For a cadaveric transplant programme

ONE of the objectives of the Transplantation of Human Organs Act, 1994 was to clear the decks legally for the development of a cadaver-based organ transplantation programme. Towards this end, the Act recognised and defined, for the first time in India, the concept of "brain-stem death".

Since the Act came into force, however, only about 110 kidney transplants from cadavers have been performed in the country, according to Dr. J.V. Thachil, Chief Urologist at the Apollo Hospitals, Chennai, and Dr. J. Amalorpavanathan, Transplant Coordinator at the Government General Hospital, Chennai. Tamil Nadu is the clear leader in the field, with three leading medical institutions in the State accounting for 79 of these. Apollo Hospitals, Chennai, has done 53 cadaveric renal transplants; the Sri Ramachandra Medical College and Research Institute, Chennai, 14; and the Christian Medical College and Hospital, Vellore, 12. In addition, the Government General Hospital, Chennai, has done 8 cadaveric kidney transplants, and K.G. Hospital, Coimbatore, 2.

Leading nephrologists and urologists argue that the continuing commerce in kidneys acts as a disincentive to investments in cadaver-based programmes by capable medical institutions. There are, however, a few hospitals and organisations that are working with the objective of putting in place an effective cadaveric transplant programme and changing social attitudes towards organ donation.

Apollo Hospitals, Chennai, is way ahead of the rest. It performed the country's first renal transplant from a brain-dead person in October 1995. Since then the hospital has performed 52 more, making its programme the best cadaveric transplant programme in the country.

One lesson to be learnt from the Apollo experience is that a cadaveric transplant programme cannot take off unless the paid-donor programme is stopped and independent investments are made in setting up the infrastructure for a cadaveric programme. "What a hospital needs for a cadaveric transplant is a 24-hour laboratory that can do cross-matching as soon as we harvest a kidney from a cadaver," notes Dr. Thachil. "It must have a physical plan and an infrastructure for transplants; not just doctors, but theatres and nurses in a constant state of preparedness. We have done up to five transplants in a day."

A kidney can be harvested from brain-dead accident victims and also from victims of brain haemorrhage and cardiac arrest. Apollo has up to 35 persons on a waiting list for cadaver-based kidney transplants. Many of these patients, who are on dialysis, return to their cities and workplaces, and come when the hospital finds a kidney to match their specific needs. Apollo has given six kidneys that it harvested from brain-dead persons to other hospitals for transplantation as it could not find a match for persons on its waiting list.

On November 21, Dr. Thachil performed a renal transplant surgery on a 75-year-old patient from South Africa. Two kidneys harvested from a cadaver were transplanted into the recipient using what is called a "piggy-back technique". The patient had been on the waiting list for almost four months. Dr. Thachil says: "This man could easily have bought a kidney, but he chose to wait."

Once a brain-dead person's relatives have agreed to his or her organs being harvested, the transplant team has to move fast as delays affect the success rate; the best results are obtained when the kidney is harvested while the heart is still beating. The hospital bears the expenses of keeping the person on a life-support system; the organ retrieval costs are passed on to the recipient.

Asking for permission to harvest a brain-dead person's organs requires sensitivity to the family's grief. Dr. Thachil says that in 90 per cent of such cases, the relatives have given permission. "We brief the family fully and we tell them that the organ can be taken without any physical disfigurement of the body. Whenever I give a lecture, I tell people: when you die let you soul go to heaven, but leave your organs behind."

A donor card programme, under which a person may give consent for doctors to harvest his or her organs in the event of death, is at work in its initial stages in Chennai, Bangalore and some other cities. Such programmes are popular in other countries. Moreover, in several countries, the Law of Assumed Consent prevails: the state assumes that it has an accident victim's consent to harvest his or her organs in the event of death, unless he or she has left a statement expressly forbidding this (see interview with Dr. Christiaan Barnard, Frontline, November 14).

Dr. Thachil, however, believes that such a law may "backfire" in India. "In India you cannot overlook the family's wishes after a death has occurred. Apollo's experience has shown that you can have a cadaveric programme and can convince persons on a case-by-case basis."

AN organisation whose objective is to change social attitudes to organ donation is the Chennai-based Multiple Organ Harvesting Aid Network (MOHAN). MOHAN was launched in January 1997 by Dr. Sunil Shroff, a transplant surgeon who heads the Department of Urology and Renal Transplantation at the Sri Ramachandra Medical College and Research Institute, Chennai. It has begun a donor card scheme to raise awareness about the need to donate 'solid' organs (kidney, heart, liver, lungs and pancreas). A person who enrols in the scheme signs a card and thus consents to his organs being harvested after his death. MOHAN has distributed 17,000 donor cards so far.

The SRMC&RI has performed 57 kidney transplants (including 14 cadaveric kidney transplants) since 1995. A team of doctors from the Department of Urology and Renal Transplantation at SRMC&RI conducted a sample survey in Chennai to test social attitudes towards organ donation. The sample was stratified to capture different socio-economic classes and religious groups in Chennai's population. Individual questionnaires were given to 8,000 persons, of whom 5,008 responded. Their responses indicated that awareness about organ transplants was high; more than half the people who responded expressed "some degree of familiarity" with the concept of brain-death. More than 70 per cent were willing to carry a donor card. The most significant finding was that the proportion of people who were willing to donate their eyes was substantially higher than the proportion of people who were willing to donate solid organs after death.

The survey's results point to the significant success of the campaign for eye donations. Such a campaign could serve as an example for a similar effort to raise awareness about the need for donating other organs.

NO cadaveric renal transplant has yet been performed in Karnataka. However, the Foundation for Organ Retrieval and Transplant Education, a non-profit trust founded in September 1996, is helping put in place a programme under which people can signify their willingness to allow doctors to harvest their kidneys, liver, pancreas, heart, heart valves and eyes after their death. The programme was begun by Dr. Philip G. Thomas, a transplant surgeon at St. John's Hospital, Bangalore, and his wife Rebecca Thomas, a trained transplant coordinator who worked at the Centre for Organ Recovery and Education (CORE), Pittsburgh.

FORTE works with the 10 Bangalore hospitals that are authorised by the Karnataka Government to perform cadaveric transplants, and coordinates the donation and transplantation of organs. It has distributed 1,000 donor cards and received consent from 200 persons for the harvest of their organs after death. Nine patients with End-Stage Renal Disease and one heart patient are currently registered with FORTE seeking organ donors.