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Dialysis and after
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The number of cases of renal failure is increasing by the day and the prohibitive cost of drugs is making life more miserable for the patients, writes SMITHA SADANANDAN.
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Shyamala had no choice but to let her mother die. The only way to save her was to increase her dialysis support to two sessions every week. The case was referred to the Thiruvananthapuram Medical College Hospital where the treatment continued for a few weeks. Alone and unemployed, and without other financial resources, footing the medical bills was beyond Shyamala.
Shyamala's mother, a daily wage labourer, had been under treatment for chronic renal failure, at a local hospital for six months.
Nephrologists in the State say the number of patients seeking treatment for renal failure is increasing by approximately 10 per cent every year. The prohibitive cost of drugs is making life miserable for the patients as well as their relatives. A large number of patients with Chronic Renal Failure (CRF) require dialysis as part of the treatment. Each dialysis session costs approximately Rs. 1,000. The mandatory drug, erythropoeitin, used for the treatment of patients with renal failure, costs Rs. 1,000 per injection. Not all patients have the resource to undergo dialysis twice or thrice a week.
"The number of diabetics has increased in Kerala. Acute diabetes and hypertension may also lead to renal failure," says Dr. Ramdas Pisharody, a nephrologist at the Kozhikode MCH.
About 20 years ago, if a patient had renal failure, he would have died sooner or later. Fortunately, medical technology has made considerable advancement since then. The symptoms of renal problem are nausea, fatigue, breathlessness on slight exertion, oedema, hypertension of any unrecognised reason and urinary abnormality. Most people tend to overlook these symptoms, and are diagnosed late, say nephrologists.
Acute Renal Failure (ARF) may be the result of severe dehydration or injury to kidney caused by leptospirosis (rat fever), snakebite, obstetric renal failure and so on. "If an accident victim has not suffered from serious injuries, despite a temporary shutdown of the kidneys, dialysis can save his or her life," explains Dr. Pisharody.
"When the kidneys fail, the waste produced by the body is not discarded. If the waste products remain in the body for long, it becomes harmful. Dialysis acts as the artificial kidney and does the recycling, filtering out impurities," says Dr. M. R. Somarajan of Alappuzha MCH.
In Maintenance Haemo-Dialysis (MHD), the patient is `maintained' for the rest of his life on dialysis. Obviously, the cost can be prohibitive. The treatment can be made accessible to the poor if the Government establishes more dialysis centres, and gives precedence to donors who are relatives of the patient over donors who are not. "Compared with other States, Kerala has been doing a good job. As in the West, cadaver transplantations need to be promoted in India," says Dr. Pisharody. Cadaver transplants can be carried out only when a person is certified `brain-dead' (where the brain stops functioning but the heart continues to beat) by a team of doctors. The life of a `brain dead' person is `maintained' artificially on a ventilator (respiratory aid). If the respiratory support system is withdrawn, the patient will die. `Brain-death' occurs when the brain becomes irreparably defunct. The kidney has to be retrieved while the heart is still functioning.
Only one per cent of the CRF patients go in for MHD, while one or two per cent opt for kidney transplantation. "Continuous Ambulatory Peritoneal Dialysis (CAPD) is another option, but this treatment may cost Rs. 15,000 to Rs. 20,000 a month. A sterile fluid, filled into the abdominal cavity, filters the waste. The CAPD apparatus is expensive and the fluid is also imported. A minimum of three exchanges (per day) is needed to maintain the patient in good health," points out Dr. A. Vimala, head of the Department of Nephrology, Thiruvananthapuram MCH.
"Dialysis is meant to sustain life in chronic cases where the kidneys shut down. If treatment were to be made `free' for the CRF patients, the Government would have to spend at least Rs. 1 lakh a year per patient. So you cannot expect a Government hospital to provide medical treatment free of cost," explains Dr. Pisharody. However, Government hospitals charge a reasonable amount unlike private hospitals.
The Kozhikode MCH, for instance, charges a modest Rs. 600 for a single dialysis session, including the disposables. The hospital has three dialysis machines that are operated in two shifts a day. Yet, the facility is inadequate to cater to all patients who require regular dialysis.
Says Dr. Vimala, "Life expectancy of patients could be extended to over 10 years provided the patient undergoes three dialysis sessions a week. If the number of sessions is reduced, it will affect the patient's health adversely. We, at the Thiruvananthapuram MCH, have carried out 29 transplantations so far. Kidney transplants give the patients a new lease of life. Not many people are willing to donate kidney. A proposal has been submitted to provide `Maintenance Haemo-Dialysis' at a subsidised rate. We hope it will materialise soon."
According to Dr. Georgie K. Ninan, who is associated with the P. V. S. Hospital, the Lakeshore and Samaritan hospitals in Kochi, a few alternative drugs have been introduced in the market. "At one of the hospitals where I work, the cost for dialysis is around Rs. 750. The kidney transplants will amount to Rs. 1.3 lakhs or Rs. 1.5 lakhs. The cost is high because we do a laparoscopic (key hole) surgery using sophisticated equipment," says Dr. Ninan.
The expensive equipment and cost of medicines involved do not allow private hospitals to compromise on medical bills.
The equipment for dialysis is imported from Switzerland, Germany, Japan or Europe. Each machine is worth Rs. 6 lakhs and the installation charge costs Rs. 1 lakh. "Only dialysate (fluid) is prepared in hospitals locally.
Another essential drug is Cyclosporin, which is administered to kidney (transplant) recipients to prevent the body from rejecting the graft. The cost of this medicine has come down, yet it remains beyond the common man's reach," points out Dr. Pisharody.
The situation in Government hospitals has become worse. Some hospitals do not have dialysis machines while some do not have people to operate them. In Alappuzha MCH, two dialysis machines have been relegated to the `temporarily obsolete' category.
If the patient is poor and suffers from chronic renal failure, a slow and painful death is inevitable. Every hi-tech medicine comes with a cost. Those who can afford the treatment will survive. Poor patients who cannot afford even regular sessions of dialysis, leave alone kidney transplantation, are left with no choice. It is not just the medicines, but life too, that comes with a price tag.
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