Status of renal transplant in India--May 1994.VN Acharya
Keywords: Human, India, Kidney Transplantation, trends,
The concept of organ transplantation as a therapy for replacement of non-functioning organs began in India, originated in mythological medicine in the twelfth century B.C. Lord Ganesh, is popular in this part of the world, revered as a God of wisdom and vanquisher of obstacles, is an example of the very first xenograft performed by Lord Shiva using an elephant's head. This Aryan legend in the Rig Veda has been followed by several similar examples in many other civilizations round the world involving use of limbs, heart and the spirit.
This mythical timeline lasted upto second century B.C., when Sushruta, our ancient Indian surgeon introduced the surgical timeline of transplantation by using skin autografts for rhinoplasty. Several Greek, Italian and other surgeons from many other parts of the world followed suit. Their efforts provided a tremendous insight into the likely surgical problems to be encountered in organ transplantation including the anastomosis of blood vessels. All aspects of surgical technique were mastered by generations of surgeons, extending over a prolonged period lasting almost upto the 17th century A.D. The immunological timeline was heralded by the discovery of he co-dominant major histocompatibility gene complex that controlled transplant survival between inbred mouse strains. The recognition by body cells of "self from non- self" and attempts to overcome the same, has been the greatest advance noticed in the Immunological Timeline of transplantation. Immunosuppression and Tolerance Timelines of the twentieth century succeeded the immunological timeline.
In keeping with progress made in the rest of the world, in India too, attempts were made towards human organ transplantation. In the immunosuppressive timeline, initial experimental kidney and liver transplants were attempted in dogs by Dr. PK Sen and his team from King Edward VII Memorial Hospital from Mumbai in the 1950s. The first ever human kidney transplant performed in India was done at the King Edward Memorial Hospital at Bombay in May 1965, using a cadaver donor in a non-renal failure patient who had had hypernephroma. The second kidney transplant in April 1966 - a cadaver donor once again - was carried out by the same team in a case of chronic renal failure. This was followed by a similar cadaver transplant by Dr. Udupa and his team from BHU Varanasi. The detailed report of these first two transplants have been published in the Indian Journal of Surgery in February 1967. The first patient, mentioned above, died, on the 11th post operative day following acute myocardial infarction, with a functioning graft. The second patient died on the 3rd post operative day due to bilateral pneumonic consolidation.
The first successful Live Donor renal transplant in India was done at the CMC Hospital, Vellore in January 1971. Johny and Mohan Rao reported an account of their first five successful renal grafts in Indian Practitioner in July 1972. Though this was almost 17 years after the first “identical twin” transplanted by Murray et at in 1954, a successful start had been made in the field of human renal transplantation in India by the Vellore team. They concluded that renal transplantation was feasible in India and has a definite future. They had however warned that inadequately and improperly planned attempts at transplantation might lower the morale of the patients, as well as the public. Since then several thousand transplants have been done in our country, but in the absence of a proper registry, it has been impossible to ascertain the exact number of transplants done so far in India.
As more and more transplants were being performed the problem of nonavailability of suitable donors from amongst the family members has been felt by clinicians treating such recepients. As reported by Muthusethupathi and his team from Madras at the Nth ISOT meet held at Bangalore in 1992, out of 616 eligible ESRD patients who had 450 (73%) potential related donors, only 217 (35%) were found fit. Amongst them, only 148 (24%) ultimately donated their kidneys for their related recipients. With such a reality, clinicians have been made to look for other alternatives. With the introduction of cyclosporin in 1983, transplantation from not so well matched donor has become a practical feasibility. The results of cadaver donor transplants too, done in the western world, have improved to the same levels as those obtained from live related donors, in short term studies of 5 years.
Having realised the potential of such transplants an attempt was made to formulate and legislate the use of cadaver kidneys for the first time in India in the state of Maharashtra to which Bombay belongs. This law designated as “Maharashtra Kidney Transplantation Act of 1982” was passed in December 1982. However, it became impossible to implement the same in view of the absence of "Brain Stem death" criteria in this law. This needed a specific set of rules to be made for the purpose. Meanwhile, as the problem of inadequate availability of donors from amongst the family members was mounting, some clinicians started using kidneys from unrelated donors for the said purpose. Thiagarajan and Ready have by now reported their experience of more than thousand cases done by them so far, with some measure of success. However, in our impoverished developing world this has lead to commerce and trafficking in human organs with "market forces" taking over with resultant trading in human organs.
While perhaps most of us along with others from countries abroad do not condone this commerce, there are individuals and groups both professional and lay who do not see any objection to such a practice and openly advocate the same and quote their results on the recipients demonstrating their successes. However there are many, who have been indulging in this commerce surreptiously. These clinicians remain in their dens behind a veil of secrecy, concealing their actions.
Most of their donors come from a strata of society where their health and nutrition are already compromised due to economic stringency. Hence, removal of organs from them is likely to further impair their health and functional integrity. Many of these donors are not even properly investigated for transmissible diseases like hepatitis, AIDS, malaria and others.
There is no doubt about the excellent technical and medical expertise available in the country as offered by many of the dialysis units and the nephrologists and transplant surgeons. The impact of this practice is adequately corroborated by the fact that several foreign nationals from neighbouring countries are attracted to this country where they obtain their renal transplants at a price, which is definitely cheaper than anywhere else in the world. This has given scope to development of an intricate system of brokers, middlemen and blatant commercialisation in organ donation. Many such transplants are done now in centres, which are set up by untrained staff, using old fashioned decrepit equipments in private “back street” dialysis centres. These have had their encouragement from the reports of people like Thiagarajan and Reddy from Guest Hospital from Madras who presented their preliminary observations on results of their first 350 unrelated live donor transplants in August 1989 at a Congress on "Ethics. Justice and Commerce in Transplantation - A Global Issue" held at Ottawa in Canada and advocated the concept of "Rewarded Gifting". These well meaning clinicians firmly believe that living unrelated donation is a lesser evil than the death of a young recipient. They thought it was beneficial in an unusual sense – i.e. the donor and the recipient both benefit from the transaction and in the absence of cadaver donor programme paid donors should be allowed to be continued.
This attitude has had its ill effects, which have left their mark on society, resulted in exploitation and compromised the transplantation programme.
It has been proposed that - an individual is free to donate his kidney and for a price, sell of his labour or other services, - hence why should society object? There are grave dangers, in such a proposition, to the value system in our social structure. It directly puts in the value system of an individual in need and his methods of fulfilling the need versus the value system of the organised society. The freedom of an individual to behave as he likes is always circumscribed by the greater good of social morality. The members of the society see an opportunity to make short lasting easy money by selling not only a kidney but many other paired organs like eyes, lungs, etc. This can lead to the replacement of the ethical concept of "Intrinsic Value" of the human organism by that of the concept of "extrinsic value" of the body or its parts as a "saleable and marketable commodity" with a price structure dictated by market forces.
This is totally against the grain of maintaining a human beings autonomy and dignity. We as the learned members and likely leaders of the society should never be responsible for such an untoward impact on the society as a whole for a very short term gain that one is likely to achieve as individuals in the society.
The exploitation that occurs in such a transaction should be of grave concern to the society. The most despicable of these is that by the broker or the middlemen. In their initial efforts at the unrelated donor programme Thiagarajan et al at the Guest Hospital - Madras used 2 brokers in 1984-85 to find out donors and one Mr. Selvia supplied 10 donors in the early stages of the programme making an estimated Rs.14000 per case. These are allegedly registered brokers in Madras as reported by Dirs. Robert Selies and Abdulla Dhar of the "Ethical Committee of the International Society of transplantation" to the President of the Council of Transplantation Society in January 1990.
However, Guest Hospital stopped using brokers after their first 20 cases. Nevertheless such brokers have now become a common phenomenon in several other cities in India, making the gullible and illiterate public believe that it offers a golden opportunity to make money for satisfying their daily needs. Several of us as nephrologists continue to receive letters from members of the learned public who think that they can do the same without the help of middlemen if they contact us directly. They feel very indignant when they realise that we as nephrologists are not going to be of help to them, Long-term followup for such donors hardly exists. As reported by Dr. Mani et al from Madras recently in the Indian Journal of Nephrology, even in live related donors, there is a danger of morbidity to the tune of 6.04% in these subjects on long term followup, but with good family support these have been adequately manageable. However, the unrelated donor has no such support and though Reddy et al in their scheme of "Rewarded gifting" have offered them insurance cover for the first three years, their long term follow up is hardly available. Moreover the spread of knowledge that such a "rewarded gifting" has been made feasible has led to a belief that this could be used as an easy means of making much sought money for their needs as exemplified by Vileevakkam village in Tamil Nadu. There every family has at least one member who has donated his kidney for a very short-term gain. Moreover, our own work at the King Edward Memorial Hospital which was presented at the IVth ISOT meeting at Bangalore in 1991 has revealed a state of hyperfiltration in these donors which has a predictable morbidity of developing chronic renal failure over a 20 year period if no active measures are taken to prevent the same. I still shudder at the thought of the possibility of several such villages springing up all over the country in the next three decades. Is it not our mandatory responsibility to think of long term ill effects of our actions to the society at large? We must exert ourselves to prevent such occurances.
Moreover, the recipient who can afford to pay is the one to exploit the situation. It has been argued that a poor man needs the money and the rich man has it to give and hence a little redistribution of wealth is made. It's in fact a redistribution of health from the poor, who can ill afford it, to the rich. The social inequality of such a proposition is very evident. Besides this, the dangers of extortion and blackmail can get built into such situations posing a greater danger of criminalisation in an organised seller.
The commercialisation mentioned above first and foremost is likely to have a deleterious effect on the most successful and viable programme of genetically related live donor transplantation. Secondly, the other viable alternative and most vitally needed cadaver transplant programme is likely to be hindered if professionals and Society take the easier way out by buying or selling kidney. The need for Cadaver donation programme is crying out aloud in our country. Moreover, our religions encourage such donations as a "supreme act of sacrifice after death which leads one on the pathway to heaven".
Developing a viable cadaver transplant programme needs suitable legislation to not only make organs available, but also protect the medical profession. The absence of such a suitable legislation in our country has lead to an entire new "Business of Trafficking in human organs, by a well established network of needy patients, financially needy donors from essentially poor socio-economic strata of society, middlemen, agents and some unscrupulous clinicians too. This has now taken international dimensions with advertisements such as "Asian Transplant- cum holiday package Deal" being noted in the foreign media. Here again, the recipients are affluent ones from Europe, North America, Middle East and Singapore. The donors being essentially from poorer countries of Latin America, Turkey, India, China and other Asian countries.
Recently, an article written by KC Reddy from Madras in the National Medical Journal of India on "Should paid organ donations be banned in India? To buy or let die" has put forth several arguments, the first and the foremost of which is that there is no cadaver programme in the country. If this be so, it's our mandatory responsibility to see that this is made feasible by helping enact a suitable law for the purpose. A comprehensively studied draft legislation called “Human Organ Transplant Bill” which was approved by the Central Cabinet in 1992 and discussed and passed in the Rajya Sabha last year in May 1993, is awaiting its passage by the Lok Sabha.
The said bill was referred to a "Select Committee" of members of Parliament for further scrutiny and approval before being brought for discussion in Parliament this year.
The Indian nephrologists and Surgeons have long since declared their objectives of Cadaver organ donation as the first fine of treatment for ESRD patients as per resolutions passed by Indian Society of Organ Transplantation, Indian Society of Nephrology and Urological Society of India. If we have to achieve these objectives, an all out effort must be made to prevail upon our members of Parliament to discuss all aspects of this legislation on "Human organ Transplantation in our country. It should help legalise cadaver donation by approving the "Brain Stem Death Criteria". It should also open the doors for ethical practice of organ transplantation. The passage of such a bill will only be a beginning of our long struggle to achieve successful results in our endeavour to make Cadaver organ Transplant programme a reality and our Dream come true.