Three decades of nephrology.KS Chugh
Asian Pacific Society of Nephrology, Chandigarh.
Keywords: History of Medicine, 20th Cent., Human, India, Nephrology, history,trends,
Science has made breath-taking advances in the recent times. What has been achieved during the last three decades outstrips all the technological accomplishments put together in the last two centuries. In medical science, several undreamt of advances have occurred - dialysis and transplantation are only two amongst these.
Let me first take you back to the world scene before 1962. In the 1940's and 50' s, nephrology as an organised discipline did not exist in the world. It was perhaps, a distant dream in the minds and imagination of a few scientists and a handful of clinicians, with a particular insight into the unique and vital role, which the kidneys and its diseases played in human biology. These scientists were mostly located in a few larger medical centres and in many countries they did not exist. Budding nephrologists could literally come from nowhere. Vigorous growth in dialysis experimentation was going on and new ingenious dialysis systems were being devised. Dr. Willem Kolff had designed the rotating drum kidney and after lot of experimentation, it was put to clinical trial. The first successful dialysis was performed at the Mount Sinai Hospital on Jan 26, 1948 in a patient who had inserted mercury tablets in her vagina to induce abortion. The toxin level significantly diminished after 6 hours of dialysis and she started having a diuresis 8 hours later. In the mid forties, Dr. Nils Alwall had developed another type of artificial kidney in Sweden and opened the first dialysis treatment centre in 1950.
During the same decade, Drs. John Merill and David Hume and their colleagues were trying some rather naive and primitive efforts to transplant kidneys between dogs using small amounts of corticosteroids then available and antihistaminics. In Pads, Dr. Hamburger and his colleagues transplanted a kidney from a mother to son where the only kidney had been fractured in an accident. The kidney functioned immediately but rejected on the 23rd day.
These studies at various centres and the experience gained led Drs. Joseph Murray, JP Merrill and their colleagues to transplant a kidney from identical twin into his brother with end stage renal failure due to chronic glomerulonephritis and malignant hypertension on Dec 23, 1954. This was the first successful kidney transplant in the world. This patient survived for 7 years and finally died of myocardial infarction with adequate though not normal kidney function. The impact of immunological barriers became clearer.
Another advance occurred on the diagnostic side. Iversen and Brun published a report of 42 successful renal biopsies performed in 66 patients in the sifting position but the procedure did not gain a wide acceptance because of a low success rate of 38.5%. Kark and Muefficke in 1954, published their experience with renal biopsies performed in the prone position and a success rate of 90% and emphasised the safety of this procedure as well as the diagnostic help it provided for differentiating various types of glomerular diseases.
With the background of these happenings in the world, let me turn to the Indian scene. At the time of pdrtition of India In 1947, the medical scene was dismal and medical education was limited to 10 - 12 medical colleges in the country. The concept of specialities and the name 'nephrology' did not exist at that time. I have no doubt that many clinicians and students (like me who graduated in 1955) realised the futility of treating patients with Bull's diet. With newer developments occurring in the world, I was convinced that a qualified nephrologist was what India needed at that time. I took up "Evaluation of renal biopsies as a diagnostic procedure in medical diseases of the kidney" as the subject for my MD thesis in 1956 and applied to the Punjab University for permission to do MD Medicine in Nephrology, as was the prevailing pattern at that time. The medical faculty repeatedly dissuaded me from doing so as this subject did not exist and wanted me to do MD Medicine with Cardiology or Gastroenterology, which had become recognised specialities by that time. The struggle went on for 9-10 months but the University finally relented and allowed me to do MD Medicine with Nephrology as my special subject. I submitted the MD thesis on 50 successful biopsies out of which I had shown amyloid disease in 6 patients in 1958, and passed the MD examination in 1961 and became the first qualified nephrologist of the country. In 1962, I was selected as a Lecturer in Medicine (Nephrology) at the PGI Chandigarh with the promise by the then Director late Dr. Tulsi Das that an artificial kidney machine would soon be ordered.
While still working at Arnritsar but having been selected as a Lecturer at Chandigarh, I read a news item published in the newspapers in July 1962 that a kidney machine had arrived in Vellore. I applied to the Director Health Services and was deputed to see it working in Sept. 1962. This Kollf twin coil artificial kidney machine had been sent as a gift through the Christian Mission in USA to Vellore but could not be installed till His Excellency Shri Gopeshwar Prasad Sahi, the erstwhile Maharaja of Hathwa, an old state of Bihar, developed 'chronic uraemia'. Dr. Lala Suraj Nandan Prasad who was looking after him consulted late Dr. P Koshy, the then Professor of Medicine at the CMC regarding the feasibility of dialysis on this Maharaja. They rang up Dr. Willem Kolff in USA if he could come to India for consultation and dialysis. Dr. Kolff agreed to send Dr. Nakamoto for installation of this machine. The travel expenses of Dr. Nakamoto were borne by the late Maharaja. Dr. Nakamoto thus conducted the first two dialysis at Vellore along with Dr. P Koshy in June 1962 and returned to USA.
The Maharaja stayed in Vellore for 3 months and wanted to be taken to USA tor transplantation but he finally died in Calcutta while being treated for severe 'anaemia of uraemia', which had failed to respond to treatment.
I joined the PGI in Jan 1963, and our Travenol machine arrived in March 1963. We performed the first dialysis at Chandigarh in July 1963 on a patient of obstetrical renal failure who recovered.
In 1962 the King Edward Memorial Hospital, Mumbai received one Alwall dialysis machine as a gift from a Swedish philanthropist Mr. AA Johnson and Dr P Raghavan, who was the Director - Professor of Medicine at that time, established an artificial kidney unit at the King Edward Memorial Dr. Vidya Acharya who had graduated from the King Edward Memorial Hospital while working as a postgraduate with Prof. Raghavan in 1963 initially experimented with dogs to master the technique of cannulation and performed the first dialysis on 31st May 1963. Dr. Acharya was selected as a Nuffield Foundation Travelling Follow to work in Renal Research Unit at Leeds in England in 1969-70 and returned to put the unit on a firmer footing. Till 1970, Vellore, Chandigarh and King Edward Memorial Bombay were the only institutions where dialysis facilities were available.
In 1971, the first successful renal transplant in India was performed at CMC Vellore by Dr. Mohan Rao and Dr KV Johny, both of whom had been trained in Australia. The transplant programme at the PGI Chandigarh and Jaslok Hospital Bombay were started in 1974. By November 1974, a total of 59 transplants had been performed - 46 at Vellore, 5 at Chandigarh, 4 at Jaslok Bombay and 4 at AIIMS Delhi. The results of these transplants were communicated at the First Asian Colloquitim in Nephrology in November 1974 in the same meeting, results of 47 transplants done in Taiwan, 51 in Phillipines, 14 in Singapore, 12 in Thailand and 165 in Australia and New Zealand were communicated. Dr MK Mani and Dr Chacko Kuruvila performed 10 cadaver transplants between 1973 and 1983, 2 cadaver kidneys having been brought by Dr Samuel Kountz and Dr TKS Rao from the USA.
By the end of 1978, 6 centres had been established to treat patients of ESRD with dialysis and transplantation. These included Christian Medical College Vellore which had performed 165 renal transplants by that time, Jaslok Hospital, Mumbai (83), PGI Chandigarh (70), King Edward Memorial Hospital Bombay (18), AIIMS New Delhi (17) and Nanavati Hospital (12) transplants with an overall total of 365 transplants (353 live donors and 12 cadaver) by that time. In addition, dialysis facilities had become available in 27 more centres and by that time over 40,000 dialyses had been performed. The cost of renal transplantation was assessed as Rs. 40,000-70,000 in a private centre (47008900 US$) and 10,000-15,000 (U.S $ 1175-1750) in a Government hospital.
CMC Voilore reported a high incidence of tuberculosis (18.5%) amongst their allograft recipients. Compared to that, it was 7.8% at the Jaslok Hospital and 1.5% at the PG1, Chandigarh. The subsequent 15 years have seen a phenomenal growth in the number of centres, which can today provide dialysis and transplant facilities for the management of endstage renal failure. In April 1979, I was invited to New York by Dr. John P Merrill to present the status of dialysis and transplantation in India in a symposium on 'Uraemia therapy around the world' where 1 had presented these data after compiling the statistics for the entire country.
CAPD, which offers a useful alternative to haemodialysis, could not become popular in India because of high cost, lack of proper equipment and bags, poor socio-economic and sanitary conditions, lack of motivation, and education of our people, and lack of trained personnel. With the efforts of Dr. Abraham and others, the procedure has now been started at Madras and one or two more centres.
Though in the developed world, denial of access to treatment for ESRD in medically suitable patients is normally "intolerable", in the developing countries, resource allocation for primary health care services still remains a priority. Except for a small segment of the society who are in government jobs, the remaining majority have to bear the costs of uremia therapy from their personal sources. Most of them get the treatment by selling off their land or property.
The data regarding the renal services in the developing countries including India are poor and scanty and therefore no meaningful conclusions can be made. It has been estimated that more than 90.000 patients require dialysis or kidney transplants every year. The experience of most of us in this country, like the rest of the world, has confirmed that the successful transplant recipients are healthier than those who are on chronic maintenance dialysis. The recurrent expenditure on dialysis leads to exhaustion of resources of even those few who belong to middle or even those few who belong to middle or even higher income groups. For the developing countries in particular, but it holds true for the developed world also, renal transplants remain the gold standard for treatment of patients with advanced renal failure. Presently about 3000 transplants are being done with living related and unrelated donors every year which constitute only about 3% of the total number of patients requiring this therapy. More than 70% of the kidney transplants in the country are today being done with unrelated donor kidneys. The availability of the kidneys in 'kidney bazaars' of India has not only led to a decline in the number of living related donors (if the family could afford to purchase a kidney) but it has also had a negative impact on the initiation of the cadaver donor programme in our country.
We are all aware of the increasing success now being reported in heart, liver pancreas and other organs not only from the advanced countries but also from Thailand, Singapore, Saudi Arabia, Taiwan, Croatia and some of the Southern American countries. No such transplants would be possible in our country if a cadaver programme is not initiated.
This would become possible only when Parliament gives its consent and enacts the law for brain death and puts a stop to the unrelated donor transplants. It has been estimated that nearly 55000 deaths occur annually due to accidents alone, where the kidneys are likely to be healthy and fit for transplantation. Even if 20% of the 110,000 kidneys thus available are transplantable, the benefit could be afforded to at least 20,000 patients every year, that is over 20% of patient population compared to only 3% receiving transplants from living related and unrelated donors presently. The time is appropriate for stopping these unethical transplants and bringing in a new legislation for cadaver donor transplants, before it is too late.
The very fact that an enormous number of new centres doing transplants have come up in the big cities during the last 5-6 years, is in itself proof that more and more newly trained nephrologists and transplant surgeons are now getting attracted to take up only dialysis and transplant work which is far more lucrative than working in the academic institutions.
Transplants are being performed in many places with hardly any worthwhile laboratory facilities and the outcome is left to cyclosporine and other immunosuppressive agents, which can take care of rejections to a considerable extent. It is more that obvious that very few of the newer generation of trained nephrologists would in future involve themselves in academic or research in this speciality.
One of the most important events, which has contributed to the growth of nephrology to its present status, has been the formation of the Indian Society of Nephrology. The Society was founded by me and came into existence in 1970. The first meeting of the founder members was held at the Topiwala Medical College Bombay on the 18th of January, 1970 and was attended by ten members. Dr. P Koshy and Or. KS Chugh were elected as the President and the Secretary of the Society respectively. The Society was registered under the Society's Registration Act at Chandigarh, with its headquarters at the Postgraduate Institute of Medical Education and Research, Chandigarh. The first Annual Conference was held jointly with the API at Mangalore and was formally inaugurated by Dr. E Rotellar of Spain, the then reigning President of EDTA, on Jan 16, 1971. Within a year of its formation, the Society was accepted as an affiliated unit of the International Society of Nephrology. In 1979, it became a part of the newly formed Asian Pacific Society of Nephrology. The total membership of the Society now stands at over 300.
Since its inception, the annual meetings of the Society have been providing an opportunity to the consultants and postgraduates to interact with nephrologists from within the country and from abroad. The Society has been inviting, and the tradition still continues, atleast one distinguished scientist from abroad every year, which enabled sharing of newer knowledge and a free exchange of ideas on the various renal problems with these experts. The visiting nephrologists have included international celebrities like Prof Hugh de Wardener, Prof Keith Peters, Prof Shaul Massry, Prof Carl Kjellstrand, Prof John Dossetor, Prof Oliver Wrong, Prof Neil Kurtzman and Prof. Sandra Kurtzman, Prof Ram Golkal, Prof NP Mallick and many others. Of all the sessions at the Annual Congresses of API, the most popular were of the Indian Society of Nephrology. The standard of research papers presented at these annual congresses has gradually improved and I am proud to say that many of the papers presented in these meetings have been published in the most reputed international and national journals, thus attracting worldwide attention.
The holding of the first Nephrology Forum in Asia, the Fifth Asian Pacific Congress of Nephrology and the International Society of Nephrology's offer to sponsor a Continuing Medical Education programme at the time of the Silver Jubilee Congress of Indian Society of Nephrology being held in October this year; epitomises the coming of age of Nephrology in India. I am confident that in the years to come, more and more nephrologists and post-graduates from our country would participate and benefit from the Asian and International meetings. The Society has established five renal chapters, each one holding a mid term regional meeting every year. Those regional chapter meetings provide an excellent opportunity to the internists and postgraduates working in those areas so that they get a sufficient exposure to the scientific advances occuring in our speciality. Though the joint meetings with the API gave an immense opportunity to several general physicians and postgraduates in medicine to expose themselves to our discipline, we were unable to devote enough time to our scientific sessions. Hence the Society decided to have an independent Annual Congress every year. The first separate meeting was held at Jaipur in March 1991.
Another symbol of growth of Nephrology in our country has been the establishment of the Indian Journal of Nephrology. I was asked to put this Journal on the rails and 1 am happy to say that the journal is now doing well.
A problem of major concern is the shortage of training centres with adequate facilities. The first two year postgraduate course in Nephrology for the award of DM degree was started at Chandigarh in 1969 and at Vellore in 1974. It may surprise some of you that the first batch of postgraduates with DM degree in Nephrology in India was out from the PGI in 1971, one year before the first batch completed their board certification in Nephrology (in 1972) in the USA. Subsequently, the DM courses were started at Madras, Bombay, Ahmedabad, Hyderabad Lucknow and Calicut. The DM training programmes of Varanasi and Bombay Hospital are still awaiting recognition by the Medical Council of India. In the face of increasing demand of renal services in the country, the existing centres are able to produce only 10-20 qualified nephrologists every year. With the present strength of less than 200 trained renal physicians to meet the renal needs of 900 million population in the country we have one nephrologist for 4 million population. In contrast, the present membership of the Chinese Society of Nephrology is about 1500. 305 hospitals are equipped with dialysis machines and about 11,600 patients receive haemodialysis each year. 4000 amongst these being on maintenance dialysis and about 3000 patients are living on CAPD. Of course, even these numbers still fall considerably short of their actual needs.
The National Academy of Medical Sciences accepted Nephrology as one of the specialities in 1975 and, presently there are a number of hospitals and institutions, which are recognised by the National Board of Examination for training in Nephrology. It is again a common knowledge that some of the centres running these courses do not possess adequate facilities for training in terms of skills or the laboratory investigations. In some centres, library facilities for the postgraduates are indeed inadequate because of lack of sufficient funds. The core group of teachers and researchers who initiated the teaching and training programme in Nephrology comprised of Dr. Chugh at Chandigarh, Dr. KV Johny at Vellore, Dr VN Acharya at Bombay and Dr. KK Malhotra at New Delhi. The other nephrologists who played a leading role in the training of postgraduates in the early years are Dr. C Prakash (Rohtak), Dr. BK Sharma (Chandigarh), Dr. MK Mani (Bombay), Dr. MS Amaresan (Madras) & Dr. PD Gulati at New Delhi. The next generation of stalwarts- who have been instrumental in the organization of renal centres are Prof. JCM Shastry and Dr. Kinibakaran at Vellore, Prof. MA Muthusethupathi at Madras, Dr. Chacko Kuruvilla at Bombay, Dr. Ramesh Kumar and Dr. SNA Rizvi at New Delhi, Dr. Thomas Mathew at Calicut, Dr. HL Trivedi at Ahmedabad, Col. Yashpal (Armed Forces), Dr. Gopal Kishan at Hyderabad, Dr. Rajapurkar at Nadiad and Dr. KS Ratnu at Jaipur. Dr. Mrs. Sada Vaishnava (Delhi), Dr. Mrs. Kumud Mehta (Bombay) and Dr. RN Srivastava (New Delhi) are the three outstanding Paediatric nephrologists who have been responsible for training paediatricians and in promoting the speciality of Paediatric nephrology. Simultaneously, a strong group of surgeons who have been responsible for establishing renal transplant programmes are Dr. Mohan Rao of Vellore who is presently in Australia, Dr. BN Colabawalia (Bombay), Dr. Fardoon Soonawala, Dr. Dev Pardanani, Dr. DK Karanjawala (Bombay), Dr. Madhav Kamat, Dr. RVS Yadav (Chandigarh), Dr. Ajit Phadke (Bombay), Dr. SS Joshi (Bombay), Dr. S Sahariah (Chandigarh and Hyderabad) and Dr. AP Pandey (Vellore). The pathologists who have richly contributed to the understanding of renal histology are Dr. A Date, Dr. UN Bhuyan, Dr. Dutta, Dr. BV Mittal and Dr. SG Kinare.
Among the third generation of nephrologists who are now toiling hard to improve the existing facilities include Dr. Chacko Jacob, Dr. Thiagrajan, Dr. Ram Bhoopal, Dr. SK Pareek, Dr. V Kher, Dr. RK Sharma, Dr. Vinay Salkhuja, Dr. SC Dash, Dr. AF Almeida, Dr. Ashok Kirpalani, Dr. IRV Gandhi, Dr. Sushila Bulchand, Dr. MK Mitra, Dr. NL Patney, Dr. Kasi Visweswaran, Dr. Nandita Chaudhary and many others.
Some of the nephrologists who started their career in India and whose contributions have' been recognised internationally include Dr. Ramesh Khanna, Dr. VK Bansal, Dr. PC Singhal and Dr. Ravi Mehta who are all working in the United States at the moment.
Research: Apart from service commitments, it is only an active research programme, which raises and complements the standard of clinical practice of any speciality. Research in the field of renal diseases in the advanced countries of the world has today reached the genetic, molecular and cellular levels.
In a country with limited resources, is there a place for carrying out such a research? The answer is provided by establishments like Tata Institute of Fundamental Research, Space Research Programmes, Satellite Launching Centres, Atomic Energy Establishment and alike which have vindicated their value in enabling the country to remain with the mainstream of contemporary scientific and technological advances. However, it will eventually depend on the availability of research grants, the department's ability to attract staff of the right calibre and creation of a congenial environment. Whereas there is no bar to plan or conduct research of a high order, it must be relevant to the disease pattern and the needs of the country. With the limited resources and research grants available in our country, to concentrate on hi- tech projects will not prove fruitful and may be suicidal. There is a wealth of clinical material for research work in nephrology in our country. We have yet not been able to even define the pattern or natural history of several diseases, their prevalence and their response to therapy in our ethnic populations with variable nutritional status and living conditions.
The work on urinary tract infections, immunological basis of chronic pyelonephritis, snake venom induced renal disease, renovascular hypertension due to aortoarteritis and problems of hepatitis in the dialysis units by Prof. Acharya and her colleagues Dr. Sen and Dr. Kinare at Bombay filarial nephropathy by Dr. Thomas Mathew at Calicut, immunopathology, course and spectrum of RPGN, lupus nephritis and renal stones by Dr. KK Malhotra, Dr. UN Bhuyan and colleagues at the. AIIMS, renal bone disease by Dr. SNA Rizvi and Dr. PD Gulati at Delhi, leptospirosis and the kidney by Dr. Kasi Visweswaran at Kottayam and by Dr. Muthusethupati at Madras, etiopathogenesis of acute renal failure, amytoid disease, snake venom toxicity in the monkey the man, renal lesions in leprosy and Takayasu arteritis by Dr. Chugh and his associates at Chandigarh, cost reduction in peritoneal dialysis and hemodialysis, diabetic nephropathy and several other aspects of nephrology by Dr. MK Mani at .Madras, patterns of glomerulonephritis, infections in allograft recipients, hemolytic uremic syndrome and renal involvement in leprosy by Dr. KV Johny, Dr. A Date and Dr. JCM Shastry and associates at Vellore, various aspects of hypertension by Dr. BK Sharma at Chandigarh, patterns of glomerulonephritis, acute renal failure and other renal problems in the children by Dr. Kumud Mehta in Bombay and Prof. FN Srivastava in Delhi and several other works by various nephrologists of the country are only few of the examples which have received both national and international attention.
We must encourage the new generation of young scientists who are gifted and creative and could blend the newer developments in the context of the local problems and devise innovative approaches to make research more orientated to our own needs. The country must provide them with adequate research grants and create a working environment and opportunities to enable them to improve the standard of medical care of our patients. For, no matter how well developed a speciality is in a country, it is only as good as the people who are running and managing these departments. Who does not know that sometimes it is difficult to trace the record of even a recent admission in the so called 'big' hospitals and institutions.
Despite numerous difficulties we have faced during the last three decades in terms of financial resources, lack of equipment and lack of sufficiently trained nursing, technical and medical staff, we have come a long way and have performed better than many other developing countries, so much so that several postgraduates and trainees are now coming to us for advanced training from the neighbouring countries. The research work carried out in some of the centres in the country has attracted world wide attention and it is a matter of great pride that the international Society of Nephrology, National Kidney Foundation of USA, Kidney International and the Asian Pacific
Society of Nephrology have given due recognition to several Indian nephrologists by nominating or electing them as council members and by conferring awards. With the addition of newer facilities and establishment of several centres, we are coming closer to several front line nations of the world. I have no doubt that if the current trend of progress continues and as we enter the 21st century, India may offer world class facilities not only to our own patients but may become a referral centre for many countries. I would appeal to every citizen of the country especially the medical profession, the scientists, intellectuals and our political leaders that early steps are taken to bring in a bill for cadaver transplantation so that we can raise our heads high like all advanced nations and serve the ailing humanity better.
At the end, I would like to congratulate Dr VN Acharya who is today amongst the leading nephrologists of the world and her team of dedicated workers who conceived the idea of having a 'Nephrology Janus 1994' and allowing me to present the nephrology scene over the past three decades before this august gathering.