Collaborating to make a safer transplant


The recently held full-day conference ‘Kidney Update 2017’ saw experts from Spain share their thoughts and build stronger bonds with Goa in terms of organ donation systems in the state. NT Network met up with the resource persons to find out more about this collaboration

Janice Savina Rodrigues|NT Network

There are people who die in vain, as they cannot afford or cannot find a donor to help replace their failing organs. Some wait for months or even years, cutting the circuits of various hospitals and in case of ailing kidneys, the long arduous procedure of dialysis. There have been medical advancements in the West as far as donations and transplants are concerned, especially in the area of cadaver or deceased donations, but India and more particularly Goa is way behind in catching up with the developed countries.

With the aim of promoting the idea of organ donation and transplants the Indian Medical Association (IMA) Goa organised the Kidney Update 2017 recently. The conference saw the promotion of the India-Spain collaboration on the subject of transplants. The director of the National Organ and Tissue Transplant Organisation (NOTTO) Vimal Bhandari was in Goa for the event and speaking about the transplant scene in India said: “There is a big gap between the demand and supply in the transplant scenes now. We are trying to promote our deceased organ donation campaign simply because there is a dire need.”

Taking inspiration from Spain where the donation and transplant rates have increased tremendously over the past 30 years, the IMA and NOTTO are trying to work on a module that will streamline the process. “Spain as a country has the highest per million population transplants, and we want to seek their help in creating awareness about deceased organ donation and forming and maintaining a registry and how to improve the system,” says Bhandari.

The Barcelona-based TPM DTI (Transplant Procurement Management Donation & Transplantation Institute) is a not-for-profit organisation committed to raise awareness about organ donation around the world and improve the quality of life and help curb organ trade and trafficking. Its executive director Maria Paula Gomez is a medical doctor specialised in organ donation, healthcare management and has 17 years of experience supporting countries and regions in the implementation and development of its organ donation systems. “Our mission is to help and support the whole of the organ donation system,” she says.

The collaboration programme had initially started with one of the doctors from Goa going to Spain to learn about the processes involved in the organ donation. “And then they would come back and try and work with the all the stakeholders of the field here. One of the aims is to work towards organ procurement units, that is to educate the doctors and nurses in departments in hospitals dealing with deceased patients to obtain organs for transplant,” says Gomez.

Speaking about her observations in Goa, Gomez is quiet enthusiastic with the response and the commitment of the health care professionals here towards organ donation. “In Goa there is a commitment and interest by the health care professionals and societies like the Indian Medical Association. I have been given to understand that the IMA has done some kidney transplants from living donors. There are also all the requisites needed to start the programme: a law that authorises the doctors to take organs from deceased people, and the healthcare system. The attitude of the community is also positive, we just need to raise more awareness about the issues and educate the doctors,” she says. While she praised the state’s initiative towards organ donation, she didn’t seem too positive about the scenarios at the national level. “In India on the whole it is a challenge, the country is huge and so is the population, it takes time to get things started. The national organisations have been working towards the aim, in different zones and opening transplant centres, private and public, and trying to get all the stakeholders to work together, it is progressing slowly,” she says.

Speaking about the legalities that are applicable in the sphere of organ donation, Bhandari states that the laws are in place. “The law is strict and the punishment for illegal transplant is in crores. However, because of the strict laws genuine people are also being denied their rights. We should not let a person die because of the fear of illegal activities and India is working towards a more just distribution of organs. People are taking it seriously now. As far as money transactions are involved, we always try to rule that out. However, it is also not possible for a doctor to monitor if a sibling is offering monetary or other help to his donor-sibling in lieu for an organ,” he says.

Gomez asserts that in Spain, money transactions are prohibited as the concept of money changing hands is completely against what organ donation actually means. “Prosecuting these practices is very important. There are national and state level organisations that oversee these procedures. Also the World Health Organisation (WHO) is doing hard work to develop laws on an international scale.”

The laws associated with the donors, and the order of the likely donors that is the spouse, siblings, parent and children in that order, that is followed in India is the same system followed in Spain, “The only thing is that in Spain everyone is a donor by law but the right to donate still lies with the family, in case of the deceased donations,” says Gomez. In Spain, the family is helped in the healing process by professionals, “the families look back and feel good that they could give life to five to six other people through the donation.”

She further adds that the success of the Spanish model of the organ procurement and donation lies in the structure of the system. “The national office followed by regional offices and then the hospitals and organs procurement units. This is not about high technology; it is about following an organised system. The key of the Spanish model is that in every hospital in Spain there is a health care professional responsible for organ donation. They are the ones who run the model,” says Gomez.

Ask about who can be a donor and who cannot, the reply is that anyone can become a donor. “Of course we have some criteria with regard to the health of the person. In case of deceased donation, if the death has happened in the hospital it has to be harvested within the given time. Only people who die in brain death are able to become donors. The persons who die at home and then brought to the hospital are not able to become donors. Organs have a specific time to remain suitable for transplantation. We have to analyse the time the person has died to transplant,” says Gomez. Bhandari adds that it depends on the health of the person and the organ: “In case of kidney we have to make sure the person has no diabetes, or for liver it has to be made sure that the person doesn’t have a fatty liver. That way each organ has its own criteria.”

So how does the process of procurement and transplantation work? The Spain module is quite a well thought out system. “A hospital has to be registered as a transplant hospital. If anyone dies in these registered hospitals the other patients that are on the waiting list with the national authority are contacted immediately. The patients have to be registered at the transplant centres and they will then be put on the national waiting list. And according to the medical history of the patient the organ will then be allocated to the recipient,” says Gomez.

A similar waiting list is also followed in the context of the all-India level. Transplants are happening at a positive rate, with NOTTO alone carrying out 10 transplants last year. “The state-level Tamil Nadu has done very well with about 200 transplants,” says Bhandari. Working with Spain, NOTTO wants to help spread awareness and learn from their registry and how to improve that system. “We have been moving from state to state to spread awareness. We started with Madhya Pradesh, Telangana, Andhra Pradesh, Maharashtra, Delhi and now moving to other states,” he adds. NOTTO is trying to create a national networking system in the country and is working on how to distribute organs and who is a priority; and to promote deceased transplants.

Goa has already done transplantations for kidneys from living donors but is there scope to go beyond? Gomez shares her observations that Goa seems to be ready to go beyond. “Though I have to visit the hospitals to see the processes and infrastructure, I know that Goa has done kidney transplants from living donors. There are nephrologists, surgery professionals and so I think there is a scope to go beyond, and that Goa is ready to do a transplant in heart, liver or lung but the infrastructure and the knowledge required for these transplants are very different from that of a kidney, which needs to be worked upon,” she adds.

Bhandari adds that Goa being a small state, it is very unfortunate that we haven’t started a deceased organ donation centre here. “We will be able to provide credible training and we can help with the expertise. And the chief minister is also very supportive of our efforts. Adequate budget and funds are available through NOTTO for training retrieval surgeons and appointing dedicated transplant coordinators,” he says. Goa being a small state has distinct advantages according to the director – good road network and more than 60 ICU beds across the state. “We can easily have up to 30 donations a year making it 20 per million population.”

The IMA Goa State has appointed nephrologist Amol Mahaldar to work on the organ donation theme this year. Having acquired a post graduate diploma in transplant management in Spain, Mahaldar has been trying to work on multiple levels, in association with the secretary for Health, Goa; director Health Services and dean of Goa Medical College to try and put in place a brain death declaration panel for the state. “We have met and submitted a representation to the chief minister about the process to start the deceased donor programme in Goa,” says Mahaldar.

Health care professionals are trying to work tirelessly on the TPM DTI MoU that was signed in February this year improving collaboration to adapt the successful Spain model with important local modifications to suit the state of Goa. “The visit of the TPM DTI expert Maria Paula Gomez along with Vimal Bhandari was a tremendous opportunity for IMA to impress on both its members and the political and bureaucracy of Goa the importance of the program. This is an important programme for the central government and Goa needs to setup a state level SOTTO for early development,” says Mahaladar.

Bhandari having visited the GMC and Manipal Hospital Goa has given a thumbs-up to the facility to initiate a public-private partnership for building better networks. “Maria visited the ICUs at GMC and Manipal-Goa and predicted that for a state with almost 60 ICU beds it is possible to have one patient per bed per year as a successful donor,” says Mahaldar. This figure roughly indicates that we could have anywhere between 30-60 donations per year – a huge upgrade as compared to the 14 living donations in 5 years. “The above figure is consistent with the almost 350 fatal accidents each year that have a majority of head injuries. If we improve the care and save 50 per cent and among those that don’t, 10 per cent could be considered as donors, thus we can still have 35 donations each year,” says Mahaldar.

Recently the IMA Goa State had a joint meeting with stakeholders where the NOTTO director suggested that an all India meeting be held in Goa and the state could also play host to the Spanish experts to train delegates from all over the country. “That will also work as a positive for Goa. The only thing we have to see now is when will the local leaders take the jump and save lives,” concludes Mahaldar.