cost constraints within the first 3 months. The cost of peritoneal dialysis (PD) is two times higher than that of HD, fewer than 2% of patients are started on PD. Among the three RRT options available, renal transplant is the preferred mode, as it is most cost-effective and provides a better quality of life. But due to financial constraints and nonavailability of organs, only about 5% of ESRD patients undergo transplant surgery. Though the removal of organs from brain-dead patients has been legalized, the concept of donation of organs from deceased donors has not received adequate social sanction. Only 2% of all transplants are performed from deceased donors. Due to limited access to RRT, the ideal approach should be to reduce the incidence of ESRD and attempt preventive measures. Preemptive transplant, reducing the duration of dialysis prior to transplant, use of immunosuppression for only up to 1 year, and availability of more deceased donor organs may be helpful to make RRT options within the reach of the common man.
T
HE PATTERN OF CHRONIC RENAL FAILURE in India does not differ greatly from the developed countries. However, it carries a poorer prognosis due to late referral, limited availability, and lack of affordability of renal replacement therapy (RRT) in India. According to an estimated incidence of 100 pmp, approximately 1,000,000 patients among our population base of one billion develop end-stage renal disease (ESRD) each year.1 Management of patients with ESRD is largely guided by economic considerations. In the absence of health insurance plans, fewer than 10% of all patients receive any kind of RRT. In developed countries like the United States, the annual cost of RRT is about twice the per capita gross national product (GNP), and 80% of the costs are reimbursed by insurance policies and the government. In contrast in India the annual cost of RRT is more than 10 times the per capita GNP. There is a great disparity in the provision of RRT in India. Women, the elderly, and small children bear the brunt of such discrimination. More than 70% of RRT facilities exist in private institutions. India has 0.2 pmp dialysis centers, 600 nephrologist, 300 to 400 dialysis units, and 1000 dialysis
stations. Hemodialysis (HD) is mainly a short-term measure to support ESRD patients to transplant. In view of the compromised care, early mortality is high due to inadequate dialysis. Infections are common among patients on dialysis, accounting for 57% of all deaths with fewer than 30% deaths due to ischemic heart disease.2 Because of cost constraints the vast majority of patients starting HD are forced to abandon treatment within the first 3 months. The cost of peritoneal dialysis (PD) is double that of HD (HD $300/pm, and CAPD $600/pm). Fewer than 2% of patients are started on PD. The socioeconomic status in Asian countries is diverse, and financial compensation policies for treatment of ESRD patients vary greatly from one country to another. Both of these factors have a major impact not
From the Sanjai Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Address reprint requests to Professor Mahendra Bhandari, Vice Chancellor, CSM Medical University, Shahmina Road, Chowk, Lucknow 226003 (U.P.), IndiaE-mail: [email protected]
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.08.003
Transplantation Proceedings, 36, 2013–2014 (2004)
2013
2014
only on the choice of treatment for ESRD but also on the utilization of PD in this region. Among the three RRT options available, renal transplant is the preferred course because it is most cost-effective and provides a better quality of life.3 Also, the long-term survival is superior compared to dialysis patients,4 but only about 5% of all patients with ESRD are able to undergo transplant surgery. Living related donor transplants constitute 30% to 40% of all transplants in India. There is a gender bias with female donors donating kidneys for their male relatives. Transplantation from deceased donor organs has yet to take off, accounting for fewer than 2% of all transplants.5 In India, though the removal of organs from brain-dead patients has been legalized, the concept of donation of organs from deceased donors has not received adequate social sanction, which is evident by dismal transplant statistics from deceased donors. After the legislation, 538 kidneys, 25 livers, two pancreata-kidneys, 53 hearts, three lungs were transplanted from deceased donors compared with 13,436 kidneys and 16 livers from living donors between 1996 and 2000.6 India has approximately 100 transplant centers. The cost of transplant procedures varies from $1500 (US) in government to as much as $7000 in private hospitals. The cost of immunosuppressive therapy is about $3000 for the first year. About 30% of patients cannot
SINGH AND BHANDARI
afford to continue cyclosporine beyond 1 year. The Indian 2-year cost of transplant is considerably less than that of HD or CAPD ($11,099 renal transplant, $16,900 HD, $19,500 CAPD).1 Thus renal transplant is the preferred modality, provided that a suitable donor is available. Due to limited access to RRT, an important approach would be to reduce the incidence of ESRD and the need for RRT by preventive measures. Diabetes and hypertension are major risk factors for ESRD. Early detection and timely treatment can reduce the incidence of ESRD. Preemptive transplant, reducing the duration of dialysis prior to transplant, use of immunosuppression for 6 to 12 months, and viable programs to retrieve more organs from deceased donors may help to make the RRT options within the reach of the middle-income group.
REFERENCES 1. Kher V: Kidney International 62:350, 2002 2. Rao M, Juneja R, Shirly RB, et al: Nephrol Dial Transplant 13:3494, 1998 3. Pageaux GP, Dorent R, Mourad G, et al: Transplant Proc 34:1687, 2002 4. Hariharan S, et al: N Eng J Med 342:605, 2000 5. Sakhuja V, Sud K: Kidney International 63:S115, 2003 6. Ota K: Transplant Proc 35:8, 2003
T
HE PATTERN OF CHRONIC RENAL FAILURE in India does not differ greatly from the developed countries. However, it carries a poorer prognosis due to late referral, limited availability, and lack of affordability of renal replacement therapy (RRT) in India. According to an estimated incidence of 100 pmp, approximately 1,000,000 patients among our population base of one billion develop end-stage renal disease (ESRD) each year.1 Management of patients with ESRD is largely guided by economic considerations. In the absence of health insurance plans, fewer than 10% of all patients receive any kind of RRT. In developed countries like the United States, the annual cost of RRT is about twice the per capita gross national product (GNP), and 80% of the costs are reimbursed by insurance policies and the government. In contrast in India the annual cost of RRT is more than 10 times the per capita GNP. There is a great disparity in the provision of RRT in India. Women, the elderly, and small children bear the brunt of such discrimination. More than 70% of RRT facilities exist in private institutions. India has 0.2 pmp dialysis centers, 600 nephrologist, 300 to 400 dialysis units, and 1000 dialysis
stations. Hemodialysis (HD) is mainly a short-term measure to support ESRD patients to transplant. In view of the compromised care, early mortality is high due to inadequate dialysis. Infections are common among patients on dialysis, accounting for 57% of all deaths with fewer than 30% deaths due to ischemic heart disease.2 Because of cost constraints the vast majority of patients starting HD are forced to abandon treatment within the first 3 months. The cost of peritoneal dialysis (PD) is double that of HD (HD $300/pm, and CAPD $600/pm). Fewer than 2% of patients are started on PD. The socioeconomic status in Asian countries is diverse, and financial compensation policies for treatment of ESRD patients vary greatly from one country to another. Both of these factors have a major impact not
From the Sanjai Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Address reprint requests to Professor Mahendra Bhandari, Vice Chancellor, CSM Medical University, Shahmina Road, Chowk, Lucknow 226003 (U.P.), IndiaE-mail: [email protected]
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.08.003
Transplantation Proceedings, 36, 2013–2014 (2004)
2013
2014
only on the choice of treatment for ESRD but also on the utilization of PD in this region. Among the three RRT options available, renal transplant is the preferred course because it is most cost-effective and provides a better quality of life.3 Also, the long-term survival is superior compared to dialysis patients,4 but only about 5% of all patients with ESRD are able to undergo transplant surgery. Living related donor transplants constitute 30% to 40% of all transplants in India. There is a gender bias with female donors donating kidneys for their male relatives. Transplantation from deceased donor organs has yet to take off, accounting for fewer than 2% of all transplants.5 In India, though the removal of organs from brain-dead patients has been legalized, the concept of donation of organs from deceased donors has not received adequate social sanction, which is evident by dismal transplant statistics from deceased donors. After the legislation, 538 kidneys, 25 livers, two pancreata-kidneys, 53 hearts, three lungs were transplanted from deceased donors compared with 13,436 kidneys and 16 livers from living donors between 1996 and 2000.6 India has approximately 100 transplant centers. The cost of transplant procedures varies from $1500 (US) in government to as much as $7000 in private hospitals. The cost of immunosuppressive therapy is about $3000 for the first year. About 30% of patients cannot
SINGH AND BHANDARI
afford to continue cyclosporine beyond 1 year. The Indian 2-year cost of transplant is considerably less than that of HD or CAPD ($11,099 renal transplant, $16,900 HD, $19,500 CAPD).1 Thus renal transplant is the preferred modality, provided that a suitable donor is available. Due to limited access to RRT, an important approach would be to reduce the incidence of ESRD and the need for RRT by preventive measures. Diabetes and hypertension are major risk factors for ESRD. Early detection and timely treatment can reduce the incidence of ESRD. Preemptive transplant, reducing the duration of dialysis prior to transplant, use of immunosuppression for 6 to 12 months, and viable programs to retrieve more organs from deceased donors may help to make the RRT options within the reach of the middle-income group.
REFERENCES 1. Kher V: Kidney International 62:350, 2002 2. Rao M, Juneja R, Shirly RB, et al: Nephrol Dial Transplant 13:3494, 1998 3. Pageaux GP, Dorent R, Mourad G, et al: Transplant Proc 34:1687, 2002 4. Hariharan S, et al: N Eng J Med 342:605, 2000 5. Sakhuja V, Sud K: Kidney International 63:S115, 2003 6. Ota K: Transplant Proc 35:8, 2003