Nephrology in Tamil Nadu

Introduction

Tamil Nadu has established itself in the history of Indian nephrology with several ‘firsts’ to its credit. The first qualified nephrologist in India, Prof. M.S. Amaresan, established a nephrology department at Madras Medical College (MMC). The first hemodialysis (HD) and kidney transplants in India were done at Christian Medical College (CMC), Vellore. The strong public and private health infrastructure makes nephrology services widely available in all 38 districts of the state. Currently, there are about 400 qualified nephrologists in the state.

Overall Scenario of Health Sector

Tamil Nadu is the sixth most populous state of India, with an estimated population of 8.4 crores. The robust government health system has ensured steady progress, with 60% and 40% government health facility utilization in rural and urban areas, respectively, against the national average of 37%. Tamil Nadu is among the top three Indian states regarding health indices. All districts have government medical colleges. The private sector has grown significantly and made tremendous contributions towards health care.

The Global Burden of Disease report has highlighted the epidemiologic transition in India with an exponential increase in non-communicable diseases (NCDs). In Tamil Nadu, NCDs contribute to 69% of premature deaths and 68% of disability-adjusted life years.^1,2 Chronic kidney disease (CKD) is the fifth most common cause of mortality in the state.

Chronic Kidney Disease Prevalence

In 2022, the Institute of Nephrology & Community Medicine, MMC, conceptualized a pioneering state-wide CKD prevalence study executed by the Directorate of Public Health. This randomized cluster sample study encompassing the entire state revealed the hypertension (HTN) (33.9%), diabetes (17.6%), and CKD (8.4%) prevalence in adults (unpublished data). About 50% of patients with CKD did not have diabetes or HTN.

CKD of unknown etiology (CKDu) is a menace in Tamil Nadu. Several CKDu hotspots have been identified. CKDu clustering in northern districts has been coined -- ‘Thondaimandalam Nephropathy”³

Nephrology Services in Tamil Nadu

The Tamil Nadu government has been playing a pivotal role in establishing and promoting nephrology services. There are 54 qualified nephrologists in 20 public sector hospitals, most in the country. Under the Prime Minister’s National Dialysis Program, Tamil Nadu has established 139 HD centers, with 1,219 dialysis machines. These centers are managed by trained physicians and dialysis technicians with assistance and guidance from nephrologists. Although dialysis has been made universally accessible, ensuring quality remains a challenge.

The Chief Minister’s Comprehensive Health Insurance (CMCHIS), 2012 by the Tamil Nadu government aimed to provide equitable tertiary care access to individuals below the poverty line. The Pradhan Mantri Jan Arogya Yojana and CMCHIS merger allowed ∼1.4 crore families (annual income < Rs 1,20,000) to enroll for health insurance. Health insurance covers a wide range of services, including acute kidney injury (AKI), rapidly progressive glomerulonephritis, continous renal replacement therapy, kidney biopsy, HD, continuous ambulatory peritoneal dialysis (CAPD), and kidney transplantation. Since the CMCHIS launch, maintenance HD remains the most utilized package, covering 13.16 lakh sessions and a Rs 1,077 crore claim. So far, about 4,500 renal transplant surgeries have been done under the scheme. Post-transplant immunosuppressives, procured centrally by Tamil Nadu Medical Services Corporation (TNMSC), are provided free of charge for life to those who undergo transplantation in government or private hospitals. The Tamil Nadu government launched its flagship program, ‘Makkalai Thedi Maruthuvam’ (MTM), which translates to ‘Medicare searching the masses’, in 2022. Under this program, trained health staff periodically visit the residences of patients with HTN and diabetes. They check blood pressure and capillary blood glucose, and deliver anti-hypertensives, anti-diabetics, and CAPD dialysate bags. Patients on CAPD undergo medical check-ups. MTM has improved CAPD use in the state, with about 300 patients availing CAPD services, currently. A new kidney disease screening program, Urine Dipstick for Proteinuria was launched. All adults with HTN, diabetes, and at high kidney disease risk undergo screening. Among the 57.5 lakh people screened so far, 13,000 tested positive (0.2%). Further evaluation showed 947 people with CKD (7.2%).⁴

Voluntary Organisations

Tamil Nadu Kidney Research Foundation (TANKER), founded in 1993 by Dr. Georgi Abraham, initiated maintenance HD services at very subsidized charges. The organization has progressed over three decades, with 14 centers and 250 dialysis machines. Inspired by TANKER, organizations like Lion’s and Rotary Club opened several other dialysis centers. These centers played a big role in the maintenance dialysis program, particularly before the inclusion of dialysis under insurance schemes. Multi-Organ Harvesting Aid Network (MOHAN) Foundation, by Dr. Sunil Shroff, has supported the deceased donor transplant program by providing trained grief counselors to hospitals. Sapiens Health Foundation, started by Dr. Rajan Ravichandran, in 1997, spreads awareness of kidney disease, with a special focus on cutting down salt consumption.

Nephropathology

Prof. Anand Date, CMC Vellore, and Dr. Rama Mani, Apollo Hospitals, Chennai, have been the pioneers of nephropathology services in Tamil Nadu. Dr. Anila Kurien (Renopath, Centre for Renal and Urological Pathology, Chennai), a contemporary nephropathologist, caters to most of the centers of the state. She elucidated Nell 1 antigen association with indigenous medicine-associated membranous nephropathy.

Interventional Nephrology

Tamil Nadu contributed to the growth of interventional nephrology in South India. Dr. J. Balasubramanian (Tirunelveli) and Dr. K. Sampath Kumar (Madurai) have been pioneers in the field of interventional nephrology.

Women in Nephrology

Women contribute to 20% of the nephrology workforce in the state. There are 80 active members in the Tamil Nadu Women in Nephrology unit. Prof. Muthu Jayaraman is one of the first few women nephrologists of India.

The MMC has conducted a state-wide competitive examination (Prof. M. A. Muthusethupathi Gold Medal Examination) for post-graduate general medicine and pediatric trainees since 2000. This examination has become popular. In 2024, a record-high number of 350 students from 27 centers participated in it.

Dr. M. Jayakumar’s Gold medal, instituted by the MMC Nephrology Alumni Association, is awarded to the topper of the DM Nephrology examination conducted by Dr. M. G. R. Medical University.

Academic Meetings

Annual academic conferences are held by Nephrology Association of Tamil Nadu & Puducherry (NATPU), MMC Nephrology Alumni Association (NEPHSIL), CMC (Renal Clinical Conference), Madurai Kidney Centre & Transplantation Research Institute (Dr. T. Dhinakaran) and WIN Tamil Nadu. Monthly academic sessions are held by nephrology associations of Chennai, Tiruchirapalli & Thanjavur (TANTRA), Madurai, Tirunelveli, Thoothukudi & Kanyakumari Nephrology Group (TTKNG) and Coimbatore.

Nephrology Education through WhatsApp platform

Dr. P. Ravichandran started this in 2015, through a WhatsApp group, ‘Nephrology Update’, which has received widespread appreciation and has more than 2,000 members. INForm (Dr. J. Balasubramanian, 2021, 711 members) and Peculiar Renal Transplant Cases (Dr. Vel Arvind & Dr. T. Rajarajan, 2022, 1,023 members) are the other popular groups with large memberships from the world. These groups serve as ready reckoners for updated information, provide a platform for discussion among experts, and share volumes of scientific material.

Research Scenario in Nephrology

• A CKD prevalence study in the adult population of Tamil Nadu has been conducted (funded by the National Health Mission, Tamil Nadu). This is a novel state-wide study applying the randomized cluster sampling method and has provided valuable information. (under publication process).

• A similar study has been conducted assessing CKD prevalence among agricultural laborers in Tamil Nadu (divided into five agro-climatic zones), funded by the Tamil Nadu Health System Project.

  Both these studies have been jointly conducted by the Institutes of Nephrology & Community Medicine, MMC, and the Directorate of Public Health.

• The Institute of Nephrology, MMC, funded by the Indian Council for Medical Research (ICMR), is conducting an ongoing multi-centric follow-up study of survivors of dialysis requiring acute kidney injury (DRAKI).

• Prof. Suceena Alexander, CMC, Vellore started India Alliance GRACE -IgA N Platform Trial – a multi-centric, multi-arm, multi-stage, real-world pragmatic platform trial in IgA Nephropathy.

• The Department of Nephrology, MMC (Prof. Manoranjan and team) and Tiruchirapalli Nephrology group (Dr. SP SS Subramaniam) initiated CKDu field-level research studies.