Question

Academic Study and Writing

1. Recommendations for inadequacy of nation’s transplant policy on “altruism” and inadequate supply of kidney donors

Answer 1

Successful kidney transplantation offers the best possible quality of life for patients with end stage renal disease (ESRD). Despite this, renal transplantation rates in the developing world are considerably lower than in the developed world. Identified reasons for this include lack of awareness, low education levels, lack of a clear national policy, absence of functional dialysis and transplant units with adequately trained staff, and absence of an organized system of organ retrieval from deceased donors and lack of opportunities to fund long-term immunosuppression. Measures to improve the quality of care should center on improvement of the socioeconomic status of the country. Key action points include the implementation of: (1) Chronic kidney disease (CKD) screening and prevention programs; (2) ESRD and transplantation registries; (3) transplantation legislation, covering both living and deceased organ donation; (4) international and regional collaborations for transfer of knowledge and technology. The government should make transplantation more affordable by strengthening the public sector hospitals and by making the transplant medication more affordable. With the National Organ Transplant Programme (NOTP) in the process of being established in India, the transplant community should strive to increase the organ donation awareness, improve the infrastructure for organ retrieval, storage and allocation in an equitable way.

Challenges faced by medical facilities during

transplantation program -

Identified obstructions to a functional kidney transplant

program in developing countries such as India include:

Individual levels

• Lack of awareness: Lack of organ donation awareness

in India is a major barrier for deceased donation.

Socioeconomic factors, educational status, and language

barrier affect the functioning of the transplantation

program. One of our studies revealed that 3.3% of subjects

with renal impairment were aware of their disease[3]

• Sociocultural factors: In many cultures in the developing

world, reverence of the dead is deep rooted, and several

countries do not permit autopsies and thus do not have

cadaveric transplant edicts. India enacted its own edict in

1995 and prohibit commercialized donation of organs and

to facilitate organ donation after death, including brain

stem death. The donors are often exploited, and previous

studies have revealed that 75% of commercialdonors remain in debt, 90% reported deterioration in their

health, and about 80% would not recommend donation to

others if asked[22]

• Immunosuppression: High cost of immunosuppressive

agents and antibodies use for induction and treatment of

rejection are often unaffordable for most patients, resulting

in poorer graft survival rates.

Future recommendations for a successful transplantation program--

Although no one country in the world generates sufficient

organs from the available sources to meet the needs of their

citizens, deceased donor transplantation can bridge the ever

widening gap between availability and demand of organs for

transplantation. Combined greater efforts of members of the

health ministry, NGOs, and private and government medical

college hospitals in the state can improve the functioning of the

program. Recently, the National Kidney Foundation launched

the Big Ask/The Big Give initiative to help better improve the

lives of those with kidney disease through living donation. The

following recommendations should be commencement for a

successful transplantation program:

Improve the socioeconomic status: Improvement in

literacy, sanitation, and establishment of functional health

program for better socioeconomic status.

• Implementation of ESRD and transplantation registries: The

enactment of a solid organ transplant edict by the countries

yet to do this is also essential as is the development of renal

registries to enable more effective planning.

• We need to establish a transparent, independent, and

functional national kidney foundation to serve the interests

of the patients and to act as a unified group presenting

their views to the government when the need arises.

• Implementation of guidelines concerning (a) evaluation

of donor and recipient, (b) diagnostic and therapeutic

procedures after transplantation, and (c) long-term

follow-up procedures for donor and recipient.

• Newer techniques to reduce infections: There should

be a continuous training to enhance the skills to reduce

morbidity and mortality. Use of newer techniques

in kidney transplant surgery may help to minimize

postoperative recovery time and hospitalization.

• Commencement of national health insurance covering

RRT: The majority of the patients cannot afford a

transplant surgery due to financial constraints, and there

being a lack of a national health insurance scheme. Scheme

such as insurance coverage of RRT may help in mitigation

of financial constraints.

• Public awareness programs focusing on the causes,

prevention, and management of kidney disease must be

encouraged.

• Greater efforts of trained transplant coordinator and nurse

can empower the transplant program: The hospitals should

be advised to set up a counseling service for individuals

involved in organ transplant.

• The high cost of immunosuppression remains a major

problem: Availability of immunosuppressive medications

at affordable prices and government subsidies if possible,

should be one of the focuses of such a kidney foundation.

A common strategy should be adopted to reduce the

cost of immunosuppression (i.e. Use of agents such as

ketoconazole and diltiazem which inhibit calcineurin

inhibitor metabolism).

• Transplant legislation should be mandatory: Transplant

legislation should be developed by each country or

jurisdiction for governing the recovery of organs

from deceased and living donors and the practice of

transplantation, consistent with international standards.

• Enforcement of deceased donor transplantation program:

Deceased donation should be performed with altruistic

motives and in a charitable manner. Cadaver renal

transplantation involves declaring brain death, seeking

permission from the relatives, retrieval of the organs,

storage of organs, transport to the recipient’s hospital, and

ultimately transplantation. Future studies should focus

on how to safely, ethically, and effectively use social

networking sites to inform potential donors and potentially

expand live and cadaveric kidney donation.