Kashmir’s AILING Healthcare

Patients suffering from chronic kidney diseases in Kashmir valley have increased manifold over the last two decades. While the failure in improving infrastructure at government hospitals has forced many people to abandon treatment, private hospitals are offering some reprieve, Saima Bhat reports.

Every year, around one lakh new cases of End-Stage Renal Disease (ESRD) are diagnosed in Kashmir. A study conducted by the All India Institute of Medical Sciences (AIIMS) says that out of one billion people, 7.8 million people or 150 cases per 1 million people have Chronic Kidney Disease (CKD).

Dr Salim Wani, a senior Nephrologist at SKIMS says the problem is growing in Kashmir given the number of patients visiting his hospital. Dr Wani says the problem of ESRD has doubled in the last 15 years due to an increase in lifestyle diseases like diabetes and hypertension.

“Due to diabetes, the problem has increased up to 40 to 45 per cent. Due to hypertension, it has increased up to 20 to 25 per cent. Then there are other reasons like Childhood Nephritic syndrome, Alport syndrome, Glomerul Onephritis, Hemolytic Uremic Syndrome, Polycystic kidney diseases, Systemic Lupus Erythematosus, Wilm’s tumour and Kidney stones which add two to five per cent to the frequency of the cases reported in Kashmir.”

Initially, the doctors prescribe drugs as a treatment to such patients. But when drugs stop working, Renal Replacement Therapy (RRT) is opted which, nephrologists say, is expensive and lifelong treatment. Kidneys remove waste products from the body and retain other important minerals of the body. They also control the blood pressure of the body. But once kidneys stop functioning, all other actions stop as well due to which waste products produced by the body have to be removed through artificial means.

One temporary way out is dialysis in which waste products are removed with the help of machines and dialyzing fluids twice or thrice a week. There are two main types of dialysis; peritoneal dialysis and Hemodialysis, but the latter is the most common among ESRD patients in Kashmir.

ESDR patients are treated at two main government hospitals in Kashmir valley – Sher-e-Kashmir Institute of Medical Sciences, Soura, and SHMS hospital. SHMS started offering treatment for ESRD in 2007 while SKIMS has been offering it for the last 30 years. SKIMS has six working dialysis machines and a five-bedded ICU specially meant for ESRD patients. But these machines are used only for those patients who undergo a kidney transplant at SKIMS and for emergency patients.

“Each year, one lakh additional ESRD patients visit SKIMS and every year we perform 2000 kidney transplant surgeries,” says Dr Wani. “ESRD is a big problem. Lakhs of people are suffering from it. But there are only six machines in SKIMS and two at SMHS. Where will other patients go?” a doctor at SMHS, wishing anonymity, asks.

At SMHS, there are six dialysis machines but only two are working. The rest of the machines remain off due to the unavailability of space. The dialysis ward at the hospital has a capacity of only two beds. But they provide bedside dialysis as well, which is the first of its kind in the valley.

The government hospitals in Kashmir tackle emergency cases and transplant cases only but the patients who need maintenance dialysis are referred to private hospitals. “Patients who need maintenance dialysis are referred to private hospitals as we cannot cater to all patients. This hospital was built 30 years back to take care of the population at that time. How can we manage the influx of patients 30 years later?” asks Dr Wani.

Dialysis costs a good amount of money which patients belonging to lower economic strata can’t afford. In many cases, such patients end up losing their lives. “I have seen patients who were prescribed dialysis thrice a week. But due to less income, they couldn’t continue with the treatment and died,” says Fayaz Ahmad, a senior technician of dialysis treatment with eight years of experience, at Florence Hospital, Srinagar.

Presently, there are three private hospitals where hemodialysis is done. Khyber hospital, which offers dialysis to a maximum number of maintenance dialysis cases, has eight machines that handle 24 patients per day. 500 patients are treated per month at Khyber who go for dialysis sessions only twice a week. For a session with a new dialyzer (fluid), they are charged Rs 2200 and the patients who use the same dialyzer are charged Rs 1300. The same dialyzer is used at least three times.

All ESRD patients have to undergo dialysis on regular basis, usually twice or thrice a week. About 70 to 80 per cent of these patients are referred to private hospitals, Shahnawaz, a medical coordinator at Khyber Hospital, which offers treatment to patients suffering from ESRD, said.

Khyber hospital is the only hospital where HBaAg test [surface antigen of the hepatitis B virus (HBV) which indicates current hepatitis B infection] is carried out. At Florence hospital, there are four machines that provide dialysis to 250 patients per month. Imam Hussain hospital also has four machines.

Dialysis treatment costs more than Rs 12,000 a month, excluding the cost of medicines. Dialysis technician, Fayaz Ahmad, says patients rarely take injections to increase their blood cell count. In dialysis, minerals needed for regeneration of haemoglobin also get washed out with waste products, “90 per cent Kashmiris can’t bear the cost of this treatment. Many patients have only six months to earn due to harsh winters. Economically, Kashmiris are not well-off. How can a person afford to pay Rs 20,000 per month for such lifelong treatment,” says Dr Wani, adding, “This is the reason we suggest ESRD patients opt for Renal transplant (RT), which is cost-effective.”

SKIMS is the only hospital in the valley which has a license to perform RT surgeries under the guidelines of the Human Organ Transplant Act (HOTA) of 1994. The Act is binding on patients undergoing transplants that the organ should be donated by first relatives; father, mother, brother, sister, son, daughter or wife. But due to this provision, not more than 2,000 such surgeries are performed at SKIMS. The state government is providing Rs 1 lakh to the RT patients for their post-operation care. After the transplant, such patients need to be on medicines and checkups routinely.

Dr Wani says the donor pool is limited in Kashmir and the shortage of organs is further compounded by the fact that everybody cannot donate because everybody cannot be medically fit. “We are looking for Cadaver transplants from the people who are about to die. We can take their organs and transplant them to others which is legal. Even religion allows it. In this way, one dying person can save at least seven lives,” Dr Wani says.

Kidney disease usually progresses silently, often destroying most of the kidney function before showing any symptoms. People at risk of developing kidney disease should therefore get regularly examined. These people include those with diabetes, high blood pressure or blood vessel diseases, and close relatives of people with hereditary kidney disease. Members of certain ethnic groups are also at high risk because of the greater incidence of diabetes and high blood pressure. The most common causes of Chronic Kidney Disease are diabetes mellitus, hypertension, and glomerulonephritis. Together, these cause approximately 75 per cent of all adult cases. Certain geographic areas have a high incidence of HIV nephropathy. CKD is initially without specific symptoms and can only be detected as an increase in serum creatinine or protein in the urine. A simple test to estimate glomerular filtration rate (eGFR) or kidney function level can be also done.