Cadaver transplant of Human Organs Dr Rajesh Bharani

Cadaver transplant of Human Organs Dr. Rajesh Bharani

What is Organ donation? Organ donation is the process of removing tissues or organs from a live, or recently dead, person to be used in another. The former is the donor and the latter is the recipient. People of all ages can become donors.

NEED OF THE HOUR In India 10 Lakhs need Organ Donation

Organ Donation Type of donors Some organs can be donated by a living person Almost all organs can be donated by someone dead but this has to reach the recipient within a few hours after the donor's death. In case of live donation the donor should give his consent. In case of cadaver donation, relatives need to provide consent.

Voluntary Donation Organ Donation Everywhere organ donation is voluntary Two voluntary systems include – 1. Opt In - Where the donor gives consent 2. Opt Out - Where anyone who has not refused is considered as a donor In India we have the Opt in system, while many western countries practice the opt out system

Organs for Donation Skin and Bones Some of the organs that are commonly donated …,

World Status of Transplants Annual Number of kidney transplantations per million population (pmp) per year USA - 52 Predominantly Cadaver Donors Europe -27 Predominantly Cadaver Donors Asia - Predominantly Living Donors 3 In last 10 to 15 years the rate of both kidney and liver transplants have increased but heart has remained static. In 2000 approx. 15, 000 kidneys were transplanted in each region.

Transplantation Live Majority No waiting Less time on dialysis Needs from Family members only ◦ Blood group constraints ◦ In diabetics and Family diseases difficult. ◦ ◦ Cadaver ◦ Occasional ◦ In families with familial disease and blood group incompatibility this is the solution ◦ Small families ◦ Will help many patients who will otherwise live on dialysis

Live donor vs. cadaver donor Living or Deceased Donor Kidney Transplantation: A Comparison of Results and Survival Rates Among Iranian Patients ◦ Living donor kidney transplantations showed comparable graft survival and acute rejection rates compared with those from deceased donors Transplantation proceedings 2009: 41: 2772 -4

Current status 10% of willing and affording renal failure patients gets Transplant Non availability of donor.

Historical Aspects – Cadaver Transplantation - India 1967 - First successful cadaver Kidney Transplant in India at KEM Hospital, Bombay 1994 - First successful heart transplant done at AIIMS, N. Delhi 1995 - First successful multi-organ transplant done at Apollo Hospital, Chennai 1998 – First Successful Lung transplant, Madras Medical Mission Hospital, Chennai 1999 – First Pancreas Transplant, Ahemdabad

Cadaver donor Types- Somatic death ◦ Home – Eyes, Skin ◦ Hospital- Eyes, Skin, Bone Brain death – Kidney, Liver, Heart, Lung, Intestine, Pancreas

DONATIONS BEFORE DEATH ( Live) • BLOOD • KIDNEY • LIVER (1/4)

Body Donation V/S Organ Donation Each Body Donation – 10 -15 medical students benefited Each cadaver organ Donor – 50 persons benefited

Problems with Cadaver Organ Donation Programme in India Community Problem No Awareness of “Brain. Death” Concept, Misconcepts Hospital problem No efforts to identify & maintain “Brain Dead” donors Govt. Problem No Funding for programme No Interest Spain has the highest number of brain death patients going on to organ donation – 32 per million population

Dealing with community problems

Mass education by all possible medium.

Role of Media & Organ Donation ◦ The power of the press can also be demonstrated in the so-called "Nicholas Green effect. “ ◦ Nicholas was a 7 -year-old American child, shot dead by bandits in Italy in 1994 ◦ His parents agreed to donate his organs ◦ Italian press reported it extensively ◦ The positives impact kick started the Italian cadaver programme

Project Positive Aspects Many donor relatives have stated that donating their loved one's organs does not make the pain of their death disappear Bereaved families can experience comfort that their loved one's gift gave another person a second chance at life

Encouraging People to Discuss Organ Donation When the wishes of the deceased are not known, only 50% of people will agree to organ retrieval from their relatives No disfigurement of body Rituals possible Encouraging people to speak about organ donation and transplantation and to make their wishes known to their relatives could change the picture resulting in 93 -94% of people allowing donation Initiation by Eye and Skin Donation

Hospital and Doctors related Problem

Under-reporting of Brain death There is underreporting of brain death cases. Neurologists and Neurosurgeons have to take lead In Tamilnadu- Declaration of braindeath has been made mandatory in medical colleges. G. O. No. 75 dated 03. 2008.

Hospital Infra-Structural & Support Logistics Adequate No. of Qualified Intensivists in ICUs Qualified Trained transplant Co-coordinators Well qualified Surgeons to undertake Retrieval & TX Transport of organs –between cities Support Organisation to Network HLA Tissue typing and Cross-match

Cadaver Transplants Scene in M. P. – The Way Forward The Way Ahead

The Way Forward Education of Doctors, Health care workers regarding THOA Education of Society regarding organ donation and concept of Brain Death. Media support Government support Strengthen the Transplant Network. Transport facilities for organ donor Establish a common programme. Initiatives to promote concept and making some changes as done by Tamilnadu government ◦ Start sharing organs that are not used locally ◦ ◦

Institutional changes Employing and training more transplant councilors-coordinators. Regular Courses to impart expertise to the councilors-coordinators Training and sensitizing ICU staff on braindeath. Proactive steps to promote Programme. Help in educating public by all means. Think beyond business

Organisation helping with organ donation & Transplant programmes in India MOHAN Foundation (INOS) - Tamil Nadu, Andhra Pradesh, Maharastra 236 Organs shared. ( 212 -Kidneys, 9 -Hearts, 15 -Liver ) 236 Organs shared FORTE, BANGALORE – 32 Organs Shared ( 32 - Kidneys, 1 - Heart, 1 - Liver ) ZTCC, Mumbai – 55 Organs Shared - all kidneys ORBO, N. Delhi – Few organs shared SORT, Cochin – 4 organs shared

Consent for Donation Pre-mortem – via Donor Cards, Driving License Consent of his family following death Some form of a combination of the two are necessary ‘Supererogatory permission’ - Underlying premise of such a consent would be that “organs of dead people are public goods”, and donation must be considered “similar to other compulsory civil obligations” within society ◦ The permission is a moral rather than a legal requirement

Consent of Donation For cadaveric donation “society remains a crucial aspect in a transplant programme” Strategies to decrease refusal rates by families include efforts at education ◦ ◦ the general population, Religious heads & opinion leaders health care workers individually through the mass media

Consent for Donation At the time of issuing driving license, filling form for other government schemes like Adhar Card. Government help and determination needed

Promote Organ Donation Among Blood, Skin and Eye Donors Study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an Donor card than general public. It would be useful to design promotion programs to facilitate blood donor and families of Skin and Eye donors participation in organ donation. Social Appreciation for donors and their families

Presence of Family Member During Brain Death Testing Most families faced with brain stem death of a relative find the concept difficult to understand have trouble in accepting that their relative is actually dead Family members were given choice to be or not to be present during brain stem death testing It is suggested that presence of family members during brain stem death testing not only helps families to accept this concept of death but also promotes the grieving process The presence of family during brain stem death testing. Intensive Crit Care Nurs. 2004 Feb; 20(1): 32 -7 Doran M.

Required Request Law Requires that formal request for organ donation be made of the families of all potential donors in the ICU. ◦ The rationale is that a statutory approach would overcome hesitancy by healthcare professionals at a time of such emotional distress. Required Request Law has been introduced into many states in India by legislation to improve organ donation.

ORGAN DONATION RATE Current organ donation rate - India is 0. 05 per million population per year If in India - 1 per million donation rate we would have 1100 organ donors – 2200 kidneys, 1000 hearts, 1100 Livers, 2200 Eyes At 3 per million Donation rate we would have 3300 organ donors – 6600 kidneys, 3300 hearts, 33001 Livers, 6600 Eyes At 10 per million donation rate- 11, 000 organ donors 22, 000 kidneys, 11, 000 hearts, 11, 000 Livers, 22, 000 Eyes 20 per million donation rate - 22, 000 organ donors 44, 000 kidneys, 22, 000 hearts, 22, 000 Livers, 22, 400 Eyes Source: Indian Transplant Newsletter Issue no. 19 Feb 2006

Retrieval Surgery This can be performed only at centers approved for Transplant surgery. Retrieval time -2 to 4 hours Problem◦ Need to shift brain death person from one hospital to other. ◦ Loss of organs from small center and peripheral centers.

Retrieval Surgery Tamilnadu government introduced a law by which they approved all hospitals in state with bed more than 25 an OT and ICU as NON TRANSPLANT ORGAN RETRIVEAL CENTRES ( NTORCs) NTORC works in collaboration of Transplant center for all procedures from declaration of brain death to removal of organs.

Retrieval Surgery & Packing of Organs Standardize retrieval techniques CD be made on kidney Retrieval to be circulated to all the hospital. Packing of organs being standardised for transportation Education and training of coordinators and

What is Required NGO or Groups involved in Organ donation in any part of the M. P. have to tackle various issues in the field of cadaver organ donation and transplantation simultaneously More Support groups with common objectives are needed More resources necessary to Kick start such an Initiative like cross match lab

Need of time Formation of state level coordination committee to streamline project SOP for declaration to transplantation Common waiting list of patients Common lab for Cross match of tissue Proper format for unbiased distribution of organ. Committee should decide for best possible recipient for said organ All center should work under committee

Cadaver Transplant - Conclusion Organ Shortage is a Crisis, however the Crisis has a Cure Ø In india we need to Network and start thinking of sharing resources, expertise and organs Ø Set up Collaborative projects Ø Use Media for Promotion Ø Get Religious heads to Participate Ø Have Transparency in programme Ø Set up regional Transplant coordinators Forums

THANK YOU In my end is my beginning - T. S. Eliot, Four Quartets