| | Five Decades of Indian Nephrology: A Personal Journey published online 03 September 2009. Impressive accomplishments have been made in Indian nephrology during the last 5 decades. The first renal biopsy performed in 1956 ushered in a new era of modern nephrology practice in India and led to the recognition of nephrology as a distinct specialty. The first hemodialysis facility was established in 1961; presently, there are 950 nephrologists, 850 hospitals equipped with dialysis facilities, and 170 institutions recognized for kidney transplantation, with approximately 3,500 transplantations performed every year. The majority of dialysis units are small minimal-care facilities with fewer than 5 dialysis stations, and more than 85% are in the private sector. Government hospitals provide free treatment to poor patients with chronic kidney disease; however, inadequate funding and lack of health insurance schemes pose serious hurdles in providing renal replacement therapy. In contrast, private/corporate hospitals located in big cities have large units with state-of-the-art dialysis and transplantation facilities, similar to advanced centers of the world, but are accessible to only upper-income groups. Of the estimated 175,000 new patients who develop end-stage renal disease annually, less than 10% are able to gain access to renal replacement therapy. Research in the field of renal diseases has evolved slowly and is focused primarily on tropical conditions. The availability of structured nephrology training programs coupled with excellent diagnostic and therapeutic facilities in some academic institutions and tertiary-care private/corporate hospitals have diminished the need for foreign travel by students, patients, and consultants to a considerable extent. The expansion of therapeutic facilities in India is hampered by only economic constraints, not lack of expertise. The medical scene was dismal in India at the time of independence from British colonial rule in 1947. Although there currently are 205 recognized medical colleges in India that graduate approximately 27,000 doctors per year, at that time, medical education was limited to 17 medical colleges, a tiny number given that the country's population was 330 million. Specialties did not exist, and the word “nephrology” was unknown in the medical community. For want of anything better, uremic patients were treated with “Bull's diet,” which was low in protein and sufficiently high in carbohydrate and fat (peanut oil) to prevent the breakdown of endogenous protein.1 As an undergraduate medical student at the Government Medical College in Amritsar, Punjab (see Fig 1 for map), in the early 1950s, I heard of the efforts to develop dialysis systems in the United States and was excited to learn about the first successful dialysis treatment at Mount Sinai Hospital in 1948, the opening of the first dialysis treatment center by Dr Nils Alwall in 1950, and attempts at kidney transplantation, culminating in the first successful twin transplantation, by Drs David Hume, Joseph Murray, and John Merrill in Boston, MA, in 1954. I also was puzzled by our inability to make an exact diagnosis of kidney disease and was intrigued by the first report of successful renal biopsies by Iversen and Brun in 1950.3 However, the low success rate (38.5% in a series of 42 biopsies) was disappointing. The vast improvement reported by Kark and Muehrcke4 by changing the patient's position from sitting to prone convinced me of the utility of this procedure as a diagnostic aid for differentiating various renal diseases. With a strong motivation, I decided to take up “Evaluation of renal biopsies” as the subject for my postgraduate thesis.5 Having completed my undergraduate studies in Amritsar in 1955, I moved to Patiala to work as a research fellow in the Government Medical College and enrolled myself with Panjab University for an MD degree in Medicine in 1956. The prevailing practice for postgraduate training in medicine then was to select a special subject, and I chose “kidney diseases.” This request was refused by the Faculty of Medicine of Panjab University because this subject did not exist in the list of specialties. Instead, I was advised to select cardiology or gastroenterology, which had become recognized specialties. However, I persevered and a compromise was reached after several representations, such that the university approved my request for doing postgraduate work in Medicine with “genitourinary medicine” as my special subject. I ended up reporting on 50 successful renal biopsies; Fig 2 shows the needles used in these early procedures. Completed in 1958, my thesis is the first systematic study in the field of renal diseases in India,5 and in 1961, it enabled me to become the first “qualified” nephrologist in the country. Major Milestones in Clinical Nephrology in India  Dialysis The first Kolff twin-coil artificial kidney dialysis machine arrived in India in 1961, donated to the Christian Medical College (CMC), Vellore, as a gift from the Christian Mission of USA. The first patient to receive dialysis in May 1961 was His Excellency Shri Gopeshwar Prasad Sahi, the erstwhile Maharaja of Hathwa, in the old state of Bihar, who had developed “chronic uremia.” The first few sessions were supervised by Dr Satoru Nakamoto, who had been sent by Dr Willem Kolff. Dr Nakamoto trained Dr Phillip Koshy, then Professor of Medicine at the CMC, about the technique of dialysis. After learning of these developments from the newspapers, I traveled to Vellore in 1962 to see the workings of the Kolff machine. There, I witnessed 6 dialysis sessions during 3 months. That same year, an Alwall hemodialysis machine was acquired by the King Edward Memorial Hospital (KEM), Mumbai. During my stay at Vellore, I saw a patient who had bronchiectasis and proteinuria. On the basis of my previous findings on renal biopsy studies,6 I strongly suspected renal amyloidosis and asked Dr Koshy's permission for a renal biopsy for confirmation of diagnosis. He agreed after an initial hesitation, and the biopsy—the first ever performed outside Patiala and Amritsar in India—showed extensive amyloid deposits. I performed 5 more renal biopsies and trained 2 faculty members to perform this procedure. I joined the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Punjab, in January of 1963, and our Kolff twin-coil machine (Fig 3) arrived in March of that year. The first dialysis treatment was performed on July 3, 1963, on a patient with acute renal failure of obstetrical origin, who recovered. We would prepare the dialysis bath by adding preweighed chemicals to the 100-L tank, which contained warm tap water and was maintained at body temperature by a heater incorporated within. The twin coil required 2 units of blood for priming. Access to circulation was obtained with an arteriovenous cannula through a cutdown in the radial artery or a femoral vein and another cannula in the radial vein. The cannula could be kept operative for only 1 or 2 dialysis treatments, and it did not take long to use up all access sites. Meanwhile, on May 31, 1963, the first dialysis at the KEM was performed by Professor P. Raghavan, a gastroenterologist. While working with Professor Raghavan, Dr Vidya Acharya, who had just graduated, experimented with dogs to master the technique of arteriovenous cannulation. After a year spent at the Hammersmith Hospital, London, working with Dr Oliver Wrong, I returned to Chandigarh in 1968 and started a program for long-term dialysis therapy at PGIMER with 2 Kiil dialyzers. Arteriovenous shunts were made with 2 silastic tubings which were connected to the artery and the vein through teflon tips. The other end of each silastic tubings was connected to each other by a teflon bridge. The teflon tips and the bridge were molded over a candle flame to fit snuggly into the vessels and the silastic tubings. We designed a steel tank that was placed at a height of 10 feet, and dialysis fluid was fed to 2 Kiil dialyzers by gravity (Fig 4). Except for the temperature of the dialysis fluid, no other parameter was monitored during dialysis (Fig 5). Later that year, we acquired a Lucas monitoring machine, and then in 1969, Dr Rabindranath started a hemodialysis program at the Government General Hospital in Chennai, also using the Lucas monitoring system. For the next 2 years, CMC Hospital in Vellore, KEM Hospital in Mumbai, Government General Hospital in Chennai, and PGIMER in Chandigarh remained the only dialysis facilities in the country. The next center to start dialysis was the All India Institute of Medical Sciences (AIIMS), New Delhi, in 1971. With limited dialysis facilities, only patients with acute renal failure were accepted for dialysis in these centers until 1970. Within a decade, dialysis facilities became available in 27 centers in the country and more than 40,000 dialysis sessions had been performed.7 Presently, there are 800 to 850 hospitals with dialysis facilities available, serving a country with a current population of more than 1 billion individuals. Over the years, we have seen increasing sophistication in the process of hemodialysis in the country with the introduction of modern machines with provision for bicarbonate dialysis, volumetric ultrafiltration, and microprocessor-based control of temperature, conductivity, and blood leaks. The flat-plate Kiil dialyzers using cuprophane membranes have been replaced with hollow-fiber dialyzers. The days when we walked around with a screw driver in the pocket are gone and have been replaced by a requirement for electronic technologists. One year after hemodialysis therapy was introduced to India, the first peritoneal dialysis (PD) in the country was performed at PGIMER in 1964. At that time, PD catheters were not available in the country, so we improvised by drilling holes in suitably sized polythene tubing (used tubing from the twin-coil dialyzer), and an abdominal trochar and cannula were used for inserting the catheter into the peritoneal cavity (Fig 6). The catheter could be used for 4 to 6 months. Although the procedure was simple, in the 1960s and 1970s, the majority of hospitals in the country were hesitant to initiate PD therapy because of nonavailability of catheters and dialysate (our PD solution was prepared in-house by the pharmacy department). Sporadic attempts were made to start continuous ambulatory PD (CAPD) at several centers in the late 1980s. We unsuccessfully tried it at PGIMER in 1988 with catheters brought as a gift from Seattle, WA, but it did not become popular because of the lack of proper equipment and understanding. Transplantation The first successful kidney transplantation in India was performed in 1971 at CMC by Drs Mohan Rao and Kaivilayil V. Johny, both of whom had been trained in Adelaide, Australia. In 1972, Dr Inder Dhawan also performed a transplantation at AIIMS. Working with Dr Rajveer Yadav, I helped start the renal transplantation program at PGIMER in 1974. Our first kidney transplant recipient was an 18-year-old man who had lost his kidneys secondary to membranoproliferative glomerulonephritis, and his mother was willing to donate a kidney for her son. This is prescient because even today, the “mother-son” donor-recipient pairing vastly outnumbers any other in India. As the day dawned, both Dr. Yadav and I were not sure if the surgery would be successful. As soon as the anastomosis was completed and clamps were released, we could see the kidney go turgid and pink and immediately started to produce urine. I still thought it too good to be true, collected the fluid in a test tube, and ran all the way to our Biochemistry Department to verify that this was indeed urine. To our great satisfaction and also relief, the patient recovered uneventfully. He worked as an attendant in our Renal Laboratory and lived for 4½ years before he died of fulminant pneumonia with a functioning graft. Infections were the major scourge for our transplant recipients and still remain so, albeit to a lesser extent. Other surgeries had equally satisfying outcomes, and today, the longest surviving patient with a normally functioning live-related donor graft at PGIMER has completed 31 years. Jaslok Hospital, Mumbai, also started performing renal transplantations in 1974 with living donors. By November 1974, a total of 59 transplantation surgeries had been performed in India; the results of these efforts were communicated at the First Asian Colloquium in Nephrology in Singapore.8 We performed 5 deceased donor transplantation surgeries at PGIMER in 1976 to 1977. However, we stopped performing these surgeries because there was no law governing organ procurement from deceased donors. One cadaveric donor renal allograft recipient survived for 13 months, whereas the others rejected the allografts in 1 to 8 months. During this period, Drs Samuel Kountz and T.K. Sreepada Rao from the Downstate Medical Centre in Brooklyn, NY, flew 2 cadaver kidneys from the United States on December 27, 1977, for transplantation into 2 patients in Jaslok Hospital in collaboration with Dr Chako Kuruvilla. The 2 American cadaver donor kidneys created headlines in the newspapers and drew the attention of the government and the public in India for the need of legislation required for cadaver organ transplantation. In the following week, Dr Kountz also visited Chandigarh and was surprised to meet one of our patients, Mr Dhawan, who had received a cadaver donor kidney and was doing well at 9 months. In 1979, I was invited to New York by Dr John Merrill and Dr Eli Freedman to participate in the Second Conference of the International Society of Artificial Internal Organs. By that time, 365 transplantations (353 live donors and 12 cadaver donors) had been performed in India in 6 centers. To support the living donor kidney transplant program, the first tissue typing laboratory had been set up at AIIMS in 1978. Even so, the 2-year graft survival rate was estimated at less than 50%. Development of Nephrology Training and Research in India Professional Organizations Formation of the Indian Society of Nephrology was a major milestone in the growth of nephrology in India. As described in an interview conducted as part of the Video Legacy program of the International Society of Nephrology (ISN),9 I conceived the idea of forming this society and, together with Dr Koshy, organized a founding meeting of 10 members at the Topiwala Medical College Mumbai on January 18, 1970. The first scientific meeting was formally inaugurated by the then reigning President of the European Dialysis and Transplant Association, Dr Emilio Rotellar of Spain, on January 16, 1971. Until 1990, the annual meetings of the Indian Society of Nephrology were organized along with the Association of Physicians of India. In 1991, the society came into its own, and the first stand-alone meeting was held at Jaipur. The membership of the society now stands at more than 950 and has been joined on the scene by the Indian Society of Organ Transplantation, the Indian Society of Peritoneal Dialysis, and Indian Society of Hemodialysis, which were founded in 1988, 1997, and 2002, respectively. From the beginning, the Indian Society of Nephrology had strong connections with the rest of the world. The annual meetings have always had many international participants, and within a year of its formation, the society was accepted as an affiliated unit of the ISN. The ISN cosponsored a Silver Jubilee Conference of the Indian Society of Nephrology in 1994; thereafter, ISN-sponsored medical education events became a regular feature of the society's annual conferences. Under the auspices of the ISN's official journal, Kidney International, 4 Nephrology Forums were conducted in India. The talks were given by nephrologists from India (Vijay Kher and myself) and overseas (Robert Atkins and Leishi Li), and articles arising from the live forums were published in Kidney International.10, 11, 12, 13 In addition to supporting these activities, the ISN funded individual Indian nephrologists through fellowships and underwrote such efforts as the Renal Sister Center Program at Chennai that were designed to help nephrology units in capacity building and development of collaboration with centers in developed countries. Medical education activities also were extended to the neighboring countries of Nepal, Sri Lanka, and Bangladesh with financial assistance from the ISN Commission for the Global Advancement of Nephrology.14 At approximately the same time as the relationship with the ISN began, I started corresponding with Dr Kenzo Oshima of Japan and Dr Priscilla Kincaid-Smith of Australia about working toward forming an Asian Society of Nephrology. After several deliberations, we succeeded in forming the Asian Pacific Society of Nephrology (APSN). The First Congress of the APSN was held in Tokyo, Japan, in 1979, and the latest conference in 2008 in Kuala Lumpur was attended by 700 delegates from all over the world. I was honored to serve as the third president of the APSN, and during my tenure, Ike Robinson and Bob Schrier mooted the idea of having joint meetings of the ISN with the 5 major regional societies of the world every 2 years. The Australian Society of Nephrology and the APSN jointly bid for the right to hold the first World Congress of Nephrology, which took place in Sydney in 1997. This landmark event ushered in the new era of the “world” congresses. Postgraduate Training In recognition of the importance of establishing a formal training program for the growth of nephrology in the country, a 2-year postgraduate superspecialty training course was started at PGIMER in 1969. It may surprise some that the first batch of postgraduates with a Doctor of Medicine degree in Nephrology qualified in 1971, one year before the first students in the United States completed their Board Certification in Nephrology. Eligibility for the training requires completion of a 5½-year undergraduate (MBBS) course, including a 1-year internship, followed by a 3-year postgraduate (MD) course in Internal Medicine or Pediatrics. Currently, 2 types of nephrology training courses are available. There are 22 university-affiliated academic institutions that admit about 40 to 45 candidates every year for a 3-year postdoctoral course leading to the award of a DM in Nephrology degree, which is recognized by the Medical Council of India. In addition, about 20 hospitals, mostly private/corporate (not university affiliated), are recognized by the National Board of Examinations for a 3-year Diplomate in National Boards (DNB) course in Nephrology with an annual intake of 40 candidates. India has been an important “exporter” of a highly trained nephrology workforce to several Western countries, most notably the United States. My best estimate is that approximately 20% of nephrologists trained in India have relocated to the Western countries. A number of them are recognized internationally for their outstanding contributions (Table 1). | | |  | Name | Position or Award | |
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| Editorial Board Involvement | | | Acharya, Vidya | Editorial Board, Nephrology | | | Agarwal, Rajiv | Editorial Board, Kidney Int, Nephrol Dial Transplant | | | Agarwal, Anupam | Editorial Board, J Am Soc Nephrol | | | Balakrishnan, V.S. | Co-Editor, Am J Kidney Dis | | | Chawla, Lakhmir S. | Editorial Board, Clin J Am Soc Nephrol | | | Chugh, Kirpal S. | Editorial Board, Clin J Am Soc Nephrol, Nephrology, Ren Fail, Transplantation | | | Garg, Amit | Editorial Board, J Am Soc Nephrol | | | Grewal, H. | Editorial Board, Transplantation | | | Hariharan, Sundram | Editorial Board, Transplantation | | | Johny, K.V. | Editorial Board, Nephrology | | | Kalluri, Raghu | Editorial Board, Kidney Int | | | Kapur, S. | Editorial Board, Transplantation | | | Kasinath, Balakuntalam S. | Editorial Board, Kidney Int | | | Kumar, Anil | Editorial Board, Transplantation | | | Kumar, Rajiv | Editorial Board, J Am Soc Nephrol | | | Mani, M.K. | Editorial Board, Nephrology | | | Mehrotra, Rajnish | Editorial Board, Kidney Int, Clin J Am Soc Nephrol | | | Mehta, Ravindra L. | Editorial Board, J Am Soc Nephrol | | | Mohankumar, T. | Editorial Board, Transplantation | | | Natarajan, Rama | Editorial Board, Kidney Int | | | Parekh, Rulan S. | Editorial Board, Am J Kidney Dis | | | Pereira, Brian | Editorial Board, Kidney Int | | | Radhakrishnan, Jai | Co-Editor, Kidney Int | | | Rangan, Gopal | Editorial Board, Nephrology | | | Rao, V.K. | Editorial Board, Transplantation | | | Sakhuja, Vinay | Editorial Board, Transplantation | | | Seshan, S. | Editorial Board, Transplantation | | | Sharma, Kumar | Editorial Board, J Am Soc Nephrol | | | Sharma, Raj Kumar | Editorial Board, Nephrology | | | Singh, Ajay K. | Editorial Board, J Am Soc Nephrol, Clin J Am Soc Nephrol | | | Singh, Nina | Editorial Board, Transplantation | | | Suthanthiran, Manikkam | Editor, Transplantation; Editorial Board, Kidney Int, J Am Soc Nephrol, Nat Rev Nephrol | | | Thadhani, Ravi I. | Editorial Board, Clin J Am Soc Nephrol | | | Awards and Honors | | | Abraham, Georgi | International Distinguished Medal, 2003 (National Kidney Foundation) | | | Chugh, Kirpal S. | International Distinguished Medal, 1991 (National Kidney Foundation) | | | Chugh, Sumant | American Society of Nephrology Carl Gottschalk Research Award, 2002 | | | Kalluri, Raghu | American Society of Nephrology Young Investigator Award, 2005 & Carl Gottschalk Research Award, 1998 | | | Karihaloo, Anil | American Society of Nephrology Carl Gottschalk Research Award, 2007 | | | Karumanchi, S. Ananth | American Society of Nephrology Young Investigator Award, 2008 & Carl Gottschalk Research Award, 2002 | | | Keshaviah, Prakesh | International Distinguished Medal, 2006 (National Kidney Foundation) | | | Kumar, Rajiv | American Society of Nephrology Young Investigator Award, 1989 | | | Nigam, Sanjay K. | American Society of Nephrology Young Investigator Award, 1999 | | | Parekh, Rulan | American Society of Nephrology Carl Gottschalk Research Award, 2000 | | | Parikh, Samir M. | American Society of Nephrology Carl Gottschalk Research Award, 2008 | | | Pereira, Brian | David M. Hume Award, 2009 (National Kidney Foundation) | | | Rao, Reena | American Society of Nephrology Carl Gottschalk Research Award, 2007 | | | | |
Research In India, research in the field of renal diseases has evolved rather slowly during the last 4 decades and has been confined largely to the major teaching hospitals. Clinical nephrologists have been busy taking care of the huge loads of patients, neglecting the equally important aspect of research. As a result, we have yet not been able to even define the incidence, prevalence, pattern, or natural history of common kidney diseases in the country. There is an urgent need to develop research programs for addressing the importance of ethnicity, dietary habits, nutritional status, and the role of tropical infections and living conditions of our populations. To that end, the Indian Society of Nephrology set up a voluntary chronic kidney disease registry in 2005. It started as a pilot project with 10 centers, but 152 centers currently are contributing data to this registry, which now contains a database of more than 35,000 patients. Equally important to the development of a vibrant research community in India has been the development of national and regional journals. The Indian Journal of Nephrology was launched in 1991, and 4 years later, APSN introduced its official journal, Nephrology. The Indian Society of Peritoneal Dialysis and Indian Society of Organ Transplantation also recently have started publishing their own journals. As suggested by the honors listed in Table 1, contributions of several Indian nephrologists have been recognized worldwide. The areas of research by Indian nephrologists that have attracted national and international attention include tropical acute renal failure; glomerular diseases specific to tropics; hemolytic uremic syndrome; amyloid disease; venom-induced renal disease in snakebite victims; renovascular hypertension caused by Takayasu arteritis; filarial nephropathy; renal involvement in leptospirosis, leprosy, and tuberculosis; and bacterial, fungal, and viral infections in dialysis and transplant recipients.15, 16 The institutions most actively involved in research in various aspects of renal diseases are PGIMER Chandigarh, AIIMS New Delhi, CMC Vellore, Sanjay Gandhi Postgraduate Institute (SGPGI) Lucknow, KEM Mumbai, Madras Medical College Chennai, Institute of Kidney Diseases Ahmedabad, Muljibhai Patel Institute Nadiad, and Nizam Institute Hyderabad. Some of these centers currently are involved in research on stem cell biology, molecular biology of angiogenesis, and genetic and molecular biology of renal diseases in India. Renal Replacement Therapy in India Today Difficulty securing financing, compounded by the lack of a government policy for treatment of emerging chronic diseases, has been a major hurdle for the development of renal replacement therapy (RRT) facilities in India, as in neighboring countries. The exact cost of RRT is difficult to estimate. Although less expensive than in developed countries because of the lower staff salaries and low cost of drugs in India, it still is 10 to 20 times higher than the per-capita gross national product (US $745) and remains out of reach of a majority of the population. The poor clinical status of patients necessitates frequent and often long-term hospitalizations. It is not uncommon for a patient to present for the first time to a nephrologist already in advanced renal failure with hyperkalemia, acidosis, encephalopathy, or fluid overload. Dialysis time often is reduced to accommodate more patients. Poor hygiene, a hot and humid climate, and overcrowding predispose these patients to a variety of life-threatening infections. Repeated hospitalizations and prolonged treatment represent additional financial burdens. It is estimated that approximately 175,000 new patients develop end-stage renal disease (ESRD) annually in India.17 However, according to recent estimates, only approximately 15,000 patients are on hemodialysis therapy at any given time. As a result, less than 10% of patients with ESRD gain access to any kind of RRT.18 Health insurance (both government funded and private) is in a primitive stage; and RRT costs have to be borne largely by the patients out of their own funds. Charitable organizations and government-administered “relief funds” provide limited assistance to poor patients getting treatment in a government hospital.19 These hospitals are able to accept only a limited number of patients for RRT. Most large public hospitals have active transplantation programs and preferentially accept patients believed suitable for transplantation, leaving others to seek dialysis therapy in the more expensive private hospitals. Currently, more than 85% of dialysis units are in the private sector. These hospitals accept patients for maintenance hemodialysis and renal transplantation. The charges in these hospitals vary depending on hospital size, type, location, reputation, and additional facilities. Some private/corporate hospitals have large dialysis units with state-of-the-art facilities, but these are accessible to only upper-income groups. More typically, the annual cost of twice-weekly hemodialysis is approximately US $2,500 to $5,000, with an additional US $2,000 to $2,500 needed per year to cover the costs of 4,000 to 8,000 U/wk of erythropoietin. To cut costs, it is universal practice to reuse dialyzers for 4 to 10 treatments. Even so, lack of proper medical reimbursement schemes and well-formed policies for treatment of patients with ESRD prevents the majority of the population from being able to afford long-term dialysis therapy. After exhausting their resources, most patients are forced to stop dialysis therapy or opt for once-weekly dialysis and thus fail to achieve minimum benchmark targets. CAPD After initial setbacks, a CAPD program was initiated in 1990 by Dr Georgi Abraham at Chennai, who had trained with Dr Dimitrios Oreopolous in Toronto, Canada. Several other centers in the country followed suit around 1991. It was slow to pick up, but more and more patients are being initiated on this modality, and approximately 5,000 patients currently are on CAPD therapy. Cycler-assisted PD is being used by only a few patients. Despite its obvious attraction as the dialysis modality of choice in resource-constrained settings, CAPD generally has not been considered as first-line therapy. Because of poor patient selection and lack of funding, a large proportion of patients reduce the number of daily exchanges and drop out early. The 2-year survival rate of patients on CAPD therapy is approximately 60% in good centers; however, peritonitis rates have decreased significantly over the years. PD fluid in a collapsible bag currently is being manufactured in India, but it is still very expensive. The annual cost of CAPD, excluding erythropoietin, and with 3 exchanges daily is approximately US $5,000. The higher cost of CAPD is the major deterrent to this procedure gaining popularity in India. It is my belief that this modality needs a boost by the government. A PD-first policy with judicious shift of selected patients to hemodialysis holds a lot of promise. Transplantation As mentioned, kidney transplantation was recognized early as the most viable form of long-term RRT in India. Presently, India is among the leading nations in the world in the field of transplantation, and 170 centers are recognized by the government for performing kidney transplantations. About 3,500 transplantation surgeries are being performed every year, the majority with living donors. Graft survival rates in good centers are approximately 90% in living donor transplants and 80% in cadaver donor transplants. The cost of a renal transplantation is approximately US $2,000 to $3,000 with a living related donor in a government hospital and US $6,000 to $8,000 in a private sector hospital. Immunosuppressive therapy costs approximately US $380 to $400 per month. The worldwide shortage of organs gave rise to the practice of purchasing kidneys from poor individuals by affluent persons in the 1980s and early 1990s. The buyers came from within and outside the country, giving rise to the term “transplant tourism.”20 The donor exploitation and substandard medical care provided to recipients was widely condemned and prompted enactment of an act by the Indian parliament (Transplantation of Human Organs Act [THOA]) in 1994 banning the sale of human organs (Box 1). Recently, the act was modified to close loopholes that were exploited for sporadic instances of commerce in organ transplants. Since then, this practice has occurred only clandestinely. Box 1 Major Milestones in Indian NephrologyTHOA provided the first legal basis for brain death, thus opening the door for the development of a deceased donor program. However, fewer than 1,000 cadaver transplantation surgeries have been performed in the country to date. Cadaver donor transplantation has been bedeviled by several obstacles, such as pressure on scarce intensive care unit beds, paucity of finances required for maintaining the potential donors, availability of organ-sharing agencies in only a few centers, illiteracy, and social beliefs of the population and thus has remained sporadic. A National Organ Transplant Program has now been launched with the aim of facilitating transplantation from both living related and deceased donors. The program envisages a centralized organ procurement and distribution system and would have a component of capacity building. Recent modifications to THOA also have sought to improve conditions by streamlining the process of donation. Predicting the Future Despite numerous obstacles, dramatic developments have changed the face of Indian nephrology over the years (Box 1). Well-organized structured training programs and excellent therapeutic facilities available in some of the advanced centers have largely eliminated the need for foreign travel by students, consultants, and patients. The expansion of therapeutic facilities and research programs relevant to our country is hampered by only economic constraints, not by the lack of expertise. Predicting the future is a dangerous game; almost always, one is proved wrong. I can only make a wish that in the years to come, our younger generation of nephrologists will organize renal services in such a way that the benefits of modern nephrology are made available to all sections of the populations in India, rich or poor, urban or rural, male or female, and young or old. Special efforts need to be directed for the prevention of renal disease in populations at increased risk. Acknowledgements Financial Disclosure: None. References 1. 1In: Conn HF editors. Current Therapy. Philadelphia, PA: Saunders; 1955;p. 356. 2. 2CIA. CIAWorld Factbook: India. https://www.cia.gov/library/publications/the-world-factbook/maps/maptemplate_IN.html. 3. 3Iversen P, Brun C. Aspiration biopsy of kidney. Am J Med. 1951;11:324–330. Abstract |
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4. 4Kark RM, Muehrcke RC. Biopsy of kidney in prone position. Lancet. 1954;266:1047–1049. MEDLINE 5. 5Chugh KS. Evaluation of Renal Biopsy. Chandigarh, India: Panjab University; 1958;. 6. 6Chugh KS, Singh S, Balasubrahmanyan M, Chhuttani PN. Secondary amyloidosis. J Assoc Physicians India. 1960;8:583–594. 7. 7Chugh KS. Management of renal failure in India. Proc Second Meeting Int Soc Artif Intern Organs (USA). 1979;3:12–16. 8. 8Mohan Rao M, Pandey AP, Shastry JCM, Johny KV. Status of renal transplantation in India. Ann Acad Med Singapore. 1975;4:183–185. 9. 9ISN Video Legacy Project: Dr K.S. Chugh. http://cybernephrology.ualberta.ca/ISN/VLP/Trans/chugh.htm. 10. 10Chugh KS. Nephrology Forum: Snake-bite-induced acute renal failure in India. Kidney Int. 1989;35:891–907. MEDLINE |
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11. 11Atkins RC. Nephrology Forum: Interleukin-1 in crescentic glomerulonephritis. Kidney Int. 1995;48:576–586. MEDLINE |
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12. 12Li L. Nephrology Forum: End-stage renal disease in China. Kidney Int. 1996;49:287–301. MEDLINE |
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13. 13Kher V. Nephrology Forum: End-stage renal disease in developing countries. Kidney Int. 2002;62:350–362. MEDLINE |
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14. 14Dirks J. Developing Nephrology Worldwide: The work of COMGAN (ISN News, Fall 2000. Cited by Robinson RR, Richet G: International Society of Nephrology: A forty year history). Kidney Int Suppl. 2001;79:S1–S100. MEDLINE 15. 15Chugh KS. Renal Disease in India. Am J Kidney Dis. 1998;31:57–59. 16. 16Jha V, Chugh KS. Post-transplant infections in the tropical countries. Artif Organs. 2002;26:369–372. 17. 17Modi GK, Jha V. The incidence of end stage renal disease in India: A population based study. Kidney Int. 2006;70:2131–2133. MEDLINE 18. 18Agarwal SK, Srivastava RK. Chronic kidney disease in India: Challenges and solutions. Nephron Clin Pract. 2009;111:c197–c203. 19. 19Mani MK. The management of end stage renal disease in India. Artif Organs. 1997;22:182–186.
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20. 20Chugh KS, Jha V. Commerce in transplantation in third world countries. Kidney Int. 1996;49:1181–1186. MEDLINE |
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Postgraduate Institute of Medical Education and Research, Chandigarh, India  Address correspondence to Kirpal S. Chugh, MD, FRCP, FACP, FAMS, FICP, National Kidney Clinic and Research Centre, 601, Sector 18-B, Chandigarh 160 018, India
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