Kidney Transplantation revisited- with Dr Rajesh Ahlawat, Chairman, Fortis Escorts Kidney and Urology Institute

In  a span of less than a decade, India has seen a substantial rise in incidence of chronic kidney diseases. A recent report in Lancet Global health noted that deaths due to renal failure doubled during the previous decade, with around 1,36,000 Indians dying in the year 2015 alone. The researchers concluded that "Reduction in renal failure mortality require, most urgently, improved blood sugar control of patients with diabetes paired with earlier diagnosis and prevention of diabetes with other key risk factors. Those patients with end stage renal failure require substantially improved access to renal replacement therapy especially transplantation"

Medical Dialogues team recently interviewed Dr Rajesh Kumar Ahlawat, Chairman – Urology & Renal Transplantation, Fortis Escorts Kidney & Urology Institute, Okhla Road, Delhi, on the latest updates on kidney transplantation as well as the rising use of robotic kidney transplantation. Read the excerpts

Q) In the past few decades, what new revolutions have taken place in the field of kidney transplantation ?

I would say that the most dramatic evolutions that have changed kidney transplantation have occurred in field of immunosuppression and understanding their proper usage. Newer immunosuppression drugs and their proper usage has improved transplant outcomes significantly over last two decades, to more than 90-95% success in first year. Other important evolutionary steps have been in the area of blood group incompatibility, and our capability now to transplant across the blood group ABO barrier. We had not been able to reduce the surgical morbidity of kidney transplant since the open transplant procedure remained largely unchanged since last 50 years. Recent advent of minimally invasive kidney transplant using robotic interface has provided the opportunity to do that too.

Q) In which group of patients is a kidney transplant recommended?

Kidney function is measured in ability to clear the quantity of blood every minute by the body, and is depicted as GFR. Normal GFR value in a healthy adult is about 100 ml/min. Kidney replacement therapy, dialysis or Kidney transplant, is recommended when GFR falls below 10 ml/min as such kidneys are unable to support body functions. The diabetics and children are advised to undergo renal replacement therapy much earlier.

Q) What are the various laws that need to be fulfilled in order to get a kidney transplant? (In Brief).

As per medical “law” requirement a donor has to have two kidneys, each capable of taking care of normal kidney functions, should not have a disease like diabetes predisposing to kidney damage in future, should not have a disease which may be transmitted to the recipient with the transfer of kidney, and should have a minimal surgical risks. As per the requirement of the law a donor has to be a first degree relative of recipient, parent, sibling, partner or offspring.

Q) How does robotic kidney transplant work. Can you please elaborate on this?

A robot allows a very magnified 3-D vision and instruments with movements like wrists. It enables, and in fact improves the quality of vascular anastomosis. The donated kidney can be placed inside abdomen through a small incision with no exposure to outside, which  mitigates wound complications and provides all advantages of laparoscopic or minimally invasive surgery, including no or minimal pain and blood loss as well as very quick recovery. Problems associated with collections around kidney after transplantation, like lymphoceles, are also not seen after robotic transplantation.

 Q) In which group of patients, Is robotic transplant recommended

Robotic transplant would provide outcomes equivalent to open surgery with all benefits of minimally invasive surgery including cosmesis and quick recovery in any patient requiring kidney transplantation. Its advantages get multiplied in patients with higher BMI, avoiding collections and surgical wound complications.

 Q) What is the price difference between the two modalities?

Robotic approach adds about  Rs 1.5 lac to the open kidney transplant budget.

 Q) How popular is the new modality in India?

We evolved the current robotic technique with regional hypothermia, called the icy technique,  in January 2013. It took us two years to collect data and prove to the world its benefits. It is heartening to see that at least 6 other centres in India have seen the advantages and have thus started the robotic transplant program in within last one year.

Q) How can a  conventional urologist, equip himself with this new modality?

We have performed learning curve analysis of the new technique, and insist that a urologist wanting to equip himself with robotic kidney transplant technique should have ample robotic surgery as well as open transplant experience. With the background of both experiences, one should be able to gain proficiency in robotic kidney transplantation within 10 to 25 cases.