Dr.Sunil Shroff, Dr.Sumana Sundaram, Dr.Georgi Abraham, Dr.Sounddarajan, Dr.Suresh, Dr.Subba Rao, Dr.Paulose Thomas
Since the passing of the legislation in India, entitled, 'Transplantation of Human Organ (THO) Act' in 1994, it has been possible to undertake multi-organ transplant activity from brain dead donors. The required pre-requisite for success of the cadaver program depend on various factors1-3 and these include:
- Positive attitude of public towards organ donation
- Consent by relatives for organ donation in event of brain death.
- Successful brain Death identification and certification.
- Adequate hospital infra-structural and support logistics
- Successful retrieval and transplantation of organs and auditing long term graft outcomes.
This review looks at these aspects in the Indian context and discusses the difficulties encountered in implementing this program over the last 6 years.
Patients & Method
- After passing of the THO legislation a major survey of the 5008 members of Indian public's attitude towards organ donation was conducted in 1995-96 by the principal author and a brief analysis of this survey's result are presented 4.
- In one major hospital in Chennai, undertaking cadaver transplants regularly; an audit of 159 'Brain death' patients over the last 5 years was undertaken. This was to look at the number of these patients who actually became organ donors.
- Data of all the transplants centers in India undertaking cadaver transplants since the passing of the legislation was collated for this study.
- Infra-structural Support services available at the hospitals undertaking the cadaver program was looked at and a critical analysis was made of the deficiencies.
- The results of first 100-kidney cadaver transplant from 4 major hospitals in the country were analyzed to look at 1 and 2 year kidney allograft and patient survival.
- "Public attitude Survey to organ donation": This survey showed 72% of the population were willing to donate eyes and carry a 'Donor Card', however less than 50% were willing to consider solid organ donation. 74% of Hindus, 72% Christians, 58% Muslims were willing to consider organ donation; however the concept of brain death was new to most of the people surveyed 4.
- Organ donation in Brain death situation: An audit of 159 brain death patients showed that 30 or 19% of the relatives donated of the organs of their loved ones.
- The Total Cadaver Transplants activities: For various solid organs5 are as follows from Jan 1995 to Jun 2001:
In the last 6 years 35 hospitals in the country from various regions have undertaken cadaver transplants. Chennai has done the maximum number of cadaver transplants in the country (189). Besides Chennai the other cites where the cadaver organ transplantation is taking place include New Delhi (68), Ahmedabad (46), Pune(32), Bangalore (32), Vellore (22), Mumbai (20) and Coimbatore (12).
- Hospital Infra-structural and Support Logistics: All 35 hospitals were supported by intensivists and adequate Intensive care facilities and fully qualified and trained medical and para-medical staff to undertake the cadaver transplant program. However most of them lacked motivated medical or social workers who could be trained to speak to the relatives in brain death situations. There were only 15 transplant co-coordinators of whom very few had any proper or formal training in the field. There were about 12 organizations in the country working to promote and help out with the cause of organ donation however only 3 were actively involved and worked as a central co-coordinating agency for allocation and distribution of organs.
- Results of the first 100 transplants from 4 major centers: The mean age of the patients was 45 years with a range from 3 years to 72 years. There were 62 males and 38 females transplanted. The one-year allograft and patient survival was 82% and 86% respectively and the 2-year allograft and patient survival was 74% and 80%.
The passing of Transplantation of Human Organ Act heralded a new era in Indian medicine. This legislation was written on similar likes as the UK Transplant Act. The essence of this legislation was threefold:
- To accept brain death as also a definition of death.
- To stop commercial dealing in organs
- To define the first relative (father, mother, brother, sister, son, daughter and wife) who could donate organs without permission from the government. In event of the donor not being a first relative an approval had to be obtained by a government appointed authorization committee in each state of the country.
When the THO act was passed there were very few evangelist and many more detractors of this legislation. The evangelist in the country felt it would stop commercial dealing in organs, open up multi-organ transplant activity and increase the number of transplants in India. The detractors felt that this legislation was unlikely to succeed in the Indian context in view of the religious and cultural diversity, poor socio-economic background and lack of infra structural support available for implementing the cadaver transplant program.
The public attitude survey indicated a positive attitude of the people towards eye donation. After this survey a simple protocol was devised (Ramachandra required request protocol when asking for organ from relatives). It was suggested that' Eyes' should be requested for first and only if the relatives were willing other organs requested. This it was felt was less likely to upset the relatives in a brain death situation, and would also give the hospital staff asking for organs an idea about the family's attitude towards the sensitive issue like organ donation in the difficult brain death situation4. The Eye donation activists of the country are already lobbying for a "required request law" in event of a death in a hospital. This is likely to be soon passed by the parliament and be enacted as a law. This same law can be extended for solid organs in a brain death situation. If this is done it can give the required boost to the program and make it obligatory for the hospitals staff to ask for organs.
A major center (Sri Ramachandra Research Medical College And Research Center) undertaking cadaver transplants in the last 6 years has had a brain death conversion rate of 19% (30/159). In this institution the ICU staff have been sensitized to the issue of brain death and organ donation. The number of fatal road traffic accidents every year in India is constantly rising and averages at about 8,500 per year. At any given time there are 8 to 10 brain dead patients in different ICU's in any major city of the country. There is hence potentially a huge pool of brain death donors available in India6.
Most of the hospitals undertaking cadaver transplants are either private or trust hospitals and there are very few government hospitals undertaking this program. Out of 27 states in India four states are still to enact the 'Transplant legislation' and accept brain death concepts. Hence to make the cadaver program a success a re-think of how to implement this program is necessary. One of the major hurdles seems to be the unrelated transplant activity that continues unabated. Kidney scandals still continue to haunt the country every so often. The unrelated activity is due to loop holes in the present THO Act as under the Sub Clause (3), Clause 9 of Chapter II it states: "If any donor authorizes the removal of any of his human organs before his death under sub-section (1) of section 3 for transplantation into the body of such recipient, not being a near relative as is specified by the donor, by reason of affection or attachment towards the recipient or for any other special reasons, such human organ shall not be removed and transplanted without the prior approval of the Authorization Committee". It is not necessarily difficult to find an unrelated donor who suddenly develops an "affection or attachment" for the recipient provided he or she is properly rewarded. Most of the unrelated transplants are a result of the patients and clinicians using this section of the law to obtain permission from the Government to do live unrelated transplants. This aspect of the law has either to be scrapped or tightened so that only genuine cases are helped, otherwise unrelated activity will continue with the permission of government's authorization committee.
Up to 1997 only four hospitals in the country were undertaking cadaver transplants. However, now more and more hospitals encouraged by the success of others are now indulging themselves in this program. On an average over 55 cadaver transplants are being undertaken in India every year. This is unlikely to meet the present demand for organs. It is estimated that every year there are 3500 kidney transplants are being undertaken.
As the cadaver program is still in infancy stage the early results of kidney cadaver transplants are acceptable. Two hospitals (All India Me Institutes of Medical Science, Delhi and Madras Medical Mission, Chennai) are undertaking heart transplants. Only one hospital, Indraprastha Apollo Hospital Delhi is undertaking liver transplants regularly.Over the last 2 years local state based networks are being established by a few non- governmental and non-profit motivated organizations in the country. Among these the Initiative for Organ sharing group started by MOHAN (Multi Organ Harvesting Aid Network) Foundation in Tamil Nadu has shared 68 organs in the last 2 years between five hospitals. This is a encouraging start to the program. The foundation is also hoping to affiliate with other similar organization in other regions such as FORTE (Foundation for Organ Transplantation and Education) at Bangalore & ZTCC (Zonal Transplant Co-coordinating Committee) at Mumbai that have also similarly shared organs between different hospitals.
There is potentially a huge pool of brain-death patients in the country who could not only meet the local demands of organs but may be able to meet the needs of some of the neighboring countries which sometimes looks towards India for their healthcare needs. Despite the many problem in implementation of this program in India a start has been made and the first hurdle has been crossed. Education of public on concepts of brain death and having more trained transplant coordinators, allocation of resources from government and private agencies for the program and having a state based network with a central network office would help to give this program the required boost in the country.
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- Cadaver Transplant Activity - All India Figures - 1999 to
June 2001 Indian Transplant Newsletter 3:9, 4,2001
- INOS and the essence of organ sharing- Editorial, Indian
Transplant Newsletter, 3-10, 2001
Sri Ramachandra Medical College & Research Institute, Chennai
Apollo Hospital, Chennai,
Christian Medical College, Vellore,
Sundaram Medical Foundation, Chennai
MOHAN (Multi Organ Harvesting Aid Network) Foundation, Chennai