Dr. Ram Dulal ‘Back-door’ Realities of Renal Transplantation global health rounds
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Transcript of Dr. Ram Dulal ‘Back-door’ Realities of Renal Transplantation global health rounds
ObjectivesObjectives
Discuss health system of NepalDiscuss health system of Nepal Describe the shifting trend in Describe the shifting trend in
disease patternsdisease patterns Discuss renal transplantation and Discuss renal transplantation and
issues of public health ethics and issues of public health ethics and ‘‘back-doorback-door’’ reality reality
Nepal is known asNepal is known as
Land of brave Land of brave ““Gurkha warrierGurkha warrier””
Land of Himalayas, Land of Himalayas, 8 out of 10 world highest peaks8 out of 10 world highest peaks
Birth Place of Lord Buddha,Birth Place of Lord Buddha,
World Heritage sitesWorld Heritage sites
Nepal At A Nepal At A GlanceGlance
Mount Everest Mount Everest & Buddha& Buddha
Bakhtapur
Kathmandu Valley: Kathmandu Valley: World Heritage World Heritage Sites Sites ( Contd..)( Contd..)
Changunarayan
Basantapur Durbar Square
Kathmandu Valley - Kathmandu Valley - World World Heritage SitesHeritage SitesSwayambhunat
hPatan Durbar Squre
Basic Basic CharacteristicsCharacteristics
NepalNepal Area of 147,181 sq. km Area of 147,181 sq. km Population: Population: 26.5 million (2011)26.5 million (2011) Total fertility rate: 2.6 (2010)Total fertility rate: 2.6 (2010) Infant mortality: 65.3 per 1,000 Infant mortality: 65.3 per 1,000 Life expectancy: 64.6 male/ Life expectancy: 64.6 male/
67.1 female (2010) 67.1 female (2010) Per Capita health expenditures: US-$64 Per Capita health expenditures: US-$64
(Int.)(Int.) GDP per Capita US$ 500 GDP per Capita US$ 500
Ministry of Health
Department of Health Services
Regional Health Directorate - 5
Central Hospitals - 5CENTRALLEVEL
Zonal Hospital - 11
District Public Health Office - 14
District Health Office61
Primary Health Care Centre/Health Centre - 188
Health Post - 698
Sub Health Post - 3,129
FCHV48,307
TBA15,553
PHC ORC Clinic14,769
EPI Outreach Clinic15,833
D I V I S I O N S C E N T R E S
District Hospital62
District health system is integrated – preventive and District health system is integrated – preventive and curative servicescurative services
Nepal Total Death by CauseNepal Total Death by Cause S.No. Particulars Deaths %
1 Coronary Heart Disease 21,152 14.22 Influenza & Pneumonia 18,406 12.43 Stroke 11,119 7.54 Diarrhoeal diseases 7,787 5.25 Tuberculosis 6,330 4.36 Lung Disease 5,973 4.07 Birth Trauma 5,967 4.08 Low Birth Weight 5,584 3.89 Hypertension 5,570 3.8
10 HIV/AIDS 4,796 3.211 Diabetes Mellitus 3,224 2.212 Lung Cancers 3,100 2.113 Maternal Conditions 2,791 1.914 Road Traffic Accidents 2,527 1.715 Violence 2,455 1.7
16 Othe Injuries 2,358 1.59
17 Kidney Disease 2,212 1.49http://www.worldlifeexpectancy.com/country-health-profile/nepal
Patients Increased in Patients Increased in HemodialysisHemodialysis
Kidney Kidney transplantationtransplantation
Treatment Treatment of choice and of choice and preferredpreferred
DialysisDialysis Temporary in Temporary in
End Stage Renal End Stage Renal Diseases Diseases
Kidney TransplantKidney Transplant
Treatment for Kidney Disease Remains Elusive
Treatment for Kidney Disease Remains Elusive
and Unaffordableand Unaffordable
Dr. Sudha Khakurel, Chief of Nephrology Unit at Bir
Dr. Sudha Khakurel, Chief of Nephrology Unit at Bir
HospitalHospital
History on Kidney Transplantation History on Kidney Transplantation in Nepalin Nepal
Three cases – nursing home (private Three cases – nursing home (private hospital) in 1996hospital) in 1996
One case – central govt hospital (Bir One case – central govt hospital (Bir Hospital) in November 2004Hospital) in November 2004
Prior to August 2008, abroad for transplantation mostly to India until TUTH, Nepal started..
Bir Hospital & TUTH
HECAF-Nepal / National Kidney HECAF-Nepal / National Kidney CentreCentre
Study on Kidney Transplant Study on Kidney Transplant Recipient Recipient
A cohort retrospectiveA cohort retrospective Follow up registryFollow up registry June 16, 2003 to July 15, June 16, 2003 to July 15,
2008. 2008. Population 452 Population 452
transplant recipientstransplant recipients
Lawful DonorsLawful Donors
Law of the land defined: the potential Law of the land defined: the potential kidney donorkidney donor’’s can be: s can be:
father, mother, sister, brother, father, mother, sister, brother, husband, wife, son, daughter, uncle, husband, wife, son, daughter, uncle, aunt, sworn friend (Mitajyu), mother-aunt, sworn friend (Mitajyu), mother-in-law and father-in-lawin-law and father-in-law
Type of Hospital and Type of Hospital and CountryCountry
93.75% - 45 different hospitals in India, 71.7% - private hospitals – IndiaOut of 45 - No. of cases 190, 58 and 25
Source of KidneysSource of Kidneys
Unrelated 315 (69.69%), related 134 (29.43%) and undisclosed 4 (0.88%)
EthnicityEthnicity
Age Group of Recipients Age Group of Recipients
AgeAge NumberNumber ≤≤15 years15 years 4 (0.9%)4 (0.9%) 16-3016-30 113 (25.0%) 113 (25.0%) >>
90%90% 31-4531-45 156 (34.5%)156 (34.5%) 46-6046-60 144 (31.9%)144 (31.9%) 61-75 61-75 35 (7.7%)35 (7.7%)
Male to female ratio of 3:1.
Benefit of Kidney Transplantation….. …Back to Work (contd…..)
Croatian vs Poland Croatian vs Poland
Final Euro Cup 2008Final Euro Cup 2008 played and won by 28 Yrs old Striker played and won by 28 Yrs old Striker Ivan Klasnic after 2Ivan Klasnic after 2ndnd Renal Tx Renal Tx
Benefit of Kidney Transplantation….. …Back to Work
Donor Lisa George Danhw Recipient: Dan Donor Lisa George Danhw Recipient: Dan GeorgesGeorgesRelationship to donor: Spouse Date of Relationship to donor: Spouse Date of donation: May 24, 2002donation: May 24, 2002
Your gift has given me a new outlook on life, our family, and our marriage. I thank God every day for you and our children, David and Alexandra. My life is not complete without you. And now that you're truly a part of me, physically, I know I cannot be complete without you. I love you, >Dan
http://www.livingdonorsonline.org/halloffame.htm
Who Got His Kidney?Who Got His Kidney?
Selling kidneys for a few rupees more
Kidney Stealing From Kidney Stealing From PoorPoor
http://www.canada.com/story.html?id=7a0f0f8a-daac-45f2-91c6-c4a3090d1e0d
http://www.asianewsnet.net/Nepal-police-arrest-kidney-dealers-http://www.asianewsnet.net/Nepal-police-arrest-kidney-dealers-46735.html46735.html
Ex-student Leader Among 8 Held Ex-student Leader Among 8 Held for Kidney Trade for Kidney Trade
BANEPA, May 14: Police have arrested eight persons including a former vice-president of Free Student Union of Patan Campus on the charge of their involvement in kidney trade.
A special team of police dispatched from Kathmandu arrested the eight individuals from different parts of the country within a period of one month and paraded them before the media at Dhulikhel on Tuesday.
The arrested have been identified as Puja Dahal aka Puna Thakuri and …………………….
Among the arrested, Sachin Maharjan was reportedly a former vice-president of the Free Students Union at Patan Campus.
Published on 2013-05-14 http://myrepublica.com/portal/index.php/twb/?action=news_details&news_id=54697
ConcernConcern
In some families there are four to five In some families there are four to five members who have sold their kidneys.members who have sold their kidneys.
Kidney seller do not know who got Kidney seller do not know who got his/her kidney?his/her kidney?
The Nepali Kidney Bank The Nepali Kidney Bank by by Sunil NeupaneSunil Neupane http://www.asiacalling.org/en/news/nepal/2010-the-nepali-kid
ney-bank Saturday, 14 May Saturday, 14 May
2011 18:162011 18:16
The Village of Stolen KidneysThe Village of Stolen Kidneyshttp://www.youtube.com/watch?v=EE6cdPTkD5khttp://www.youtube.com/watch?v=EE6cdPTkD5k
MessageMessage
Tribhuvan University Teaching Tribhuvan University Teaching Hospital and Bir Hospital provide Hospital and Bir Hospital provide kidney transplantation kidney transplantation
Rigorously selected lawful cases only Rigorously selected lawful cases only
Results presented are based on the Results presented are based on the data on kidney transplantation done data on kidney transplantation done abroad, mostly in Indiaabroad, mostly in India
Where Are We?Where Are We?
What is individuals professionalWhat is individuals professional’’s s role? role?
Whether live donor is lawful Whether live donor is lawful volunteervolunteer
or or poverty driven, misinformed, poverty driven, misinformed,
forcefully mediatedforcefully mediated
Disrupting Ethical Issues Disrupting Ethical Issues Renal care team members (Nurse, Nephrologist, Renal care team members (Nurse, Nephrologist,
Radiologist/Sonologists, Pathologists etc.) participation Radiologist/Sonologists, Pathologists etc.) participation in the process of living donor screening and approval in the process of living donor screening and approval
Policy of homelandPolicy of homeland Initial Screening Process: Donor health and psychosocial historyInitial Screening Process: Donor health and psychosocial history Indication / contra-indicationIndication / contra-indication
http://www.youtube.com/watch?v=m96_v5b0Mws
ConclusionConclusion
Entire enterprise of transplantation is Entire enterprise of transplantation is vulnerablevulnerable
Protect ignorant and poor kidney Protect ignorant and poor kidney sellerseller
Protect health care workers (renal) Protect health care workers (renal) by implementing an appropriate / by implementing an appropriate / robust guidelines robust guidelines