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Table of Contents
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 62-65

Deceased donor transplantation – Success story from a state

1 Department of Nephrology, Government Medical College, Trivandrum, Kerala, India
2 Department of Anaesthesiology, KIMS Hospital, Trivandrum, Kerala, India
3 Department of Anaesthesiology, Government Medical College, Trivandrum, Kerala, India

Date of Submission25-Sep-2020
Date of Acceptance14-Jan-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Noble Gracious
Government Medical College, Thiruvananthapuram, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_122_20

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In India, live donor transplantation is more common than deceased donor transplantations which are quite contrary to developed nations. The enactment of The Transplantation of Human Organ and Tissue Act in India in the year 1994 legalized organ donation after brainstem death. However, it was only in the last few years that the deceased donor transplantation (DDT) program increased in popularity, possibly due to increasing public awareness and direct involvement of Government in the donation and transplant process through national and regional organizations. The Government of Kerala in association with Donation and Transplantation Institute Foundation of Spain implemented transplant procurement management (TPM model) in the state in the year 2019. In Kerala, Kerala Network for Organ Sharing, a local networking organization under Government acts as a public, private provider interface, ensuring a transparent and equitable organ allocation. The purpose of this article is to highlight the importance of hospital-based organ procurement units headed by transplant procurement managers (TPM) and the role of government-run networking organizations in improving the DDT. When the COVID 19 pandemic resulted in the suspension of the transplant programs across the country, the deceased donation and transplantation activity in Kerala were going unabated.

Keywords: A networking organization, COVID-19 pandemic, deceased donor transplantation, organ allocation, public–private interface, transplant procurement management

How to cite this article:
Gracious N, Gopal A, Muraleedharan R, Sathyadas A. Deceased donor transplantation – Success story from a state. Indian J Transplant 2021;15:62-5

How to cite this URL:
Gracious N, Gopal A, Muraleedharan R, Sathyadas A. Deceased donor transplantation – Success story from a state. Indian J Transplant [serial online] 2021 [cited 2021 Jul 30];15:62-5. Available from: https://www.ijtonline.in/text.asp?2021/15/1/62/312747

  Introduction Top

Even though transplantation is an accepted therapeutic option to save or improve the quality of life when organ failure occurs, it is limited by the availability of organs. Low- and middle-income countries, including India, resort to living donor donation to surpass this shortage of organs.[1] The deceased donor transplantation rate in India is now 0.65 per million population (pmp), among the lowest in the world, whereas living donation rate is 5 pmp.[2] In contrast, the highest performing countries like Spain have deceased organ donation rate as high as 48.9 pmp and live donation of 7 pmp.[2]

The crucial factors in developing efficient organ donation and transplantation programs are the professional training in organ donation along with the establishment of a robust organizational system. The appointment of transplant procurement managers in both government and private hospitals across the state was a step toward improving the organ donation rate. Transplant procurement managers (TPM) are health-care professionals, mostly intensive care unit (ICU) doctors, who dedicate their part-time to the deceased donation process.[3]

  Transplant Procurement Management Model Top

Deceased organ donation is a complex in-hospital process involving many health-care professionals, teamwork, and leadership from the responsible personnel. In Europe, donation after brain death pathway start when a patient with a devastating brain injury and poor prognosis is admitting to the emergency department, from this stage, TPMs will monitor and follow-up the possible brain dead donor. TPMs carry out both clinical and nonclinical tasks related to converting deceased patients into donors, training, management, research, and implementation of quality programs in the field.[4] Organ donation units were involved in the training of intensive care doctors in donor identification, death determination, and family approach.

The Government of Kerala in association with donation and transplantation institute (DTI foundation) of Barcelona, Spain implemented transplant procurement management model (TPM model) in the state in the year 2019.[5] In the year, 2018 the total number of organs retrieved were 29 from eight donors and following the introduction of the TPM model, the number of organs retrieved increased to 55 from 19 donors in the year 2019 and seventy from 21 donors in the year 2020 showing a steady increase in deceased organ donation as well as organ utilization.[6] DTI is a nonprofit organization which mission is to advise and support international public and private health-care entities to design, develop and strengthen networks, programs, services, and research projects in the field of organ donation and transplantation. Two doctors from Kerala, one from a multi-specialty hospital in the private sector with a Kidney and Liver Transplant Centre in Trivandrum, and another from a government medical college in Trivandrum underwent training as TPM from the DTI Foundation training program in Barcelona.[7] DTI also conducted an advanced TPM training and simulation workshops in brain death diagnosis, donor maintenance, family approach for donation request for intensive care doctors in both private and government sectors. They were instrumental in the establishment of organ donation units (ODU) in various tertiary care hospitals in Kerala.

The ODU headed by TPM is composed of ICU doctors, nurses, and a counselor with well-defined roles and responsibilities within the donation process. Besides, the ODU teamwork in collaboration with nursing supervisors of various ICUs in trauma care, stroke unit, and emergency departments.

The cornerstone of the success of the ODU team was early and proactive identification of potential donors. Patient in ICU with severe irreversible neurological damage with Glasgow Coma Scale <4, Intubated, ventilated, and end-of-life care status form the various components of the GIVE protocol. The identified patients will be monitored and followed by the TPMs. If indicated the potential organ donors are transferred to the ODU for optimization and maintenance for satisfying the prerequisites for death certification by neurological criteria as stipulated in the Transplantation of Human Organ and Tissues Act.[7] Once death determination is complete as per the legal statute, family is approached for organ donation or termination of care. The ODU team together with the primary physician approaches the family and breaks the bad news, deliver grief counseling and offer the opportunity for organ donation. After the family consent for organ donation, Kerala Network for Organ Sharing (KNOS) is informed for organ retrieval arrangements and organ allocation, including organ transport to recipient hospitals. The entire process of donation is shown in [Figure 1].
Figure 1: Donation after brainstem death pathway

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The detailed standard operating procedure of the deceased organ donation program in our state is as described below. The clinical evidence of an acute central nervous catastrophe which is compatible with a clinical diagnosis of brain death should be established before subjecting a person to further tests for evaluating brain stem death. Then the medical practitioners should have a conversation with the near relatives regarding the medical status and prognosis of the patient in whom brain stem death testing including apnea test is being considered. The assessment of brain stem reflexes should be done using a series of tests including apnea test, which are to be repeated after an interval of 6 h by a panel of four doctors which are empanelled by the appropriate authority. A neurophysiological or imaging study to prove the absence of electrical activity or blood flow should be carried out if the treating team or panel of doctors who are certifying are in doubt of the diagnosis of brain stem death. After completion of the tests by the panel of medical experts, if the criteria for brain stem death are met, the committee must declare the patient brain dead. The family member is informed about the confirmation of brain stem death and given options regarding organ donation or termination of care.[8]

Following the initiation of TPM in various hospitals across Kerala, when compared to last year, the organ donation improved, and it seemed to be unaffected by the COVID pandemic [Figure 2].
Figure 2: Comparison of organs harvested in 2019 and 2020

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  Kerala Network for Organ Sharing Top

KNOS work as a public, private interface organization responsible for organ allocation, ensuring transparency and accountability in organ donation and transplantation. They help to foster the trust of the public and counter-allegations of profiteering from transplants. In Kerala, the organ allocation principle followed is different from the rest of the world that the preference of organs is given to the hospital, which identifies the donor and one kidney is shared with the government hospital. This organ allocation system provides an incentive for the hospitals to identify brain dead donor and mobilize deceased donation, which may help to overcome the abysmally low organ donation rate in our country. KNOS conducts periodic education programs for increasing awareness about brainstem death and organ donation to the public as well as health-care providers.

  Delinking Death Determination from Organ Donation Top

At present, the determination of brain stem death for the declaration of death in India is a clinical practice followed only in the context of organ donation. It has still not evolved into a standard clinical practice in ICUs for determination of death. The probable explanation for this could be that, in India, the declaration of death by the determination of brain stem death is mentioned only in the Transplantation of Human Organs and Tissues Act, 1994.[9] The lack of uniform code of Indian practice guidelines in brain stem death diagnosis and aftercare of those individuals who are not organ donors are the most critical hurdles in bringing the determination of death using neurological criterion into standard clinical practice.

In the early part of this year, the government had brought out an order delinking brain death declaration from organ donation, which gave families the precise options of termination of ICU care or organ donation.[10] The executive order which delinked death determination from organ donation might have given the impetus to the deceased organ donation process in the past few months. Instructions were given to all ICUs in the state to identify the potential organ donors using the GIVE Protocol and to discuss the option of organ donation to the family of every potential donor.

  Conclusion Top

Transplantation supports social cohesion as transplants are the only surgeries that begin in acts of altruism – individuals positively affirm their desire to donate and help others. The establishment of ODUs headed by TPMs, Government-run Networking Organization coordinating transplant activities in a public–private partnership model formed the basis of the success of the deceased donation transplantation program in our state.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Abraham G, Reddy YN, Reddy YN, Shroff S, Mathew M, Saravanan S. Evolution of deceased-donor transplantation in India with the decline of commercial transplantation: A lesson for developing countries. Kidney Int Suppl 2013;3:190-4.  Back to cited text no. 1
Mañalich R, Paez G, Valero R, Manyalich M. IRODaT: The international online registry for organ donation and transplantation 2007. Transplant Proc 2009;41:2030-4.  Back to cited text no. 2
Yoshikawa M, Yoshinaga K, Imamura Y, Hayashi T, Osako T, Takahashi K, et al. Transplant procurement management model training: marked improvement in the mindset of in-hospital procurement coordinators at Hyogo prefecture, Japan. Transplant Proc 2016;48:2437-41.  Back to cited text no. 3
Istrate MG, Harrison TR, Valero R, Morgan SE, Páez G, Zhou Q, et al. Benefits of transplant procurement management (TPM) specialized training on professional competence development and career evolutions of health care workers in organ donation and transplantation. Exp Clin Transplant 2015;13:148-55.  Back to cited text no. 4
Transplant Procurement Manager Appointment, Government of Kerala. Available from: https://kerala.gov.in/documents/10180/0f16d101-0424-499e-a984-2143a9653c13. [Last assessed on 2020 Sep 03].  Back to cited text no. 5
Available from: http://knos.org.in/. [Last assessed on 2020 Sep 03].  Back to cited text no. 6
Manyalich M, Cabrer CA, Garcia-Fages LC, Valero R, Salvador L, Sanchez J. Training the transplant procurement management (TPM) coordinator. In: Organ Shortage: The Solutions. Netherlands: Springer; 1995. p. 191-5. Available from: https://link.springer.com/chapter/10.1007/978-94-011-0201-8_25. [Last accessed on 2020 Jul 08].  Back to cited text no. 7
Available from: http://knos.org.in/pdf/7-2020-BRAIN-STEM-DEATH-CERTIFICATION-GUIDELINES.pdf. [Last assessed on 2020 Sep 03].  Back to cited text no. 8
Ministry of Law, Justice and Company Affairs (Legislative Department) New Delhi; 1994. p. 1-13.  Back to cited text no. 9
Gracious N, Jose VR. Certification of brain stem death in India: Medico-Legal perspectives. Amrita J Med 2020;16:71.  Back to cited text no. 10
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  [Figure 1], [Figure 2]


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