Kidney transplant: hope for better quality of life
Dr Baldev Singh Aulakh
Organ transplantation has travelled a long way to achieve the present status with very good results owing to the availability of high-tech surgical management and immunosuppressive drugs. The selection of the patient for kidney transplant is a very difficult job but it should be offered to every patient with ESRD if he or she is able to live for more than six months of independent or supervised life of reasonable quality.

HEALTH BULLETIN
Poor strategy, poorer results
Dr J. D. Wig
Everyday, doctors are called on to promptly diagnose and effectively manage a wide variety of key clinical conditions. Sir William Osler wrote:" To prevent disease, to relieve suffering, and to heal the sick — this is our work".

Kidney transplant: hope for better quality of life
Dr Baldev Singh Aulakh

Organ transplantation has travelled a long way to achieve the present status with very good results owing to the availability of high-tech surgical management and immunosuppressive drugs. The selection of the patient for kidney transplant is a very difficult job but it should be offered to every patient with ESRD if he or she is able to live for more than six months of independent or supervised life of reasonable quality.

Transplantation should be avoided if the patient is having refractory, cardiac or respiratory failure or any of the diseases mentioned below:

Widespread cancer
Progressive liver disease
Bleeding disorder
Severe urinary tract abnormality
AIDS
Severe mental retardation
Psychological problems (sychosis, alcoholism drug addiction)

The age range within which renal transplantation is being performed continues to broaden and the lower end now extends down to the first year of life. In young adults, survival is much better with a transplant than with dialysis. A reasonable policy seems to be free access up to the age of 60 years, greater selection from 60 to 70 years and a limited role of transplantation beyond 70 years. Well-controlled diabetics and heart-patients are also getting transplants without much risk but they should be carefully evaluated for the functioning of their hearts and lungs, the status of vessels, the gastrointestinal system and the urinary system.

With the availability of effective immuno-suppressive drugs, kidney transplant has achieved a big success so as to offer one-year survival of transplant patients in more than 90% of the cases. So far in India, most of the donors have been live ones. Anybody between the age of 18 and 65 years with no medical illness having two normal kidneys can donate one kidney without any harm to his or her body, as one kidney is sufficient for life-long work.

Even children and old persons can donate kidneys provided they are medically fit. Each donor is thoroughly evaluated through blood, urine and radiological investigations.

A live donor can be related to the patient — mother, father, brother, sister, son or daughter. If there is an unrelated donor, he or she should be emotionally attached to the patient — wife, husband or friend. The other important source of kidney is a brain-dead patient (cadaver donor).

In developed countries like the USA and the UK, 80 to 90% transplants are from cadaver donors, whereas in developing countries like India the majority of cases are from live donors. India has the dubious distinction of having probably the largest number of unrelated donors. The main reason behind this is the shortage of donors and the absence of the law, which would enable the doctors to take out the kidneys from brain-dead patients and utilise these for the needy patients. Also for this programme to be successful, social organisations, educational institution and the media have to take the responsibility of creating awareness so that the public accepts cadaveric donation and society gets benefited. After all, man is a social being and his well-being demands a social duty.

Kidney failure is treatable now! See Health & Fitness, April 25

The final step of the technique

After the removal of the donor kidney, it is placed in the left or the right side of the lower part of the abdomen.

Normally, the original kidneys of the patient remain as such and these are removed only when they are a source of frequent urinary infection, very large size due to some disease leading to difficulty in placing the transplant kidney or the patient having very high blood pressure.

Many kidney transplant patients report an immediate feeling of "rebirth" following a successful renal transplant; such a feeling is linked with a perceived "promise" of extended and enhanced quality of life. The quality of life after a successful kidney transplant is much better than life with haemodialysis in terms of psychological and physical well-being. When compared to dialysis, kidney transplantation has greater rehabilitation potential for the patient with end-stage kidney disease; indeed, a successful transplantation is often viewed by the patient as the gateway to "personal liberation" and to the restoration of "control over one's life and one's self".

Kidney transplant is being performed successfully in India. Because of immunological disparity between the donor and the recipient, the recipient has to take drugs throughout his life, which will prevent the graft kidney from being rejected. Such drugs are prednisolone, azathioprin and cyclosporin. These drugs do prevent rejection but at the same time decrease the immunity (resistance) of the patient to fight infection. Infections happen to be the most common cause of fever and it should not be taken lightly, especially in these patients. Infections can be bacterial, viral, fungal or parasitic — bacterial being the most common. After six months of transplant, generally common community-acquired infections do occur. So, a hygienic and healthy diet and a healthy environment are recommended for these patients at least for three months after which they can work as other do. But taking care while going to congested and dirty places is necessary. Also, the regular use of the above-mentioned drugs without missing any dose is strongly recommended.

Another problem faced by these patients is rejection because the body treats the new kidney as foreign tissue. Rejection can occur in a few days or in a few weeks — or even after a few months. The anti-rejection drug, methylprednisolone, is used. Another very effective drug is OKT-3, which can be used in resistant rejection but it is very costly and one course costs about Rs 70 -80 thousand. Urological complications are rare because of the surgical technique and meticulous care.

You'll be happy to know that you'll be able to resume normal sexual activity after transplantation. Over time, your sexual desire will return to what you consider normal.

Today, more and more transplant patients are successfully having or fathering children. Both defects are no more common in children of transplant recipients than they are in the general population.

Before planning a trip, it is important to check with your Transplant Team and follow these guidelines:

• Don't use ice made from unpurified water; to be truly safe, drink and brush your teeth with only purified water.
  
  

• Try to avoid uncooked or undercooked foods, especially meat and seafood.
  
  

• Ask your transplant physician if you should get vaccinated for any disease that is found in the areas you are visiting, or if you should get a specific medication.
  
  

• If you feel yourself getting ill, get to the nearest facility that is qualified to care for transplant recipients.
  
  

• Avoid extended exposure to the sun.

Take along a supply of your medication — especially your immunosuppressants — that will last throughout your trip; some drugs are hard to come by in certain parts of the world.

One year survival of kidney transplant recipients all over the world is about 95-98%.

Do:

Keep a record of trade and generic names of all medications you are taking, as well as the dose (milligram) and dosage (number of tablets or capsules per day) of each.

Take all your medication as advised.

Notify your doctors immediately if you've a missed a dose of your medicines.

Keep the medication in a dry place away from heat or light.

Keep the medicines in the original container and out of the reach of children.

Report any side-effects to your doctor immediately.

Do not stop taking medication because of side-effects or because you feel fine.

Do not change your dose-schedule on your own.

Do not take a double dose of the medication if you have missed the previous dose.

Take only the prescribed dose and tell the transplant team immediately if you have missed the dose.

Do not take any medication not prescribed by your doctor, including nonprescribed cough, cold or allergy medications without checking with your doctor.

Do not keep the medicines in the refrigerator or in the toilet cabinet where it can be exposed to moisture.

Do not mix the different tablets or capsules in the same pill container.

Although it is impossible to avoid all potential sources of infection, here are some guidelines that may help minimise the risk:

Try to avoid people who are obviously sick.

Wash your hands as often as possible.

Try to avoid uncooked meat or seafood.

Avoid changing cat litter boxes or bird cages; they can be a major source of infection.

Carefully clean all the cuts and scrapes — no matter how small — with soap and water; then apply an antibiotic ointment and clean; dry dressings are to be done.

Practise good oral hygiene and schedule regular dental checkups and changing; your mouth can be a source of infection.

Complications can still occur.

The risks of complications, including the rejection episodes, are greatest during the first six months after your transplant.

If you do get a complication of a rejection episode, remember that this doesn't mean you are going to lose your transplant. Your doctor and, if necessary, your Transplant Team can call for a wide variety of drugs and other treatments to prevent or control most potential problems.

A summary of the most common warning signs is provided here:

Fever over 100F (38C)

"Flu-like" symptoms: headache, dizziness, fatigue, chills, aches, nausea, vomiting pain or tenderness around your transplant.

Fluid retention or sudden weight gain.

A sudden increase in blood pressure (diastolic pressure over 100) shortness of breath.

A change in the heart rhythm, urine colour or smell, or bowl habits.

Note: you may not discover these signs; you simply may not feel "normal".

Remember: If you even think you are having a rejection, contact your doctors immediately.

A common problem after transplant is excessive weight gain. This can lead to many of the complications frequently seen in transplant recipients, including hypertension, diabetes, and atherosclerosis. To limit weight gain, transplant recipients are usually encouraged to eat a well-balanced diet that is low in salts, cholesterol, fat and sugar.

When it comes to weight control and good health, exercise is as important as eating right. As well as helping to minimise the risks of post transplant complications, exercise will result in:

Increased energy.
Reduced stress
Improved sleep
Better emotional health
Better digestion
Improved posture

Be sure to check with your doctor about how soon, and how much, you should exercise.

In the general population, smoking has been identified as a major risk fetors for heart ailments and certain types of cancer. As a transplant recipient, you may be more vulnerable to these conditions anyway; it is strongly recommended that you do not smoke after your transplant. It is also recommended that you limit your consumption of alcohol or, if possible, avoid it completely.

Research in transplant is being focused on finding suitable immunosuppressant drugs that will prevent rejection, is less toxic, and renders the patient less susceptible to infection. A few new drugs are FK-506, tacrolimus, 15-Deoxyspurgualine, Mycophenolate mofetil, Rapamycin etc.

Secondly, research is focused on finding a suitable animal donor who can be utilised for humanity. Such animals can be monkeys, baboon and pigs. But the pig seems to be closer to human beings. Such factors as much-improved immunosuppression and ways of altering some of the foreignness of animal tissue by genetic manipulation will help achieve this goal.

The correspondence address of Dr Aulakh is:
Dr Baldev Singh Aulakh, Consultant Urologist & Transplant Surgeon, and Head of the Transplant Department, Dayanand Medical College and Hospital, Ludhiana.

HEALTH BULLETIN
Poor strategy, poorer results
Dr J. D. Wig

Everyday, doctors are called on to promptly diagnose and effectively manage a wide variety of key clinical conditions. Sir William Osler wrote:"To prevent disease, to relieve suffering, and to heal the sick — this is our work".

The physician cannot prescribe health. A health system must include emphasis on health promotion, disease prevention, early diagnosis, and universal access to quality care. Health-promotion and disease-prevention embody the core of medical practice and will receive growing emphasis. Preventive medicine and public health are the critical foundations if we are to provide health care to the entire population. Emphasise health as a positive state of well being and not merely as absence of disease.

Life expectancy has increased. Health care providers need to think and act for prevention of diseases and increase the implementation and evaluation of preventive strategies. An optimal strategy for the prevention requires participation by primary care physicians, public health workers and the community. The aim should be to improve the health of the worst off in the society and to narrow the health gap.

Preventive strategies have been designed to improve the quality of life, optimise resource allocation, and prolong survival in a number of situations especially heart and lung disease, cancer and HIV. Preventive strategies in liver disease are now being increasingly employed.

Increasing patient awareness for the avoidance and early recognition of risk factors is a reasonable goal for health-care-providers. Public education is an effective, relatively low-cost and easily delivered intervention. Education about the avoidance of risk factors is essential. Strategies such as vaccination for viral hepatitis, and the development of therapies to prevent or delay complications of liver disease reflect on increasing recognition of the importance of prevention of liver disease. High-risk activities, occupations, or medical exposures increase the likelihood of the hepatitis C virus, the hepatitis B virus, and faecal-oral exposure to the hepatitis A virus.

Vaccines that can prevent the acquisition of viral diseases are currently available. These vaccines are highly effective and immunogenic in healthy populations. Certain populations such as those comprising Dialysis patients, alcoholics, and those with AIDS have lower response rates to the standard dose vaccination. In these situations, immunogenicity of the vaccines may be improved with the use of higher doses.

Chronic liver disease is a major cause of morbidity and mortality. Strategies need to be focused on the prevention of the development of liver disease and the prevention of complications in these individuals.

Teaching self-examination procedures (Breast examination, testicular examination and skin care), require a good understanding of the advantage and limitations of the examination techniques and a practical understanding of effective teaching strategies. We also must advocate population health in areas such as doing screening for various diseases. Your skin is an important part of your total body health. If you take care of your skin, it will take care of you throughout your life. Check your body for moles from head to toe; watch out for skin, changes which could be harmful.

Any genuine attempt to prevent disease and promote health and wellbeing must be targeted at local levels especially in rural areas and in areas where people are poor and illiterate. Severe restrictions need to be applied to the tobacco industry so that they do not manipulate the public in anyway. The distribution of free packets of cigarettes should be banned, and the product should not be glamourised. Despite the government campaign, there is still considerable room for improvement.

Do people take notice of campaigns aimed at making them aware of various hazards? We have seen the conquest of smallpox and polio. The strategy for polio eradication relies on a functioning expanded programme on immunisation, complemented by mass vaccination campaigns. If, with this strategy, polio coverage remains low, this strategy will be optimum for other problems such as hepatitis and measles.

Ignorance of mothers is a major concern. Constructive communication is needed at all levels and this has to be taken seriously. This is particularly needed as eradication in one region may not help if it is not achieved in the neighbouring region. Printed health information continues to play an important role in many health education activities. There is little effort in this area in our country. Health information leaflets need to be distributed on a vast scale and should be easy to understand.

The shortcuts between sewage and drinking water might result in the distribution of contaminated water. Exposure to infected water will not help the eradication programmes. The risk of people acquiring infection from environmental water might be phenomenal. Efforts are needed to avoid poor hygiene and sanitation. Programmes are needed to improve hygiene practice. Hand washing reduces the incidence of many infections in the community. Foods that are not covered, are not fit for human consumption. The sale of all these should be strictly banned. This will avoid the frequent outbreaks of food-borne diseases.

Schools need to be identified as having a key role to play in promoting health in the community. All those involved in schools — teachers, pupils and parents — have an important role in promoting health. School-based drug abuse prevention programmes have reduced the prevalence of drug use. This preventive strategy is both feasible and effective.

Public health information campaigns provide useful information, ideas and tips to promote health protection and prevention. They are interventions designed to protect the people's health. Patient education about the avoidance of risk factors is essential. The establishment of new or improvement of the existing programmes will have a key role in the eradication of diseases. Excellent surveillance will give the right answers to how successful the programmes are.

The new millennium has stimulated a renewed flurry of activity to set new health targets globally. The World Health Organisation has been going through a process of "global health for all" strategy for the 21st century. Health is being seen as an integral part of development and, therefore, the subject of several targets all over the world. We should also aim at a healthier nation. The necessary reforms must be effective, efficacious and affordable.

Dr Wig is one of the best known surgeons of the country.

There is a Chinese proverb which says that somebody asking questions may be a fool for five minutes, but if he does not ask questions, he may be a fool for his whole life.

In the era of "a pill for every ill", all human beings consume drugs, capsules and powders through the oral route. But before starting with any medication we have to have clearcut instructions or clarifications from the prescribing community. These are as follows:

• How long will the drug take to start working?

• How will it help me?

• How should I recognise an allergic reaction to the drug?

• What side-effects should I expect and how severe those would be?

• What may happen if I don't take the drug?

• Should I report the reaction or side-effects to you on the next scheduled visit or can I come in between as and when the need arises?

• What is the best time of the day when I should take the drug in view of the biorhythms?

• Should I take the drug before or after food?

• What type of food must be taken or avoided while I am on medication?

• Can I drive or work on machines after taking them?

• Can I smoke or take alcohol while I am taking the medication?

• Should Iavoid direct sun exposure or other activities while taking the drugs?

• Should I consume other medicines with the drug which the prescriber is prescribing or should I avoid other kinds of medication?

• Can I use the generic version without losing effectiveness?

• Should I be careful while taking the drugs with a narrow therapeutic margin or should I stick to a brand name?

*****

Don't be afraid of asking for advice? Doctors are your friends. So don't be hesitant.

General tips on taking medicines

• Never ever be an olympian in taking tablets/capsules without water.

• Drink enough water to lubricate your oesophagus before taking a pill.

• It is mandatory to shake your liquid medicament thoroughly before taking your dose.

• Use a measuring spoon, and not a regular kitchen spoon, for liquid medicament.

• Report regularly the progress, or the lack of it, to your doctor.

• Keep drugs in the original container to avoid mistakes.

• Keep drugs out of children's reach, direct sunlight, freezer, humid conditions and hot automobiles.

• Do not stop the drug on your own.

• Do not increase shift or decrease the dose of the drug on your own.

• Do not mix tablets or capsules with food without consulting your doctor.

• Avoid alcohol when you are taking drugs.

• Consult your doctor before taking any drug if you are pregnant, planning to get pregnant or breast-feeding your child.

• Do not shift to an other systems of therapy on your own. It may prove to be disadvantageous.

• Unless you are told, do not consume drugs on an empty stomach.

• Avoid a pill for every ill.

• Follow healthy lifestyles, eat proper nutritious food and drink clear water to avoid uncalled-for health problems.

• Follow your drug compliance as told by your doctor and do not leave the medication leave on your whims and fancies.

• You must ensure that the expiry date is far away while purchasing drugs.

Any discolouration of tablets disfiguring of the tablets or capsule or the appearance of moisture should make you avoid the drugs you are going to buy.

"Asthma has emerged as one of the world’s major serious and increasing global health problem predominantly attacking the young. Allergens must be treated" — Dr Shakuntala Lavasa, noted allergy specialist and paeditrician, who will answer The Tribune Readers’ questions next week. (Ph 562239, 563447 and 782766).