Nephrology Services in West Bengal

Overview of Service provision

Non-dialysis CKD care: Seven out of 26 medical colleges now have established departments of Nephrology. However, considering about 40% of patients admitted require nephrology referral, there is a need for more departments in peripheral medical colleges, especially to start preventive programs led by nephrologists.^1,4 With the expansion of the teaching program under the National Board, trainees also increased in the private sector. The skilled manpower support improved nephrology care. Private sectors invested in transplantation dialysis and critical care nephrology, and clinical and preventive nephrology practices spreading to the rural and small-town ships as nephrologists increased in number and reached out to the periphery [Table 1].

Dialysis (HD and PD): West Bengal has developed a well-penetrated hospitals and center network offering HD and PD services, catering to a diverse patient population across the state. Nearly all the districts now have dialysis centers supporting the PMNDP project (total of 73 PPP dialysis units currently 71 functioning, 2 soon will start, 45 are in district hospitals [Figure 1], and 10 new units are being commissioned to provide dialysis support in geographically challenging areas). The state-run insurance coverage, Swasthya sathi also supports maintenance and acute dialysis costs, admission-based care for patients AKI and end stage kidney disease (ESKD), and related issues like dialysis.^1,5 The number of beds and IPD care are still below requirement and many patients get admitted to private hospitals, increasing the out-of-pocket expenditure (OPE). Nephrology trainees are trained in CAPD catheter insertion by nephrologists, and currently, there are 37 active patients (SSKM 14, MCK 12, NRS 5, NBMC 6) in the government sector undergoing CAPD through NHM support.^1,5

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Figure 1:

Functional dialysis units under Pradhan Mantri National Dialysis Program (PMNDP) support.

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Intervention Nephrology: Seven private facilities and one government sector, are doing advanced intervention nephrology procedures, i.e., fistuloplasty, central venoplasty, and tunneled catheter insertion. Most of the multidisciplinary private hospitals and all medical colleges with appropriate facilities provide tunneled catheter insertion and renal biopsy. There has been a surge of PD catheter insertion by nephrologists after government support extended to cover PD costs in 5 medical colleges (3 in Kolkata and 2 in periphery).¹

Kidney Transplantation: The state is home to several government and private transplant centers. Deceased donation started late in West Bengal, with the first case in 2012 at IPGMER Kolkata, and since 2016, the institute has been performing as Regional Organ and Tissue Transplantation Centre for Eastern India, covering Bihar, Odisha, Jharkhand, West Bengal, and Sikkim. Multi-organ transplant facilities are available in one government sector, IPGMER, and many private sectors, with facilities for kidney, liver, heart, lung, and hand transplantation.^5,6 IPGMER Kolkata is transplanting free of cost and, as the regional organ and tissue transplant organization (ROTTO), facilitates organ sharing with other states. One government sector has active participation in the deceased donor program involving liver, heart, and lung transplants and addressing needs of the lower socioeconomic strata. On average, the state performs >1000 renal transplants a year, >97% being living donor transplants and 2.5% being deceased-donor⁵ [Table 2]. Private hospitals do >90% of the living donor transplants in the state. Living donor pool expansion in terms of ABO incompatible transplants is happening in private and government sectors. There is an impending need to develop a Kidney share based transplant program and promotion of deceased donation, to meet the demand-supply gap.

Conservative Care and AKI Treatment: Conservative management strategies are implemented for those ineligible for dialysis, focusing on symptom control, dietary modifications, and close monitoring. However, no structured program with community penetration is available and it remains an individualized patient care approach. However, early AKI identification and appropriate management have improved over the years. Additionally, during the COVID-19 pandemic, protocols for AKI management had been developed and shared with all healthcare sectors, and AKI awareness relatively improved across healthcare facilities. No structured program is available for conservative kidney care and palliative therapy.

Availability of Essential Diagnostics and Treatment: Advanced diagnostic tools such as renal imaging (CT, CT ANGIO, MRI, DMSA, and DTPA scans), laboratory tests, and biopsy facilities are readily available in most teaching hospitals and large private health care facilities. A complement laboratory, which is inevitable for complete glomerular disease workup, is not available, and the government sector only has a CDC Crossmatch facility. Flow cytometry and Luminex based investigations for sensitized transplants are outsource to private laboratories. Some advanced imaging facilities are free of cost in government hospitals and through state health insurance in some diagnostic centers.

Treatment funding scenarios and out-of-pocket expenditure

Various funding mechanisms like government health schemes, private insurance, and corporate initiatives support treatment costs for many patients. Allied surgical interventions are still inadequate and 90% of dialysis patients are initiated on central venous access. Despite adequate counselling for fistula, arterio-venous fistula creation is low before dialysis initiation.^6,7 Fistula intervention procedures for access failure are still limited to major cities, and patients often need to do OPE. These OPEs remain a concern for lower socioeconomic groups, necessitating continuous efforts to improve financial support mechanisms and reduce economic barriers to care. Early dropout from dialysis is mainly due to OPE, which ultimately interferes with survival on dialysis.

Successes and challenges

Successes: The major success achieved since 2016 is the availability of state and central-supported dialysis facilities.^1,7 More than one government-supported HD facility is available in all districts (mostly district hospitals), offering facilities for free-of-cost diagnostic investigations, medicine supply, and inpatient care when required. The transplant facility is now available in two government hospitals in Kolkata. Several awareness programs are regularly held in schools and colleges through coordination with NGOs to improve kidney health, promote organ pledges, and tackle myths against organ donation. The intensivists and neurosurgeons are included in many CME updates addressing the organ donation need and active participation in BSD declaration and donor maintenance programs.

Challenges: Challenges are mostly faced in rural areas where a shortage of nephrologists and trained healthcare professionals requires referral to overburdened tertiary centers. Over the years the nephrology trainee seats and technician trainee seats have increased, but rural areas are still underserved in terms of advanced nephrology care. Financial constraints, limited availability of certain advanced treatments, and lack of infrastructural support remain the most difficult hurdles to overcome.