Nephrology Services in Maharashtra

Introduction

Maharashtra is the third largest state of India, occupying 307,713 sq. km (9.36%). Maharashtra is home to >10% of India’s population (12.67 crores in July 2024), making it the second most populous state of the country. With a projected gross state domestic product (GSDP) of 42.67 trillion rupees (2024-2025), Maharashtra contributes the most (13.3%) to national GDP. Maharashtra has 36 districts and six administrative zones. It is the country’s most industrialized and third most urbanized state, with a literacy rate of 82.34% (2011 census) and a high Human Development Index (National Statistical Commission of India).

Burden of kidney diseases in the state

Chronic kidney disease (CKD) is substantially prevalent in South Asia (14%).¹ Maharashtra is estimated to have a high burden of kidney diseases. As per the Indian CKD registry, including 10 centers from different regions of Maharashtra, diabetic nephropathy was the most common cause of CKD (29.3%) in the west zone, followed by CKD of undetermined etiology (15.7%), hypertensive nephrosclerosis (14.4%), and glomerulonephritis (GN) (14.2%).² Focal segmental glomerulosclerosis and membranous nephropathy are the most frequently encountered glomerulonephritides.³

Maharashtra, especially in the north and east, is known to harbor hotspots of CKD of unknown origin (CKDu), experiencing heat waves from central India. Nineteen of 357 patients from the Yavatmal district were diagnosed with criteria-defined CKDu.⁴ The mean age of patients was ∼55 years, with a preponderance in men and those engaged in farm labor or outdoor work. Studies from the Buldhana district found elevated cadmium, copper, and lead concentrations in clay soil and drinking water.^5,6 In one study, 18 of 23 recorded deaths were attributable to CKDu.⁵ Sporadic news of villages with a high CKDu incidence may hint toward a tip-of-the-iceberg phenomenon.⁷ Global warming, regional climate changes, and water scarcity have been implicated in nephrolithiasis.^8,9 Maharashtra is a part of the ‘Indian Stone Belt’.^10,11 The state also reports a high burden of acute kidney injury (AKI) in association with tropical fever (malaria, dengue, leptospirosis).¹² Rural areas exhibit high snake bite rates and associated AKI.^13,14 Pregnancy-associated AKI is a frequent occurrence, though specific estimates from the state are lacking.¹⁵ Inherited kidney disorders are prevalent due to endogamous marriage patterns. These constitute specific challenges for the state, warranting more clinical work and research.

Peritoneal dialysis

Maharashtra offers CAPD services in ∼78 centers [Figure 1], accounting for 6-7% of prevalent CAPD patients in the country. There has been a 63.6% growth in the number of patients initiated on CAPD in the past decade (337 patients in 2023 vs 206 patients in 2013: industry data). Chiefly through out-of-pocket expenditure (OPEs), the running cost for CAPD and automated PD is approximately Rs. 30,000 and Rs. 65,000 per month, respectively. Beneficiaries of the Central Government Health Scheme (CGHS), Employee’s State Insurance Scheme (ESIS), and Defense Personnel can access CAPD free of cost. CAPD fluid expenses are covered in public hospitals of Mumbai through the Brihanmumbai Municipal Corporation. More recently, the new revised MJPJAY has covered CAPD under a package of Rs. 35,000 per month. This is expected to positively affect CAPD use. Cost barriers, sparse catheter insertion services, and trained persons (CAPD nurse/technician) unavailability, especially in interior regions, are the chief challenges in successfully maintaining this modality in the state.

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Figure 1:

Centers of kidney transplantation (approved by NOTTO) and centers offering CAPD services in Maharashtra. CAPD: Chronic ambulatory peritoneal dialysis, NOTTO: National organ and tissue transplant organization.

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Interventional Nephrology

Interventional Nephrology is slowly emerging as an integral part of care for patients suffering from kidney diseases. All nephrologists across Maharashtra perform HD catheter placements (non-tunneled/tunneled) and ultrasound-guided kidney biopsies. PD catheter placement (open surgical or laparoscopic) is predominantly done by surgeons (∼75% of centers), while nephrologists themselves perform percutaneous placement (∼25% of centers). AVF surgeries, including complex procedures like superficialization, transposition, and prosthetic AVF (AV graft), are performed by >10 nephrologists, most from the Marathwada region. Endovascular AVF interventions (surgical or percutaneous salvage) are largely performed by radiologists or cardiologists [Figure 2].

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Figure 2:

Specialized services related to Nephrology in Maharashtra. EM: Electron microscopy, HLA: Human leucocyte antigen, AV: Arterio-venous.

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Nephrology Education

The state has 21 training institutes for nephrology, pediatric nephrology, and nephropathology [Figure 3, Supplementary material]. Accredited training courses and continued medical education programs are regularly conducted for renal dieticians and dialysis technicians (including one for pediatric dialysis). Regional societies (Mumbai Nephrology Group, Pune branch of Indian Society of Nephrology (ISN), and the Nephrology Society, Central India) conduct monthly educational meetings. ‘ApEx Pathshala-the Nephrology Board Review Course’ and ‘Dialysis beyond text-books’ are popular annual educational meetings.

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Figure 3:

Training centers for Nephrology and Nephropathology in Maharashtra, number (capacity). DM: Doctorate of medicine, DNB: Diplomate of national board, MUHS: Maharashtra university of health sciences.

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Policy initiatives

MJPJAY, operational since July 2012, is the flagship health insurance scheme of the State Government. Since April 2020, MJPJAY has been integrated (60:40) with the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana [Table 2]. The most recent revision (July 2024) is a significant step towards rolling out universal healthcare, making Maharashtra one of the few states moving rapidly toward achieving this objective. MJPJAY 2.0 expands the number of covered medical procedures from 996 to 1356 and impaneled hospitals from 1000 to 1900. The inclusion of more nephrology-specific codes (for, e.g. CAPD, AVF) and increased cost-coverage (for, e.g. total package for KT) are promising developments [Table 3]. Maharashtra State Road Traffic Corporation offers free travel to patients traveling for dialysis and KT consultations.

Community involvement

Many dedicated NGOs and patient groups work toward the welfare of patients with kidney disease and conduct exemplary advocacy and support activities [Supplementary material]. Apart from providing a social platform, raising awareness, and extending financial aid, they partake in the training of paramedical staff (dialysis technicians, nurses, and dieticians). Notably, a CAPD outreach program was conducted in 33 districts by an NGO focusing on children with kidney diseases. Funding from charitable institutions and other public-private partnership initiatives has made HD affordable to the under-resourced.

History and timelines

Maharashtra has many firsts to its credit, thanks to the vision and lifework of the ‘Iron Lady’ Dr. Vidya N. Acharya, Mother of Indian Nephrology. KEM Hospital, Mumbai. She acquired the first dialysis machine- an Alwall’s dialyzer donated to the Department of Medicine by the Swedish philanthropist Mr. Alex Johnson in 1962 [Figure 4].²¹ The unit performed its first HD session on May 31^st, 1963, and until 1971, was one of the only four institutes in the country operating an HD unit.²² As KT was making great strides globally, the KEMH team, under urologist Dr. Karanjawala and cardiothoracic surgeon Dr. P.K. Sen, whose team was experimenting on liver, heart, and kidney transplants in dogs through the 1950s, performed the first two deceased-donor KTs ever in India in 1965.²³ The first live-donor KT took place in March 1974. Other hospitals soon followed suit. Jaslok Hospital, Mumbai was the first multispecialty hospital in India and pioneered various organ transplant activities. In 1977, Dr. Samuel Kountz and Dr. TK Sreepada Rao from Downstate Medical Centre, Brooklyn, flew two cadaver kidneys from New York to be transplanted into two patients with ESRD at Jaslok Hospital.²⁴ Dr. VN Acharya was instrumental in drafting and getting the Transplantation of Human Organs and Tissues Act (THOA) passed in Parliament, a landmark that changed the face of organ transplantation in India. ZTCC, Mumbai, established in 2000, was the first center for coordinating organ transplant activities. The standard operating procedures laid down by ZTCC were subsequently adopted by many states.

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Figure 4:

Senior dialysis technician Mr. Claude Lobo, Dr. Carl Kjellstrand, Dr. P. Raghavan, Dr. Vidya Acharya photographed in the Nephrology Department Museum in 1987, standing alongside the Nils Alwall’s Rotating Drum Kidney, donated to KEM Hospital, Mumbai in 1962.

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KEM Hospital, Mumbai, was one of the first in the country to set up acute PD in 1960s, employing in-house catheters and pharmacy-compounded dialysate. CAPD came into practice once PD connectology became commercially available throughout the country in the 1990s. The earliest use of CRRT in the state dates back to the late 1990s, with innovative use of circuitry at Bombay Hospital, Mumbai, and KEM Hospital, Pune. KEM Hospital, Pune, set up one of the first endotoxin laboratories in the country in 2004 to ensure water quality in HD.

Dr. VN Acharya was a pioneer, researcher, teacher, and global leader. She was a founding member of various national nephrology societies-Indian Society of Nephrology (founded in Mumbai in 1970), Indian Society of Organ Transplantation, and Hypertension Society of India. She was elemental in starting the first accredited postgraduate courses of DNB Nephrology (1977) and DM Nephrology (1986) at KEM Hospital, Mumbai. Dr. MV Divekar and Dr. VV Shanbag headed the nephrology departments at Lokmanya Tilak Municipal General Hospital, Sion, and BYL Nair Charitable Hospital, respectively. In 1976, Dr. Kumud P. Mehta started one of the country’s first pediatric nephrology subspecialty programs at BJ Wadia Children’s Hospital, Mumbai. Dr. Balswarup S. Choubey (Vidarbha), Dr. Farrokh F. Wadia (Pune) were contemporary stalwarts who propelled nephrology in other regions of Maharashtra, followed by Dr. Prashant P. Pargaonkar (Marathwada), Dr. Devdutta Chafekar (Nashik) and others.

Challenges and future directions

Government health expenditure is comparatively lower than GSDP.²⁵ The state allocates 4.6% of total expenditure towards health and family welfare, lower than other states.²⁶ The state has the least number of government hospitals per lakh population compared to the national average (0.4 vs 2.6). The state has curtailed its expenditure on state-sponsored health schemes in 2024-2025, which is concerning.²⁷ Increasing privatization of healthcare coupled with lack of family insurance accounts for higher OPEs.²⁶ Catastrophic health expenditure is remarkably high, though kidney-specific estimates are lacking.²⁶ Outside public health schemes, the majority deem KRT non-affordable.

Modern-day achievements

With good professional networks, state-of-the-art infrastructure, affordable HD, and easy access to KT, Maharashtra remains a hub for medical tourism in nephrology. Unique cost-saving models for HD are a boon for under-privileged patients. ‘Project Victory’ (an innovative citywide dashboard) is a laudable example of concerted work between public and private hospitals that enormously simplified the challenging task of dialyzing ∼10000 patients impacted by the pandemic in Greater Mumbai.¹⁷ Third, for the number of KTs in the country, transplantation in the state benefits from expanded state coverage, the availability of specialized diagnostics, community funding, and participation. Maharashtra hosts many top-tier coveted medical colleges, affording excellent educational opportunities across higher specialties. Focus on scientific research is increasing with higher participation in clinical trials, ongoing cohort studies (dialysis, nephrotic syndrome, aHUS, renal tubular disease), and registries (VN Acharya Glomerulonephritis Registry, IPNA ISN KRT registry). The state is also expanding the spectrum of services to newer areas like kidney-centered palliative-care, telemedicine, and integrated nephrology practice (onco-nephrology, critical-care nephrology).

Concluding remarks

Despite challenges, Maharashtra is making consistent strides towards advancing nephrology. There is a pressing need to tap the potential of current growth, existing socio-economic resources, and progressive stature of the state for the larger benefit of patients with kidney disease.