Nephrology services in Pakistan

Saiyid Ali Jaffar Naqvi

The Kidney Centre, Karachi, Pakistan

Introduction

Pakistan came into existence in 1947. Though young as a nation, it has an ancient past. Lying between the two giant historical civilizations, the Aryans to the east and Zoroastrians to the west, the earliest known civilization—the Indus valley—flourished here about 4500 years ago. It has been the marching ground of several peoples who came from or through Central Asia.

Pakistan is a land of many contrasts and great beauty, of rich fertile plains and great deserts, of impenetrable forests and incredible mountains. It boasts some of the highest peaks of the world, including the famous K2. It has an area of 803 900 square kilometres, nearly one-quarter of which comprises well-irrigated and fertile agricultural land. With a population of 135 million and an annual growth rate of 2.9% it is one of the 10 most populous countries of the world.

Pakistan has four provinces, each having a distinct culture and a regional language. Sixty-five per cent of the population resides in the rural areas. Economy is mainly agricultural. Per capita income is about US $380/annum. Health expenditure by the government is only 0.6% of GNP. The literacy rate is 29%. Life expectancy is 62 years.

Pakistan has 823 major hospitals including 64 teaching hospitals and 23 medical colleges. It has about 4925 dispensaries and 256 maternity homes. There are on average 1.8 hospital beds, 1.8 doctors, and 9.8 nurses per thousand population [1]. Health services and expertise are not uniform throughout the country.

Nephrology

Nephrology as a distinct discipline of medicine started in 1970 when the first facility for the care of renal patients was established at the Jinnah Postgraduate Medical Centre, Karachi, one of the largest health institutions of Pakistan. Nephrologists were unknown until then. This department was named Nephro–Urology so that the physicians and surgeons could work together and be complementary to each other.

Progress in the field of nephrology could perhaps be seen in three phases. In the first 10 years only very few explorations could be done. The next 10 years saw some laboratory facilities start. In the last 10 years all types of exploration, including immunofluorescence and electron microscopy, have become available. These developments, along with increasing awareness of renal disease, have resulted in a tremendous increase in the inflow of renal patients over the last 10 years. Today over 17 nephrology departments are functioning in Pakistan, 12 have academic affiliation with either the College of Physicians & Surgeons of Pakistan or the nearby university. Almost half of these nephrology departments have complete laboratory facilities including immunology. Immunofluorescence for renal histopathology is available in four centres and electron microscopy in three. One must say that electron microscopy is expensive and these three centres are giving assistance to other centres as far as diagnosis is concerned. This is probably more cost-effective than every individual centre having such a facility.

The prevalence of various diseases at the largest postgraduate centre in Pakistan is shown in Table 1Go. About 36% of patients either have obvious renal stone disease or have crystalluria. Chronic renal failure is 14%, urinary-tract infection is about 10%, immunological diseases 3.6%, acute renal failure 2.6%, and about 7% conditions remain undiagnosed.


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Table 1. Disease patterns

 

Acute renal failure

The major cause of acute renal failure (ARF) is hypovolaemia secondary to dehydration as a result of gastroenteritis (32%). Obstetric blood loss (antepartum and postpartum haemorrhage) largely due to inadequate obstetric care is also an important cause (15%). Other main causes are nephrolithiasis (10%), acute glomerulonephritis (12%), and sepsis (10%) [2]. The precise drug involved is usually difficult to identify in drug-induced ARF because of over-the-counter sales of drugs.

End-stage renal disease

The incidence of end-stage renal disease (ESRD) is estimated to be about 100 patients/million population. The aetiology of ESRD at a leading dialysis facility is shown in Table 2Go. During the last 5 years the incidence of diabetes mellitus as a cause of ESRD has increased and now diabetes and chronic glomerulonephritis are the leading causes of ESRD, followed by hypertension and renal stone disease.


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Table 2. Aetiology of ESRD

 
Occasionally the diagnosis of the underlying renal disease is difficult to establish due to inadequate facilities or late referral of a patient to a tertiary care centre, and at times because of the patients' inability to travel long distances to reach the nearest tertiary centre as a result of financial constraints.

Haemodialysis

Dialysis and transplantation facilities are expensive all over the world. This is particularly felt in a country that has financial constraints, and where health and education services seem to suffer the most. In Pakistan, the cost of dialysis per patient is approximately $3000 per year, which is about eight times the average annual per capita income. Whether treatment is provided at a public or a private hospital, the expense is passed on to the taxpayers or the philanthropists.

Intermittent haemodialysis treatment in Pakistan began in 1970. At present there are 72 public and private haemodialysis centres, mainly in the urban areas. Facilities in rural areas are almost non-existent. Therefore most of the patients from rural areas tend to be referred late, usually in emergency units at the nearest tertiary care centre. However, these facilities are gradually improving with philanthropic support. Recently the government has started sponsoring a programme to provide free dialysis. This has not only increased the number of patients on dialysis but has also improved the dialysis facilities. At present, over 2000 patients are being dialysed under this programme.

Most of the patients are dialysed twice weekly, i.e. 8 h/week. However, with the new government-sponsored programme more patients are now getting thrice-weekly bicarbonate dialysis. Over 90% of centres reuse dialysers. In most of the centres reuse is manual, only four centres are using automated cleaning systems. Most of the centres, particularly in cities, have a reverse osmosis system.

Blood transfusion used to be the way to treat anaemia because of the cost of recombinant human erythropoietin. However, the use of erythropoietin has recently increased after the introduction of different brands of erythropoietin, which are cheaper and yet equally effective. It is also provided under the government-sponsored programme. Because of a relatively high prevalence of hepatitis C in the general community and multiple blood transfusions in dialysis patients, the prevalence of hepatitis C in our dialysis population is high. It varies from 40 to 72% in different centres. Some large dialysis units have started dialysing hepatitis C-positive patients on dedicated machines. It is too early to comment if this has decreased the seroconversion rate. The prevalence of hepatitis B was quite high (10%) in our community but with increasing awareness and immunization it has decreased considerably (3%). All centres are dialysing hepatitis B-positive patients on dedicated machines in a separate room. The seroconversion rate of hepatitis B in the dialysis population is around 3%. The mortality of haemodialysis patients is between 25 and 30% per year [3]. Malnutrition and inadequate dialysis appear to be the major factors causing such a high mortality rate [4]. There seems to be more anxiety and depression in these patients [5]. In one dialysis centre 87% of patients were rehabilitated and were living a near-normal life after the initiation of dialysis.

Group therapy
One of the dialysis centres in the country (The Kidney Centre, Karachi) conducts a meeting of their patients and their staff regularly, once a month. In these meetings experts discuss various aspects of dialysis with the patients. Psychiatric help is also available to the patients on regular basis.

There is also a Paediatric Dialysis Centre in Karachi, which provides chronic ambulatory peritoneal dialysis (CAPD), haemodialysis, and renal transplantation.

Chronic ambulatory peritoneal dialysis

In Pakistan CAPD has not taken off because of the high cost of the dialysis solution compared with haemodialysis and because of the high infection rate in these patients as a result of poor hygiene and patient care.

Renal transplantation

There are 12 transplantation centres in Pakistan, five in the public sector and seven in the private sector. Approximately 400 renal transplantations are done every year, which is not enough. The problem is availability of organs. Kidneys are procured mainly from living donors. Some centres have a strict policy of accepting kidneys only from living donors whereas others accept kidneys from both related and unrelated donors. Cadaver-donor transplantation has yet to take off in Pakistan. So far seven cadaveric kidneys, received from abroad, have been harvested. Recently kidneys were also retrieved from a local cadaver. Lack of understanding of ‘brain death’ by the general public and cultural and religious beliefs have prevented approval of any law permitting cadaver organ donation. Political will is also lacking. Apparently it is going to take a long time before a cadaver organ donation programme becomes established in Pakistan.

In one transplant centre in Karachi, 3 years ago, as many as 723 ESRD patients were registered. Of these 371 were potentially transplantable. Twenty-six per cent had no donor, the families of another 25% were not willing to donate their kidneys [6]. The cost of post-transplant medicines is also holding up transplantation. So far, philanthropists formed the only support for the transplant programme; now to some extent the government is also providing immunosuppressive drugs.

One- and 5-year patient and graft survival rates are 95 and 81%, and 92 and 73% respectively. Chronic rejection is responsible for 63% of graft failures [7].

Teaching and training

Teaching and training of nephrologists has in recent years taken root with the efforts of the ISN and the introduction of COMGAN. Through the efforts of ISN there are sister-exchange programmes with various institutions and this has come off very well indeed with The Kidney Centre. Seventeen doctors have been sent by the Kidney Foundation (of Pakistan) and ISN to attend various courses at Dubai, Australia, and other places. The Kidney Foundation (of Pakistan) arranges a symposium on dialysis every year: ‘Excellence in Dialysis’. Besides three or four invited foreign speakers, there is very active local participation. This has also generated important local data. A feature of this symposium is a 1-day training programme for nurses and dialysis technicians.

Regular monthly meetings at various nephrology units in Karachi for the last 9 years have helped in the exchange of ideas. Such meetings are now being organized in Islamabad and Lahore as well. This is the sort of approach that one is adopting in propagating and educating physicians. Efforts are being made through the Pakistan Society of Nephrology to harmonize the fellowship-training programme for nephrology. With the passage of time this will succeed because there is awareness and congenial atmosphere prevalent in the Pakistan Society of Nephrology at present.

As stated previously, in Pakistan the health sector gets a paltry 0.6% of the total GNP. Nephrology, being an infant section in the overall health sector, gets almost nothing. The efforts of the community have on the other hand been tremendous as far as Karachi is concerned. There have been institutions built up entirely by donations, ranging from 2 to 2 million rupees. Various philanthropists are financing these centres, which are made by the community, so that a fair number of patients are fortunate to get free treatment. However, one must say that these efforts can only be supplementary and cannot solve the problems as far as the nephrology services are concerned. Because of the inadequate attention given to the public health sector, private hospitals with modern facilities are being developed and various private medical universities have also been established. However, they provide expensive treatment, and do not improve the plight of the common man.

Notes

Correspondence and offprint requests to: Prof. S. Ali Jaffar Naqvi, The Kidney Centre Karachi, 197/9, Rafiqui Shaheed Road, Karachi 75530, Pakistan. Back

References

  1. Pakistan Demographic Surveys. Federal Bureau of Statistics, Government of Pakistan. Data for the year 1993–94
  2. Naqvi SAJ. Commentary on acute renal failure in Asian region. Nephrology1996; 2: 213[ISI]
  3. Jamil B, Kumar H, Naqvi SAJ. Predictors of mortality in hemodialysis patients. J Pak Med Assoc1996; 46: 58–60[Medline]
  4. Kumar H, Safdar N, Naqvi SAJ. Nutritional assessment of patients on maintenance haemodialysis. J Pak Med Assoc1994; 44: 277–279[Medline]
  5. Kumar H, Alam F, Naqvi SAJ. Experience of haemodialysis at The Kidney Centre. J Pak Med Assoc1992; 42: 234–236[Medline]
  6. Rizvi SAH. Present state of Dialysis and Transplantation in Pakistan. Am J Kidney Dis1998; 31: xiv–xiviii
  7. Naqvi A, Rizvi SAH. Renal transplantation in Pakistan. Transplant Proc1995; 27: 2778[ISI][Medline]




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