In an exclusive interview with the Delhi Post, Dr Rohini Prashar, MD, Medical Director, Kidney Living Donor Transplant Programme, Henry Ford Hospital, USA, shares her expertise on the growing kidney diseases and the importance of pre-emptive kidney transplant. After Selena Gomez’s kidney transplant from a living donor, Dr Rohini sites this as a perfect example and urges to create more awareness about the ease of a kidney transplant from a living donor. She did her initial medical training in Patiala, India, after which she applied for residency in the USA. She underwent various fellowships in Internal Medicine, Nephrology and Hypertension, Transplant Nephrology Fellowship in the USA. The interview is part of the #EminentSpeaks series where experts and prominent citizens from different fields will share their expertise and impact stories.
Delhi Post: What are your views on Pre-Emptive Kidney Transplantation?
Dr Rohini: Pre-Emptive Kidney Transplantation is getting a kidney transplant before you start dialysis. According to a study done in 2001-2002, the strongest modifiable risk factor that impacts your survival after transplant is your time on dialysis. The more time you spend on dialysis before you get a transplant, the lesser is your survival after the transplant. So, dialysis adversely affects the transplant outcomes. Therefore, ideally one should get a transplant before the dialysis, as dialysis can cause heart disease, calcification of vessels and other complications. But then the question arises: How pre-emptive is too pre-emptive? So we have a general cut off (after looking at the patient of course), which is known as GFR – Glomerular Filtration Rate. If the GFR is less than 15 in diabetics and less than 10 in non-diabetics, then it is considered a good time to get a kidney transplant. If the transplant takes place too soon, the patient is subjected to surgery, immunuosuppression and a lot of unwanted things. So, you have to find the right window, but there is no doubt that pre-emptive transplant is better than getting a transplant after starting dialysis.
Delhi Post: Other than Selena Gomez’s case, can you share with us some other challenges involved?
Dr Rohini: Actually, Selena Gomez`s surgery was not done in our hospital.; they haven`t disclosed where the surgery was done. However, Selena Gomez being such a popular youth icon, the operation was a very good chance for us to spread awareness about living kidney donation. The risks involved are not as much! The mortality risk for a donor in a living kidney donation is less than one dying from a cholecystectomy, which is the removal of gall bladder. If you remove a kidney for transplant purposes, the mortality risk is way less compared to a kidney removal for a tumour or stone. Therefore, it is not a big surgery as far as the donor is concerned. Even for the recipients, there are new techniques such as robotic transplantations etc, which makes the surgery much less risky. The bigger challenge is immunesuppression, which is like a cancer drugs, so they come with side effects – infections, cancer, anaemia etc. However, if patients take good care of themselves, are monitored by a good team, are taking their medications, then most of them do well. Therefore, the surgery is not that big an issue.
Delhi Post: What are the steps taken in the US to promote kidney donation?
Dr Rohini: There is a need for increased awareness about organ donation (both living as well as deceased) everywhere, not just the US. Unfortunately in the US, unlike other countries, the living organ donation rates are very stagnant – people do not donate their organs. We use a phrase – ‘Share the spare’ – one out of the 2 kidneys can be shared. So letting people know they can live with 1 kidney is important. At the same time, we also have to be cognisant that the donors we are selecting are healthy, as we don`t want to put them at harm. Also, there is a need to increase the deceased donor pool, especially in countries like India or Japan, where deceased organ donation is considered a taboo. Therefore, spreading awareness about organ donation in the society is the key.
Delhi Post: What measures do you suggest to prevent illegal organ trade?
Dr Rohini: There is a push toward incentivisation of organ donation – which means paying people to donate organs. People against this argument state that the existing system should be fixed instead of swapping it for a free market. This argument is partially reasonable, because if we are paying people for an organ, we undermine a very essential component of organ donation, which is trust. Therefore, there are pros and cons both. The ideal way is to come up with a regulated system of incentives in the organ donation framework. In that way, there would be less room for organ trafficking, illegal trade, and at the same time our donors don`t feel pressurised. The best solution is to remove the disincentives: don`t pay the donors, but at least pay for their lost wages. For example, if I donate my organs, I am taking 6 weeks off of work. So we could at least pay them for that. That is where I think the transplant community should be headed.
Delhi Post: Why are people still reluctant to sign organ donation forms?
Dr Rohini: I think that is also because there is not enough awareness. Firstly, there needs to be awareness about kidney diseases. For example, by the time your creatinine (a measure of kidney function) is 2, you have lost half your kidney functions. After that, it’s just a downward spiral. Therefore, people need to be made aware from the beginning, not just about the diseases, but also risk factors for kidney diseases such as diabetes or hypertension. So there is a need for awareness about prevention of kidney diseases, and organ donation (again, both living and deceased) in case of a kidney disease.
Delhi Post: What are your hopes and aspirations for the future?
Dr Rohini: As I specialise in living organ donation, I want to spread awareness about it and also come up with innovative ways and means. We also try and build chains – the biggest chain I know is of 53 transplants, starting from one altruistic donor and eventually spreading across the country. Also, a lot of times, people who intend to donate to their loved ones cannot do so because of incompatibility with the recipient. So we try to swap the donor with another person with whom he/she is compatible and get a compatible donor for the intended recipient. Establishing a good system of incentives and removing disincentives is also important for increasing organ donation rates. At the same time, we have to be ethical in our quest to increase donors.
Delhi Post: What are your views on schemes introduced for treatment of kidney diseases in India? Do you have any suggestions?
Dr Rohini: Kidney disease already is an epidemic. It is going to consume alarming populations since the cause of kidney disease are mostly diabetes and hypertension – both of which are highly prevalent in India. These diseases are going to be translated to kidney diseases and there is a need for measures to both prevent it, and treat it. Dialysis is of course going to help. Firstly, one thing that needs to be stressed is that peritoneal dialysis is a better modality for dialysis than hemodialysis. Peritoneal dialysis can be done easily at home, using a little knowledge, a sterile environment, someone to help you etc. Secondly, organ donation needs to be promoted. I am aware of some centres in South India which have a good network of deceased organs. In the United States, there is a united network of organ sharing, which is a country wide system. Under this, the organs are allocated according to whoever is on top of the list. So that leaves very little room for illegal trade and market. Therefore, I think something like that should be implemented on a national platform in India too.