Looking at Chandran driving an auto rickshaw in Chennai, one would not know that he had a kidney transplant over a decade ago. Or that he had no money for the surgery although his wife had volunteered to be a donor. That’s when Dr Georgi Abraham turned to crowdfunding so that the procedure could be done. Today, Chandran lives to see his son excel at his job.
“Ever since then, I realised that transplant is often a question of money before medicine,” says Dr Abraham, the veteran nephrologist who is now working actively through his foundation to make transplants accessible to patients with kidney failure. “The medicine has advanced dramatically. Donor-recipient matching is better, screening is more sophisticated and newer anti-rejection drugs have helped transplanted kidneys survive longer. But for a poor patient, the path from dialysis to transplantation can still depend on whether a family can assemble enough money to cross the distance between having a donor and reaching an operating table,” he says.
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He is building a low-cost, high-access transplant-care model built around reducing the biggest recurring costs through subsidies, expanding the donor pool by efficiently recovering kidneys from deceased donors and ensuring post-surgery care as anti-rejection medicines are expensive but ensure the transplants last longer.
On average, a kidney from a living donor functions for 15 to 20+ years, while a deceased donor kidney lasts 10 to 15 years with the right follow-ups. “Many organ recipients abandon this stage because of high costs,” says Dr Abraham.
“Immediately after the transplantation, the cost of anti-rejection medication, depending upon the matching between the donor and the recipient, could be as high as Rs 20,000 or Rs 25,000 a month to as low as Rs 10,000 a month,” Dr Abraham says. That expenditure generally declines over time as the amount of immunosuppression required decreases. “If some assistance can be given for post-discharge compliance, then, like Chandran, a patient can meet the cost of medication from their own earnings. Since Chandran’s transplant has survived, his requirement for anti-rejection drugs is relatively low,” he adds.
Dr Abraham has already worked on reducing dialysis costs by pioneering peritoneal dialysis, a home-based treatment for kidney failure. It uses the lining of the abdomen (the peritoneum) and a special cleansing fluid to filter waste and extra fluid from your blood. One of his patients, Shanti Raj Mohan, lived with kidney failure and dialysis for 23 years.
“Shanti taught me that you could be a very purpose-driven person despite having kidney failure,” says Dr Abraham, who has just set up a private museum, containing such documented patient memories, to build awareness around kidney health and help transplantees live longer, meaningful lives.
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In 33 years, his foundation has provided more than 9.04 lakh free or subsidised dialysis sessions to 3,378 patients. It currently provides close to 10,000 dialysis sessions a month through 16 centres, with most treatments offered free through a combination of government health insurance, civic bodies and private donors.
In the early 1990s, obtaining the dialysis fluid was difficult. “Initially it was a Herculean task because the government did not permit import of dialysis fluid to India until 1994,” Dr Abraham says. That changed when the fluid was placed under open general licensing in 1994. India now has domestic manufacturers supplying peritoneal dialysis fluid across the country. Yet Dr Abraham says the treatment remains underused. “The reluctance is because of logistical and reimbursement problems,” he says.
These days he is busy with a more elementary question, why wait for the kidneys to fail? A question that has fuelled his campaign for targeted kidney screening through primary health centres across panchayats in India, using simple creatinine, urine and blood-pressure tests. The goal is to identify chronic kidney disease among high-risk populations before irreversible damage sets in.
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His proposed screening model is strikingly simple: a creatinine blood test, a urine examination and a blood-pressure measurement. Those who should be prioritised, he says, include people with diabetes, hypertension or heart disease, those with a family history of kidney disease, people who have previously suffered acute kidney injury, those using alternative medicines and people above 45.
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“A simple blood test to measure creatinine using a strip with a meter and a simple urine test can identify most of the time whether you have kidney disease or not,” says Dr Abraham. The urgency is considerable. He cites a 2016 publication in The Lancet that estimated the prevalence of chronic kidney disease in India at about 17.2 per cent. For a country of India’s size, even a relatively small failure to detect disease early can translate into an enormous number of people eventually reaching advanced kidney failure.
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“Over 46 years, the kidney care in the country has changed. Today, people in their 60s, 70s, 80s and even 90s undergo dialysis. Kidney transplantation has become safer because of better donor-recipient matching, improved screening and newer anti-rejection medicines. Patients who once might have been considered too old for aggressive treatment can now be kept alive for years,” he says.
Yet India has not built an equally ambitious preventive screening infrastructure for people from reaching that stage. Transplantation, for one, cannot solve the problem at population scale. There will never be enough donor kidneys for everyone who needs one. “We cannot provide transplants to all the patients who are on dialysis. This will never happen in any part of the world,” says Dr Abraham.
Besides, India now has roughly 3,300 kidney specialists, according to Abraham, compared with a very small pool two decades ago. He hopes that number can rise to 10,000 within another decade. “During a recent visit to AIIMS in New Delhi, I had watched a colleague facing a clinic load of more than 100 patients. To see 100 patients and to get every detail from them takes time,” he says.
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That tension — between increasingly sophisticated medicine and increasingly crowded systems — is one reason Abraham believes screening cannot remain confined to specialist centres. If kidney disease can be identified earlier at the primary-care level, some patients can be monitored and treated before they reach the point where dialysis becomes inevitable, he feels.
He is also wary of assuming that India can simply import its understanding of kidney disease from Western countries. His own team recently examined lipid profiles among about 1,000 dialysis patients and found differences from patterns described in developed countries, raising questions about whether treatment protocols should simply be imported.
“We were blindly following what was practised in Western countries,” he said. “We need to have a strong platform for research to deal with our own diseases, our own disease patterns and how to treat them cost effectively.”
Dr Abraham is equally cautious about another increasingly common assumption: that India is witnessing a distinct epidemic of kidney disease among the young. What has changed, he argues, is visibility. India’s population has expanded, diagnostic methods have improved, kidney biopsies and imaging are more accessible, patients are more aware, and the number of trained nephrologists has risen substantially. “The challenge now is to ensure that greater visibility comes early enough to make a difference,” he says.
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