Kathmandu’s Bir Hospital celebrates first anniversary of successful kidney transplant.

12 December 2009

Today, the 120 year old Bir hospital in Kathmandu celebrates the anniversary of its first successful kidney transplant.

Bir’s renal transplant department was the brainchild of surgeon Dr. Pukar Shrestha who spent six years training in UK. In his last role he was a senior registrar at the Freeman Hospital in Newcastle before choosing to return to Nepal over promotion to consultant.

“I was thinking, ‘Nepal needs me’,” he recalls. “In the UK there are many like me, but here in Nepal every patient needs doctors like me.”

In the past 12 months 16 patients have been given kidneys donated from family members. “16 is good success over 11 months, however we used to operate on up to 15 patients every week in Newcastle.”

The department’s target is one transplantation per week. But there are major obstacles to achieving this. For instance, the department has no operating theatre. “We have to borrow the theatre from cardiology or neurology and this is a big limitation,” says Shrestha. Additionally there is no facility for tissue cross matching in Nepal and samples need to be sent to India which is both costly and takes 4-6 days. “On the positive side,” adds Dr Shrestha, “we have a really capable and dedicated team here. We’re also lucky to have strong ties with organisations outside Nepal such as Freeman Hospital, Transplant links and Health Exchange Nepal who are helping us with training.”

Previously the only option for those with Chronic Renal Failure (CRF) was to go to India. While there is no official data, it is thought that up to 100 people cross the border every year paying upwards of 8,000 Euro, sometimes purchasing an organ there.

Now Nepali’s have the option of both Bir Hospital and Tribhuvan University Teaching Hospital (TUTH) which had its first transplant success in mid-2008. While the average cost of a transplant in the USA for example is at least US$ 50,000, both hospitals charge less than 3,500 Euro for a transplant using the best available drugs. “I was trained in the UK and want to work in the same way,” says Dr. Shrestha.

Dr Rajani Hada, Associate Professor of Nephrology at Bir is enthusiastic about transplantation. “Over 50% of patients are below 30. With a transplant they can go on to lead normal, productive lives.”

It is estimated that annually 2800 people suffer from CRF in Nepal. Dr Hada believes that while transplants save lives, the most effective way is early screening and thus prevention. “In my ideal world I would screen all children at school. It costs just 25 NRP (23 Euro cents) for a urine test, and we could catch problems early and treat them. We could eventually reduce that number significantly.”

Present at the short ceremony at the hospital is Dinesh Thapa, 22, who was transplanted seven months ago with a kidney donated by his mother. “We have a new life. For us, the transplant is a miracle,” says Dinesh.

The immunosuppressant drugs he takes daily to stop the body rejecting the kidney cost around 150 euro per month, an amount that is equivalent to a good government salary. “We sell our land,” says his mother when asked how they finance this cost. He is studying journalism and in two years hopes to be able to have job and be able to cover this cost himself.

While operations themselves have been very successful, the cost of medication is a major stumbling block. Some organisations such as UNDP are looking into income generation programs to help transplanted patients and their families afford the drugs. Dr Hada called for the government to remove taxes from immunosuppressants and even offer a subsidy to patients.

“We need to do something for these people,” says Shrestha later, “Dinesh is not working, how long can he sustain these costs?”

“We can’t make an emotional bond with patients or we’d end up in a mental hospital,” says Dr Hada. “Making good decisions for all our patients is the best we can do.”

Impossible, nay improbable head-on colision.

At approaching midnight the roads of Kathmandu are dark and quiet. The quietness is good: less dust, less choking fumes from ancient engines, and none of the just-bearable decibels from impatient motorcyclist’s horns. The darkness is bad: potholes become invisible and, occasionally, wandering people appear out of nowhere.

I am still trying to comprehend how the accident happened last night. The road along Ratna park in the heart of Kathmandu is as wide as a racing track, four lanes wide, although the concept of organised lanes doesn’t apply here. And like a racing track, the road is one way. Out of the blackness and into the weak beam of my headlight came another cyclist, head on, moving. At 30km/hr, the time between seeing him and collision was less than a short swear word in length.

As a few passing pedestrians formed a crowd around us – us, the two participants in this unlikely stupidity – we sat on the ground trying to understand what had just happened.

The prevailing opinion was that it was my fault as I had a light (so should have seen him coming) and was travelling too fast. This perhaps gave me an insight into the Nepalese view on fault attribution in traffic mishaps (the word the English language press choose for ‘accidents’). I was not happy and delivered my tirade to the uncomprehending audience.

“Sir, you maybe give him 1000 Rupees.” “Sir, you take to hospital.”

“Well, does he have insurance?”

Of course not. I explained once again that this stupid idiot was riding unlit, in dark clothing, the wrong way down a one way street, more or less in the middle of the road, saw me from a distance and still hit me. And now you want me to take him to hospital and pay for treatment?

I was ready to leave the scene, to go home and clean up my bleeding hand. But then if his wrist was broken, as he seemed to be indicating, the boy sitting on the ground would be in deep trouble.

We got up, straightened handlebars and drifted towards Bir hospital, coincidentally less than 200m away.

While it had a similar strained and exhausted atmosphere of other accident and emergency departments I have visited late at night, it differed in that it looked threadbare, sorrowful and dirty. We sat on a bench and waited. A cleaner came by and we lifted our feet so that she could mop the blood stains from the floor. I asked what work he did. He worked as a cook in a place I didn’t know.

“Do you have a ticket sir?” Before being treated it was necessary to be registered and so I was directed outside to the window where name and age were recorded in a computer and 10 Rp charged. Then back inside I was asked to repeat the process as I was not the patient of course. A young doctor in jeans and a hooded top, with a stethoscope around his neck to confirm that he was a doctor, looked at the boys wrist. An x-ray would be required to check, though he was sure it was not broken.

We followed the green arrows to the x-ray room. We were seen immediately by a friendly (in a lukewarm way) radiographer. While the hand was x-rayed, I was directed to the pay the 300 Rp that it would cost. Along the way, I passed a person on a bed in the corridor who was either sleeping deeply, or dead. A blanket covered the face so it was hard to tell.

I returned to the x-ray room to see that the boy was having his head x-rayed for good measure (the collision was not strictly head on as his forehead hit my now swelling shoulder). Would be interesting to have a CAT scan too see if there was a brain in there.

We waited again on the bench with the clean floor underneath our feet and the boy fell asleep. I witnessed a thin and frail man on the bed in front of me having his genital region exposed and examined. Three policemen walked in and out again with a handcuffed pair of drunken youths.

After 15 minutes we returned to pick up the still-wet x-rays. Behind the counter most of the doctors were sitting huddled around an electric heater. I asked one doctor, probably rather abruptly, to please dry an x-ray for me. “Dry it yourself sir,” came the reply. I can understand that it must have been difficult and frustrating for the doctors to do this work in such conditions and I could hear this in her voice.

Now it was over and we could return home. The hooded doctor gave the all clear, prescribing only strong pain killers for the wrist. Forty minutes in all, which was very speedy in comparison to the war zone of any English A&E department on a Saturday night.

We shook our uninjured hands and parted. I continued back along the road where we’d collided and reflected: tomorrow it would be perhaps a little funny and that it could, of course, have been much worse.