Legal and ethical aspects of organ donation and transplantation

Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement

This position statement is documented based on the input from all contributing coauthors from the Indian Society of Critical Care Medicine (ISCCM), following a comprehensive literature review and summary of current scientific evidence. Its objective is to provide the standard perspective for the management of potential organ/tissue donors after brain death (BD) in adults only, regardless of the availability of technology. This document should only be used for guidance only and is not a substitute for proper clinical decision making in particular circumstances of any case. Endorsement by the ISCCM does not imply that the statements given in the document are applicable in all or in a particular case; however, they may provide guidance for the users thus facilitating maximum organ availability from brain-dead patients. Thus, the care of potential brain-dead organ donors is "caring for multiple recipients."

How to cite this article

Zirpe K, Pandit R, Gurav S, Mani RK, Prabhakar H, Clerk A, et al. Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement. Indian J Crit Care Med 2024;28(S2):S249-278.

Assessment of Knowledge of Legal Provisions on Organ Donation and Transplantation amongst Healthcare Workers in Nigeria: A Cross-sectional Study

BACKGROUND

Advancements in the medical field have made organ transplantation an attractive treatment option for patients when indicated. Shortage of organs and commodification of organs are major challenges encountered in organ donation and transplantation. These could potentially breed unethical practices, if the process is not well regulated.

AIM

The aim of this study was to assess the knowledge of healthcare workers (HCWs) on the legal provisions regulating organ donation and transplantation in Nigeria.

METHODOLOGY

This cross-sectional study was conducted amongst physicians and nurses across Nigeria. Knowledge of legal provisions on organ donation and transplantation was assessed using a validated questionnaire that had 21 questions derived from the National Health Act. Each correctly answered question was given 1 point with a total obtainable score of 21 points. A score of ≥14 points was classified as good knowledge. P <0.05 was considered significant.

RESULTS

A total of 836 physicians and nurses with a mean age of 37.61 ± 9.78 years participated in the study. Females and physicians constituted 53.3% and 62.9% of the respondents, respectively. The mean knowledge score of the respondents was 9.70 ± 2.91 points. Eighty-three (9.9%) respondents had a good knowledge score. There was a significantly higher proportion of male HCWs (P < 0.037) and older HCWs (P = 0.017) with good knowledge of legal provisions. On logistic regression, age was the only factor found to be associated with good knowledge of legal provision (adjusted odds ratio: 3.92; confidence interval: 1.33-11.59; P = 0.01).

CONCLUSION

The overall knowledge of legal provisions on organ donation and transplant was very poor amongst HCWs in Nigeria. There is a need to educate them on these provisions to curb unethical practices.

The psychology, legality, ethics and medical aspects of organ donation by minors

Any individual who has not attained the chronological age of legal majority as per national law is termed a minor. The concept of living donation (LD) has always been a subject of ethical debate and further compounding the controversy is the question of LD by minors. The decision for a minor to donate poses a special challenge as it involves a close family unit of parent-child relationship. Such an emotionally loaded situation wherein questions of attachment, perceived duties, moral obligation are likely to cloud a truly informed consent on the part of the minor to donation, who may find themselves in a vulnerable position. Furthermore, a minor's cognitive ability to comprehend the gravity of LD and when required defy parental coercion need to be elucidates before a minor is accepted for LD. Experts have set out stringent conditions which need to be met prior to the exceptional circumstance that a minor is considered for organ donation. Such donations should require parental permission, child's assent and the involvement of a paediatric-trained donor advocacy team. This article debates the question of minors acting as live donors from ethical, medical, psychosocial and legal viewpoints with an aim to present internationally defined circumstances when a minor may morally participate as a LD, thereby laying the foundation for future deliberations in this regard using traditional metrics to juxtapose divergent courses of action.

A Cross-Sectional Study on Knowledge and Attitudes About Organ Donation and Transplantation in an Urban Population in a Low-Income Country

BACKGROUND

Uganda's Health Sector Development Plan (2015/16 through 2019/2020) noted that most referrals for treatment abroad were for organ transplant services that cost the government >5.6 million USD. The government of Uganda has invested in building the capacity for organ donation and transplantation services by training human resources personnel and setting up infrastructure in Kampala, where these services can be accessed. However, there is no information on the readiness of communities and the scientific community to embrace (communities) or undertake (science) organ transplantation in the country. We set out to assess knowledge and attitudes about organ donation and transplantation among the urban population in Kampala.

METHODS

We conducted a cross-sectional survey among 395 participants from the urban population of Kampala at Garden City Mall, Wandegeya market, and Nakawa market from 28 May through 7 June 2021. We asked about knowledge of organ donation and transplantation, collected sociodemographic data, and performed a sentiment analysis of participants' attitudes toward organ donation and transplantation.

RESULTS

The M:F ratio of participants was 1:1; the majority (55.9%) of participants were Baganda, two-thirds of participants knew about organ donation, and 90% of participants did not know of any government policy on organ donation and transplantation. Radio/television was the most common source of information, and the kidney was the most frequently transplanted organ. Overall, there were 94.3% and 93.2% positive sentiments toward organ transplantation and organ donation, respectively. The need for stricter laws governing organ donation and transplantation, corruption, and fear were the main negative sentiments expressed by participants.

CONCLUSIONS

Sensitization of the community is required regarding government policy on organ donation and transplantation, and this should be communicated through radio/television and social media. There was a positive attitude toward organ donation and transplantation.

Awareness, Attitude, and Beliefs Regarding Organ Donation Among the General Public in Saudi Arabia

Background

Organ donation is a lifesaving option to rescue many patients with end-stage organ failure from possible morbidities and mortalities. Unfortunately, due to a shortage of donors, many patients suffering from their illnesses are waiting for an organ. This study aimed to determine the awareness, attitude, and beliefs toward organ donation among the Saudi population.

Patients and Methods

This is an online cross-sectional survey that was conducted in Saudi Arabia between July and September 2022. A self-administered questionnaire was distributed to the general public using an online platform. The questionnaire consists of two sections: the first is about demographic data, and the second is about questions to assess awareness, attitude, and beliefs regarding organ donation. The Chi-squared test was used to examine the differences in participants' awareness, attitude, and beliefs towards organ donation. A binary logistic regression analysis was used to identify predictors of a positive attitude towards organ donation.

Results

A total of 3507 individuals participated in this study. Around 68.1% were aged between 18 and 30 years. Twenty-four percent of them knew of the legislative body for organ donation; 58.5% believed that organ donation should be promoted; and 66.1% had a positive attitude toward donating body organs. Younger age (31-50 years), male gender, being unemployed or working in a government job, and being married were factors that decreased the likelihood of having a positive attitude towards organ donation.

Conclusion

Although there was a positive attitude and belief about organ donation, awareness was suboptimal. Younger age, male gender, being unemployed or working in a government job, and being married were factors that decreased the likelihood of having a positive attitude towards organ donation. It is necessary to address the gaps in knowledge, and social media as well as mass media may have an important role in bridging the gaps.

Corneal blindness and eye banking: Current strategies and best practices

Corneal blindness (CB) is one of the leading causes of blindness in India and globally, affecting around 8 million population worldwide. Many of these corneal blind patients may be visually rehabilitated by corneal transplantation (CT). Eye banking plays a crucial role in facilitating CT and ocular research. Many countries have adopted regulatory frameworks, quality assurance programs, and technological advancements to enhance the efficacy and safety of CT. Various infrastructural and organizational frameworks of eye banks (EBs) in India, according to the Eye Bank Association of India (EBAI), aid in establishing guidelines and standards for EB practices. Initiatives such as the National Programme for Control of Blindness (NPCB) have significantly contributed to eye donation rates and improved access to donor corneas. This review article discusses the established eye banking networks in countries such as India, the United States (USA), and Europe, where dedicated EB organizations work collaboratively to ensure efficient procurement, processing, and distribution of corneal tissue. It also highlights specific strategies employed in India and global countries to address EBs' challenges. These challenges include the shortage of donor corneas, improving donor screening and tissue processing techniques, ensuring timely distribution of corneal tissue, and maintaining high-quality standards. Interestingly, the comparative analysis between India and other developed countries highlights the similarities and differences in eye banking strategies. By understanding the strategies employed by different regions, EBs can learn from each other's experiences and work toward achieving optimal outcomes in CT and ocular research worldwide. It underscores the importance of knowledge sharing and collaborative efforts in addressing common challenges and implementing best practices in eye banking.

Transplant: The Success of Renal Transplant Programs

In the absence of malignancy or other severe comorbidity, kidney transplantation offers better survival rates and quality of life than dialysis. Despite this survival advantage, many lower- and upper-middle-income countries do not offer adequate kidney transplant services. This is particularly troubling because end-stage kidney disease often is more common in these countries than in high-income countries and overall is less costly in the life of a patient. We describe the contrasting levels of provision of kidney transplantation in Mexico, India, Nigeria, Ghana, and Zimbabwe, and kidney transplant services for children in Africa.

The immunobiology and clinical use of genetically engineered porcine hearts for cardiac xenotransplantation

A summary of the scientific rationale of the advancements that led to the first genetically modified pig-to-human cardiac xenotransplantation is lacking in a complex and rapidly evolving field. Here, we aim to aid the general readership in the understanding of the gradual progression of cardiac (xeno)transplantation research, the immunobiology of cardiac xenotransplantation (including the latest immunosuppression, cardiac preservation and genetic engineering required for successful transplantation) and the regulatory landscape related to the clinical application of cardiac xenotransplantation for people with end-stage heart failure. Finally, we provide an overview of the outcomes and lessons learned from the first genetically modified pig-to-human cardiac heart xenotransplantation.

Strategies to Improvise Organ Donor Pool: A Study on the Knowledge, Attitudes, and Performance of Higher Secondary School Teachers Towards the Organ Donation

Introduction

This study aimed to assess higher secondary school teachers' knowledge, attitude, and performance levels towards organ transplantation and donation (OTD). Teachers have an essential role in giving knowledge to children and teenagers, and they can influence their views. Organ transplantation offers re-life to many patients, yet organ shortages are a global issue. Teachers who influence students' future attitudes regarding organ donation must have a favorable attitude and genuine knowledge.

Materials and Methods

The research method was descriptive and cross-sectional. The sample size was 372 school teachers in Villupuram district of Tamilnadu, India, selected using a convenient sampling method. A survey questionnaire was used to assess the knowledge and attitude about OTD, the reason for donating/not donating organs. Multivariate analysis was performed to identify critical variables affecting intent to practice.

Results

The teachers' mean scores with SD on knowledge, attitude, and performance were 7.61 ± 2.74, 8.81 ± 2.08, and 0.38 ± 0.11, respectively. The linear regression analysis showed that the knowledge (p < 0.001) and attitude (p < 0.05) of the participants were positively associated with organ donation performance. A significant relationship was also observed between gender (p < 0.036), age (p < 0.01), and education status (p < 0.001) with the performance of the teachers. Lack of family support was the most spelt reason for unwillingness for organ donation.

Conclusion

The positive linear correlations underline that having more information may lead to a more optimistic mindset and, as a result, to better practices. Teachers should be provided with overall health teaching campaigns to increase the number of possible organ donors. Teachers serve as role models for students, families, and society by changing their attitudes.

3D Printing: Advancement in Biogenerative Engineering to Combat Shortage of Organs and Bioapplicable Materials

Abstract

Organ or cell transplantation is medically evaluated for end-stage failure saving or extending the lives of thousands of patients who are suffering from organ failure disorders. The unavailability of adequate organs for transplantation to meet the existing demand is a major challenge in the medical field. This led to day-day-increase in the number of patients on transplant waiting lists as well as in the number of patients dying while on the queue. Recently, technological advancements in the field of biogenerative engineering have the potential to regenerate tissues and, in some cases, create new tissues and organs. In this context, major advances and innovations are being made in the fields of tissue engineering and regenerative medicine which have a huge impact on the scientific community is three-dimensional bioprinting (3D bioprinting) of tissues and organs. Besides this, the decellularization of organs and using this as a scaffold for generating new organs through the recellularization process shows promising results. This review discussed about current approaches for tissue and organ engineering including methods of scaffold designing, recent advances in 3D bioprinting, organs regenerated successfully using 3D printing, and extended application of 3D bioprinting technique in the field of medicine. Besides this, information about commercially available 3D printers has also been included in this article.

Lay Summary

Today's need for organs for the transplantation process in order to save a patient's life or to enhance the survival rate of diseased one is the prime concern among the scientific community. Recent, advances in the field of biogenerative engineering have the potential to regenerate tissues and create organs compatible with the patient's body. In this context, major advances and innovations are being made in the fields of tissue engineering and regenerative medicine which have a huge impact on the scientific community is three-dimensional bioprinting (3D bioprinting) of tissues and organs. Besides this, the decellularization of organs and using this as a scaffold for generating new organs through the recellularization process shows promising results. This review dealt with the current approaches for tissue and organ engineering including methods of scaffold designing, recent advances in 3D bioprinting, organs regenerated successfully using 3D printing, and extended application of 3D bioprinting technique in the field of medicine. Furthermore, information about commercially available 3D printers has also been included in this article.

Assessment of knowledge and attitudes regarding organ donation among doctors and students of a tertiary care hospital

Organ donation is a lifesaving treatment option for patients with end-organ damage. However, many patients are unable to avail this option due to the low availability of viable organs for transplantation. The availability of donor organs can be improved by increasing awareness and resolving organ donation misconceptions among the general population. It can be assumed that healthcare workers are most aware of the value of organ donation. They are also in a position to influence the willingness of the general population to donate organs after death or sign up for an organ donor card. The knowledge and attitudes of current and future healthcare professionals regarding this subject have neither been evaluated nor considered a topic of priority in the existing Indian medical education program.

OBJECTIVES

To evaluate the knowledge, attitudes, and beliefs of licensed medical doctors and undergraduate Bachelor of Medicine and Bachelor of Surgery (MBBS) students and analyze differences between the two groups with respect to the above.

METHODOLOGY

A total of 650 doctors and MBBS students from a Tertiary care hospital were included in the study and subjected to a questionnaire with 11 questions. Responses to the questionnaire were analyzed to evaluate knowledge and attitudes regarding organ donation. Statistical analysis was carried out using IBM SPSS Statistics for Windows, version 24.

RESULTS AND CONCLUSIONS

About 29.9% of doctors and 49.8% of students knew about the law governing organ donation. The concept of brain death was entirely understood by only 31.7% of doctors and 14.7% of students. Only 16% of doctors and 3.2% of students had filled an organ donor card. About 40.9% of doctors and 51% of students favored the opt-out system, as followed by western nations. Fear of illegal selling or purchase of organs was predominant in 61.9% of doctors and 52.2% of students. The current study reveals that the medical fraternity's knowledge and personal responsibility need improvements. However, the system also needs to be improved to win their trust.

Knowledge and Attitudes on Organ Donation From the Perspective of Liver Transplant Patients

PURPOSE

This study was performed to investigate the knowledge and attitudes about organ donation from the perspective of liver transplant patients.

DESIGN AND METHODS

The study was conducted at the organ transplantation clinics. The data were collected by the researchers from 129 participants using in-person interviews.

FINDINGS

In this study, 83% of patients received the organ from live donors, 36% received liver transplants in the previous 1 year, more than 70% agreed to donate their organs, and 80% thought awareness should be raised in society about organ donation.

CONCLUSION

It was found that the participants in the sample needed information on the issue, although the sample consisted of individuals who had experienced organ donation. It is important that nurses and nurse managers understand the level of knowledge and the attitudes of organ donation patients who have undergone liver transplantation. Worldwide, organ donation is not at the desired level. This study aims to enhance in nurses and nurse managers the foresight regarding and awareness about behaviors of transplantation patients.

Study of Knowledge, Attitude, and Practice of Organ Donation Among Medical Students in a Tertiary Care Centre in South India

Introduction The deceased donor renal transplantation (DDRT) program in India has seen its ups and downs. The Indian state of Tamilnadu runs a successful DDRT program. Future doctors play an important role in continuing with this success and hence educating them on organ donation is of paramount importance. Methods We conducted a cross-sectional questionnaire-based study from June 2015 to December 2017 among 480 medical students to analyse their knowledge, attitude and practice regarding organ donation. The validated questionnaire sheets were distributed during lecture hours and completed sheets were analysed. Results Of the 480 participants, 425 completed the questionnaire which is a response rate of 88.5%. Knowledge scores were uniformly low among all four batches of students (p=0.001). The first and third-year students scored better in practice (p=0.001) and attitude (p=0.001) domains. Females outnumbered males by scoring high in all three domains. Conclusion The poor knowledge score among all the batches of medical students is alarming. This implies the need for urgent changes in the medical curriculum to better educate future doctors of the country. Durable changes in practice can be brought about by changing the attitude of medical students.

Brain Death and Management of Potential Organ Donor: An Indian Perspective

How to cite this article: Zirpe K, Gurav S. Brain Death and Management of Potential Organ Donor: An Indian Perspective. Indian J Crit Care Med 2019;23(Suppl 2):S151-S156.

Ethical dilemmas related to living donor liver transplantation in Asia

Living donor liver transplantation (LDLT) has evolved rapidly in Asia with good outcomes for both donor and recipient. Nonetheless, LDLT remains a highly demanding technique and complex surgery. The potential risks to the donors provide the basis for many of the ethical dilemmas associated with LDLT. The transplant team must have a good knowledge of the principles of bioethics in order to handle these matters. To look after the need, donor's safety and the chance for good recipient outcomes, the principles of respect for the donor's autonomy, beneficence, and non-maleficence should be practiced. In accordance with the concept of equipoise, the risk to the donor must balance the benefit to the recipient. The transplant center should have adequate experience and proven expertise in LDLT. There are concerns regarding the validity of informed consent given by the donor. While donations to non-relative patients may, at first sight, indicate radical altruism, it is important to apply careful scrutiny. Though organ trading is strictly prohibited by the law, there seems to be an inherent risk with directed donations to strangers. Transplant tourism has flourished in some countries in spite of the existence of strict laws. There are reservations regarding transplantation done by foreign visiting teams. Donor websites facilitating patients and donors and Facebook pages bear no responsibility for the outcomes of their matches and cannot ensure sufficient and accurate information about donation, transplantation, and post-operation life. Telemedicine and virtual consultations appeared to work better when the clinician and the patient know and trust each other.

Devising focused strategies to improve organ donor registrations: A cross-sectional study among professional drivers in coastal South India

BACKGROUND

In India, annually, 500,000 people die due to non-availability of organs. Given the large proportion of brain death amongst road accident victims, any improvement in organ donation practices amongst this cohort could potentially address this deficit. In this study, we identify the potential areas for intervention to improve organ donation amongst professional drivers, a population more likely to suffer from road accidents.

METHODS

300 participants were surveyed using a structured, orally-administered questionnaire to assess knowledge, attitudes and practices regarding organ donation. Multivariate analysis was performed to identify key variables affecting intent to practice.

RESULTS

Nearly half our participants had unsatisfactory knowledge and attitude scores. Knowledge and attitude was positively correlated, rs (298) = .247, p < .001, with better scores associated with a higher likelihood of intent to practice organ donation [AOR: 2.23 (1.26-3.94), p = .006; AOR: 12.164 (6.85-21.59), p < .001 respectively]. Lack of family support and fear of donated organs going into medical research were the key barriers for the same [AOR: 0.43 (0.19-0.97), p = .04; AOR: 0.27 (0.09-0.85), p = .02 respectively].

CONCLUSION

Targeted health-education, behaviour change communication, and legal interventions, in conjunction, are key to improving organ donor registrations.

Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the End of Life: The Indian Council of Medical Research Commission Report

BACKGROUND

Indian hospitals, in general, lack policies on the limitation of inappropriate life-sustaining interventions at the end of life. To facilitate discussion, preparation of guidelines and framing of laws, terminologies relating to the treatment limitation, and providing palliative care at the end-of-life care (EOLC) need to be defined and brought up to date.

METHODOLOGY

This consensus document on terminologies and definitions of terminologies was prepared under the aegis of the Indian Council of Medical Research. The consensus statement was created using Nominal Group and Delphi Method.

RESULTS

Twenty-five definitions related to the limitations of treatment and providing palliative care at the end of life were created by reviewing existing international documents and suitably modifying it to the Indian sociocultural context by achieving national consensus. Twenty-five terminologies defined within the scope of this document are (1) terminal illness, (2) actively dying, (3) life-sustaining treatment, (4) potentially inappropriate treatment, (5) cardiopulmonary resuscitation (CPR), (6) do not attempt CPR, (7) withholding life-sustaining treatment, (8) withdrawing life-sustaining treatment, (9) euthanasia (10) active shortening of the dying process, (11) physician-assisted suicide, (12) palliative care, (13) EOLC, (14) palliative sedation, (15) double effect, (16) death, (17) best interests, (18) health-care decision-making capacity, (19) shared decision-making, (20) advance directives, (21) surrogates, (22) autonomy, (23) beneficence, (24) nonmaleficence, and (25) justice.

Altruism and Religion: A New Paradigm for Organ Donation

Activity of NGO's supporting living donor kidney donations can affect the shortage of kidneys. Matnat Chaim is a Jewish orthodox organization active in Israel since 2009. This is a voluntary organization with aims to shorten and eliminate the waiting list for kidneys. Since the beginning of its activity, it has said to play a key role in 379 kidney transplantations. In 2015, out of 174 live donor kidney transplantations that took place in Israel, Matnat Chaim had a key role in 88 of them (50.6%). We found some ethical issues concerning the organization's activity. The donor can restrict his or her donation to specific characteristics of recipient which can result in organs transplanted in a homogeneous group of the population. Another issue is the question of whether nudging people to kidney donation takes place and whether it is valid to do so. We found that Matnat Chaim does a great deal for promotion and intermediation of kidney donations in Israel. This form of promotion can be implemented by other organizations and countries.

Knowledge and Attitude Regarding Organ Donation among Medical Students

Introduction. All over the world people on organ transplant waiting lists die due to shortage of donor organs. The success of organ donation program needs education of the population regarding organ donation for which healthcare professionals are most suitable. The present study was taken up to assess the knowledge and attitude of 1st, 2nd and 3rd year medical students about organ donation. Methods. A specially designed self-administered questionnaire was distributed amongst all willing 1st, 2nd and 3rd year medical students at our Medical College and later analyzed statistically. Results. A total of 157, 145 and 92 students from each year of medical education respectively gave their consent for participation in the study. Awareness regarding organ donation was found to be 98.7-100%, 69.4% claimed television as their source of information regarding organ donation and 46.7% stated that it is possible for patient to recover from brain death. The awareness regarding eye, liver, heart and kidney donations was found to be 92.4%, 87%, 87% and 97.8%, respectively. 87% of medical students were aware of need for legal supervision, and awareness regarding the existing laws was found to be 57.6%. Conclusion. Medical students had a high level of awareness and a positive attitude towards organ donation. However, knowledge regarding “brain-death”, organs and tissues donated, legislation and ethical issues was poor. A teaching intervention designed to specifically address these issues could help increase the confidence of the health-care professionals and may result finally in increased organ procurement rates.

An institutional study of awareness of brain-death declaration among resident doctors for cadaver organ donation

Background and Aims:

Brain death is defined as irreversible and complete cessation of all brain function including that of the brainstem. The aim of this study was to assess the level of knowledge and awareness about brain-death declaration among resident doctors.

Methods:

This was an observational questionnaire-based study conducted in single institute in which 112 junior residents and 46 senior resident doctors in various medical specialities were included by universal sampling method. A prevalidated questionnaire consisting of questions related to knowledge, attitude and performance of brain-death declaration were distributed among residents as per the inclusion criteria to fill in the time limit of 30 min. Statistical tools used were mean and standard deviation, proportion and Chi-square test.

Results:

A total 87 resident doctors consisting of 71.26% males and 28.73% females responded to the questionnaire. About 91.95% correctly defined it as complete cessation of brain activity including brainstem reflexes. Most of the resident doctors (80.45%) knew about the documentation of absence of brainstem reflexes at 6 h intervals and 64.36% were aware about positive apnoea test. When asked about whether there is legal sanction for disconnecting life support in India, 56.32% said no, and 43.67% said yes. Only 12.64% of resident doctors were aware about a panel of 4 physicians are mandatory to declare brain death in India.

Conclusion:

Awareness and attitude towards the identification of brain death and possible deceased donor organ transplantation were lacking amongst resident doctors.

A Single-center Experience of Kidney Transplantation from Donation after Circulatory Death: Challenges and Scope in India

Donation after circulatory death (DCD) has never been attempted in India because of legal constraints and lack of guidelines for the withdrawal of life support in end-of-life situations. The present report describes the initial experience of transplantation of organs from DCD donors in a tertiary care center in India. Between 2011 and 2015, five donors had kidneys retrieved after cardiac arrest. These patients were declared dead after waiting for 5 min with no electrocardiographic signal on monitor following cardiopulmonary resuscitation (CPR), which was restarted in three patients till organ retrieval. All donors received heparin and underwent rapid cannulation of aorta, infusion of preservative cold solution, and immediate surface cooling of organs during retrieval surgery. 9/10 kidneys were utilized. Mean donor age was 29.6 ± 16.3 years, M:F 4:1 and mean age of recipients was 38.7 ± 10.8 years, M:F 7:2. Seven patients required dialysis in postoperative period. Mean postoperative day 0 urine output was 1.9 ± 2.6 L. Baseline creatinine achieved was 1.38 ± 0.35 mg/dl after a mean duration of 26.12 ± 15.4 days. Kidneys from donors where CPR was continued after the declaration of death (n = 3) had better recovery of renal function (time to reach baseline creatinine 21.2 ± 7.2 vs. 34.3 ± 23.7 days, baseline creatinine 1.36 ± 0.25 vs. 1.52 ± 0.45 mg%). In donors without CPR, one kidney never functioned and others had patchy cortical necrosis on protocol biopsy, which was not seen in the kidneys from donors with CPR. Kidneys from DCD donors can serve as a useful adjunct in deceased donor program. Continuing CPR after the declaration of death seems to help in improving outcomes.

Successful Renal Transplantation Across HLA Barrier: Report from India

Organ donors are sometimes found “unsuitable” due to the presence of donor-specific anti-HLA antibodies in the recipient. In recent years, improved desensitization protocols have successfully helped to overcome HLA incompatibility hurdle. We present three cases where optimum desensitization was achieved in patients with the donor-specific anti-HLA antibody (DSA) leading to successful renal transplantation. All patient–donor pair underwent HLA typing, complement dependent cytotoxicity crossmatch (CDC-XM), flow cytometry XM (FC-XM), and panel reactive antibody. If any of the three tests was positive, single antigen bead assay was performed to determine the specificity of the anti-HLA antibody (s). Patients with DSA were offered organ-swap or anti-HLA antibody desensitization followed by transplantation. Desensitization protocol consisted of single dose rituximab and cascade plasmapheresis (CP) along with standard triple immunosuppression. The target DSA mean fluorescence index (MFI) was <500, along with negative CDC-XM and FC-XM for both T- and B-cells. Three patients with anti-HLA DSA, who did not find a suitable match in organ swap program, consented to anti-HLA antibody desensitization, followed by transplantation. Mean pre-desensitization antibody MFI was 1740 (1422–2280). Mean number of CP required to achieve the target MFI was 2.3 (2–3). All the three patients are on regular follow-up and have normal renal function test at a mean follow-up of 8 months. This report underlines successful application of desensitization protocol leading to successful HLA-antibody incompatible renal transplants and their continued normal renal functions.

Management of Graft Duodenal Leak in Simultaneous Pancreas Kidney Transplant-a Case Report from India and Review of Literature

Pancreatic transplantation is currently the only effective cure for Type 1 diabetes mellitus. It allows long-term glycemic control without exogenous insulin and amelioration of secondary diabetic complications. In India, pancreas transplant has not yet established with only a single successful transplant reported so far in the literature. We report a 24-year-old Type 1 diabetic patient with renal failure who underwent a simultaneous pancreas kidney transplant. On postoperative day 15, he had leak from the graft duodenal stump for which a tube duodenostomy and proximal diversion enterostomy was done. He had a high output pancreatic fistula following the procedure which was managed conservatively. The tube duodenostomy was removed at three and half months and enterostomy closure with restoration of bowel continuity was done at 6 months. After a follow up of 7 months, patient is doing well with a serum creatinine of 0.8 mg/dl and normal blood sugars, not requiring any exogenous insulin or oral hypoglycemic drugs. Managing patients with graft duodenal complications after pancreas transplant is challenging. Tube duodenostomy is a safe option in management of duodenal leak, although can lead to a persistent pancreatic fistula. A proximal diversion enterostomy allows early oral feeding and avoids the cost as well as the long term complications associated with parenteral nutrition.

Long-term health-related quality of life in living liver donors: A south Asian experience

AIM

The aim of this study was to evaluate long-term health-related quality of life (HRQOL), changes in lifestyle, and complications in living liver donors at a single transplant center from southern India.

METHODS

A total of 64 consecutive living liver donors from 2008 to 2011 were evaluated; 46 of 64 donors completed the short form 36 (SF-36) via telephonic interviews or clinic consultations. Mean follow-up was 48 months (range: 37-84 months).

RESULTS

There was no mortality in the donors evaluated. Overall morbidity was 23%, which included wound infections (4.3%), incisional hernia (2.1%), biliary leak (4.3%), and nonspecific complaints regarding the incision site (15.2%). All 46 donors who completed the SF-36 had no change in career path or predonation lifestyle. A total of 40 of 46 (87%) donors had no limitations, decrements, or disability in any domain, while six of 46 (13%) had these in some domains of which general health (GH) was most severely affected.

CONCLUSIONS

Living donor hepatectomy is safe with acceptable morbidity and excellent long-term HRQOL with no change in career path or significant alteration of lifestyle for donors.

Brain death and care of the organ donor

Brain death has specific implications for organ donation with the potential for saving several lives. Awareness on maintenance of the brain dead has increased over the last decade with the progress in the field of transplant. The diagnosis of brain death is clinical and can be confirmed by apnea testing. Ancillary tests can be considered when the apnea test cannot be completed or is inconclusive. Reflexes of spinal origin may be present and should not be confused against the diagnosis of brain death. Adequate care for the donor targeting hemodynamic indices and lung protective ventilator strategies can improve graft quality for donation. Hormone supplementation using thyroxine, antidiuretic hormone, corticosteroid and insulin has shown to improve outcomes following transplant. India still ranks low compared to the rest of the world in deceased donation. The formation of organ sharing networks supported by state governments has shown a substantial increase in the numbers of deceased donors primarily by creating awareness and ensuring protocols in caring for the donor. This review describes the steps in the establishment of brain death and the management of the organ donor. Material for the review was collected through a Medline search, and the search terms included were brain death and organ donation.

Why are we Poor Organ Donors: A Survey Focusing on Attitudes of the Lay Public From Northern India

BACKGROUND

Knowledge, sociocultural views, and awareness about organ donation in the general population are important for the success of deceased organ donation. There is an urgent need to gather this information in order to find out the reasons for poor organ donation rates in India.

METHODS

A 30-item questionnaire was designed in the English and Hindi language and was administered to the lay people in order to assess their knowledge, views, and attitude regarding brain death and organ donation.

RESULTS

Three hundred and fifty-two people (male:female = 202:150; mean age = 30.6 ± 13.9 years) completed the questionnaire. Only 70% of the people were aware that the organs can be donated after brain death and only 44% thought that they understood the meaning of brain death. Media and Internet were the preferred sources for seeking information on brain death and organ donation. The majority of people (81.2%) were willing to donate organs after brain death but only 1.4% had registered for organ donation. Lack of awareness (80.1%), religious beliefs and superstitions (63.4%), and lack of faith in the healthcare system (40.3%) were believed to be the most important reasons for poor deceased organ donation rates in India. The survey also highlighted the importance of the opinion of family members and the religious leaders in making the decision for organ donation. Educational qualification above matriculation was significantly associated with the knowledge of brain death and the willingness for organ donation.

CONCLUSION

Lack of awareness appears to be the most important factor for low donation rates in India. Educating people by using media and Internet and conducting awareness programs may help in improving the donation rates.

Living donor liver transplantation in India

Liver transplantation is currently in its golden period in India. The number of transplants being performed and the steady increase in the new programs that have emerged over the last decade is a testimony to it. The growth was not smooth, especially in the early years. But a multipronged approach in developing infrastructure and the involvement of multidisciplinary teams in the management of transplant patients has had a major positive impact on the outcome and as a result a positive impetus to the growth of this specialty in India. To date, the majority of transplants performed in India are live donor liver transplants. Deceased donation is more sporadic and concentrated in a couple of regions. With phenomenal increase in transplant activity in India, there is huge potential for streamlining data sharing among programs in India and with the rest of the world to ultimately benefit the transplant community.

Establishing a deceased donor program in north Indian region: lessons learnt

INTRODUCTION

Living-related donors are the source of almost all organ transplants in India. However, these donations fall far short of current needs, and there remains a huge disparity between demand and supply of organs. In the last five yr, a consistent increase in deceased donor transplant activity has been observed in some southern Indian states. This report describes our experience of establishing a new deceased donor program in the state of Uttar Pradesh in north India.

METHODS

We describe our experience on counseling families of all brain-dead patients admitted to our center from October 2013 to September 2014 and data on retrieving and transplanting organs.

RESULTS

A total of 99 brain-dead patients were identified, of which 67 were medically eligible as donors. Fourteen patients developed cardiac arrest before the counseling could begin. Only eight families agreed for multi-organ donation.

CONCLUSION

Lack of consensus among the family members, mistrust of the medical system, fear of mutilation of the body, and delay in the funeral were identified as the main reasons behind negative consent. Conversely, mass media campaign, proper ICU care of brain-dead patients, rapport with the family and streamlining all medico legal processes were associated with positive consent.

Awareness and Attitudes toward Organ Donation in Rural Puducherry, India

BACKGROUND

For many of the end-stage organ diseases, organ transplantation is the most preferred treatment. The need for the organ transplantation is higher than the availability. For the transplantation program to be successful, awareness regarding organ donation is needed and people must have a positive attitude toward donating organs.

AIM

This study aims to assess the awareness and attitudes regarding organ donation among the rural population and to evaluate the sociodemographic factors associated with their awareness.

SUBJECTS AND METHODS

This community-based cross-sectional study was conducted among 360 people living in 4 villages of Puducherry. Face-to-face interviews were carried out using pretested questionnaire, which included the sociodemographic data. Data were entered into Excel and analyzed using Statistical Package for Social Sciences.

RESULTS

Of 360 participants, 88% (317/360) were aware of organ donation. Among these 317 participants, awareness was highest in the age group 18-30 years 98.8% (87/88), male 91% (147/161), higher secondary and above 100% (58/58), and Class 1 socioeconomic status 92% (13/14). Source of awareness about organ donation was primarily through media 83% (263/317). The majority of the participants 88% (281/317) felt that the purpose of organ donation was to save life. Most of the participants 91% (290/317) said that all healthy adults are eligible organ donors and 87% (275/317) of the participants said that monetary benefits could not be accepted for organ donation. Most of the participants 70% (223/317) were willing to donate their organs after death. Among the participants who refused to donate their organs, family refusal 57% (25/44) was the most common reason.

CONCLUSION

This study shows that there is a high level of awareness about organ donation among rural people and most of the participants are willing to donate their organs.

Better innovate than compromise: a novel hepatic outflow reconstruction technique in pediatric living donor liver transplantation

Pediatric LDLT using donors with unfavorable vascular anatomy is challenging in terms of donor safety, and complexity of reconstruction in the recipient. We describe an innovative technique of hepatic venous outflow reconstruction involving the recipient RHV, in the presence of a rudimentary RHV in the donor. The postoperative course of the donor and recipient was uneventful with satisfactory venous outflow in both. This technique avoided the use of prosthetic material, an important consideration given the recipient age and requirement for growth. This shows that donors previously considered unsuitable for donation can be utilized safely as long as principles of vascular anastomosis are adhered to. Moreover, it highlights that innovation is sometimes necessary to avoid compromise in donor safety.

Cascade plasmapheresis (CP) as a preconditioning regime in ABO-incompatible live related donor liver transplants (ABOi-LDLT)

Background

ABO-incompatible live donor liver transplant (ABOi-LDLT) is being widely done to bridge the gap of demand and supply of organs. Different desensitization regimes are being used to reduce titer of blood group antibodies for successful transplant and accommodation of graft. The authors used cascade plasmapheresis (CP) to bring down titer of naturally occurring blood group antibody to 16 or lower.

Material and methods

Four recipients of ABOi-LDLT were of blood groups O, O, B, and B while donors were of blood groups B, A, AB, and AB, respectively. Desensitization protocol included immunosuppressive drugs and plasmapheresis. CP consisted of separating patient’s plasma as the first step and passing it through pore size based filter column as the second step. The first step was performed using disposable kit (PL1, Fresenius Kabi, Germany) with minor modification on apheresis equipment COM.TEC (Fresenius Kabi, Germany). Pore size based filter column used was 2A column (Evaflux, Kawasumi Laboratories, Japan). Blood group antibody titer (immunoglobulin G (IgG)) was done by column agglutination technology (Ortho-Clinical Diagnostics).

Results

Cases 1, 2, 3, and 4 with pre-CP titer of 1,024, 512, 32, and 64 required four, three, one, and one CP procedures, respectively. No signs of antibody-mediated rejection were exhibited on histopathological evaluation by any of the patients. Successful organ engraftment occurred as documented by post-operative liver function tests and liver biopsy.

Conclusion

Cascade plasmapheresis offers a cost-effective and efficient way to decrease blood group antibody titer and helps in successful transplant.

Perceptions and attitudes towards organ donation among people seeking healthcare in tertiary care centers of coastal South India

Background:

Organ transplantation is the most preferred treatment modality for end-stage organ diseases. The need for the transplants is higher than the availability. Prerequisites for the success of transplantation program include awareness and positive attitudes.

Aim:

To assess the perceptions and attitudes of the people seeking health care in tertiary care centers towards organ donation in Mangalore, India.

Settings and Design:

This cross-sectional study included 863 people seeking general healthcare as outpatients.

Materials and Methods:

Face to face interviews were carried out using pretested tools which included the socio demographic data. Data was analyzed using Statistical Package for Social Sciences version 11.5.

Results:

Overall, 59.6% participants showed the willingness to donate organs. Females (64.1%) and participants from upper socio economic status (62.7%) had higher willingness rates for organ donations. Hindus (63.6%) and Christians (63.3%) had higher willingness rates for organ donations than Muslims (38.2%). Also, 23.7% participants showed willingness to donate eyes and 33.6% wished to donate any organ after death. Most of the participants (67%) were aware that money should not be accepted for donating organs, and 58.1% were aware that it is an offence to accept any benefit for organ donations. Forty percent participants had perceived risks associated with organ donation. Regarding donor cards, 42.3% of the participants knew about it and 3.7% already possessed it.

Conclusion:

It is apparent from the study that though there was high level of awareness about organ donation, a high proportion of the participants did not have positive attitudes towards organ donation.

Key issues in transplant tourism

Access to organ transplantation depends on national circumstances, and is partly determined by the cost of health care, availability of transplant services, the level of technical capacity and the availability of organs. Commercial transplantation is estimated to account for 5%-10% (3500-7000) of kidney transplants performed annually throughout the world. This review is to determine the state and outcome of renal transplantation associated with transplant tourism (TT) and the key challenges with such transplantation. The stakeholders of commercial transplantation include: patients on the waiting lists in developed countries or not on any list in developing countries; dialysis funding bodies; middlemen, hosting transplant centres; organ-exporting countries; and organ vendors. TT and commercial kidney transplants are associated with a high incidence of surgical complications, acute rejection and invasive infection which cause major morbidity and mortality. There are ethical and medical concerns regarding the management of recipients of organs from vendors. The growing demand for transplantation, the perceived failure of altruistic donation in providing enough organs has led to calls for a legalised market in organ procurement or regulated trial in incentives for donation. Developing transplant services worldwide has many benefits - improving results of transplantation as they would be performed legally, increasing the donor pool and making TT unnecessary. Meanwhile there is a need to re-examine intrinsic attitudes to TT bearing in mind the cultural and economic realities of globalisation. Perhaps the World Health Organization in conjunction with The Transplantation Society would set up a working party of stakeholders to study this matter in greater detail and make recommendations.

Transplant tourism outcome: a single center experience

BACKGROUND

Transplant tourism is the term used for patients who travel abroad for transplantation. Transplant tourism has always been surrounded with controversy regarding how these organs were obtained, the donor's care after transplantation, and the recipient outcome. Many authors have found that the outcome of the recipients in transplant tourism is inferior to those transplanted in their own countries. However, most these studies were small, with the latest one including only 33 patients. Here, we describe the outcome of 93 patients who were transplanted abroad compared with local transplantation.

MATERIAL AND METHODS

All transplant patients who were followed up at our Nephrology Clinic from 1998 until 2008 were identified using our data base system. We selected patients transplanted from 2003 and forward because the computerized system for laboratory and electronic records began operation that year.

RESULTS

A total of 165 patients were identified (93 in the tourist group and 72 in the local one). Transplant tourists had a higher rate of acute rejection in the first year compared with local transplantation (27.9% vs. 9.9, P=0.005), higher mean creatinine at 6 months and 1 year (120 vs. 101 micromol/L, P=0.0007, 113 vs. 98 micromol/L, P=0.008). There was no statistical difference in graft or patient survival in 1 or 2 years after transplantation. However, transplant tourist had a higher rate of cytomegalovirus infection (15.1% vs. 5.6%, P=0.05) and hepatitis C seroconversion (7.5% vs. 0%, P=0.02).

CONCLUSION

Transplant tourists had a more complex posttransplantation course with higher incidence of acute rejection and infectious complications.