Since 2006, every second Thursday in March has been celebrated world wide as the World Kidney Day, to educate the public and to increase their awareness to protect the kidneys from diseases. Acute Kidney Injury (A5I) and Chronic Kidney Disease (CKD) are the worst forms of kidney diseases. The final stage of CKD is called ‘End Stage Renal Disease’ (ESRD) when the kidney filtration rate is below l5ml/mt. (normal 100- 120 ml/mt.). The prevalence of CKD in India is about 80 per 100,000 people and ESRD is about 15 per 100,000 CKD is the third major killer disease in India next to cancer and heart disease.
Kidney is the major scavenger organ in the human body. Besides maintaining the fluid and electrolyte balance in the body, it pushes out toxic, waste products like ammonia, urea, creatinine, uric acid, drug metabolites, ingested chemicals and poisons through urine. The kidneys also synthesise hormones like ‘erythropoietin’ necessary for the formation of red blood cells and ‘renin’ for maintaining the blood pressure. About 170 litres of fluid is excreted through the two million glomeruli in the kidneys per day out of which 168.5L is reabsorbed back into blood and the balance 1’5L comes out as urine containing all the waste products.
About 20 percent of the patients with CKD ends up in ESRD and the option of treatment is only dialysis followed by transplantation. Dialysis is of 2 types i) haemodialysis which could be life long as was in the case of late Jayaprakash Narayan or (ii) peritoneal dialysis where 4-5L of dialyzing fluid is pushed into the abdominal cavity and taken back. The permanent cure for ESRD is transplantation.
The first transplanted organ was ‘cornea’ done in 1906 in Checkozlovakia. The problem with organ transplantation is the risk of rejection. When the body identifies the transplanted organ as ‘foreign’ it would immediately activate the organ recipient’s immune system to reject it whether it is a grafted tissue, cell or organ. Once the antirejection drugs (immuno suppressive) became available rejection could be prevented making transplantation fully successful. In the case of cornea, there is no rejection since the cornea is avascular (no blood supply) and the body has no way to identify the grafted cornea as foreign.
The entire credit of identifying this immune system goes to Peter Medawar, a Briish Biologist born in Brazil (1915-1937) who was awarded the Nobel prize in 1974.
The first kidney transplantation was done in Little Mary Hospital, Illinois, USA in 1950 and the transplanted Kidney functioned only for 27 days. However the first successful kidney transplantation was done four years later at Boston (Peter Bent Brigham Hospital) on December 23, 1954 by Dr Joseph Murray’s team and the patient survived for 8 years (Dr Murray also received the Nobel prize for this work but only 36 years later in 1990).From 1954 onwards, anti rejection drugs were available. In India the first two kidney transplants were performed first in 1965 (cadaver donor) at Bombay, and then in 1966 at Varanasi; unfortunately both patients died within two weeks. In l97l, at CMC Vellore the first successful kidney transplant in India was done from a living donor and since then many institutions in India are performing this surgery (now 200 hospitals in India, but only 35 hospitals are accepting cadaver donors). The maximum survival after a kidney transplant (from identical twin girls) is 52 years (both the donor and recipient aged 64 are healthy and living in Canada now). Chakravarthy from Chennai is the longest surviving kidney transplant patient in India still living 27 years after surgery. We have strict regulation for Kid for Kidney transplantation. In 1992, the Indian parliament passed a bill to prohibit commercial kidney trade by middle men with the connivance of doctors. ‘The Transplantation of Human organ Act 1954’. Foreigners are not permitted to receive kidneys from Indian donors, at the same time no permission from the ‘State Organ Transplantation committee’ is needed if the donor is a first degree relative (father, mother, son, daughter and wife). In lndia, the total number of existing ESRD patients are 2.5 lakhs, however the number of kidney transplant surgery is only around 1000 per year because of the non availability of donors. Only 20,000 kidney transplantations were performed till now (1971 - 2013) in India. If cadaver kidneys are permitted to be utilized, more kidneys would be available for transplantation since 1,34000 people die by accidents in India every year and 70 per cent of these accident victims are eligible for kidney donation. In Tamil Nadu, the transplantation laws are liberal, and hence they could perform 223 cadaver kidney transplantations in four years (2008-2012).The success rate of kidney transplantation is maximum if the donor is a twin sibling. It is also better to accept from a living donor as compared to a cadaver donor. The total expenses initially will be `10-15 lakhs for an unrelated donor transplant and around `10,000/month for anti rejection medicines.
Not all people can be donors as they have to undergo ABO compatibility (blood group test) and tissue compatibility (MHC antigen)tests. In some patients if rejection happens repeat transplantation can be done as was in the case of late M G Ramachandran. Kidneys can also be transplanted along with pancreas in diabetic patients with ESRD.