Transcript Document

Cadaver Organ Donation & Transplantation
in Asia – The Way Ahead
Sunil Shroff
Head of Department - Urology & Renal Transplantation,
Sri Ramachandra Medical College & Research Institution, Managing Trustee,
MOHAN Foundation, Chennai
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
The Organ Shortage
Each day, about 60 people around the world
receive an organ transplant, while another 13 die
due to non-availability of organs.
 Organ shortage — the main limitation to saving
lives of critically ill patients — is due to
individuals and their families not considering
organ donation out of fear, ignorance or
misunderstanding.
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Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Transplant in Asia – The Road Ahead
 Overview
of Cadaver Transplants in Asia
 Common Problems & Platforms
 The Road Ahead
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Overview of Asia
Asia
World
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Population
3.6 Billion (1.7% inc)
6.4 Billion
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No Of Countries
51
235
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Land Mass
44,390,000 Sq.Km
6,233,821,945 Sq.Km
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Life Expectancy
M 63 yr F 66yrs
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Transplants in Asia
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Kidney
Liver
Heart
Heart Lung
Pancreas
Source: Asian Transplant Registry
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
PER CAPITA INCOME FOR ASIAN COUNTRIES ( In US Dollars)
High Per Capita Income 2500
Average Per Capita Income 1200
Japan
Hong Kong
Singapore
Kuwait
Israel
S Korea
Taiwan
Saudi Arabia
Lebanon
Malaysia
Turkey
Maldives
Thailand
Iran
Kazakhstan
Jordan
Syria
China
Turkmenistan
Philippines
34,180
25,860
21,230
17,960
16,240
12,030
13,530
9,240
4,040
3,880
2,800
2,510
2,190
2,010
1,780
1,850
1,190
1,100
1,120
1,080
No Data - Afghanistan
-Bhutan, Palestine, Bahrain,
Cyprus, Iraq, Qatar, UAE,
Myanmar, Timor , Oman,
Brunei, N.Korea
Low Per Capita Income - 1000
Sri Lanka
930
Armenia
950
Indonesia
810
Azerbaijan
820
Georgia
770
India
540
Yemen
520
Pakistan
520
Mongolia
480
Vietnam
480
Bangladesh
400
Uzbekistan
Laos
Kyrgyzstan
Cambodia
Nepal
Tajikistan
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
420
340
340
300
240
210
High per capita income & Successful Transplant
Programmes
Japan
Hong Kong
Singapore
Kuwait
Israel
S Korea
Taiwan
Saudi Arabia
Lebanon
Malaysia
Turkey
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
High per capita income & Cadaver Tansplant
Programme
Hong Kong
Singapore
Taiwan
Saudi Arabia
Malaysia
Turkey
Iran
Lebanon
Kuwait
Israel
S Korea
Japan
Most of Asia is struggling with Cadaver Programme including regions with high
per capita
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Kidney Tx Waiting List in Asia (2002)
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Japan
–
Taiwan
–
Saudi Arabia –
Korea
–
Pakistan
Hong Kong Singapore
–
Bangladesh -
12,974
7000
4248
4000
1650
1018
666
125
Waiting Time
Taiwan
Korea
Hong Kong
Singapore
– 1.9 yrs
– 2.2 yrs
– 4.3 yrs
– 5.8 yrs
No figures available for China, India, Philipines, Indonesia
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Transplant Expertise - Asia
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Japan has - 352 transplant centres
Thailand - 27 kidney, 6 liver, and 6 Cardiac
transplantation centers,
India has 5 centres- Liver, 6 - Cardiac and over 100 for
Kidneys.
 35 centres have undertaken cadaver transplants
 However only 6 do it regular frequency.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Historical Aspects – Cadaver Transplantation - India
1967 - First succeesful cadaver Kidney Transplant in India
at KEM Hospital, Bombay
1994 - First successful heart transplant done at AIIMS,
N.Delhi
1995 - First successful multi-organ transplant done at
Apollo Hospital, Chennai
1998 – First Successful Lung transplant, Madras Medical
Mission Hospital, Chennai
1999 – First Pancreas Transplant, Ahembdabad
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Transplants - Japan
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Kidney Transplant since 1964
-15 113
Liver transplants since 1989
- 2411
Heart Transplants since 1998
- 17
Lung transplants since 1998
- 39
The organs have largely been obtained from living and
to some extent from non-heart beating donors
Ref: Shirakura -WHO/HTP/EHT/T-2003.1Ethics, access and safety in tissue and
organ transplantation:Issues of global concern. Madrid, Spain, 6-9 October 2003
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Kidney Transplants in Asia
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India, Taiwan, Korea, Thailand, Iran, Saudi Arabia and Singapore
– Regularly are undertaking Kidney Cadaver Transplants
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Taiwan, Thailand, Singapore follow the western model and run
the programme almost on the same line
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Japan is still struggling with the programme though their numbers
are slowly rising
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India is emerging as one of the Key players despite still
struggling with the programme logistics
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Very Little information from China is Available on their modus
operandi
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Heart Transplants in Asia
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Hong Kong, India, Japan, Malaysia, Saudi Arabia,
Singapore and Thailand are doing Heart transplants
Taiwan and Korea do the max heart transplants in Asia
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Liver Transplants in Asia
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Korea do the maximum living liver transplants and has high level
of expertise in the field
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2,345 LTs (1,860 from the living donor and 485 from the deceased
donor) were performed in 24 institutes from March 1988 to
December 2004, although 5 institutes had performed more than
10 LTs per year.
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Japan, Hong Kong, Taiwan similarly have expertise in living liver
transplants
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Four centres in India – located atHyderabad, Vellore and Delhi
have fair expertise with liver transplants and emerging as the key
players in the country.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Kidney Transplants Scene in India
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In past seven years approx. 592 Cadaver organ transplants
(518 kidneys, 35 Livers and 37 Hearts) have been performed
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35 Centres have undertaken Cadaver transplants
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Majority of these 35 centres are Private or trust hospitals
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Of these only half a dozen undertake cadaver transplants
regularly
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Almost 50% of the cadaver transplants in India done in Tamil
Nadu
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Tamil Nadu Organ Sharing Network could become the role
model for rest of the country
Approx.200 centres in India have expertise to undertake kidney
transplants
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Brain Death Legislation
Most countries have some law for tissue procurement but not
all have Brain Death Legislation in Place
Singapore – 1987
Iran
Philippine – 1991
Saudi Arabia
Thailand – 1986 / 1996
Malaysia
India -1995
Taiwan
Japan – 1997
Kuwait
S. Korea - 2000
Turkey
Bangladesh – 1999
Sri Lanka - 1987
Malaysia -1974
Over 20 countries in Asia do transplants
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Asian Countries Undertaking Transplants –
Kidneys alone
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Bangladesh – K
Pakistan - K
Philippines – K
Indonesia – K
Malaysia – K,
Iran – K,
Israel – K
Turkey – K
Syria – K
Malaysia – K
Some of these countries have done (eg Pakistan) occasional liver or heart
(eg Malaysia) transplant.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Asian Countries Undertaking Multi–organ
Transplants
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Hong Kong
– K, H, Li, H-L
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India
– K, H, Li, H-L, P
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Japan
– K, H, L, L, K-P
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Korea
- K, H, Li, L, K-P
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People Rep China
– K, H, Li
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Saudi Arabia
–K, H, L, Li
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Singapore
– K, H, L, Li
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Taiwan
– K, H, H-L, Li
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Thailand
– K, H, H-L, Li
Legend: K-Kidneys, K-P - Kidneys & Pancreas, H-Heart, L-Lung,
H-L-Heart & Lung, Li- Liver
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Transplant in Asia – The Road Ahead
 Overview
of Cadaver Transplants in
Asia
 Common Problems & Platforms
 The Way Ahead
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Common Problems & Platforms
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Magnitude of the Problem
Public and Professionals Attitude to Brain Death &
Organ Donation
Religion & Organ Donation
Legal Aspects
Media and Scandals
Reporting of Brain Death
Hospital Infrastructure
Trained Transplant Co-ordinators /Counsellors
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Incidence of ESRD In Asians & Blacks
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Black and Asian people are three to four times more
likely to develop end stage renal failure than white
people
This rises to eight times more likely for older Asians
Diabetes five times the rate of the white population
Hypertension was at least twice the rate of the white
population.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
World Status of Transplants
Annual Number of kidney transplantations per million
population (pmp) USA 52
Predominantly Cadaver Donors
Europe - 27
Predominantly Cadaver Donors
Asia 3
Predominantly Living Donors
In last 10 to 15 years the rate of both kidney an liver transplants have
increased but heart has remained static. In 2000 approx. 15,000 kidneys
were transplanted in each region.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Donor Rates
The Cadaver donors per million population per year
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USA 20.7
Europe 15.9
Asia 1.1
South America - 2.6
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Waiting List for Organs keep Growing
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Only about 2.5% of the Japanese carry donor cards, but
more than 13,000 Japanese are waiting for transplants.

In February 2000, a 44-year-old woman who was
declared brain dead following a brain hemorrhage and
stroke donated all four of the organs used in recent
transplants. The woman's heart went to a man in his
40s
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Physicians Attitude to Organ Donation
Korean health professionals' attitudes and knowledge toward
organ donation and transplantation. Kim JR, Elliott D, Hyde C. 2004
Mar;41(3):299-307.
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There was a lack of knowledge by Korean health professionals
surrounding brain death and the organ procurement process.
Participants' attitudes were mixed and somewhat negative, as
they did not regard brain death as true death
Korea – Organ donation rate below 2 per million population per year.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Physicians Attitude to Organ Donation
Outmoded attitudes toward organ donation among Turkish health
care professionals. Topbas M, Can G, Can MA, Ozgun S.Transplant Proc. 2005
Jun;37(5):1998-2000.
A large proportion of Physicians are indifferent to organ
donation process. Reason cited for this were 
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Lack of information regarding the donation process (28.7%),
Concerns about the sale of organs (22.1%),
Islamic religious beliefs (21.6%)
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Public Attitude
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Turkey (n=774) - 59.2% would consider donating organs
Pakistan(n 367) – 59.9% Willing to donate their organs
Hong Kong - 60.3% of the respondents were are willing
to donate organs
Viet Nam - 66% urban Vietnamese surveyed were
willing to donate organs or tissues after death
Ref Turkey- Ozdag N. EDTNA ERCA J. 2004 Oct-Dec;30(4):188-95
Pakistan - Artif Organs. 2005 Nov;29(11):899-905. Ashraf O, Ali S, Li SA, et al
Hong Kong - Yeung I, Kong SH, Lee J. Soc Sci
Med. 2000 Jun;50(11):1643-54
Dr.Sunil Shroff,
th Nov 2005
IV International
Kidney
Diseases,
Ahembdabad.
11-13
Viet Nam - Hai TB,
Eastlund T, Congress
Chien LA, of
Duc
PT, Giang
TH, Hoa
NT, Viet PH,
Trung
DQ.
Public Attitude - Singapore
Social and cultural aspects of organ donation in Asia.
Woo KT. Ann Acad Med Singapore. 1992 May;21(3)
Important misconceptions and fears were –
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Fear of death,
Belief that removal of organ violates sanctity of decreased
Concern about being cut up after death,
Desire to be buried whole,
Dislike of idea of kidneys inside another person,
Wrong concept of brain death,
Idea of donation being against religious conviction
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Public Attitude - China
Investigation of understanding and willingness of organ
transplantation in young people in Beijing, Shanghai, Wuhan.
Zhonghua Yi Xue Za Zhi. 1997 Jan;77(1):22-7. Liu Y, Lei H, Qiu F. China Foundation of
Organ Transplantation Development, Wuhan
Cities of China –
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Young people have a better understanding of organ
transplantation
Conventional attitudes and feudal habits are the major obstacle
to the development of organ transplantation in China.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Public Attitude and Organ donation in India
SURVEY ON “PUBLIC ATTITUDE TOWARDS ORGAN DONATION &
TRANSPLANATATION”
Shroff S, Shankar R et al, Indian Medical Tribune, 1996
Results of the Survey
 Less than 50% overall positive response in favour
of donating solid organs
 72% were willing for “Eye” donation and carry a
“Donor Card”
 All major religions were willing to consider organ
donation
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
CONCLUSION - “PUBLIC ATTITUDE SURVEY”
HOW TO ASK FOR ORGANS IN THE EVENT OF “BRAIN DEATH” PATIENT
“Request for EYES” FIRST” - SEE HOW FAMILY REACTS
Family Willing
Family Reluctant
Ask For Solid Organs
(Heart, Liver, Kidneys ..)
Abandon Efforts
Inform Transplant Co-coordinator
Above protocol called “THE RAMACHANDRA
Dr.Sunil Shroff, PROTOCOL” to ask for organs
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Singapore - Legal Aspects
THE HUMAN ORGAN TRANSPLANT ACT (HOTA) OF
1987 – Singapore
“….. Kidneys can be procured from patients of road
traffic accidentswho have been declared “brain-dead”
unless they have OPTED OUT ( Presumed Consent)
(Muslims exempted)
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Legal Aspects
Malaysia - The “LAWS OF MALAYSIA, ACT 130 1974
- which provides for the use of parts of the human
bodies of deceased persons for therapeutic
purposes and for purposes of medical education
and research.
S.Korea - The Transplant Act was first passed in 1999
and then reviewed in 2002.
 The Act covers organs and tissues (only bone
marrow (BM) and corneas).
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Thailand - Legal Aspects
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There is no law to directly govern transplant procedures
in Thailand.
The Medical Council is responsible in regulating human
organ transplantation. They decide the criteria from time
to time.
Medical Council in Thailand determines whether any
punitive action should be taken against the doctors
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
S.Korea – Legal Aspects
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
PHILIPPINES - LEGAL ASPECTS
REPUBLIC ACT 7170, 1991 which authorizes the legacy or donation of all or part of
the human body after death for specified purposes
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
VIETNAM - LEGAL ASPECTS
THE CIVIL CODE, ARTICLE 32, CHAPTER 2
- requiring consent from donor or next-of-kin.
“THE PEOPLE’S HEALTH PROTECTION CODE,
CHAPTER 4” providing for tissue transplantation.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
INDONESIA - LEGAL ASPECTS :
THE INDONESIA 1992 HEALTH REGULATION
- provides for procurement of tissues from living donors
only.
FATWA FOR BONE, SKIN & AMNION
- introduced in JUNE 1997 by religious council
permitting tissue procurement from cadaveric donors.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
BANGLADESH - LEGAL ASPECTS
TISSUE DONATION & TRANSPLANTATION
1999 ACT
- passed recently permitting donation from both living and
cadaveric donors.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
SRI LANKA - Legal Aspects
LEGAL ASPECTS : “THE HUMAN TISSUE
TRANSPLANTATION ACT NO 48 OF 1987
which requires consent from donor or next-of-kin.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
India – Legal Aspects
Transplantation of Human Organs Act, 1994
Aims
 Regulate removal, storage and
transplantation of human organs for
therapeutic purposes
 To prevent commercial dealings in
organs
 Recognise Brain Death
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
RELIGIOUS & CULTURAL ASPECTS
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Religion plays major role in promoting Organ Donation.
Major religions in Asia Pacific include Islam
Buddhism
Christianity
Hinduism
Sikhism
Judaism
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Religion and Organ Donation
Common thread that binds all religions of the world –
 Saving of life overrides all objections
 There is no religions that is against organ donation
 What holds back is cultural reservations,
• Ignorance of the process of organ donation,
• Fear of mutilation,
• Lack of emotional support at time of tragedy,
• Fear that organs will be sold or used only by the rich
• Mistrust of hospitals and health professionals
• Myths.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Religious Attitude to Donation
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Chinese–Americans are influenced by Confucian values, and to
a lesser extent, Buddhist, Daoist spiritual beliefs
- associate an intact body with respect for ancestors or nature.
The subjects were most willing to donate their organs after their
deaths – 1st to close relatives , then in descending order –
distant relatives, people from their home country and strangers
Influence of religious and spiritual values on the willingness of Chinese–
Americans to donate organs for transplantation. Wilbur Aaron Lama & Laurence B
McCulloughb .Clinical TransplantationVolume 14 Issue 5 Page 449 - October 2000 doi:10.1034/j.1399-0012.2000.140502.x
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Buddhism & Organ Donation
“The attitude of Buddhism is in perfect agreement with
organ and tissue donation; and in Buddhist Scriptures
there are stories where donation of tissues have been
referred to as an act of charity earning merits”
- The Late Dr Hudson Silva
World renowned success of the Eye Donation Society of Sri Lanka led by late
Dr. Hudson Silva: target of 40,000 eyes procurement reached in May 1999.
Guajrat in India with high no. of Jains gets 4000 corneas - highest in India.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Buddhism & Organ Donation
Predominantly Buddhist
Countries
 Sri Lanka
 Thailand
 Vietnam
 Myanmar
Less Dominant
 Korea (30%)
 Singapore (30%)
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Buddhism & Organ Donation
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In countries where Buddhism is predominant there is no
shortage of Tissue / ? Organ donors Sri Lanka
Thailand
Vietnam
Myanmar
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Buddhism & Organ Donation
Even in countries where Buddhism is less dominant
 Singapore and Korea - Buddhists are main source of
tissue donors.
 Success of NUH Tissue Bank in Singapore, entirely
due to strong support by Buddhist Community. All
donors Buddhists.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Muslims & Organ Donation
Muslims the most controversial group  Koran does not forbid tissue donation
 Koran states that if by not transplanting an organ or
tissue, the person will die, then it is permissible to
donate. It is allowed for an emergency to save life.
 Different interpretations by different religious leaders,
‘ustazs’ and ‘ulamas’
 Muslims must bury the body as soon as possible after
death – the sooner the better usually less than 8 hours.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Muslims & Organ Donation
Predominantly –
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Saudi Arabia
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Iran
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Iraq
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Kuwait
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Turkey
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Pakistan
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Bangladesh
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Malaysia
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Brunei
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Indonesia (SecularPANCASILA)
Less Dominant –
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China (200 million)
India
Singapore (20%)
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Muslims & Organ Donation
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Each country has its own ‘MUFTI’ -religious official appointed by
Govt to deal with Islamic matters
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‘FATWAS’ are religious rulings made by ‘Fatwa Committee’ as
official stand by Govt. on various issues.
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‘Fatwa Committee’ chaired by MUFTI includes prominent
religious leaders, lawyers, doctors and other members of public
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Fatwas are not legal binding.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Muslims & Organ Donation
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Fatwas declared in several countries
Saudi Arabia : 1985 - permit both living related and
cadaveric donation of organs
Pakistan,
Bangladesh,
Malaysia - 1995
Indonesia
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
POWER OF FATWA
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Merely states government’s position by MUFTI
Not necessary to follow Fatwa
Left to individual opinion and choice
No consensus among various religious leaders, ‘ustazs’
and ‘ulamas’ each with strong influence on their
followers
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
CULTURAL PRACTICES OF MUSLIMS
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Despite Fatwas Muslims reluctant to donate organs
God created them whole. They prefer to return to him
whole.
Many Muslims bury amputated limbs, foreskin from
circumcision, amnion from delivery.
Not religious requirement but cultural practice. Not all
Muslims do this
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Christianity - Organ Donation
Predominantly  Philippines
Less Dominant –
 Singapore (30%)
 Korea (30%)
 Malaysia
 India
No bar to organ donation - Shortage of Donors in Philippines,
Singapore and Korea due to cultural factors.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Christianity - Organ Donation
STATEMENT BY POPE JOHN PAUL II –
Full support of organ and tissue donation concluded
with words of Jesus narrated by evangelist and
physician LUKE:
“give…, and it will be given to you; good measure,
pressed down, shaken together, running over, will be
put into your lap (Luke 6 : 38).”
We shall receive our supreme reward from God
according to the genuine and effective love we have
shown to our neighbour.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Hinduism and Organ Donation
Predominantly •
 India
LESS DOMINANT
 Sri Lanka (<10%)
 Singapore (5%)
 Malaysia
 Indonesia
 Thailand
 Veitnam
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Jainism & Sikhism
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Religions against organ donation
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Greek Orthodox, Shinto and Gypsies are three religions
that do not encourage body donation
Jehovah’s witness is another Christian sect that is
against such acts
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Television, Films and Organ Donation
TV programmes and Films that have projected donation as
potentially harmful & Expoitative. TV programs like –
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The X-Files
ER
Voyager
Law and Order
Chicago Hope
Strange Luck
Movie – Coma
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Media and Scandals - Thailand
Doctors May Face Murder Charge
The New Straits Times, September 1, 2000
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Three doctors from a Bangkok private hospital allegedly killed
patients in 1997, harvested the kidneys and sold their kidneys to
rich transplant patients will face murder charges. faking
paperwork to cover their crime.
A police inquiry into the scandal said - the organs were removed
from patients who were pronounced brain dead, a condition not
accepted as legally dead in Thailand.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Media & Scandals - Japan
The Washington Post: April 25, 1997
A Japanese surgeon who performed the operation was
investigated in connection with the alleged murder of
the donor. He was not indicted, but the lengthy criminal
proceedings blocked all further operations
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Media & Organ Donation
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The power of the press can also be demonstrated in the
so-called "Nicholas Green effect.“
Nicholas was a 7-year-old American child, shot dead by
bandits in Italy in 1994
His parents agreed to donate his organs
Italian press reported it extensively
The positives impact kick started the Italian cadaver
programme
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Under-reporting of Brain death
The efficiency of utilization of potential donors for organ
transplantation in Saudi Arabia: a pilot study. Al Sebayel MI,
Khalaf HA. Transplant Proc. 2004 Sep;36(7):1881
Data – 2001 to 2003 - 114 out of 542 deaths were due to
Brain Death & 54% - occurred in one hospital.
• 38 cases were reported to the Saudi Center for Organ
Transplantation & in 23 Documentation was completed
• 4 Cases became actual donors
Conclusion – There is underreporting of brain death
cases.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Problems with Cadaver Organ Donation Programme in Asia
Govt. Problem
No Funding for programme
Hospital problem
No efforts to identify & maintain “Brain Dead” donors
Community Problem
No Awareness of “Brain-Death” Concept
Spain has the highest number of brain death patients going
Dr.Sunil Shroff,
on
to
organ
donation
– Diseases,
32 per million
population
IV International Congress of Kidney
Ahembdabad.
11-13th Nov 2005
Common Problems - Awareness
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Lack of awareness of Brain death both public & healthcare
professionals
Religious diversity with some religions though accepting the
broad concept, are still reluctant to give their full support to the
programme.
Govt. inertia in implementation of policies to push the
programme forward.
Lack of trained personnel to run the infra-structural logistics of
the programme.
Lack of a common platform to structure some collaborative work
Lack of Organ sharing network within the region
Lack of resources in some instances to push the programme
forward
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Hospital Infra-Structural & Support Logistics
Trained transplant Co-coordinators
Qualified Intensivists in
ICUs
Successful Retrieval & TX
Packing & Transport
of organs
Support Organisation
to Network & Keep
Registries
HLA Tissue typing and Cross-match Facility
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Hospital Infra-Structural & Support Logistics
Adequate No. of Qualified
Intensivists in ICUs
Qualified
Trained transplant
Co-coordinators
Well qualified Surgeons to
undertake Retrieval & TX
Transport of organs –
between cities
Support Organisation
to Network
HLA Tissue typing and Cross-match
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Transplants Scene in Asia – The Way
Forward
 Overview
of Cadaver Transplants in
Asia
 Common Problems & Platforms
 The Way Ahead
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
The Way Forward
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Strengthen the Asian Transplant Network
Establish a common programme similar to Eurotransplant Network
Start sharing organs that are not used locally
Use technology effectively
Evolve a Spanish style co-ordinators course for Asian
countries
Do our own Asian Transplant Games to build patient
fellowship
Have more frequent Asian Transplant Society meeting
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Organisational changes
Model National Transplant Service
– Like a network to share organs that is linked to a
Asian Network for Organ Sharing (ANOS)
 Employing and training more transplant co-ordinators
and having a separate body in Asia for Tx. Coordinators
 Regular Courses to impart expertise to the coordinators
 Training and sensitising ICU staff on brain-death
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Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaveric Donation
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For cadaveric donation “society remains a crucial aspect in a transplant
programme”
Strategies to decrease refusal rates by families include
efforts at education  the general population,
 Religious heads & opinion leaders
 health care workers individually
 through the mass media
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Encouraging People to Discuss Organ
Donation
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Encouraging people to speak about organ donation and
transplantation and to make their wishes known to their
relatives could change the picture resulting in 93-94% of
people allowing donation
When the wishes of the deceased are not known, only
50% of people will agree to organ retrieval from their
relatives
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Presence of Family Member During Brain Death
Testing
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Most families faced with brain stem death of a relative find the
concept difficult to understand and have trouble in accepting that
their relative is actually dead
Family members were given choice to be or not to be present during
brain stem death testing
It is suggested that presence of family members during brain stem
death testing not only helps families to accept this concept of death
but also promotes the grieving process
The presence of family during brain stem death testing. Doran M. Intensive Crit
Care Nurs. 2004 Feb;20(1):32-7
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Project Positive Aspects
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Many donor relatives have stated that donating their
loved one's organs does not make the pain of their
death disappear
But that it gives their death meaning: that something so
positive comes from tragedy.
Bereaved families can experience comfort that their
loved one's gift gave another person a second chance
at life
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Consent for Donation
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Pre-mortem – via Donor Cards, Driving License
Consent of his family following death
Some form of a combination of the two are necessary
‘Supererogatory permission”
Underlying premise of such a consent would be that
“organs of dead people are public goods”, and donation
must be considered “similar to other compulsory civil
obligations” within society
 The permission is a moral rather than a legal
requirement
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Presumed Consent & Organ Donation
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Belgium, Austria, Finland, France, Norway, Spain, and Singapore
implemented "presumed consent"
France's presumed consent (PC) law has produced increases in
organ donation approaching 5,000%.
Belgium passed its version of PC in 1986, and organ donation
climbed by 183%, with multi-organ retrieval significantly
increased to 119% for kidneys. The donor rate increased from 10
to 22 donors per million population between 1986 and 1997.
Austria passed its PC law in 1982. By the end of 1990, the
number of patients receiving kidneys was nearly the same as the
number on the waiting list
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Required Request Law
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Requires that formal request for organ donation be
made of the families of all potential donors in the ICU.
 The rationale is that a statutory approach would
overcome hesitancy by healthcare professionals at a
time of such emotional distress.
Required Request Law has been introduced into many
states in the USA by legislation and helped improve
organ donation rate
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Mandated Choice
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Mandated choice: This requires people to state their
’willingness to donate or not’ when filing some state of
institutional return such as a driving licence or income
tax form.
 The information would be kept on a central register,
accessible at time of death
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Mandated Choice & Driving License
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1996 - Sweden instituted a mandated choice law.
There was an immediate increase of 600,000 potential
donors.
A similar 1990 law in Denmark increased their donor
registry by 150,000.
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Action Required – Muslim Countries
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More public education needed to change cultural
beliefs and practices although Islam does not forbid
Organ or tissue donation
Fatwas alone will not work.
Constantly addressing masses through media by
religious head may help to improve sentiments
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Religion & Organ Donation
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Plan major conferences of religious heads on organ donation
and transplantation in all regions of Asia .
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Most people are ill- informed about their religions attitude
towards organ donation.
 Major initiative required to correct this
An Exploratory Study Examining the Influence of Religion on Attitudes Towards
Organ Donation Among the Asian Population in Luton,UK Nephrology Dialysis and
Transplantation (1998) Volume 13: 1949-1954
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
What is Required
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NGO or Groups involved in Organ donation in
any part of the Asia have to tackle various
issues in the field of cadaver organ donation
and transplantation simultaneously
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More Support groups with common
objectives are needed
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More resources necessary to Kick start such
an Initiative
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Promote Organ Donation Among Blood Donors
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Study shows that blood donors have better knowledge
of organ donation and are more willing to donate their
organs and sign an Donor card than general public.
A substantial proportion of blood donors have not
signed a Donor Card.
It would be useful to design promotion programs to
facilitate blood donors' participation in organ donation.
Attitudes about organ and tissue donation among the general public and
blood donors in Hong Kong. Li PK, Lin CK, Lam PK, Szeto CC, Lau JT,
Cheung L, Wong M, Chan AY, Ko WM. Prog Transplant. 2001 Jun;11(2):98-103.
Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Make Local Sharing Protocols
6 Kidneys have been wasted
in the last four years of the
112 Kidneys shared in the
INOS network due to these
problems
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Poor Retrieval Technique – 2
No Blood for Cross Match – 2
Poor Packing of Organ - 2
INOS- Initiative for Organ Sharing facilitated
by MOHAN Foundation in Tamil Nadu
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Potential Countries That can Succeed with
Programme
Countries that can have success with Cadaver Transplant
programmes in Asia and make a difference  India – No Religious bar to donation
 Iran – Has a logistic approach
 Saudi Arabia – Has the laws
 Turkey – Liberal Muslim Country
 Taiwan – Well organized Skills
 China – Cabale of organizing the programme
 Sri Lanka – High Buddhist community. Eye programme success
 Mynamar - High Buddhist community
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
ORGAN DONATION RATE
Current organ donation rate - India is 0.05 per million
population per year
If in India - 1 per million donation rate we would have 1100 organ donors
– 2200 kidneys,1000 hearts, 1100 Livers, 2200 Eyes
At 3 per million Donation rate we would have 3300 organ donors – 6600
kidneys,3300 hearts, 33001 Livers, 6600 Eyes
At 10 per million donation rate- 11,000 organ donors
22,000 kidneys, 11,000 hearts, 11,000 Livers, 22,000 Eyes
20 per million donation rate - 22,000 organ donors
44,000 kidneys, 22,000 hearts, 22,000 Livers, 22,400 Eyes
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Cadaver Transplant - Conclusion
Organ Shortage is a Crisis, however the Crisis has a
Cure
 In Asia we need to Network and start thinking of
sharing resources, expertise and organs
 Set up some Collaborative projects
 Use Television Media for Promotion
 Get Religious heads to Participate regularly
 Have Transparency in programme
 Set up regional Transplant co-ordinators Forums
 In Asia we have failed to explore all the options
 Simple changes can make all the difference
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Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
Our Mission Statement
“ORGANS WASTED ARE LIVES LOST”
THANK YOU
This presentation has been created using 100% recycled
electrons!!
Recycle yourself and become an organ donor
In my end is my beginning
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005
- T.S.Eliot, Four Quartets
Cadaver Transplants
1995 to 2001
• 35 Hospitals have
10
undertaken Cadaver
transplants
• However only 10 of
35 undertake it on
regular basis
68
5
46
48
8
32
Source: Indian
Transplant Newsletter
Mohan Foundation
183
8
37
6
12
Dr.Sunil Shroff,
IV International Congress of Kidney Diseases, Ahembdabad. 11-13th Nov 2005