We are also trying to do cadaveric transplants in Bangladesh. We attempted this last year from a brain-dead donor, but the donor’s family finally backed out. This year we are attempting it with a deceased donor, and if the family agrees, we will do the first cadaveric transplant in Bangladesh
Dr Harun Ur Rashid joined the Bangabandhu Sheikh Mujib Medical University (BSMMU) in 1981 after getting a PhD from the United Kingdom. Over the last 38 years, he has been at the forefront of all stages of development in the treatment of kidney diseases. He introduced kidney transplant and hemodialysis in Bangladesh, and has also made major contributions in institutional developments in this field of medical science.
This nephrologist was the founding director of the National Institute of Kidney Disease and Urology, and the founding president of the Kidney Foundation Hospital and Research Institute Bangladesh -- two key institutions in this field.
Now the chief consultant in Nephrology at the Kidney Foundation and Research Institute Bangladesh, Professor Harun Ur Rashid elaborates on the treatment of kidney diseases that are available in Bangladesh, recent developments and scope for future improvements. In an interview with The Business Standard on December 11, he emphasised that early diagnosis at the primary level can save lives and money, as there are only 200 nephrologists for the 2 crore people suffering from kidney problems in the country.
TBS: Where do we stand now in treating kidney ailments?
Acute kidney injury (AKI), a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days, and chronic kidney disease (CKD), a condition that causes gradual loss of kidney function over time, are the main kidney diseases now-a-days. Kidney problem is now regarded as a worldwide public health concern as around 10% of the population of the world is suffering from kidney ailments. In Bangladesh and South Asia the incidence and prevalence of chronic kidney disease is as high as 17-18%, and this can ultimately result in kidney failure. In Bangladesh, about 40,000 people suffer from kidney failure or the end-stage of a kidney disease. In cases of kidney failure, the only treatment is dialysis or kidney transplant. There are two forms of dialysis. One is hemodialysis, which is machine-bound and usually hospital-based, while the other is a home-based dialysis called CAPD—continuous ambulatory peritoneal dialysis. But the best treatment for kidney failure is transplant.
There are two types of transplants recognised by medical practitioners around the world. The first is live-related, when the kidney comes from a living donor, and the other is cadaveric, taking an organ from a deceased person. The first type is done among close relations. In such cases, husband and wife are also considered close relations and the age of the donor must be between 18 and 65 years. In cadaveric transplants, kidneys of any person who dies in a road accident, or of cardio-vascular disease or stroke, can be used with the consent of the deceased person's family. If the family agrees, both kidneys, liver, heart, and two lungs can be used to help save the lives of others.
TBS: Can cadaveric transplant be decided instantly, or are prior arrangements required?
Cadaveric transplants can be done when a patient who is admitted to the Intensive Care Unit (ICU) does not survive despite all efforts. After the patient's death, doctors can ask the deceased person's close relatives if they want to donate the kidneys. If the family agrees, only then can the kidneys can be removed, preserved and sent to the respective hospital for transplant. In developed countries 80% of kidneys for transplant come from deceased donors and 20% from living donors who must be a close relative of the patient. In Bangladesh, we prefer live-related transplants. Parliament passed the human organs transplantation law recently and expanded the definition of close relations – thus creating more scope for live-related transplants.
We are also trying to do cadaveric transplants in Bangladesh. We attempted this last year from a brain-dead donor, but the donor's family finally backed out. This year we are attempting it with a deceased donor, and if the family agrees, we will do the first cadaveric transplant in Bangladesh.
TBS: Will it be the first cadaveric transplant in Bangladesh?
Yes, it will be the first ever cadaveric transplant in the country. There are loads of regulations, paperwork and procedures to follow before we can do the operation. As per the existing organ donation law, we have made all arrangements including forming committees, sub committees, organ retrieval, and updating the waiting list of recipients. The hardest part is yet to be done, that is convincing the close relatives to agree to donate the kidneys of the deceased.
TBS: Are the transplants only available in Dhaka?
Yes, because the advancements related to dialysis and transplant is only available in Dhaka. If we are successful here, then we will go to other cities. At present, all kidney failure patients cannot have proper treatment due to a lack of access to dialysis. We have only 170 dialysis centres and about 3,000 machines, but to serve all the 40,000 patients we have to increase the number of the dialysis centres and related facilities.
TBS: Public and private hospitals together have that number of machines and centres?
Yes, altogether, including the government-run public hospitals and private medical centres, clinics and facilitation centres, that's the number. The good news is the government is planning to have a dialysis centre in every district and at every medical college. This will enable more people to be on dialysis. Currently, there are only four centres for kidney transplant in Bangladesh. In 2003, we started with only six dialysis machines, one small laboratory and an outpatient clinic at the Kidney Foundation. Now, after 15 years, we have a full-fledged 150 bed-hospital and a 60-bed dialysis unit in operation. We do one kidney transplant each week. In addition, we also perform home dialysis successfully to over 470 patients.
TBS: Can you elaborate a bit on home dialysis?
Home dialysis is getting the service at your home instead of coming to the hospital. It is called the Continuous Ambulatory Peritoneal Dialysis (CAPD). We also have a large outpatient clinic. About 250 to 300 patients get service there from trained medical officers at a cost of Tk100. You can also see a specialist for a fee of Tk400.
TBS: What is the average cost of transplantation and dialysis?
We charge Tk1600 per dialysis, which would cost between Tk3,500 and Tk6,000 at private hospitals. We also do transplants for Tk2.6 lakh, which is a 2 week package all inclusive. Private hospitals in Bangladesh charge Tk5 lakh, and if you are planning to go to one of the neighbouring countries for a transplant, be prepared to spend Tk15 lakhs to Tk20 lakhs. We have an excellent laboratory facility at the Kidney Foundation. We also have a tissue typing laboratory for transplants. This is the largest dialysis centre in the country with 86 dialysis machines including 60 machines over here, 14 in Pabna, 8 in Sylhet and 4 in Sirajganj.
TBS: So, the Kidney Foundation has got units in other districts?
Yes, for dialysis and outpatient services. This is the biggest kidney hospital in Bangladesh for dialysis, CAPD and transplants altogether. We are expanding our facilities to the 6th, 7th and 8th floors where we will set up 120 dialysis machines next year. We are also set to double the number of weekly transplants from next year and also expand the CAPD services. The Kidney Hospital is internationally recognised. We have a MOU with the Royal London Hospital, Korea University Anam Hospital and Wayne State University, Michigan, USA. They give us technical training and do research on dialysis, CAPD and transplants patients.
TBS: How do you perceive the progress in kidney treatment in Bangladesh in the future?
In the next 10 years I hope we will be able to improve further with collaboration from international organisations. I can say for sure that you will see changes in five years at the Kidney Foundation. But before that there are factors which need attention.
Firstly, we are a bit behind the international standard of research. But we are trying to fill that gap. We have two PhD candidates from Wayne State University and Jadavpur University doing research at the hospital on kidney diseases. In addition, a Malaysian team is collaborating with us in renal nutrition research. A number of Bangladeshi universities including Jahangirnagar and Dhaka are also engaged in collaborative research. We recently formed a research cell incorporating the Kidney Foundation, Diabetic Association and Heart Foundation for high standard research. A MOU has been signed with the Royal London Hospital over this. These steps will upgrade our research.
Secondly, we have a shortage of manpower. The government has agreed to facilitate the training of renal nurses. We do not have skilled renal and transplant nurses in Bangladesh. We will provide training for one year starting in 2020.
Regarding treatment, we are weak in renal histology and pathology for diagnosing kidney diseases. As I said before, we are lagging behind in cadaveric transplantation, which we could not yet start. Apart from cadaveric transplantation and research, I think we can be compared to other Asian countries in renal care.
In next 10 years, I hope, with collaboration from international organizations, we will be able to improve ourselves further. I can say for sure that you will see the changes in five years at least at the Kidney Foundation.
TBS: Are there enough renal specialists?
Currently we have only 170 nephrologists and 32 pediatric nephrologists in Bangladesh to treat about 20 million people suffering from kidney ailments. That means each doctor has to see 800 patients per day – which is impossible. We have urged the government to take initiatives to prevent chronic kidney disease at the primary level. There are nearly 15000 community clinics in Bangladesh which can be equipped to screen for chronic kidney disease by checking blood pressure, blood sugar and urine for albumin or RBC. This is very easy and will cost less than Tk500. This way chronic kidney diseases can be detected at an early stage. Following the diagnosis, patients can be referred to district hospital for treatment. This way we can prevent at least 40% to 50% of chronic kidney cases.
TBS: What is the response of the government?
The government has responded positively, but implementation may take some more time. We already have screening facilities at a few community clinics and have called upon the authorities for more logistics support.