Transcript Cadaver Organ Donation & Transplantation in Asia – The Way

Cadaver Organ Donation & Transplantation
in Asia – The Way Ahead
Dr. Sunil Shroff
Head of Department - Urology & Renal Transplantation,
Sri Ramachandra Medical College & Research Institution,
Managing Trustee, MOHAN Foundation, Chennai
[email protected]
Dr.Sunil Shroff,
www.mohanfoundation.org
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.

Dr.Sunil Shroff,
www.mohanfoundation.org
Cadaver Transplant in Asia – The Road Ahead
 Overview
of Cadaver Transplants in Asia
 Common Problems & Platforms
 The Road Ahead
Dr.Sunil Shroff,
www.mohanfoundation.org
Overview of Asia
Asia
World
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Population
3.6 Billion
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,
www.mohanfoundation.org
Cadaver Transplants in Asia
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Kidney
Liver
Heart
Heart Lung
Pancreas
Source: Asian Transplant Registry
Dr.Sunil Shroff,
www.mohanfoundation.org
PER CAPITA INCOME FOR ASIAN COUNTRIES ( In US Dollars)
High Per Capita Income 2500
Average Per Capita Income 1000
Japan
Hong Kong
Singapore
Kuwait
Israel
S Korea
Taiwan
Saudi Arabia
Lebanon
Malaysia
Turkey
Maldives
Thailand
Iran
Kazakhstan
Jordan
Syria
Turkmenistan
China
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
1,120
1,100
1,080
No Data - Afghanistan
-Bhutan, Palestine, Bahrain,
Cyprus, Iraq, Qatar, UAE,
Myanmar, Timor , Oman,
Brunei, N.Korea
Dr.Sunil Shroff,
www.mohanfoundation.org
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
420
340
340
300
240
210
High per capita income & Successful Living
Transplant Programmes
Japan
Hong Kong
Singapore
Kuwait
Israel
S Korea
Taiwan
Saudi Arabia
Lebanon
Malaysia
Turkey
Dr.Sunil Shroff,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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 Waiting list in Iran for Kidney
Tx.
No figures available for China, India, Philipines, Indonesia
Dr.Sunil Shroff,
www.mohanfoundation.org
Transplant Expertise - Asia
 Japan
has - 352 transplant centres
 Thailand - 27 kidney, 6 liver, & 6 Cardiac
transplantation centers
 Iran has 22 centres – mainly kidneys
 India has 110 centres for Kidney Tx 5
centres Liver, 6 – Cardiac. over 35 centres
have undertaken cadaver transplants
However only 6 centres do cadaver Tx.
regularly
Dr.Sunil Shroff,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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
Dr.Sunil Shroff,
modus operandi
www.mohanfoundation.org
Cadaver Heart Transplants in Asia
Hong Kong, India, Japan, Malaysia, Saudi
Arabia, Singapore and Thailand are doing
Heart transplants
 Taiwan and Korea do the maximum heart
transplants in Asia

Dr.Sunil Shroff,
www.mohanfoundation.org
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.

Japan, Hong Kong, Taiwan similarly have expertise in living
liver transplants
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Four centres in India – located at Hyderabad, Vellore and
Delhi have fair expertise with liver transplants and emerging
as the key players in the country.
Dr.Sunil Shroff,
www.mohanfoundation.org
Cadaver Kidney Transplants Scene in India

In past ten years approx. 1000 Cadaver organ
transplants over 900 kidneys and 100 Livers and
heart have been performed
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Almost 40% 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.110 centres in India do kidney Tx.however only 25 to 30
centres Dr.Sunil
do over
25 per year.
Shroff,
www.mohanfoundation.org
Historical Aspects – Cadaver Transplantation - India
1967 - First successful 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, Ahemdabad
Dr.Sunil Shroff,
www.mohanfoundation.org
Asian Countries Undertaking Transplants –
Kidneys alone (n-10)
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Pakistan - K
Philippines – K
Indonesia – K
Malaysia – K,
Iran – K,
Israel – K
Turkey – K
Syria – K
Malaysia – K
Bangladesh – K
Some of these countries have done (eg Pakistan) occasional liver or heart
(eg Malaysia) transplant.
Dr.Sunil Shroff,
www.mohanfoundation.org
Asian Countries Undertaking Multi–organ
Transplants (n-9)
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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

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,
www.mohanfoundation.org
Cadaver Transplant in Asia – The Road Ahead
 Overview
of Cadaver Transplants in
Asia
 Common Problems & Platforms
 The Way Ahead
Dr.Sunil Shroff,
www.mohanfoundation.org
Common Problems & Platforms
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Incidence of organ failure in Asia
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
World Status of Transplants
Annual Number of kidney transplantations per million
population (pmp) per year 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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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
Dr.Sunil Shroff,
Hong Kong - Yeung I, Kong SH, Lee J. Soc Sci Med. 2000 Jun;50(11):1643-54
www.mohanfoundation.org
Viet Nam - Hai TB, Eastlund T, Chien LA, 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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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
Dr.Sunil Shroff,
Above protocol called “THE RAMACHANDRA
PROTOCOL” to ask for organs
www.mohanfoundation.org
Brain Death – Law & Guidelines
Countires
Law
Guidelines
Apnea
Test
Physicians
Obv
Time
Conf,
Test
Armenia
A
A
A
A
A
Optional
Bangladesh
P
P
DVO
3
A
Optional
China
A
A
A
A
A
Optional
Georgia
P
P
DVO
3
24
Mandatory
Hong Kong
P
P
PCO2
1
A
Optional
India
P
DVO
4
A
Mandatory
Iran
P
P
P
p
-
-
-
-
Indonesia
A
P
PCO2
3
24
Optional
Dr.Sunil Shroff,
www.mohanfoundation.org
Brain Death – Law & Guidelines
Countries
Law
Guidelines
Apnea
Test
Physicians
Obv
Time
Conf,
Test
Japan
P
P
PCO2
1
A
Mandatory
Korea (S)
P
P
PCO2
1
6
Optional
Malaysia
P
P
PCO2
2
12
Mandatory
Pakistan
A
A
A
A
A
Not known
Philippines
A
P
DVO
1
24
Optional
Singapore
P
P
PCO2
2
A
Optional
Taiwan
A
P
PCO2
1
6
Optional
Thailand
P
P
DVO
3
6
Optional
Vietnam
A
A
DVO
A
A
Optional
Dr.Sunil Shroff,
www.mohanfoundation.org
Singapore - Legal Aspects
THE HUMAN ORGAN TRANSPLANT ACT (HOTA) OF
1987 – Singapore
“….. Kidneys can be procured from patients of road
traffic accidents who have been declared “braindead” unless they have OPTED OUT ( Presumed
Consent)
(Muslims exempted)
Dr.Sunil Shroff,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
Religion and Organ Donation
Common thread that binds all religions of the world –
 Saving of life overrides all objections
 There is no religion 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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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.
Gujarat in India has high number of eye donations (Jains) gets
4000 corneas - highest in India.
Dr.Sunil Shroff,
www.mohanfoundation.org
Buddhism & Organ Donation
Predominantly Buddhist
Countries
 Sri Lanka
 Thailand
 Vietnam
 Myanmar
Less Dominant
 Korea (30%)
 Singapore (30%)
Dr.Sunil Shroff,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
Muslims & Organ Donation
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Each country has its own ‘MUFTI’ -religious official
appointed by Govt to deal with Islamic matters

‘FATWAS’ are religious rulings made by ‘Fatwa
Committee’ as official stand by Govt. on various issues.

‘Fatwa Committee’ chaired by MUFTI includes
prominent religious leaders, lawyers, doctors and other
members of public

Fatwas are not legal binding.
Dr.Sunil Shroff,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
Hinduism and Organ Donation
Predominantly
 India
LESS DOMINANT
 Sri Lanka (<10%)
 Singapore (5%)
 Malaysia
 Indonesia
 Thailand
 Veitnam
Dr.Sunil Shroff,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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 “BrainDeath” Concept
Dr.Sunilof
Shroff,
Spain has the highest number
brain death patients going
www.mohanfoundation.org
on to organ donation – 32 per million population
Hospital Infra-Structural & Support Logistics
Qualified
Trained transplant
Co-coordinators
Adequate No. of Qualified
Intensivists in ICUs
Well qualified Surgeons to
undertake Retrieval & TX
Support Organisation
to Network
Transport of organs –
between cities
HLA Tissue typing and Cross-match
Dr.Sunil Shroff,
www.mohanfoundation.org
Cadaver Transplants Scene in Asia – The Way
Forward
 Overview
of Cadaver Transplants in
Asia
 Common Problems & Platforms
 The Way Ahead
Dr.Sunil Shroff,
www.mohanfoundation.org
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,
www.mohanfoundation.org
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

Dr.Sunil Shroff,
www.mohanfoundation.org
Organisation helping with organ donation &
Transplants programmes in India
MOHAN Foundation (INOS) - Tamil Nadu, Andhra Pradesh,
Maharastra
236 Organs shared. ( 212-Kidneys, 9-Hearts, 15-Liver )
FORTE, BANGALORE – 32 Organs Shared
( 32 - Kidneys, 1- Heart, 1- Liver )
ZTCC, Mumbai – 55 Organs Shared - all kidneys
ORBO, N.Delhi – Few organs shared
SORT, Cochin – 4 organs shared
Dr.Sunil Shroff,
www.mohanfoundation.org
Cadaveric Donation


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,
www.mohanfoundation.org
Encouraging People to Discuss Organ
Donation

When the wishes of the deceased are not known, only
50% of people will agree to organ retrieval from their
relatives

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
Dr.Sunil Shroff,
www.mohanfoundation.org
Presence of Family Member During Brain Death
Testing



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,
www.mohanfoundation.org
Project Positive Aspects

Many donor relatives have stated that donating their
loved one's organs does not make the pain of their
death disappear

Bereaved families can experience comfort that their
loved one's gift gave another person a second chance
at life
Dr.Sunil Shroff,
www.mohanfoundation.org
Consent for Donation




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,
www.mohanfoundation.org
Mohan Foundation Intiatives –
INOS ( Indian Network for Organ Sharing)
Essence of INOS – “Not to Waste Any Organ.
Organs should be treated like National Resource”
 Hospital in group includes – Apollo, CMC Vellore,
Sri Ramachandra Hospital and Sundaram Medical
Foundation
 Hospitals in Andhra Pradesh- Nizam’s Institute
of Medical Sciences, Global Hospitals, Kamanneini
Hosp, Apollo Hospital, Care Hospital
 Many Affiliate hospitals from other parts of
country

Dr.Sunil Shroff,
www.mohanfoundation.org
Presumed Consent & Organ Donation




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,
www.mohanfoundation.org
Required Request Law


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,
www.mohanfoundation.org
Mandated Choice

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,
www.mohanfoundation.org
Mandated Choice & Driving License


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,
www.mohanfoundation.org
Action Required – Muslim Countries



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,
www.mohanfoundation.org
Religion & Organ Donation

Plan major conferences of religious heads on organ
donation and transplantation in all regions of Asia .

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,
www.mohanfoundation.org
What is Required

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

More Support groups with common objectives
are needed

More resources necessary to Kick start such an
Initiative
Dr.Sunil Shroff,
www.mohanfoundation.org
Patient Support Group

Purpose of the group - to provide emotional support
to organ failure & transplant patients

Meeting held every two months between doctors,
dietician and counselors and patients to discuss
their problems

Provide subsidized investigation and a few selected
drugs

We have about 250 members from Mumbai and
Chennai
Dr.Sunil
Shroff,
“Patients should be the
advocate
of cadaver organ
www.mohanfoundation.org
movement, this will generate better publicity for the cause”
Patient Support Group



We have held Eight meetings in Chennai, four in
Mumbai and one in Hyderabad
Some of them keen to help out with cadaver
organ donation programme
The group held ‘All India Transplant Games’ in
Dec 2003
Dr.Sunil Shroff,
www.mohanfoundation.org
Promote Organ Donation Among Blood Donors



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,
www.mohanfoundation.org
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



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,
www.mohanfoundation.org
Retrieval Surgery & Packing of Organs
MOHAN in its INOS Group of
hospitals have made:



Attempts to standardize retrieval
techniques
CD made on kidney Retrieval to
be circulated to all the hospitals
in the group
Packing of organs being
standardised for transportation
Dr.Sunil Shroff,
www.mohanfoundation.org
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 – Capable of organizing the programme
 Sri Lanka – High Buddhist community. Eye programme success
 Mynamar - High Buddhist community
Dr.Sunil Shroff,
www.mohanfoundation.org
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
Source: Indian Transplant Newsletter Issue no.19 Feb 2006
Dr.Sunil Shroff,
www.mohanfoundation.org
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 Collaborative projects
 Use Television Media for Promotion
 Get Religious heads to Participate regularly
 Have Transparency in programme
 Set up regional Transplant co-ordinators
Forums
Dr.Sunil Shroff,
www.mohanfoundation.org
Cadaver Transplant - Conclusion
In Asia we have failed to explore all the options
and simple steps and changes can make all the
difference for our patients
Dr.Sunil Shroff,
www.mohanfoundation.org
MOHAN Foundation –INOS Mission Statement
“ORGANS WASTED ARE LIVES LOST”
THANK YOU
In my end is my beginning
- T.S.Eliot, Four Quartets
Dr.Sunil Shroff,
www.mohanfoundation.org