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Deceased Organ Donation

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Deceased Organ Donation

Deceased donor transplant is the need of the day looking into the enormous requirement of life sustaining organs required by patients who live a miserable day to day existence. Live donor organs cannot meet the requirement. The answer lies in harvesting organs from Deceased Donors formerly called cadaver organ donors. The National scenario of such donors is dismal. In the last decade or so some centre are performing Deceased Organ transplants. In western countries Deceased Donors provide as much as 95% of the organs. In India the ratio of such organ transplant is a meager 0.05/million. Tamil Nadu once known for the infamous kidney scam in 2007 took it upon them and changed the scenario into becoming the best State for Deceased organ transplant, somuch so that today the ratio of Deceased organ donation is 1.3/million as compared to the all India figure of 0.05/million. How did this happen? It’s not miracle, but the hard and dedicated work by the Health & Family Welfare Department and Social workers and most important the cooperation of the public at large. Every aspect of the subject was closely studied & refined resulting into a model state for others to follow. Andhra Pradesh, Karnataka, Kerala and to some extent Maharashtra also took cognizance. It started with Mumbai, then Pune and now Nagpur and Aurangabad have initiated program by instituting the Zonal Transplant Coordination Centre’s (ZTCC), who would help guide the Hospitals undertaking Deceased organ transplant activities within the framework of the Law.


ZONAL TRANSPLANT COORINATION CENTRE – NAGPUR Transplant of Human Organ Act, 1994 (Amendment 2011) was implemented in the State of Maharashtra on 23rd February 1995. The Govt. of Maharashtra appointed the Director of Health Services (DHS) as the “Appropriate Authority” (AA) and the “Authorization Committee” (AC) comprising of the following members. 1.Director of Medical Education and Research, Mumbai (DMER)- Chairman 2.Director Health Services- Member 3.Dean, Grant Medical College, Mumbai- Member The main objective of the Act is to have legal and qualitative organ transplantation of human organs, the general norms/guidelines necessary for the medical professionals and hospitals involved in organ transplantation. Based on the recommendations of various experts, the AA has formulated the guidelines to undertake this highest of altruistic act. In 1998 the Maharashtra Govt. put up a draft proposal for setting up ZTCC Mumbai after studying similar organizations elsewhere in other countries which would suit the Indian scenario. The purpose of ZTCC was to improve organ donations, procurement & transplantation system in the city of Mumbai initially & then adopt the same module all over the State. This would increase the availability & access of donor organs for patients of end organ failure in the State of Maharashtra. After the successful working of ZTCC Mumbai in December 2001, the Govt. of Maharashtra established ZTCC in Pune and recently at Nagpur ( December 2012) and Aurangabad


Aims & objectives of ZTCC’s:
1. Effective deceased organ procurement.
2. Increase patient access to the state of the art transplant technology.
3. To improve system of organ sharing by.
i Donor and recipient matching by specific criteria established for each organ.
ii. Improve transplant outcome.
iii. Provide a system by which immunologically sensitized patients are offered the best possible opportunities. iv. Decrease the waste of organs.
4.Assure quality control by collection, analysis & publication of data on organ donation, transplant, etc. 5.Maintain and improve professional skills of those involved in organ procurement & transplants. 6.To have immunosuppressive drug bank 7.To increase public awareness.


Zonal Transplant Coordination Center (ZTCC), Nagpur is a not-for-profit, non-governmental organization started to promote organ donation in December 2012. The aims of ZTCC Nagpur are: 1. To promote Deceased Donor (cadaver) transplant. 2. Optimal use of all cadaveric available organs. 3. To reach out to every needy waiting recipient with fair distribution of organs as per government guidelines.


History of successful transplants

1905: First successful cornea transplant by Eduard Zirm (Czech Republic).

1950: First successful kidney transplant by Dr Richard H. Lawler (Chicago, U.S.A).

1954: Dr. Joseph Murray transplanted kidney successfully from an identical twin.

1966: First successful pancreas transplant by Richard Lillehei and William Kelly (Minnesota, U.S.A.)

1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.)

1967: First successful heart transplant by Christian Barnard (Cape Town, South Africa)

1981: First successful heart/lung transplant by Bruce Reitz (Stanford, U.S.A.

1983: First successful lung lobe transplant by Joel Cooper (Toronto, Canada)

1984: First successful double organ transplant by Thomas Starzl and Henry T. Bahnson (Pittsburgh,U.S.A.)

1986: First successful double-lung transplant (Ann Harrison) by Joel Cooper (Toronto,Canada)

1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner and LouisKavoussi (Baltimore, U.S.A.)

1997: First successful allogeneic vascularized transplantation of a fresh and perfused human knee joint by Gunther O. Hofmann

1998: First successful live-donor partial pancreas transplant by David Sutherland (Minnesota, U.S.A.)

1998: First successful hand transplant by Dr. Jean-Michel Dubernard (Lyon, France)

1999: First successful Tissue Engineered Bladder transplanted by Anthony Atala (Boston Children’s Hospital, U.S.A.)

2005: First successful ovarian transplant by Dr P N Mhatre (Wadia hospital Mumbai (India).

2005: First successful partial face transplant (France)

2006: First jaw transplant to combine donor jaw with bone marrow from the patient, by Eric M. Genden Mount Sinai Hospital, New York

2006: First successful human penis transplant (later reversed after 15 days due to 44 year old recipient’s wife’s psychological rejection) (Guangzhou, China)

2008: First successful complete full double arm transplant by Edgar Biemer, Christoph Höhnke and Manfred Stangl (Technical University of Munich, Germany)

2008: First baby born from transplanted ovary by James Randerson

2008: First transplant of a human windpipe using a patient’s own stem cells, by Paolo Macchiarini (Barcelona, Spain)

2008: First successful transplantation of near total area (80%) of face, (including palate,nose,cheeks, and eyelid) by Maria Siemionow (Cleveland, USA)

2010: First full facial transplant, by Dr Joan Pere Barret and team (Hospital UniversitariValld’Hebron on July 26, 2010 in Barcelona, Spain.)

2011: First double leg transplant, by Dr Cavadas and team (Valencia’s Hospital La Fe, Spain)


Types of organ donors and Indian scenario:

Organ donors may be living, or brain dead. In “living donors”, the donor remains alive and donates a renewable tissue, cell, or fluid (e.g. blood, skin), or donates an organ or part of an organ in which the remaining organ can regenerate or take on the workload of the rest of the organ (primarily single kidney donation, partial donation of liver, small bowel). Brain dead or deceased donor Brain dead (formerly called cadaveric) are now called Deceased organ donors, who have been declared brain-dead and whose organs are kept viable by ventilators or other mechanical mechanisms until they can be donated for transplantation. Brain death occurs due to an injury (either traumatic or pathological) to the part of the brain (brain stem) that controls heartbeat and breathing. Breathing is maintained via artificial sources (Ventilator support), which, in turn, maintains heartbeat. Once brain death has been declared the person can be considered for organ donation


World scenario of Deceased donor (cadaver) transplant per/million

Croatia 40
Spain 39
Britain 27
USA 26
Canada 14
Australia 11
Hongkong 5
India 0.20(Tamil Nadu 2.6)
• India needs 2 lac kidney transplants, but due to lack of facilities and unawareness of the subject, only about 8,000 transplants are done. 75% of these from live donors.
• 50,000 liver transplants are needed but only 700 surgeries are conducted.
• Only 50 hearts were transplanted as against the need of 50,000.
• For transplanting cornea, 200,000 surgeries were needed but only 50,000 were conducted
• There are only 200 government approved kidney transplant centres, 30 liver transplant centres and 10 cardiac transplant centres across India.
• India has only 200 kidney transplant surgeons, 25 liver transplant surgeons and 15 cardiac transplant surgeons.


Age & Organ Donation

Corneas 0 – 100 years (Poor eyesight not a contraindication) Heart Valves 0 – 40 years (Heart attack not a contraindication) Trachea 15 – 60 years Skin 16 – 85 years Kidneys 0 – 75 years (Pediatric donors are assessed according to weight and size) Liver 0 – 70 years (size matching is usually recommended) Heart 0 – 50 years Lungs 0 – 50 years (individual assessment of each lung performed) Pancreas 18 – 45 years


ZONAL TRANSPLANT COORDINATION CENTRE -NAGPUR

At every stage there are ethical issues that have to be considered. Many questions arise that cannot be answered easily. It all depends on time, place and other circumstances.

1. Donor identification: The more donors we identify, the more we are likely to lose but still have a sufficient numbers to meet demands for organs. If we want to have successful conversion of all donors then we have to identify them early and manage them well. This can be only done if you are an ICU staff. It is best to build a rapport with the ICU staff and do daily rounds to know if there are any potential deceased donors. If the ICU staffs are sensitized to the cause they can telephone to a coordinator if this happens in out of hours.

2.Donor screening It is important to screen potential donors for serious diseases such as malignancy or infection that could be transmitted to the recipient. Since there is a serious shortage of donors we now tend to accept elderly patients and donors with hypertension and diabetes and sometimes even viral diseases – a pool that was not accepted as donors previously (extended or expanded donor criteria). We have to create a balance between accepting organs and tissues that are not good enough and not turning down organs and tissues that are sufficiently good to be used.  The screening tests are mentioned in the brain death chapter.

3.Donor management
Proper maintenance of donors is extremely important for procuring viable organs. Please see chapter on brain death.

4. Consent
In India informed consent is valid, which means that relatives always have to give consent for retrieval of the organs. They will be consulted to help evaluate the attitude of the deceased to donation, which can be positive, negative or unknown.

5. Organ retrieval
Good routines facilitate the procedures and minimize organ damage during the procurement operation. An ethical issue is what should be done with an organ that in spite of all precautions is not useable. If the organ gets damaged beyond repair – as happens sometimes during retrieval surgery, it cannot be used anymore. But if it is damaged and can be repaired, it should you use it in your own institution or can it be sent to another centre with a discussion with the surgeon? There are centres that use organs that have been discarded elsewhere with good results.