" ‘Back-door’ Realities of Renal Transplant Donor-Recipient Relationships Disrupting the Ethics of Public Health " global health rounds presentation by Dr. Ram Dulal June 24, 2013 at the University of Alberta.

2. ObjectivesObjectives
 Discuss health system of NepalDiscuss health system of Nepal
 Describe the shifting trend in disease patternsDescribe the shifting trend in disease patterns
 Discuss renal transplantation and issues ofDiscuss renal transplantation and issues of
public health ethics andpublic health ethics and ‘back-door’ reality‘back-door’ reality

3. Nepal is known asNepal is known as
Land of braveLand of brave “Gurkha warrier”“Gurkha warrier”
Land of Himalayas,Land of Himalayas,
8 out of 10 world highest peaks8 out of 10 world highest peaks
Birth Place of Lord Buddha,Birth Place of Lord Buddha,
World Heritage sitesWorld Heritage sites
Nepal At A GlanceNepal At A Glance

4. Mount EverestMount Everest
& Buddha& Buddha

5. Bakhtapur
Kathmandu Valley:Kathmandu Valley: World Heritage SitesWorld Heritage Sites ( Contd..)( Contd..)
Changunarayan
Basantapur Durbar Square

6. Kathmandu Valley -Kathmandu Valley - World Heritage SitesWorld Heritage Sites
Swayambhunath Patan Durbar Squre

7. Basic CharacteristicsBasic Characteristics
NepalNepal
 Area of 147,181 sq. kmArea of 147,181 sq. km
 Population:Population: 26.5 million (2011)26.5 million (2011)
 Total fertility rate: 2.6 (2010)Total fertility rate: 2.6 (2010)
 Infant mortality: 65.3 per 1,000Infant mortality: 65.3 per 1,000
 Life expectancy: 64.6 male/Life expectancy: 64.6 male/
67.1 female (2010)67.1 female (2010)
 Per Capita health expenditures: US-$64 (Int.)Per Capita health expenditures: US-$64 (Int.)
 GDP per Capita US$ 500GDP per Capita US$ 500

8. Ministry of Health
Department of Health Services
NHTC
NHEICC
NTC
NCASC
NPHL
Regional Health Directorate - 5
Central Hospitals - 5
CENTRAL
LEVEL
RegionalLaboratory(1)
RegionalTrainingCentre(5)
RegionalMedicalStore(5)
RegionalTBCentre(1)
REGIONAL
LEVEL (5)
ZONAL
LEVEL (14)
Zonal Hospital - 11
District Public
Health Office - 14
District Health Office
61
DISTRICT
LEVEL (75)
Primary Health Care Centre/
Health Centre - 188
ELECTORAL
CONSTITUENCY
(205)
Health Post - 698
Sub Health Post - 3,129
FCHV
48,307
TBA
15,553
PHC ORC Clinic
14,769
EPI Outreach Clinic
15,833
COMMUNITY
LEVEL
VDC LEVEL (3,995)
FHD
CHD
EDCD
MD
LMD
D I V I S I O N S C E N T R E S
RegionalHospital(1)
LCD
District Hospital
62
District health system is integrated – preventive and curative servicesDistrict health system is integrated – preventive and curative services

9. Nepal Total Death by CauseNepal Total Death by Cause
S.No. Particulars Deaths %
1 Coronary Heart Disease 21,152 14.2
2 Influenza & Pneumonia 18,406 12.4
3 Stroke 11,119 7.5
4 Diarrhoeal diseases 7,787 5.2
5 Tuberculosis 6,330 4.3
6 Lung Disease 5,973 4.0
7 Birth Trauma 5,967 4.0
8 Low Birth Weight 5,584 3.8
9 Hypertension 5,570 3.8
10 HIV/AIDS 4,796 3.2
11 Diabetes Mellitus 3,224 2.2
12 Lung Cancers 3,100 2.1
13 Maternal Conditions 2,791 1.9
14 Road Traffic Accidents 2,527 1.7
15 Violence 2,455 1.7
16 Othe Injuries 2,358 1.59
17 Kidney Disease 2,212 1.49
http://www.worldlifeexpectancy.com/country-health-profile/nepal

10. Patients Increased in HemodialysisPatients Increased in Hemodialysis

11.  Kidney transplantationKidney transplantation
 Treatment ofTreatment of
choice and preferredchoice and preferred
 DialysisDialysis
 Temporary inTemporary in EndEnd
Stage Renal DiseasesStage Renal Diseases
Kidney TransplantKidney Transplant

12. Treatment for Kidney Disease Remains Elusive
Treatment for Kidney Disease Remains Elusive
and Unaffordable
and Unaffordable
Dr. Sudha Khakurel, Chief of Nephrology Unit at Bir
Dr. Sudha Khakurel, Chief of Nephrology Unit at Bir
Hospital
Hospital

13. History on Kidney TransplantationHistory on Kidney Transplantation
in Nepalin Nepal
 Three cases – nursing home (private hospital) inThree cases – nursing home (private hospital) in
19961996
 One case – central govt hospital (Bir Hospital)One case – central govt hospital (Bir Hospital)
in November 2004in November 2004
Prior to August 2008, abroad for transplantation mostly to India
until TUTH, Nepal started..
Bir Hospital & TUTH

14. HECAF-Nepal / National Kidney CentreHECAF-Nepal / National Kidney Centre

15. Study on Kidney Transplant RecipientStudy on Kidney Transplant Recipient
 A cohort retrospectiveA cohort retrospective
 Follow up registryFollow up registry
 June 16, 2003 to July 15, 2008.June 16, 2003 to July 15, 2008.
 Population 452 transplantPopulation 452 transplant
recipientsrecipients

16. Lawful DonorsLawful Donors
Law of the land defined: the potential kidneyLaw of the land defined: the potential kidney
donordonor’s can be:’s can be:
 father, mother, sister, brother, husband, wife, son,father, mother, sister, brother, husband, wife, son,
daughter, uncle, aunt, sworn friend (Mitajyu),daughter, uncle, aunt, sworn friend (Mitajyu),
mother-in-law and father-in-lawmother-in-law and father-in-law

17. Type of Hospital and CountryType of Hospital and Country
93.75% - 45 different hospitals in India, 71.7% - private hospitals – India
Out of 45 - No. of cases 190, 58 and 25

18. Source of KidneysSource of Kidneys
Unrelated 315 (69.69%), related 134 (29.43%) and undisclosed 4 (0.88%)

19. EthnicityEthnicity

20. Age Group of RecipientsAge Group of Recipients
AgeAge NumberNumber
 ≤≤15 years15 years 4 (0.9%)4 (0.9%)
 16-3016-30 113 (25.0%)113 (25.0%) >> 90%90%
 31-4531-45 156 (34.5%)156 (34.5%)
 46-6046-60 144 (31.9%)144 (31.9%)
 61-7561-75 35 (7.7%)35 (7.7%)
Male to female ratio of 3:1.

21. Benefit of Kidney Transplantation…..
…Back to Work (contd…..)

22. Croatian vs PolandCroatian vs Poland
Final Euro Cup 2008Final Euro Cup 2008
played and won by 28 Yrs old Strikerplayed and won by 28 Yrs old Striker
Ivan Klasnic after 2Ivan Klasnic after 2ndnd
Renal TxRenal Tx
Benefit of Kidney Transplantation…..
…Back to Work

23. Donor Lisa George Danhw Recipient: Dan GeorgesDonor Lisa George Danhw Recipient: Dan Georges
Relationship to donor: Spouse Date of donation: May 24, 2002Relationship to donor: Spouse Date of donation: May 24, 2002
Your gift has given me a
new outlook on life, our
family, and our marriage.
I thank God every day for
you and our children,
David and Alexandra. My
life is not complete
without you. And now
that you're truly a part of
me, physically, I know I
cannot be complete
without you. I love you,
>Dan
http://www.livingdonorsonline.org/halloffame.htm

24. Who Got His Kidney?Who Got His Kidney?
Selling
kidneys
for a
few
rupees
more

25. Kidney Stealing From PoorKidney Stealing From Poor
http://www.canada.com/story.html?id=7a0f0f8a-daac-45f2-91c6-c4a3090d1e0d

26.  http://www.asianewsnet.net/Nepal-police-arrest-kidney-dealers-46735.htmlhttp://www.asianewsnet.net/Nepal-police-arrest-kidney-dealers-46735.html

27. Ex-student Leader Among 8 HeldEx-student Leader Among 8 Held
for Kidney Tradefor Kidney Trade
BANEPA, May 14: Police have arrested eight persons including a former vice-president
of Free Student Union of Patan Campus on the charge of their involvement in kidney
trade.
A special team of police dispatched from Kathmandu arrested the eight individuals from
different parts of the country within a period of one month and paraded them before the
media at Dhulikhel on Tuesday.
The arrested have been identified as Puja Dahal aka Puna Thakuri and
…………………….
Among the arrested, Sachin Maharjan was reportedly a former vice-president of the Free
Students Union at Patan Campus.
Published on 2013-05-14
http://myrepublica.com/portal/index.php/twb/?action=news_details&news_id=54697

28. ConcernConcern
 In some families there are four to five membersIn some families there are four to five members
who have sold their kidneys.who have sold their kidneys.
 Kidney seller do not know who got his/herKidney seller do not know who got his/her
kidney?kidney?

The Nepali Kidney BankThe Nepali Kidney Bank byby Sunil NeupaneSunil Neupane
 http://www.asiacalling.org/en/news/nepal/2010-the-nepali-kidney-bankhttp://www.asiacalling.org/en/news/nepal/2010-the-nepali-kidney-bank
Saturday, 14 May 2011 18:16Saturday, 14 May 2011 18:16
 The Village of Stolen KidneysThe Village of Stolen Kidneys
http://www.youtube.com/watch?v=EE6cdPTkD5khttp://www.youtube.com/watch?v=EE6cdPTkD5k

29. MessageMessage
 Tribhuvan University Teaching Hospital and BirTribhuvan University Teaching Hospital and Bir
Hospital provide kidney transplantationHospital provide kidney transplantation
 Rigorously selected lawful cases onlyRigorously selected lawful cases only
 Results presented are based on the data on kidneyResults presented are based on the data on kidney
transplantation done abroad, mostly in Indiatransplantation done abroad, mostly in India

30. Where Are We?Where Are We?
 What is individuals professionalWhat is individuals professional’s role?’s role?
 Whether live donor is lawful volunteerWhether live donor is lawful volunteer
oror
 poverty driven, misinformed, forcefully mediatedpoverty driven, misinformed, forcefully mediated

31. Disrupting Ethical IssuesDisrupting Ethical Issues
 Renal care team members (Nurse, Nephrologist,Renal care team members (Nurse, Nephrologist,
Radiologist/Sonologists, Pathologists etc.)Radiologist/Sonologists, Pathologists etc.)
participation in the process of living donorparticipation in the process of living donor
screening and approvalscreening and approval
 Policy of homelandPolicy of homeland
 Initial Screening Process: Donor health and psychosocialInitial Screening Process: Donor health and psychosocial
historyhistory
 Indication / contra-indicationIndication / contra-indication

32. ConclusionConclusion
 Entire enterprise of transplantation is vulnerableEntire enterprise of transplantation is vulnerable
 Protect ignorant and poor kidney sellerProtect ignorant and poor kidney seller
 Protect health care workers (renal) byProtect health care workers (renal) by
implementing an appropriate / robust guidelinesimplementing an appropriate / robust guidelines