CIN2001: DONOR SELECTION

DISCUSSION BOARD

A history was made in 1954 when Murray and his team carried out a renal transplant in man taking a kidney from identical twin brother of patient. This event soon followed by more successful living donors transplants and excellent results obtained with transplant led an increased acceptance of this form of treatment by patients as well as by professionals.

In early years only a good HLA compatibility allowed good results. Thereafter, the development of new and more potent immunosuppressive agents has permitted the acceptance of new challenges which came as living unrelated donors, marginal donors and cadaver donors.

The shortage of donor organs is one of biggest problems which major transplant programmes are facing. According to USRDS 1999 annual report, of 344,094 ESRF patients only 13,590 received transplants, 8,980 were cadaver donors and 4,526 were living while donor source not known in 84 patients.1 A published data from Asian countries ( Pakistan and India not included) reported 231,561 patients on dialysis and 23,565 patients were waiting for kidney transplant at the end of 1995. Source of living donors in these countries were living related donors (LRD), except two countries who were doing 27-70 % from unrelated living donors (LURD).2

In Pakistan estimated incidence of ESRF is approximately 100 pmp, (with a population of 144million) total number of patients accepted for renal replacement therapy annually is between 1500-2000, transplants carried out in only 5 % and sources of organs is LRDs in 40 % and LURDs in 60 %.(unpublished data). LURD transplants carried out mostly in northern part of country. Cadaver transplant is not yet legalised , although a limited number of cadaver transplants carried out at Sindh Institute of Urology and Transplantation (SIUT) from non-heart beating donors organs supplied by Eurotransplant Foundation, Netherlands. Only one pair of kidneys harvested from a local donor after brain death, also transplanted to two young patients at same institute.

The main obstacles in transplant at this country are:

Financial – In average / capita income is 400 US $ / year, of GNP spent on health is 3 %. These values result in an extremely low / capita health expenditure. This funding refrains a faster development of transplant programmes especially in government sector.
Governmental – lack of adequate policy towards transplant, for example histocompatibility testing is not available in any of government institutions other than one in forces hospital and one at SIUT which is a semi-government institution, partly funded by government.
Organisational – a national organisation with definite functions and objectives is lacking. Transplant co-ordinators are rarely found.
Medical – failure to understand extent of problem, mis-concept about organ donation, fear of society values are common among medical doctors.
Social/ familial - with an average of 6 children in family it should be rather easier to find a donor with good HLA match in the family. The problems faced in this situation are more of social and cultural , males are spared from donation as finding a dominant place in family or as excuse for bread winner of family, married females pressurized by their husbands or in-laws not to donate, unmarried females having donated an organ not accepted for marriage later on. (FIG. 1 & 2)
Media- In general , the press is favourable to organ donation and transplantation and has a strong role as written by Marshal McLuhan; Arquimedas once said, “give me a point of support and I will move the world” on referring to mass media this stage would have said, “I will support myself with your eyes, ears, nerves and your brain and I shall move the world in the way and rhythm that I want”. On the other hand occasional reports describe children being kidnapped, prisnors being forced, or kidney being removed from fraud when a person seek advice for simple ailment.
Legislation – The law defining the brain death, the authorization of organ removal and usage of living donors is lacking. It should be imposed by law srong restriction to LURD transplants and absolute forbid any form of commerce.
Religion – of nation is Islam which is pro organ transplant. Most religious leaders accept it as a means of saving human life. They quote the message from “The Quran” , which says, “saving life of one person is like you have saved the whole mankind”.3 Saudi Arab, a country which occupies a central place in Islamic world has very high rates of doing living as well as cadaver transplants. Acceptance for brain-death and will to donate in the situation is as high as 88 % according to a poll in general population.4

In the situation with an obvious need to develop transplant programmes in this part of world, or this country more specifically it requires the participation of society for their full development .

At this institute we have done 980 transplants, between Nov.1985 – Sept.2001, all LRDs 51 % siblings, 32 % parents, 6 % offsprings, 5 % spousal and 2.3 % cousins. Common practice of cousin marriages and results of graft function in cyclosporin era reported from terasaki’s large series 5 encouraged this source of organs to be utilized.This also makes an argument against paid organ donation which in all circumstances governed by commercialism and leaves a possibility of compromise in pre and post transplant care of donor and recepient . Furthermore, it drives doctors in business of organ sales and purchase which is a serious ethical issue in medical profession.

During selecting a donor from family at SIUT we follow the protocol described below:

Complete history and physical examination
Social and psychological evaluation – which is necessary to confirm that the motive to donate is altruistic.
ABO typing
Lab studies
CBC, serum chemistry profile including liver function tests and coagulation profile
Urinalysis and 24 hours urine evaluation for protein excretion and creatinine clearance
Virology – for HBV, HCV, CMV, HIV
Immunological studies: HLA typing, Lymphocyte cross-matching, PRA
Radiology, CXR, US kidneys, IVU, Renal Angiogram (if IVU normal), Nuclear studies in selected cases where suspecion of PUJ abnormality on IVU
ECG in all, Stress test in donors above 45 years + Echocardiography
Final cross-match 24-72 hours prior to transplant surgery as many recepients receive blood transfusions in interim period.

Exclusion criteria for LRDs we follow at SIUT :

Age < 18 or >60 – 65 years
Hypertension ( >140/90 or necessity for medication)
Diabetes or impaired GTT
Proteinuria > 250 mg/ 24 hours
History of recurrent stone formation
GFR < 80 ml/min
Microscopic haematuria
Donor < 40 years with family history of APKDs
Congenital urological abnormality
Significant past medical history ( e.g. bronchiectasis, any malignancy)
Strong family history of renal diseases (e.g. familial FSGS)

Concerned donors made clear that they can not be sacrificed even when are prepared to make sacrifice, as in the case of mother to children.

Fig. 1 showing prospective family donor pool when evaluated during one year among patients who received transplant and those who could not.

Fig. 2 . showing extent of problem among prospective family donors in same studied population at SIUT.

The way forward:

As only 5 % of ESRF patients in the country can receive organ transplant, a treatment option which offers the greatest potential for restoring a healthy, productive life. We need to expand transplant activity manifold. In terms of LRDTx, the attitude of public towards altruistic organ donation (even in a family) and its acceptance is a complex process in which multiple factors play a part. This attitude must be strengthened by offering a positive feedback with clear information about efficiency of transplant and the integrity and fairness of noble cause. Educational/ informative compaigns must be focused in this direction.

In terms of cadaver transplant there is an urgent need of implementation of cadaver law in this country. NHBDs are the stepping stone when cadaver donation is not readily accepted. Heart beating donation with brain death requires a lot of ground work to do, of prime importance are

Education of professionals
Development of infrastructure
Establishment of ICUs
Network of transplant co-ordinators and national registry system
Education of common men through media
Role of family physician

Practice of LURDTx where trade is involved should be discouraged by all means, as in this country poverty, unemployment and feudal culture will lead to people donating organs for small benefits or under pressure. Lots of such incidences already happening as reported by a daily magazine very recently.6

References:

1. http://www.usrds.org

2.- Takagi H; Organ Transplant Still Too Few in Japan and Asian countries. Tx Proceed. 1997, 29: 1580-3.

3.- Al-Maida 6 (5): 32. Al- Quran.( word of God for Humanity- Holy book of followers of Islam) 579 AD

4.- Gabr M; Organ Transplant in developing countries. World Health Forum. 1998, 19: 120-3.

5.- Terasaki PI, Cecka JM, Gjertson DW, Takemoto S; High survival rates of kidney transplant from spousal and LURDs. NEJM. 1995, 333: 333- 6

6.http:// www.DAWN.com Saturday, sept.29’2001. p 2.