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Thursday, November 3, 2011

Transplants: A New lease on life

Reba Paul 
Organ transplantation is hailed as one of the greatest advances of modern science in this century, giving millions of people a new chance at life.

Organ transplantation was a confusing, even horrific prospect for people living a few centuries ago to ponder.  All of the ethical, moral issues that the concept brings up in many communities have been allayed over the past few decades, and transplants are now widely considered by doctors and the public alike to be the best medical option for many diseases. In cases involving end stage kidney failure, this is the only solution that can ensure the patient a good quality of life. Organ transplantation is hailed as one of the greatest advances of modern science in this century, giving millions of people a new chance at life.
Based on human physiology, the heart, kidneys, eyes, liver, lungs, pancreas, intestine and the thymus can be transplanted. Tissues can also be transplanted – like bones, the cornea, skin, heart valves. In fact, musculoskeletal and corneal transplants are ten times more prevalent than organ transplants. In the organ transplant area, the kidneys are the most transplanted organs, followed by the liver and then the heart.

What does it entail?
Moving an organ from one body to another for the purpose of replacing the recipient’s damaged or absent organ, is a complicated endeavor. Previously it was a prerequisite that the donor and the recipient have matching or compatible blood groups. This is becoming increasingly flexible now, due to the new drugs in the market. Higher degrees of tissue compatibility are thought to help the success rate of the transplant. The first successful organ transplant happened when a kidney was transplanted between twin brothers in 1954. The main problem faced after a transplant is that the recipients’ body tries to get rid of the foreign organ.  Every body’s immune system clearly knows what belongs in the body and what is a foreign object. So after a new organ is transplanted, the immune system sees it as ‘foreign’ and keeps trying to get rid of it. This is what causes organ rejection. This problem is tackled by giving the recipient medicines that suppress this instinctive response of his immune system – these are called immunosuppressants.

Organ Donation
Any healthy adult who wishes to donate his organ is free to do so. Also, any healthy adult who wishes to bequeath his organs for transplantation after death can also do so. This is one way to positively impact the life of a fellow being even after your time on the planet is done. In case of a natural death, only a few organs can be ‘harvested’ – like the cornea, bone, skin and blood vessels. However, if a person is ‘brain dead’, then many more organs can be successfully harvested to benefit the life of other people – technically almost 37 different organs and tissues can be put to this worthy use.

The Indian Scenario
Generally speaking, chronic organ failure is still not being seen as the serious problem it really is. In India, thanks to improving mortality rates and disease management, most of the attention in the medical scenario is primarily focused on heart disease, diabetes and other such diseases. What we are failing to understand is that a huge chunk of the present population is going down the road that will inevitably lead to organ failure.
The rise in the incidence of organ failure globally has impacted India in many ways. At the time when transplants began to be commercially executed and were becoming popular, India had the rare combination of having trained transplant personnel, good medical facilities, a large impoverished population and lack of legal governance on organ transplantation. This made the country a quagmire of organ transplant activity from the late 1980s onwards. India got a lot of attention globally due to a multitude of reports regarding large-scale transplants being done with kidneys sourced from poor, illiterate donors under questionable circumstances. Following all the media criticism, the Government of India enacted the Transplantation of Human Organs Act (THOA) banning payment for human organ donation.

The Loophole
Despite this, most of the transplants happening in the country are from live donors who get paid for giving their organs. This is due to a loophole in the Act, which says that a donor can give his organs ‘for the reason of affection or attachment towards the recipient or for any other special reason’.  It is estimated that India has approximately 3500–4000 kidney transplants and 150–200 liver transplants happening every year. The main source is live or unrelated donors.
India’s Human Organ Transplantation Act says that a father, mother, brother, or sister can donate organs to the patient. Other live donors go through a screening process by a state transplantation authorization committee to make sure that they are donating organs purely due to emotional attachment to the patient and not for monetary or material gain. The fact that there are so many live, unrelated donors providing organs for the majority of the transplants seem to point to the fact that there is collusion between the agents who source the donors and the authorization committee. Several ‘kidney rackets’ have been busted which have had doctors working with kidney agents to get donors. These donors would have documents fabricated regarding their relationship with the patient, and would be eventually sanctioned by the screening committee. The worst part is that since the whole process is illegal, after the various cuts are taken by the agents and others involved, the donor actually gets only a fraction the amount that the patient pays for the organ. But the question is, when such a huge need for organs exists, should we not have a better solution?
The Multi Organ Harvesting Aid Network Foundation (MOHAN)is a non-governmental organization that has, among many others, been campaigning for more cadaveric transplants. Doctors connected to this organization say that less than 600 cadaveric transplants have been performed in India since the THOA came into being. But the annual number of kidney transplants is over 2000. They point out that ‘there doesn’t have to be a shortage of cadaver organs in India- most relatives of brain dead persons are willing to donate, but there is no system in place in most hospitals to counsel relatives and harvest organs.’
The foundation has written to the health ministry requesting that the government take steps to promote cadaveric transplantation and also enforce stricter scrutiny of live, unrelated donors. They are still waiting for a response. Meanwhile, kidney and other organ rackets flourish in the country. Stray reports surface in the media regarding these from almost all major Indian cities, but no long term official solution seems to be in sight.

The cadaver donation solution
The urgency of the situation is due to the fact that the number of people who need a transplant to save their lives far outnumbers the number of live donors. The only viable solution we are left with is to promote cadaver transplants – which can be done only through people agreeing to donate their organs after death. Oddly enough, most public surveys show that organ donation has high support from the general public. The fact that this is not becoming a reality, is most probably due to the fact that after a patient dies, their relatives are either not aware of this, or are against it, and so the individual’s wishes are not carried out. Statistics say that as many as half of all families decline to donate the organs of their recently deceased loved ones.
In a country populated by more than 1 billion people, the pool for cadaver harvest is understandably high. But in India, the number of cadaver transplants is miniscule in comparison to live donation. Every year, almost 100,000 Indians suffer from kidney failure. Of these about 3,000 actually get a donor kidney, with a very small percentage being from cadavers. In the eight year span between 1995 and 2003, only 524 cadaver transplants were done. The critical shortage of available organs is only getting worse as more people succumb to kidney and liver failure.
The issue gets even more important as we consider that India has an ever increasing number of end stage liver failure patients. Patients who have kidney failure can be helped with therapies like dialysis. But liver failure has no such therapy, and transplant is the only solution. Of the majority of liver failure patients, only a handful get timely transplants that save their lives. The same is the issue with heart-lung transplants. Unlike the kidney, which a donor could give one and still survive well on the functioning of the remaining one, no one except a cadaver can donate his heart and lungs.

Cadaver Donor Program
It would not be an exaggeration to say that unless India develops a good cadaver donation program, we will remain right where we are now, with many of our citizens dying for lack of organs. This problem has to be addressed from the side of the government and policy makers, if any significant change is to take place.
Awareness has to be created about the existing problem, and the public has to be encouraged to be cadaver donors. The family unit has to be informed, and there has to be a way of ensuring that the individual who wishes to donate will have his wishes honored after his death. There should also be a practical and efficient organ retrieval mechanism that is implemented on a national level.
Well trained staff should be present in hospitals to educate and inform families about cadaver donation – in a way that this sensitive issue is handled impeccably without compromising on the optimum time for organ retrieval. One brain dead patient can help seven patients in critical stages, to lead normal lives. Another option to consider is that a national policy could be created whereby every patient in a hospital who becomes brain dead will have his organs harvested, unless otherwise clearly specified to hospital authorities. This way more organs can be made available for the living. Infrastructure should be created for harvesting, storing, biochemical work that will facilitate the best organ-recipient match. Organ donation is possibly the last and most noble act that any human being could undertake; don’t make it so hard to do.

Paid Donation – No good for Donor?
A group of independent American researchers, who tracked down over 300 individuals who had sold a kidney in Chennai, India, found that:
•         The donors received far less money than what had been promised to them during the process of initial bargaining
•         Instead of improving, their family income declined by about one-third after donation, and the number of participants living below the poverty line increased by about 20%
•         75% of the participants who chose to sell their kidney to get out of debt, continued to be in debt
•         More than 95% of the sellers admitted that the desire to help a gravely ill patient with kidney disease was not a factor in their decision
•         Almost 90% of them reported significant decline in their health status
•         In many cases, women had been forced to donate against their wishes because the husbands needed money.
When asked what advice they would give to others thinking of selling a kidney, more than 80% said that they would not recommend such a step. The authors concluded that the Authorization Committee failed in its duty, shattering the myth that the money earned by selling an organ helps the donor to improve their financial standard and get a fresh start in life.

Iranian Model of Organ Donation
The Iranian model of transplants is seen as the one that is the most fair to the recipient as well as the donor. It is a state supported program – the compensation and regulation are done by the state. This program started functioning in 1988, and gives financial incentives to living donors who volunteer their organs. These living unrelated donors get a sum of money, without having to go through any middlemen. Anyone who needs a kidney gets it. However, there are regulations in place that ensure that transplant tourism does not get the benefit of this. So foreigners cannot have a renal transplant from an Iranian national in Iran, nor can they be a donor.
After this system was in place, renal transplants increased so much that by 1999, the waiting list was eliminated. Right now, there is no renal transplant waiting list in Iran. The advantage of this model is that many of the ethical issues surrounding live, unrelated donation are eliminated, since the donor is directly connecting to the government for his compensation. Also, he will not know who is going to get his kidney, since it going to an organ pool and given to the patient who is the best match for it.
All hospital expenses are also paid for by the government, so even poorer patients can afford to have a transplant. The transplants are only performed in government hospitals that are affiliated to universities. The transplantation teams, including the doctors, have no connection with identifying possible donors and no middlemen are involved.  More than 50% of Iranians who had end stage kidney failure are living with a functioning transplanted kidney. It is the only country that has successfully eliminated a transplant waiting list in this manner.

mail to rebekaah.paul@gmail.com the author of this article published in the Novemebr 2011 Issue of THE HEALTH CAFE'. Sign in for the health cafe newsletter for a complimentary annual e-subscription.