|Year : 2018 | Volume
| Issue : 3 | Page : 161-162
Challenges in setting up of a deceased donor transplant program in South Asia
Nephrology, Urology and Transplantation Society of SAARC; Managing Trustee, Mohan Foundation; Department of Kidney, Urology and Transplantation, Madras Medical Mission Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||28-Sep-2018|
Dr. Sunil Shroff
3rd Floor, Toshniwal Building, 267, Kilpauk Garden Road, Chennai - 600 010, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shroff S. Challenges in setting up of a deceased donor transplant program in South Asia. Indian J Transplant 2018;12:161-2
South Asia is a densely populated region that is home to almost one-quarter of the world population with over 1.9 billion people. Asian countries contribute to over 60% of the world's diabetic population, and the prevalence of diabetes is increasing in these countries.
The true incidence and prevalence in the region is not known, but estimates suggest that the prevalence may be more than that reported in western societies. The majority of affected individuals are young and in the most productive years of their lives.
The region is home to about 171 million diabetics (2010), and this is expected to increase to 366 million by 2030. The high incidence of diabetes and hypertension is a major cause of organ failure. Although the true incidence of chronic kidney disease (CKD) in the region is not known due to lack of registries, estimates suggest that it is higher than the western countries. The estimated incidence of end-stage renal disease ranges from 225 to 275 PMP in the region. Other factors that contribute to CKD include higher environmental pollution, lack of sanitation, high incidence of infections, and lower nephron mass in the South Asian population due to intrauterine growth retardation.
The majority of affected individuals are young and in the most productive years of their lives. Added to this is the lack of infrastructure with no provision for universal health care, limited access to tertiary care due to the long distance from remote towns and the high cost of treatment that only may be available in the private sector. All these factors result in majority of the patients who suffer from end-stage kidney failure having neither treatment nor being part of a screening program for early detection of kidney disease. For example, the estimated number of new patients who develop end-stage kidney failure every year in India is about 210,000, but only one-third of them are able to start some form of treatment whereas others withdraw and are condemned to a tragic death.
The estimated number of transplantation in the region versus the actual demand for kidneys depending on affordability and/ or the number of patients who undergo dialysis is shown in [Table 1]. Many are family breadwinners or homemakers, and their loss is loss not only to the family but also to the society. Hence, although the projected demand for organs is very high when it comes to actual demand in terms of financial affordability, the numbers are much lower. For example in India it is estimated that about 60,000 patients are having dialysis and against this only 10,000 live and about 2200 deceased donor transplants are undertaken annually.
|Table 1: The current status of organ transplants and the estimated demand in South Asian Counties*|
Click here to view
The shortage of organs has often resulted in exploitation of the poor and marginalized of the society, thus making the region prone to illegal organ trafficking.
Some affluent families would first explore the option of a commercially available kidney donor rather than donating it themselves. The dictum is “if you can buy why donate.” This has not only created a disparity and lack of equity in the region where the poor are sellers and the rich are receivers, but it has also not allowed the deceased donation program to develop.
Improving deceased organ donation can overcome not only the shortage of organs but also take care of the discrepancy and will help in promoting ethical organ donation in the region. Only two (India and Sri Lanka) of the five countries in the region that undertake transplants regularly do deceased donations transplants. Currently, all countries in South Asia have a law accepting brain death as death making deceased donation a real possibility and push up the number of organs available in the region and take care of some of the organ shortage. What many countries lack is a regulatory framework to implement the law. India to a large extent has succeeded in getting this regulatory framework together and hence has shown success with multi-organ donation after brain death. This has meant that not only kidney but other organ transplants such as heart, lungs, liver, pancreas, and even composite tissue transplant such as hand being undertaken regularly. The incidence of brain death is high in the region including India due to the high rate of road traffic accidents and head injuries.
Most religions in South Asia support organ donation. The Jains in India (Gujarat) and the Buddhist in Sri Lanka have a high donation rate. Sri Lanka has been world famous for its successful eye donation program and is a net exporter of corneas. In most countries in the region, the decision to not donate organs is not based on religion but on cultural beliefs and myths originating from a misunderstanding on the subject. And this maybe the reason for the low donation rate. The popular cultural beliefs and myths among the South Asian community are as follows:
- Religion does not allow organ donation (Muslims and Hindus)
- Death should not be discussed as it is not auspicious (Hindus)
- One should be buried “whole” and it is critical to preserve the integrity of the body (Muslims)
- One would be born without the organ in the next life - due to the belief in rebirth (Hindus).
Other reasons cited are that lack of trust in the health-care system, and many believe that doctors will not save life if consent is given for organ donation. Some have expressed that hospitals may use the organs for making profit.
Despite the multitude of problems in implementing the deceased donation program, India in the past 5 years has shown remarkable progress with fourfold increase in deceased donation rate. The rate increased from 0.12 per million population in 2012 (196 organ donors) to almost 0.8 per million donations in 2016 (830 donors). In 2016, there were over 830 deceased donors provided almost 2400 organs such as kidney, heart, lungs, and liver., Sri Lanka does about 40–50 deceased donors every year and is looking at improving its donation rate.
Coordinated efforts are required to push the deceased donation rate in the region and these are as follows:
- Having good trauma centers and intensive care facility in all major cities
- Capacity building and training of intensive care doctors and nurses for early identification of brain death with proper certification and maintenance of these potential donors
- Training of transplant coordinators who are familiar with cultural values of the region and who can speak the local language. Spending time and supporting the families with the decision to donate can help with the consent process. In India, the conversion rate of a trained coordinators is close to 65%
- System for fair and equitable distribution of organs when they are donated through a centralized or state-driven registry of waiting list patients. Keeping the system transparent is important to keep the public trust in the program
- Stopping organ commerce.
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