deceased organ donation challenges in india

1. Deceased organ donation
and transplantation in
India
Srivastava A, mani A. Deceased organ donation and transplantation in india: promises and challenges.
Neurol india 2018;66:316-22.

2. Organ transplant
Organ transplantation is one of
the greatest medical marvels of
the 20th century, which has
prolonged and improved the
lives of hundreds of thousands
of patients, worldwide.

3. Deceased organ donation
 The disparity between the
huge demand for organs
and their poor supply is the
main issue of concern.
 Organ shortage is a global
issue and deceased organ
donation is the major
sustainable solution.

4. The major challenges
 The deceased donor donation rate in India stands at around 0.34 per
million, which is abysmally low when compared to the organ donation rate
prevalent in other developed countries.
 In the Indian scenario, many cultural and religious beliefs influence the
decision making regarding deceased organ donation.
 Lack of awareness (80.1%), religious beliefs and superstitions (63.4%), and
lack of faith in the healthcare system (40.3%) are the most important
reasons for the family members refusing for giving their consent for organ
donation of their close relatives

5. 1. Sociocultural factor
 In Asian countries, such as in India, China
and Japan, the concept of life after death is
cross linked with the concepts of ethics,
religion and spirituality.
 It is very difficult to even start a
conservation regarding organ donation in
these regions of the world, especially in the
case of a brain-dead donor. Religious
concerns may also have an impact.

6. 2. Beliefs and superstition
 Public awareness regarding organ donation is
very low in our country and this negatively
impacts the whole concept.
 Many superstitions that are prevalent even now
create a negative attitude towards organ
donation.
 The concept of ‘brain death’ and its legal
implications are not familiar to the majority of
the population in India.

7. 3. Lack of effective
communication
 An educated donor who is willing to donate his organs usually has a good
knowledge about the concept of ‘brain death’ and the procedures related to
organ donation. He can effectively communicate with the family members
regarding his willingness to donate his organs.
 Many a times, people sign the donor card due to peer pressure and other
factors without having a complete knowledge about the issues.
 These people are less likely to stick to their decision in the future and usually
back out from their commitment prior to their death.

8. 4. Lack of organizational support
 The lack of an adequate number of transplant centers with staff, as
well as transplant coordinators who are adequately educated and
well-versed with the procedures required to conduct an organ
donation program is a significant roadblock to the deceased
donation program.
 Lack of good dialysis programs, research, and effective national
health insurance plans, also pose a challenge.

9. 4. Lack of organizational support
 Many hospitals do not have a clear protocol for declaring brain
death. Some of them also do not have effective transplant
coordinators who could sympathetically approach the family
members of the brain-dead, potential donor patients, and take
consent from them regarding organ donation.
 Even the medical community has very little knowledge, and
therefore, any efforts made in this direction are thwarted by them
to a great extent

10. 5. Negative propaganda by the
media
 The entire concept of deceased organ donation is built upon
mutual trust and a feeling of altruism.
 Any negative ideas, which breaks this trust, acts as an
impediment to the whole process.

11. Ongoing Efforts for Circumventing the
Problems
 Public-private partnerships with the help of transplant
coordinators have immensely contributed to improving organ-
procuring rates in India over the recent years.
 This holds true in the case of southern states of India (Tamil
Nadu, Kerala, Andhra Pradesh and Pondicherry), where
deceased organ donation and transplantation is much better
established than in other parts of the country.

12. Ongoing Efforts for
Circumventing the Problems
 MOHAN (Multi-Organ Harvesting and Networking) foundation is a
philanthropic non- governmental organisation based in south India,
which works to improve organ donation and transplantation rate.
 It is the first organisation to promote deceased organ donation and
has been in existence since 1997.
 It is also the first organisation in India to develop the system of organ
sharing system in India in 2000 by establishing the Indian Network for
Organ Sharing (INOS)

13. NOTTO – National Organ and Tissue
Transplant Organization
 This is a national level organization set up under the Directorate
General of Health Services, Ministry of Health and Family Welfare.
 The National Human Organ and Tissue Removal and Storage Network
is a subdivision of this organization, which was formed as mandated
by the Transplantation of Human Organ Act (THOA) amendment in
2011.
 This is established in Delhi and will gradually expand to involve other
states and regions of the country. (safdarjung hosp.)

14. NOTTO – National Organ and Tissue
Transplant Organization
 It functions as an apex centre for
conducting all India activities related to
coordination and networking, for the
procurement and distribution of organs
and tissues, for maintaining the registry
of organs, and for facilitating tissue
donation and the transplantation of the
harvested organs across the country.

15. Green corridors
 Green corridor refers to a special road route
that facilitates the transportation of
harvested organs meant for transplantation
to the desired hospitals.
 The street signals are manually operated to
avoid stoppage at red lights and to divert
the traffic to ensure a rapid transportation of
the desired organ.
 There are many recent instances in India
where organs were transported in time using

16. Tissue banks
 Tissue banking is the process in which biomedical tissue is stored
under cryogenic conditions to be used later when the need arises.
 A number of tissue banks have been established in India in the
recent times, which help in storing tissues such as the cornea, skin,
heart valves, bones and tendons for later use.
 These centres help in preventing tissue wastage to a great extent.

17. Legislation
 Transplantation of Human Organ Bill was introduced in the Lok Sabha
on 20th August 1992. Transplantation of Human Organ Act (THOA)
was passed in 1994.
 This is the primary legislation related to organ donation and
transplantation in India.
 The amendment to the Act was passed by the parliament in 2011, and
the rules were notified in 2014 as the Transplantation of Human
Organs and Tissue Rules – 2014

18. Standard and extended criteria
donors
 The donors are further differentiated into standard criteria donors
(SCD) or extended criteria donors (ECD), depending on whether
the age of the donor is 60 years or more, or the age is 50 – 59,
with the presence of at least two of the following:
1. Hypertension,
2. Death from cerebrovascular accident and
3. Terminal creatinine >1.5 mg/dL

19. Scoring systems - Kidney donor
profile index
 “Kidney donor profile index” (KDPI) : to estimate the risk of post-
transplant kidney graft failure from a particular deceased donor
kidney relative to other kidneys.
 The KDPI score includes the donor’s age, height, weight, ethnicity,
serum creatinine level, history of diabetes, history of hypertension,
hepatitis C status, cause of death, and whether the donation would
occur after cardiac death.
 Each kidney is scored in a KDPI spectrum from 0% to 100%.
 Lower scores are accepted to have a longer potential function of
the donor organ than those with higher scores

20. Scoring systems - deceased donor
score
 The deceased donor score was determined from five donor variables
obtained at the time of procurement.
 The variables were donor age (0-25 points), history of hypertension (0-4
points), creatinine clearance (0-4 points), human leukocytic antigen (HLA)
mismatch (0-3 points), and cause of death (0-3 points), with the total
number of points ranging from 0-39.
 A grade (A to D) was then assigned to the specific deceased donor based
on his cumulative score.
 Greater than 20 points or grades C and D were defined as marginal
donors with a much shorter potential function of the donor organ

21. Viability of organ
 The viability of the organs should be maintained during transportation from the donor
hospital to the transplant center.
 The main strategy of preservation is cold storage, which is based on the principle of
reducing metabolism while perfusion is absent.
 This can be achieved by static cold storage techniques and continuous machine
perfusion.
 In the static cold storage technique, the organs are perfused with cold solution via their
arterial supply and suspended in a bath of the storage media on ice.
 Static cold storage is being currently practiced in our country.

22. Viability of organ
 The continuous machine perfusion, which is a form of dynamic
preservation, uses a machine to achieve a pulsatile perfusate flow.
 This requires more equipment and a higher level of technical training.
 This technique is specifically important in the expanded criteria donors
and 'donation after circulatory death' group of kidney or liver donors, to
reduce the duration of warm ischemia so as to improve the graft
outcome.

23. Preservation solutions
 Ion solutions are the
University of Wisconsin and
the histidine-tryptophan-
ketoglutarate (HTK)
solutions, which vary in the
composition of electrolytes,
buffers, antioxidants and
energy precursors they
contain,
• Reduces graft edema,
• Reduces Intracellular acidosis
• Reduces production of reactive
oxygen species and in providing
energy substrates for metabolism.

24. Cold ischemia time
 Cold ischemia time : amount of time
that an organ is not receiving blood
supply and is maintained on a cold
preservation fluid.
 Cold ischemia time varies widely
from organ to organ, but in general,
the sooner an organ can be
transplanted, the better it is for
ensuring its viability.
Heart: 4 hours
Lungs: 4 to 6 hours
Liver: 6 to 10 hours
Pancreas: 12 to 18 hours
Intestines: 6 to 12 hours.
Kidneys: 24 hours (may be
extended up to 72 hours if placed on
mechanical perfusion)

25. Organ transport
 In India, still the conventional method of road transport is
being used for transport.
 Green corridors have been particularly helpful in this regard.
 When the distance is more, the organs are transported via
commercial airlines.
 There have been many instances where valuable organs have
been wasted due to delay in the transportation process.
 Private ambulances are too prohibitively expensive at this
point of time.