Umesh G Oza
Kidney transplantation remains the dream come true for any patient of end stage renal disease (ESRD). It offers a better quality of life compared to that on dialysis.
Once a patient develops irreversible kidney damage the options available are : haemodialysis, peritoneal dialysis and kidney transplantation.
If he is not offered one of these treatments death is certain. Kidney allograft could be acquired from a live or cadaver donor.
In our country majority of kidney transplantation is live donor transplantation where near relatives donate one of their kidneys to their dear ones; however, every patient may not be fortunate to have a relative who can donate his kidney.
Even if there is a willing donor, he may not be .t to donate his kidney. In India, only 20-25% of grafts come from related donors.
What is cadaver transplantation?
In cadaver transplantation well preserved organs are retrieved from brain dead patients and transplanted in patients with end stage disease. It is proved beyond doubt that brain death is indeed death. The common understanding was that heart
controls life. This is not true. It is the functioning of the brain that is responsible for life. There is only one kind of human death, the irreversible loss of the capacity to breath and hence to sustain a spontaneous heart beat. Whereas the function of the lungs and heart can be taken over by machines, that of brain cannot. An individual can therefore be dead only when the brain is dead. Coma is not brain death. The detailed description of this concept is given by Dr. Khadilkar in this issue.
Cadaver transplantation involves three procedures
i) Diagnosis of brain death, identifying donor and permission from the next of kin; ii) Organ retrieval, perfusion, storage and distribution; iii) Kidney transplantation operation in a recipient of kidney failure and postoperative management.
Diagnosis of brain death Brain death, diagnosed by signs of irreversible damage to the brainstem is an accepted concept in most countries of the world with the backing of medical and legal authorities. In India, Human Organ Transplantation Act, 1994 allows cadaver transplantation. This Act gives very clear guidelines for cadaver transplantation. Normally, cadaver donors are in ICU who have suffered brain death due to road traffic accidents, intra cerebral haemorrhage or intra cerebral tumour.
Once the donor is identified and the tests have proved that he is brain dead the relatives are informed. At the same time the transplant co-coordinator who is trained in proper communication skills or the concerned doctor has to take permission from the relatives and the next of kin. If they give permission, the transplant team is informed and preparations for organ retrieval, preservation and transplantation are started.
Organ retrieval, perfusion, storage and distribution
The donor is shifted to the operation theatre and retrieval of organs is done by an experienced team of surgeons with meticulous care and technique. The kidneys are removed en bloc. The organs are perfused with cold preservation solution in situ to reduce warm ischaemia time. The temperature is brought down between 4° and 11°C. This cold perfusion solution allows the kidneys to be preserved and stored safely for 24-48 hours if requiredtill suitable recipient is ready for the transplant operation.
After dissecting and labeling, the organs are stored in special plastic bags in a box at a low temperature.
Abroad there are agencies who look after organ distribution. In Maharashtra, the government has appointed Zonal Transplantation Co-ordination Committee (ZTCC) for overlooking the organ distribution and cadaver transplant programme.
This committee comprises government officials, representatives from various hospitals and representatives from different non-government social organization. The aim is to make sure that there is efficiency and total transparency in managing organ distribution. The common computerized list of all referred waiting recipients from Mumbai is maintained. Depending on the prescribed criteria approved by ZTCC, the recipient is selected from different hospitals.
Recipients are contacted and they have to undergo necessary pre-operative investigation and clinical assessment.
Standard transplant technique involves placing the kidney in the iliac fossa extraperitoneally. It involves joining renal artery of the donor (aortic patch) with external iliac artery of the recipient and renal vein with external iliac vein of the recipient
to establish blood supply to the donor kidney. The ureter is reimplanted in the bladder to establish the urinary drainage system.
Managing these patients after operation for lifetime is a challenge for transplant nephrologist. Postoperative immunosuppression has to be given life long to prevent rejection. These patients are more prone to infection and require proper care and lifetime follow up.
With advances in imaging technique, better antibiotics, surgical expertise and more selective immunosuppressive drugs, results have improved dramatically. One year graft survival is more than 90% and 5 years is 60%. Transplant patients have their share of complications. One of the major problems in our country is the cost of managing patients of renal failure.
However, successful transplant can offer physical, sexual and mental rehabilitation to a good number of patients of ESRD many of whom are young and in prime of their lives.
Today cadaver transplantation has become a well accepted option all over the world. In India, we are still in our infancy. Slowly the number is increasing. Our main stumbling blocks are :
i) Lack of awareness in medical fraternity and population at large about brain death concept and organ transplantation,
ii) Misconceptions about brain death One cadaver donation can help so many patients; we can retrieve heart, lungs, liver, pancreas, two kidneys and two corneas. One dead body can give life to 8 patients of organ failure. Many of these are
young patients who have just started living life, just married, have young children but are near the death bed. If we all become more sensitive, bring public awareness and make cadaver organ donation a success many families would be benefited.
However, this programme needs support from each and every member of the society.