International Society of Nephrology CME visit to Chandigarh 21 st -22 nd November 2011 Visitors (ISN sponsored) Dr Debasish Banerjee Prof John Eastwood Dr Iain MacPhee Additional visitor Dr Nihil Chitalia (Clinical Research Fellow) Context Cooperation between St. George s Hospital, London and Postgraduate Medical Education and Research Institute (PGI), Chandigarh was awarded Sister Centre Level C from 1 st Jan 2011. Prof Vivekanand Jha had previously visited St. George s as a Visiting Professor in 2007. This was the first visit to Chandigarh by the St. George s team. Purpose of visit To deliver two days of CME in collaboration with the Department of Nephrology in PGI. To identify and plan opportunities for extending collaboration. Travel Flight from London to Delhi followed by car journey to Chandigarh where we were welcomed at the PGI Guest House by Prof Jha. The guest house was very comfortable with provision of breakfast. We were picked up by Prof Jha each morning and driven around, as required throughout the visit, either by him or by a PGI driver. Programme See attached Monday 21 st November 09:00-10:00 Clinicopathological Conference with Residents The session was chaired by one of the Residents. Two complex cases were well presented by Residents who were unaware of the post-mortem diagnosis followed by discussion by fellow residents and faculty. A pathologist then presented detailed post-mortem findings followed by further discussion. The discussion was of a uniformly high standard. 10:00-12:00 Teaching ward-round Led by Dr Raja Ramachandran, Assistant Professor. Entry to the MD programme in Nephrology at PGI is amongst the most competitive in India which was reflected in the quality of presentation of the cases and bedside discussion. We visited 12 male and 6 female patients with a wide range of renal diseases including renal transplant recipients, haemodialysis patients, chronic renal disease and acute kidney injury. Two of the patients were adolescents. We saw two particularly ill patients, one of whom was ventilated on the ward with minimal nursing supervision and one who had been intubated and sedated with bag ventilation (by a relative) while awaiting a bed on the Intensive Care Unit. 1
The patients had been referred from a wide geographical area spanning most of India. Cases where the visitors had no previous experience included scrub typhus and Japanese type B encephalitis. There was clearly ready availability of a full range of complex investigations including MRI and PET CT scanning. While the majority of patients seemed to be covered by health insurance, some were self-supporting and treatment options were restricted by the patient s ability to pay. An example of this was a patient with refractory transplant rejection where use of antithymocyte globulin may have been prevented by cost leading to acceptance of graft loss with possible death due to inability to pay for dialysis. 12:30 Visit to meet the staff on the recently expanded haemodialysis unit (35 beds) Seventeen patients were undergoing dialysis on the day of our visit. The unit does not provide long-term haemodialysis and is primarily used for acute kidney injury and patients awaiting renal transplantation. 13:30 Lunch with the Director, Consultant medical staff and visiting maxillofacial surgeon from London and his colleagues. 15:00 Visit to Government Medical College Chandigarh for CME session Chair Prof. Sanjay D Cruz Message from ISN Prof. John Eastwood Cardiovascular complications in CKD Dr Debasish Banerjee 16:00 CME session PGI Chair Prof Vivekanand Jha Pharmacogenetics of immunosuppression Dr Iain MacPhee The total audience comprised consultant physicians, paediatricians along with junior and senior residents. Total audience No. 48. Evening: dinner at Prof. Jha s home. Tuesday 22 nd November 09:00-13:00 visit to local community health system Guided by Dr Nav Neet, Senior Resident in Public Health Medicine 1) Visit to Urban Health Training Centre (UHTC) at Manimajra in Indira Ghandi resettlement colony of people from Bihar. A local health centre in a deprived urban area. The centre was primarily staffed by Healthcare workers supported by Public Health clinical trainees. The primary focus of healthcare here was on women and children with provision of maternity services and a crèche. We were shown around by Dr Smita Tripathi, Resident in Public Health Medicine who explained local guidelines to allow the diagnosis and treatment of common medical problems by nonmedically qualified healthcare personnel. In terms of renal disease, the centre provides management of hypertension and diabetes mellitus with dispensing of drugs including amlodipine, an ACE inhibitor, a thiazide, metformin and a sulphonylurea. Follow-up was ensured by home visits by the Healthcare workers. Patients can either 2
buy the drugs or for those below the poverty line pay 3 rupees for 10 days supply of all drugs. Volunteer Anganwari workers provided care for pre-school children (aged up to 6 years) from 08:00-14:00 daily with provision of supplementary food, assessment of developmental milestones and some basic education. We saw a room full of remarkably well behaved and contented looking children. 2) Rural Health Training Centre (RHTC) at Kheri This was a clean tidy healthcentre in a deprived village with poor sanitation and lots of flies. We were welcomed by the Healthcare worker who had an extensive knowledge of all of the residents in the village. An ASHA (Accredited Social Health Advocate) was working with a group of women and children. There was a set of guidelines for the management of hypertension pinned to the wall which included the presence of renal disease in the algorithm. This was part of the CHAPPS study. 3) Community Health Training Centre (a community hospital with some inpatient beds) at Raipur Rani. This facility serves a catchment population of 129,216. At the time of our visit 6 inpatient beds were available with renovation underway to bring the bed complement to 30. There are a number of specialist Drs including a Physician, Obstetrician, Paediatrician, Gynaecologist and Orthopaedic surgeon. There was no awareness that measurement of renal function in patients with hypertension and diabetes is important with testing only applied in symptomatic patients. Indeed, there is no national policy on screening for renal disease. When asked what the response to a serum creatinine concentration of 2.5 mg/dl would be, the answer was nothing. Common themes There was screening for hypertension with referral for treatment for blood pressure >140/90 Blood testing outside PGI rarely happens Testing for proteinuria rarely happens While there was a very Dr-intensive team on the wards at PGI with minimal visible nursing presence, the reverse was the case in the community where the service is primarily delivered by non-medical healthcare workers. 15:00-16:00 Teaching of Residents based on presentation of a case of anti-glomerular basement membrane disease (Drs Banerjee, Chitalia, MacPhee) 16:00-17:00 Lecture: Detection of CKD and assessment of GFR in Ashanti Ghana. Prof. John Eastwood. 17:00-18:00 Visit to basic science laboratory facilities. We saw well equipped laboratory space with state of the art equipment and room for substantial expansion of activity. 20:00 Dinner attended by all medical staff from the Renal Department. Areas for potential interaction Chronic Kidney Disease The recent implementation in the UK of comprehensive screening for CKD in the community with implementation of measures to diagnose and treat or delay progression has generated experience and expertise that could be transferred to Chandigarh. 3
Renal transplantation PGI undertakes a high volume of live donor renal transplantation with fewer than 1% of transplants from deceased donors. There is an aspiration to develop liver and cardiothoracic transplantation which will require a system for the retrieval of deceased donor organs. This is a well developed area in the UK where support from the UK could be provided. We did not meet any of the transplant surgeons. Research There is a planned exchange working on cardiovascular complications of CKD and vitamin D deficiency in CKD. Dr Chitalia, who presented his work to the research team on Wednesday has already completed collaborative work on metabolic syndrome in North Indians with CKD. More research on comparison of South East Asians in UK and India can be done in the future with the help from ISN, which will explore the effect of genetic and environmental influences on CKD. There is a common interest in genetic factors that influence pharmacology of the immunosuppressive drugs (pharmacogenetics) with potential for collaboration. Area where ISN may be of help in influencing policy The Indian Govt has indeed included kidney disease in its policy document for the next (12th) 5-year plan. ISN input might be worthwhile to advise the Indian Govt on how to structure it. 4
The visitors from SC with members from the EC Professor John Eastwood discussing CKD in Africa 5
An ongoing lecture 6
A visit to the Urban Health training Centre The visiting team from UK in front of School of Public Health PGI Chandigarh 7
Dr Macphee presenting his experience The visiting team with resident nephrology fellows Lunch hosted by the Director 8
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