Cadaver organ donation and transplantation—an Indian perspective
Article Outline
Since the passage of legislation in India, entitled “Transplantation of Human Organ (THO) Act” in 1994, it has been possible to undertake multi-organ transplants from brain-dead donors. The prerequisites for the success of a cadaver program1, 2, 3 include: 1) a positive attitude of the public toward organ donation, 2) consent by relatives for organ donation in the event of brain death, 3) successful brain death identification and certification, 4) adequate hospital infrastructure and support logistics and 5) Successful organ retrieval and transplantation audits of long-term graft outcomes. This review looks at aspects in the Indian context and discusses the difficulties encountered in implementing this program over the past 6 years.
Patients and methods
After passage of the THO legislation a major survey was conducted in 1995 and 1996 including 5008 members of the Indian public for their attitude toward organ donation.4 In one major hospital in Chennai performing cadaver donor transplants regularly, an audit of 159 brain death patients was performed over the past 5 years to examine the number of patients who actually became organ donors. The Data from all transplant centers in India performing cadaver transplants since the passage of the legislation were collated for this study. A critical analysis was made of the deficiencies in the infrastructural support services available at the hospitals performing cadaver cases. The results of the first 100 kidney cadaver transplants from four major hospitals in the country were analyzed to examine 1- and 2-year kidney allograft and patient survivals.
Results
Public attitude survey for organ donation
The survey showed that 72% of the population was willing to donate eyes and carry a donor card. However, fewer 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 (19%) of the relatives donated organ from their loved ones.
Total cadaver transplant activities
For various solid organs5 the activities from January 1995 to June 2001 were: kidney, 379 heart, 34 liver, 12 pancreas, 2 and lungs, 1 for a total of 428 transplants. In the past 6 years, 35 hospitals in various regions of the country have undertaken cadaver transplants. Chennai has done the largest number of cadaver transplants in the country (n = 189). Besides Chennai the other cites where the cadaver organ transplantation is taking place include New Delhi (n = 68), Ahmedabad (n = 46), Pune (n = 32), Bangalore (n = 32), Vellore (n = 22), Mumbai (n = 20), and Coimbatore (n = 12).
Hospital infrastructure and support logistics
All 35 hospitals were supported by intensivists with adequate intensive care facilities and fully qualified, trained medical and paramedical staff to undertake the cadaver transplant program. However, most of these facilities lacked motivated medical or social workers who could be trained to speak to the relatives in brain death situations. There were only 15 transplant coordinators, of whom few had any proper or formal training in the field. There were bout 12 organizations in the country working to promote and help the cause of organ donation; however only 3 were actively involved and worked as a central coordinating agency for the allocation and distribution of organs.
Results of the first 100 transplants from four major centers
The mean age of the patients was 45 years (range 3 to 72 years). There were 62 men and 38 women transplanted. The 1-year allograft and patient survivals were 82% and 86%, with 2-year allograft and patient survivals of 74% and 80%, respectively.
Discussion
The passage of The Transplantation of Human Organ Act heralded a new era in Indian medicine. This legislation was similarly to the UK Transplant Act. The essence of this legislation was threefold: (1) to accept brain death as a definition of death, (2) to stop commercial dealing in organs, and (3) to define the first relative (father, mother, brother, sister, son, daughter, and spouse) who could donate organs without permission from the government. In event of the donor not being a first relative approval had to be obtained from a government-appointed authorization committee in each state of the country.
When the THO act was passed there were few supporters and many more detractors of this legislation. The supporters felt that 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 socioeconomic background and lack of infrastructural support available for implementing a cadaver donor transplant program.
The public attitude survey indicated a positive attitude of the people toward eye donation. After this survey a simple protocol was devised: the Ramachandra required request protocol when asking for organ from relatives. It was suggested that eyes should be requested first, and only if the relatives were willing were other organs requested. This approach was felt to be less likely to upset the relatives in a brain death situation. It would also give the hospital staff asking for organs an idea about the family’s attitude toward the sensitive issues of organ donation in a difficult situation.4 The eye donation activists of the country are already lobbying for a “required request law” in the event of a death in a hospital. This legislation is likely to be passed soon by parliament and enacted into law. The same law may be extended to solid organs in a brain death situation. If this is done it will give the required boost to the program, making it obligatory for hospital staff to ask for organs.
A major center (Sri Ramachandra Research Medical College and Research Center) has undertaken cadaver donor transplants for the past 6 years with a brain death donation assent rate of 19% (30/159). In this institution, the ICU staff are sensitive to the issue of brain death and organ donation. The number of fatal road traffic accidents every year in India is constantly rising, averaging about 8500 per year. At any given time there are 8 to 10 brain dead patients in different ICUs in any major city of the country. There is hence potentially a huge pool of brain dead donors available in India.6
Most hospitals undertaking cadaver donor transplants are either private or trust hospitals; there are few government hospitals performing this program. Among 27 states in India four states have not yet enacted the transplant legislation to accept brain death concepts. To make the cadaver program a success one must examine how to implement the program. One major hurdle is the unrelated donor activity that continues unabated. Kidney scandals continue to haunt the country. The unrelated activity is due to loopholes in the present THO Act as under the Sub Clause,3 Clause 9 of Chapter II which 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 unrelated transplants are a result of patients and clinicians using this section of the law to obtain permission from the government to perform living 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 goverment’s authorization committee. Up to 1997 only four hospitals in the country were performing cadaver donor transplants. However, now more hospitals, which have been encouraged by the success of the others are now beginning their programs. On an average over 55 cadaver transplants are being performed in India every year. However this number is unlikely to meet the present demand for organs. It is estimated that every year 3500 kidney transplants are performed.
As the cadaver program is still in its infancy, the early results of kidney cadaver transplants are acceptable. Two hospitals (All India Institute of Medical Science, Delhi and Madras Medical Mission, Chennai) have performed heart transplants. Only one hospital, Indraprastha Apollo Hospital Delhi, is performing liver transplants regularly.
Over the last 2 years, local state-based networks have been established by a few nongovernmental and nonprofit organizations in the country. Among these the Initiative for Organ Sharing Group started by the Multi Organ Harvesting Aid Network (MOHAN) Foundation in Tamil Nadu has shared 68 organs between five hospitals in the last 2 years. This is an encouraging start. The Foundation is also hoping to affiliate with other similar organizations in other regions such as foundation for Organ Transplantation and Education (FORTE) at Bangalore and Zonal Transplant Co-coordinating Committee (ZTCC)” at Mumbai that have also shared organs between different hospitals.
There is potentially a huge pool of brain-dead patients in the country who could not only meet the local demands for organs but also the needs of some neighboring countries, which sometimes look to India for their healthcare needs. Despite the many problems in the implementation of this program in India, a start has been made and the first hurdle crossed. Education of the public on the concepts of brain death, increased numbers of trained transplant coordinators, better allocation of resources from government and private agencies, and state-based networks with central offices would all help to give this program the required boost.
References
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- Cadaver Transplant Activity—All India Figures—1999 to June 2001. Indian Transplant Newsletter 3:9, 2001
- INOS and the essence of organ sharing. Editorial. Indian Transplant Newsletter 3:10, 2001
PII: S0041-1345(02)03907-6
doi:10.1016/S0041-1345(02)03907-6
© 2003 Elsevier Science Inc. All rights reserved.
