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No cadaver transplant programme can be successful unless there is time bound co-ordination amongst intra hospital, inter hospital and the society at large. Cadaver transplant activity is a hospital based activity with participation of all strata of society. The core group, which makes the donor organ functional in recipient, is the transplant surgeons and the Nephrologists. They in turn are dependant on entire hospital i.e. on intensivists, neurosurgeons, neurologists, administrators, anesthesiologists in addition to service branches like pathology, microbiology, imaging services.

The role of Transplant coordinator is of paramount importance; since coordinator is the first person coming in contact with the grieving family.

In India most of the transplants are from live donors since cadaver donation is still in infancy due to lack of public awareness. Hence there are a large number of patients who have no suitable donor and hence look for commercial donors.

All of such transplants are discouraged. But patients in a situation of life and death do manage to convince the doctors and the authorization committee. Occasionally doctors do turn a blind eye in order to save life.

Thus only long term solution to this problem of ‘kidney racket’ is to have a viable cadaver transplant program in the while country.

An average male will live for 75 years and female 80 years. The chances of becoming an organ donor in real are quite small. Mumbai with a population of 1.2 crores; about 600 deaths are due to vehicular deaths i.e. 1 in 20,000. If whole of the city become willing donors – then may be there will be 300 – 400 suitable donors.

Once you have decided to become a donor, the most important step is telling your family. Even if you sign the ‘donor card’ – your family still has to consent before organs are gifted.

ZTCC as organization was composed of every recognized transplant institution of Mumbai. This includes 16 recognized hospitals including 3 municipal medical colleges, 1 government medical college, 1 central government Hospital (INHS Asvini) and 11 private corporate hospitals.

1.It helps in effective cadaver organ procurement.

2.It helps in effective cadaver organ procurement.

3.It helps in effective cadaver organ procurement.

a.Donor and recipient matching by specific criteria established for each organ.

b. Improve transplant outcome.

c. Provide a system by which immunologically sensitized patients offered best possible opportunities.

d. Decrease the wastage of organs.

4.Assure quality control by collection analysis and publication of data on organ donation and transplants.

5.Maintain and improve professional skills of those involved in organ procurement and transplantation.

6.To have immunosuppressive drug bank.

7.To increase public awareness.

An organization is formed to improve organ donations, procurement and transplantation system in the city, state and the country. Thus in Sep. 1998; ZTCC (Zonal Transplant Co-ordination Center) was formed in city of Mumbai. Subsequently the same model will be adopted all over Maharashtra.

Once patient is admitted; all efforts are made to stabilize the patients. If all efforts fail, patient is pronounced brain-dead after evaluation, testing and documentation. Consent from the family is obtained to proceed with donation and organ procurement organization (OPO) is informed. Consent from coroner/legal authorities is obtained. In the mean time the organ donor is maintained on ventilator, stabilized with fluids, medications and undergoes numerous laboratory tests. Recipients are also identified for placement of organs.

Surgical team are mobilized and coordinated to arrive at hospital removal of organs and tissues. Donor is brought to the operating room. Multiple organ recovery is performed with organs being preserved through special solutions and cold packing. Ventilator support is discontinued. Donor’s body is surgically closed and released.

Blood Grouping is the most important for solid organ transplantation like kidney, heart or liver. The tissue matching and cross matching have finer implications in the long term graft survival.

The blood group should be non-interfering. If the recipient is blood group ‘O’ – only ‘O’ can be a donor; if the blood group is AB – any blood group O, A, B & AB can be a donor. This is for live kidney donation. Rh group (positive or negative is not considered at all.

In cadaver organ donation the blood group match is strictly adhered. This is an ethical issue and ‘O’ group being an universal donor will always donate to all the recipients of any blood group and the ‘O’ group recipient will waiting for ever.

As already mentioned one kidney is good enough to sustain two people. In World War II it was seen that a number of people who lost a kidney due to injury were observed for years without any long term problems. Now the live transplantation is being practiced all over the world since 1954 and donors have been observed for about 50 years without any ill effects.

Yes. The potential donor is made to undergo rigorous evaluation before the person is accepted as donor. Doctors cannot guarantee the success in recipient but it is made sure that the donor comes to no harm. However complications are known to occur in 1in 1000 surgeries.

Yes. That is the law. This law is to avoid exploitation of poor people who want to donate their kidneys for monetary benefits. However other relatives and friends can donate as an ‘altruistic’ measure.

The state authorization committee headed by DMER has to be satisfied that is it truly an altruistic donation and no commercial interests are involved.

Yes – only for kidneys and bone marrow. God has given us two kidneys which are good enough for four people. But only the near and dear ones are allowed to donate and by law parents, siblings, son, daughter and spouse are treated as ‘near relatives’.

Anyone is eligible to be an organ donor depending on doctor’s decision. Tissues and organs transplanted after death include corneas, heart, liver, kidneys, bone and cartilage, bone marrow, skin, pancreas, lungs and others. One can only donate kidneys and bone marrow as a live donor. As per the norms and guidelines of Government of Maharashtra organ donation can be done between 2 yrs to 65 yrs.

All major religious including Hinduism, Protestant, and Roman Catholic, Islam, Buddhism and others fully support organ and tissue donation.

After someone dies, organs are surgically removed as if the person were still alive. Careful attention to incisions and scars is made so that he can still receive a traditional burial or cremation.

Organ donation is often an immediate and lasting consolation. It is often comforting to the family that even though their loved one has died, one or more persons can live on through their gift of life.

As long as heart has oxygen, it continues to work. A mechanical ventilator provides enough oxygen to the heart to keep it working. Without this mechanical support it will stop beating. By giving brain dead patients oxygen making their heart beat with medication controlling their Blood Pressure, their organs continue to work. That is why brain dead patients can be organ donors. This donation of organs may not be possible if one dies out side the ICU. Without Intensive Care all brain death is followed by Cardiac arrest within minutes. Only eyes, skin and other tissues can be donated after the cardiac death.

No. Coma is decrease in brain function and thee is a chance that person may regain consciousness. Brain death is irreversible loss of brain function. There is no chance of recovery after brain death.

Brain death occurs when person’s brain has permanently stopped. Cardiac death is said to occur when heart stops beating. Both are legal declarations of death. Brain death does not occur as often as cardiac death.

Doctors who treat patients in life and death situations have nothing to do with possible donation of their organs and tissues. Every effort is made to save that person’s life. Organ donation is not even considered till that person has died.

Four doctors from a panel recommended by government, carry out a series of tests to confirm that a patient is “brain stem dead”. The standards are very strict and are accepted medically and ethically all over the world. The four doctors are of following category.

1.Neuro Surgeon / Neuro Physician

2Treating doctor

3.An other specialist as approved by State Appropriate Authority

4.Medical Superintendent of the hospital.

Brain death usually results from a severe head injury or bleeding in the brain that causes all brain activity to stop. This can happen after a major road accident or brain hemorrhage due to a stroke. This also can happen in brain tumor.

In 1959, Neurosurgeons in Lyons (France) found that deeply comatosed patients, who had sustained head injury, never regained consciousness. Although their heart continued to beat and kept their circulation going, these patients were clinically dead. If their breathing support machines were stopped, the heart also stopped. Thus a new definition of death emerged. As this death was under controlled circumstances (that is, in the intensive care unit of hospitals) it was possible to retrieve some of their organs such as kidneys, heart and liver after their relatives are consented. In the west, the transplantation of organs from brain dead patients is an accepted part of medical treatment for quite some time. The government of India has now accepted this new definition of death and has formulated the Human organs transplantation act 1994 and hence it is legal to diagnose and declare brain stem death.

Normally the death is said to occur when heart stops. But with modern technology the heart and lungs can be made to function through mechanical support even when brain function has completely and permanently ceased. Thus once brain death occurs; the person becomes a cadaver with a beating heart.

Any person in good health if dies suddenly, possibly through an accident or even other causes like brain hemorrhage and who has been declared ‘brain dead’ can be an organ donor. This is called the “cadaver donation” in contrast to “live donation” which is possible only in kidney and bone marrow.

Each of us has a number of vital organs like brain, heart, kidneys, lungs, liver etc. Failure of any organ means certain death. Except for the brain all other organs can be replaced – which might be life saving. Besides organs – many tissues like cornea, heart valve, skin and bone may be used for repair and reconstruction.

No. These vital organs need to be retrieved from a dead person immediately and can be preserved up to various lengths of time by preservation techniques. Heart and Lung can be preserved by 4-6 hours and kidneys 48 – 72 hours. Skin and bone may be preserved for 5 years or more.

It is possible to transplant many different organs and tissues including cornea, heart valves, liver, kidneys, bone and cartilage, bone marrow, skin, pancreas, lung intestine and more.

In case of kidney failure, patient can be maintained on regular dialysis. During a dialysis treatment, the patient’s blood is filtered artificially. This treatment is time consuming and is repeated 2-3 times every week for life. In case of other organ failures like heart, lungs and liver; patients can be kept alive only a short time on drugs, unlike kidney failure patients; since there is no ‘dialysis like’ treatment for other organs.

80 – 90% of patients who receive a kidney live for 5 years. Longest survivor is 34 years. Receiving this new lease of life means that the recipient will be free from continuous hospital visits to receive dialysis.

When we lose the functioning of an organ like kidney or a tissue like bone and skin it is possible put another person’s organ or tissue and with modern surgical techniques and drugs; it can be made to work. This is gifting an organ after one ceases to need it any more. This known as transplantation and it is the “Gift of Life”.

*Prevention is better than cure lost of cost is involved in treatment of ESRD

General Measures

*Following are the tips to improve the health status no matter what is your state.

*Eat healthy diet.

*Eat food that is fresh and low salt avoid fatty, refined food

*Stop smoking

*Exercise regularly

*Check blood pressure regularly

*Avoid stress, strain

Specific Measures

If you are diabetic

*Good control of diabetes prevents kidney disease

*Regular check up of urine proteins, lipid levels, blood pressure

*Micro albuminuria is the earliest affection of kidney in diabetes

*Low protein diet (consult your dietician, Doctor) retards progression

*Urinary protein reduction with angiotensin converting enzyme inhibitor

ACEI / ARB retards progression of the kidney disease in diabetes

*Control blood pressure target BP less than 130/90 mm of Hg proteinuria then it should be < 125/75 of Hg this will prevent and retard progression of kidney disease.

*Prompt treatment of urinary tract infections

*Every male and female child with recurrent urinary tract infection must be evaluated to rule out correctable cause.

*Avoid excessive use of “over the counter” pain killers which may damage your kidney

*Avoid Ayurvedic medication which contains heavy metals.

*Once you have kidney disease, regular follow up with Nephrologists may help to retard progression, maintenance of health, and planning for renal replacement therapy.

One of the major achievements in the field of transplantation in the last ten years has been a major reduction in the risk of death. Currently at this hospital, the risk of death in the first year after a kidney transplant is about 3 – 5%, occurring primarily in high risk patients, particularly those over 60-65 and, to a less extend, those with juvenile diabetes. This includes death from any cause, whether or not related to the transplant. This risk is not significantly different from that sustained during a year of dialysis. During your transplant evaluation, any risk factors you may have that will increase your risk for transplantation will be identified and discussed with you.

If the transplant fails, patients return to dialysis as before. The transplant will be removed only if it is causing symptoms, such as fever or pain. This is often necessary if the kidney fails soon after transplant, but rarely it fails after several months. You may be able to have another transplant later, if you desire.

The success rate following transplantation depends upon the closeness of the tissue match between donor and recipient. A kidney from a brother or sister with a “complete” match has a 95% chance of working gat the end of one year. A kidney from a parent, child or “half-matched” sibling has an 85% chance of working for at least one year. Finally a cadaver donor kidney has an 80% chance of working at least one year.

If you are having a repeat transplant, the success rate will b3 10%-15% less. These kidneys are not immortal, however, with 50% of cadaver kidneys declining over 6 – 10 years, a rate faster than the relatively stable success of related kidneys.

The short term risks of donation are those associated with major surgery, including the risks of general anesthesia, wound infection, and the possible need for a blood transfusion. These risks are very small in healthy people. The donor evaluation process is designed to identify any special factors which would place a donor at increased risk; such donors would not be accepted. The longer term risks are slightly more uncertain. Some studies of donors 10 – 15 years following donation have suggested a slightly higher incidence of mild high blood pressure and protein in the urine; although these changes are not particularly different from the general aging population.

The significance of these studies is known, and there is not evidence of renal failure in prior donors. The remaining kidney expands and takes over the function previously performed by two. Because most kidney diseases affect both kidneys simultaneously, the donor is not at increased risk of kidney failure should he or she contract such a disease. Donors are cautioned to avoid contract sports or other activities which could cause major trauma to the remaining kidney. We believe that donors will lead perfectly normal lives.

It is possible to transplant many different organs and tissues including cornea, heart valves, liver, kidneys, bone and cartilage, bone marrow, skin, pancreas, lung intestine and more.

Potential living related donors usually are identified in discussions with your family and your doctor. Tissue typing is then scheduled; the required tests include blood group typing, HLA typing, and a mixed lymphocyte culture. Based on these tests it is frequently possible to identify the donor most likely to result in a successful transplant. Choosing the donor is best done in consultation with your doctor and the transplant team.

The selected donor is then scheduled for admission to the hospital for a donor evaluation. This evaluation is primarily on an out-patient basis and involves a wide variety of tests to ensure the health of the donor. Included in these tests is an arteriogram, an x-ray procedure in which dye is injected into the arteries supplying the kidney. This test allows the surgeon to decide which kidney would be best to remove. After completion of all tests, the physician responsible for the donor evaluation, who is not a member of the transplant team, will discuss the results with the potential donor privately. Only donors who are healthy and have two completely normal kidneys will be accepted.

A number of factors enter into this decision, including success rates following transplantation and the availability of donors. The best results following transplantation are obtained with HLA – identical (6 antigen matched) living related donors, which almost always come from a sibling, rarely from a cadaver.

A major advantage of living donor transplants is the ready availability of the donor. This allows the transplant to be performed without a long waiting period, as thee are currently more potential recipients than available cadaver donors. For this reason, we encourage living related donation whenever the family situation is appropriate, and, if circumstances are correct, donations for spouses.

There are three sources of kidneys for transplantation: living related, living unrelated, and cadaver donors. Living donors are usually members of the recipient’s immediate family, such as siblings, parents or children. Only such close relatives are likely to have an acceptable tissue match, although recent data suggests that success with living unrelated kidneys is closer to recent data suggests that success with living unrelated kidneys is closer to that of related grafts than that of cadavers. This may be due to better state of the donor and less storage time. Cadaver donor kidneys are removed from victims of brain death, usually the result of an accident or a stroke.

In transplantation, a healthy kidney is put inside the body to do the work of failed kidneys. Although a transplant eliminates the need for dialysis and some of the dietary requirements, a commitment to take care of yourself and take some important medications is required following a transplant. The decision to undergo a kidney transplant is a personal choice of the surgeon who specializes in kidney disorders.

Dialysis does not do everything that a kidney does; people on all types of dialysis require special diets and medications. For example, healthy kidneys produce a hormone called erythropoietin, which helps the body to produce red blood cells, which are important for carrying oxygen from the lungs to all parts of the body. When the kidneys fail, the number of red blood cells drops causing anemia, a condition characterized by fatigue. Dialysis does not cause the kidneys to produce erythropoietin and therefore, people on dialysis will require synthetic erythropoietin injections. Additionally, dialysis does not affect or maintain an appropriate nutritional balance. Dialysis patients have very strict diet requirements for protein, potassium, sodium, and phosphorus. Because certain foods are limited in theses patients, a physician may recommend special vitamins.

For many people who have nonfunctional kidneys, dialysis is an alternative to kidney transplant. There are different types of dialysis.

*Hemodialysis: A dialysis machine contains an artificial kidney called a dialyzer. The dial7yzer gets rid of waste and excess fluid. The waste and fluids that are removed from your body are called the The process takes three to four ours and most people who undergo treatment with haemodialysis go to a dialysis center three times per week. The “clean” blood re-enters your body through a surgically created access on your arm, called a fistula. The access is permanent for the dialysis treatments, and it is very important to keep your access clean.

*Peritoneal Dialysis: Removes waste and excess fluid from blood internally, without the blood leaving the body. The peritoneum, the lining of the peritoneal cavity in the abdomen, acts as a natural filter, allowing waste products and fluids to pass through it into a cleansing solution, while holding important components back. It is done continuously every day. Additionally, a catheter needs to be permanently placed in the abdominal cavity.

*Continuous Ambulatory Peritoneal Dialysis (CAPD): is a continuous dialysis process in which the recipient does fluid exchanges at times and places of personal choosing. A sterile solution called the dialysate is emptied into the peritoneal cavity through a catheter in a process controlled by gravity, which takes about 30 minutes. The dialysate (Fluid) must stay in the abdomen for a predetermined time called the dwell time (dwell time is dependent on amount of waste and usually is about three to six hours). At the end of the dwell time, the dialysate must be drained from the abdominal cavity through the catheter into a special bag. This process is done several times a day.

*Continuous Cycling Peritoneal Dialysis (CCPD):is a continuous dialysis in which a fluid exchange is done at night while the recipient is sleeping, with the help of a machine called a cycler. The cycler does bag exchanges by automatically filling the abdominal cavity with fresh solution and automatically draining it out at the appropriate time. CCPD takes eight to ten hours at night.

Remember End Stage Renal Disease is not end of life Appropriate and adequate therapy can give prolonged useful, good quality of life

RRT (Renal Replacement Therapy ) will be required when more than 90% of kidney function is lost.

Common: –

1)Type II Diabetes :

*Leading cause
*Uncontrolled diabetic *Diabetic with family history of Diabetic nephropathy *Diabetic with high BP are more prone for kidney involvement

2)High Blood Pressure (Hypertension):

*Hypertension second common cause
*Remember chronic kidney disease can give rise to high BP

3)Glomerulonephritis:  Disease that damages the filtering unit called glomeruli manu time cause is not known. Loss of protein and high BP, blood in urine are important signals of disease.

4) Kidney infections:   Infection of kidney particularly repeated infection can produce small and scarred kidney called chronic pyelonephritis.

5) Hereditary diseases:   Runs in family – Polycystic kidney disease,Alport’s disease deafness with renal failure starts in childhood.

6) Obstruction to urinary tract:  Chronic obstruction by stones, prostatic enlargement, posterior urethral valve in male child pelvic cancer like cervical cancer in females, Back flow of urine from bladder to ureter and kidney (VUR) in children.

7) Analgesic nephropathy:  Use of over the counter medications – relatively uncommon in India.

8) Lupus nephritis, vasculitis, Amylordosis, heavy metal exposure, reno-vascular hypertension are rare causes of chronic kidney disease.

It mainly depends on testing urine, blood and ultrasound examination. Lab tests and the amount of urine produced are some of the signs of kidney disease. Creatinine and Blood Urea Nitrogen (BUN) are two lab tests which are done to assess the kidney’s ability to filter. Creatinine is the product of muscle breakdown and is very readily filtered by the kidneys. A normal creatinine level is around 1.0. A value much greater than 1.0 indicates decreasing renal function and a value much less than 1.0 indicates increased renal function or decreased body muscle. It is important to note that your renal function naturally decreases with age so it is likely that creatinine will go up with age. On the other hand, creatinine is directly related to the amount of body muscle and therefore, individuals who are extremely weak or malnourished will have a falsely low creatinine level. BUN is a breakdown product of protein. The kidneys are responsible for eliminating the urea in the blood, and therefore BUN is an index of kidney function. A high BUN may indicate that your kidneys are not working properly. The normal range is about 10-30, although there are other reasons aside from kidney disease which can cause an increase in BUN. Urine formation is a typical function of the kidneys, and it is directly related to the amount of fluid that a person consumes daily. However, when the kidneys fail, the amount of urine decreases, regardless of the amount of fluids consumed.

It is estimated that 1 lac Indians are affected by kidney disease and many more are at risk for developing kidney disease. Consult doctor in case you have:

*Burning sensation during urination or difficulty urinating.
*Frequent urination, especially at night
*Foamy, blood or coffee colored urine
*Swelling throughout the body, especially puffiness around the eyes or swelling of ankles or hands (particularly in children)
*Lower back pain (just below the ribs in the small of the back) that is not affected by movement.
*High blood pressurebr Listless or tired feeling

*Kidney disease which affects both kidney usually produce kidney failure
*Remember many forms of kidney disease do not produce symptoms until late in the course of disease
*Symptoms starts when approximately 80% of kidney function is lost
*Person needs replacement of renal function when 90% of kidney function is lost i.e. called as End Stage Renal Disease (ESRD) or ESRF (End Stage Renal Failure)
*Symptoms may not be directly related to kidney and urinary tract
*Urine out put may remain good till ESRD in many patients

Sign an organ donor card. Share the wish with the close relatives as their consent is required before retrieving the organs even if the donor has signed a donor card. The donor card has to be kept with the person who has signed it.

NO. It is pure donation and hence it becomes the noble act. However, the family is not charged for the investigations after the consent for organ donation is given.

Yes. All the religions in India consider it as the noble act.

No. The organs are removed carefully by taking the donor to the operation theatre and there is no disfigurement. There is cut on the body which is sutured just like any other surgery performed on the living person.

No. The name and address of the recipient is not given to the donor family and vice versa.

No. As per the priority criteria like age, blood group, waiting period, Clinical status of the recipients the organs are given to the most needy and suitable recipient. In Maharashtra the Govt. has given guidelines to give the priority score to all the waiting recipients to distribute the organs. Money, race, religion are not the criteria for distribution

Yes. The body is given back to the relatives to perform the last rites after the retrieval of organs. The organs are retrieved only for therapeutic purposes. This is different than body donation where the whole body is given to the anatomy dept. of the Medical College for the research purpose.

Yes. In India, The Human Organ Transplantation Act was passed inn 1994 which mainly covers 3 areas.

*It recognizes brain stem death
*It regulates removal, storage and transplantation of organs for therapeutic purposes
*It prevents commercial dealings in human organs. No human organ can be bought or sold.

Yes. As Brain death can occur only in ICU, one who becomes organ donor dies in ICU of the hospital. No vital organs can be retrieved if the death occurs at home. However, eyes can be retrieved up to 6 hrs. after the heart stops beating hence this could be done even if the individual dies at home.

No. Brain dead individual is declared dead and cannot come back. There is no question of survival of the individual as the set of tests done by the experts’ leave no possible doubts of the diagnosis of brain death.

Brain death has nothing to do with mercy killing; the organs are taken only after the person is declared brain dead. There is a difference between comatose patients and brain dead individuals. The comatose patients are not dead whereas brain death is the stage beyond coma and individual is declared dead. Organs are never taken at the cost of donor’s life.

Brain death is declared by the brain death committee which involves team of four doctors recognized by the Govt. and who are not involved in performing the transplant surgery. The team has to perform the brain stem death tests twice at the gap of 6 hrs. This death is declared in the hospitals recognized for transplantation. Brain death is accepted worldwide and the brain death certificate is issued to the relatives.

The vital organs like heart, liver, two kidneys, pancreas, intestine, lungs etc. can be donated if we die a brain death. However cornea [eyes], skin and other tissues can be donated after cardiac death.

The living person can donate limited organs like kidneys [as we have two kidneys] or part of the liver and only to his/her close relative. The other vital organs can be retrieved only from brain dead individual.

Human organ transplantation is the achievement of the modern medical science where through surgical procedure the healthy organ from a living or dead person is transplanted on an individual suffering from end stage organ failure. This is established surgical treatment available for the needy patients.

Organ donation is a noble act which gives us an opportunity to save many lives after our death. The donated organs are transplanted into patients who are suffering from end stage organ failure. As many patients suffer from end stage disease of various organs, the organ donation is the only ray of hope for them.