Shadowed under scams and scandals, the organ donation industry in India finds itself deep down in murky waters. The endless list of hopeful recipients never seems to abate as the numbers of transplant recipients keep rising! The organ donation and transplant system is today pitted against a surmounting wall of challenges and roadblocks with deep-rooted flaws in the system
By Sonali Patranabish
Based on data released by the Indian Society of Organ Transplant, every 10 minutes a person is added to the transplant waiting list, 3.17 lakh patients wait for either a kidney or liver transplant in India and every year there is a need for 1.75 lakh kidney transplants, in comparison to only 10,000 kidney transplants being conducted in a year.
Due to the prevalence of various comorbidities, 17 per cent of the Indian population is afflicted with chronic kidney disease which eventually proceeds towards end-stage renal disease (ESRD) which warrants a transplant. Despite this, only 7500 transplants (3.4 per cent) were done against the demand for 2 lakh transplants in 2022. National Organ and Tissue Transplant Organization (NOTTO) says that in the last five years, the kidney has been one of the most transplanted organs with close to 43,983 transplants being conducted which sums up to 75 per cent of the overall transplants.
But with the surmounting burden of numbers of ESRD cases being added annually summing up to 2.2 lakh, the situation seems grim.
Striking a balance -Supply and Demand Issues
Renal replacement therapy in the form of dialysis is the preferred treatment modality, followed by renal transplantation in the case of ESRD. However, due to high affordability costs and a host of other issues, renal transplantation is mostly preferred given the efficacy and clinical outcomes along with long-term cost benefits.
“Renal transplantation from both deceased (cadaveric) and living donors remains the gold standard for treating end-stage renal disease. However, the number of cadaveric donations often falls short of demand, leading to longer wait times. Living donor transplantation offers an alternative, but it is limited by ethical, medical, and logistical factors,” opined Dr Arun Kumar N, Senior Consultant Nephrologist and Transplant Physician, Apollo Hospitals, Seshadripuram.
Dr Dharshan, Department of Nephrology and Renal Transplant Services, Kasturba Medical College and Hospital,Manipal mentioned, “Despite that over three lakh people in India have registered to get cadaveric organs, twenty or more people pass away every day while they wait to receive an organ.”
“India ranks second globally in kidney transplants, trailing only the US, but predominantly through living donors rather than deceased ones. However, the organ donation landscape in India is marked by a severe imbalance, whereby the demand for transplants substantially surpasses the supply. The country’s deceased organ donor rate stands at less than one donor per million populations, markedly lower than the rates in countries like the US and Spain,” stated Dr PS Vali, Senior Consultant Nephrologist, Asian Institute of Nephrology & Urology, Dilsukhnagar, Hyderabad.
Organ shortage – Dismal Donation Rates
India today stands at a dismal organ donation rate of 0.86 per million as per NOTTO. In comparison to the Western countries where organ donation is 70-80 per cent higher, India needs to boost its organ donation rates significantly.
Dr Rakesh Panda, Urologist, Preeti Hospital, Hyderabad said, “A majority of donors are from CVAs (cerebral vascular accidents) and RTAs (Road traffic accidents).”
According to NOTTO, of the 11,423 kidney transplants in 2022, 9,834 were from living donors.
“Living kidney donors still make up 85 per cent of all kidney transplant cases performed in India,” opined Dr Dharshan. He feels that despite a notable four-fold increase in the number of deceased organ donors in the last ten years, the over-reliance on living kidney donors points to a situation where donors and their families have qualms over pledging their organs.
“There are extensive waitlists because 220,000 people need transplants annually, but only 7,000–8,000 are performed. Daily 17 of the 88,551 waiting for kidneys pass away. A three to five-year wait is typical,” opined Dr Panda.
Dr Kristen George, Consultant Nephrologist And Renal Transplant, Aster Whitefield, Bengaluru goes on to add that of the 7500 Kidney transplants conducted annually only 10-15 per cent are from cadaver donors.
Surmounting Challenges
The kidney organ transplant and donation landscape is fraught with challenges some of which stem from logistics issues, infrastructure and others from the ambiguity in organ retrieval and procurement procedures across states. Despite the process of organ retrieval, procurement and transportation being governed under the aegis of the Transplantation of Human Organs Act and Tissues Act (THOA), most states have adopted their methods, leaving escalating issues to slip through the cracks of an already fragmented organ donation system.
According to Dr Sachin Patil, Consultant – Nephrologist, Sahyadri Super Speciality Hospital, Hadapsar, Pune the kidney transplantation landscape is fraught with challenges, logistical challenges like coordination tasks, identifying potential donors, obtaining consent and the physical retrieval and transport of organs for organ procurement and retrieval organisations (OPROs).
Dr Patil further added, “This process is inherently time-sensitive, requiring swift action to ensure organs remain viable for transplantation. However, various hurdles, including transportation issues, regional barriers, and the lack of a unified organ-matching system, frequently slow down the process. These administrative difficulties can significantly prolong the procurement timeline, jeopardising the timely transplantation of kidneys to recipients in dire need.”
Dr Rajesh Aggarwal, Chief and Sr Consultant – Kidney Transplant & Dialysis Department, Sri Balaji Action Medical Institute, explained that the myths surrounding brain death contribute to considerable organ wastage, with India losing around two lakh kidneys and other vital organs annually.
According to Dr Kristen, “Factors such as limited public awareness about organ donation, cultural and religious taboos, and systemic barriers contribute to this gross disparity between demand and supply.”
Public-Private transplantation divide
As per a NAMS (National Academy of Medical Sciences) task force report, 2022, private hospitals carry out 80 per cent of kidney and liver transplants. Corporate hospitals like Apollo claim to have carried out 23,000 transplants in the past 11 years, in comparison to a meagre number by the public sector hospitals.
Dr Vivekanand Jha, Executive Director, The George Institute Global Health India said, “There are no good incentives for public sector hospitals. In government hospitals, organ transplant is often not a priority.”
Insiders in the industry say that the lack of incentives given to surgeons and anaesthetists, extremely long hours of surgery and lack of trained personnel in the public sector, leaves this sector an underdog concerning transplants. What is even more disturbing are the skewed numbers concerning the number of public to private sector hospitals offering transplants.
In Tamil Nadu, only eight government hospitals carry out transplants in comparison to 89 in the private sector, Karnataka with only 68 registered organ transplant centres while UP stands at fewer than 10 hospitals that offer transplant services.
Harbour of Hope
A green corridor was created at Pune, where close to four organs were successfully donated and transplanted from a brain-dead man to four needy recipients across the country. In similar situations, a 310 km green corridor was successfully created by the Madhya Pradesh traffic police to transport an organ from Jabalpur to Bansal.
Celebrating Indian Organ Donation Day (IODD) and certain awareness campaigns by NGOs like ORGAN INDIA and MOHAN Foundation help to share more knowledge about kidney donation.
Green corridors have been looked upon as the way forward to expedite the process of organ transplants reaching in time while preventing organ damage and loss.
Despite the organ shortage situation being an alarming one compounded by a lack of awareness and infrastructure, there still seems to be a glimmer of hope.
In a major move by the Government of India, the organ donation policy seems to have gone through a change bringing hope to the dozens of awaited kidney transplant recipients.
The Union Health Ministry in the revised policy has stated that henceforth there will be no age bar for registering for cadaver organ transplant. Post- COVID there seems to have been a resurgence in transplant activities, with 15,000 transplants being conducted in 2022, showing a 27 per cent annual increase.
Organ donations have gone up by 14 per cent in Tamil Nadu in 2023. Star Hospitals, Hyderabad has Introduced India’s First National-level Paired (Swap) Kidney Donation Registry or ABO Incompatible Kidney Transplant & Paired (Swap) Kidney Exchange.
In recent times acts of generosity have stood out, the daughter of an Indian army soldier pledged her organs. Her kidney was harvested at the Command Hospital, Chandi Mandir, Haryana and donated. These acts surely direct towards a shift in the society’s thought process towards organ donation at large.
In a recent report released by the PostGraduate Institute of Medical Education and Research (PGIMER), close to 290 kidney transplants were conducted till December 20, 2023, of which 215 were from female donors and 75 were from male donors. The year 2023 has been a remarkable one for PGI, conducting 326 kidney transplants.
In a recent update, the Union Health Minister has stated that UP Colleges will have Organ donation facilities by 2024 for which financial aid will be provided by the GoI.
Call to action
Circumventing challenges is the need of the hour given the bleak situation that the organ and demand and supply pool is in India. With only 0.1 per cent of the population donating their organs after death, awareness, and dispelling myths and superstitions around organ donation need to be fast-tracked.
Dr Patil feels that the concept of an organ donor card as a voluntary system to express consent by the donor will help to increase the organ pool.
“Comprehensive public awareness campaigns, coupled with educational initiatives in schools and communities, can dispel myths and encourage more individuals to pledge their organs. Furthermore, government policies by implementing effective regulatory frameworks, incentivising donation through tax benefits or healthcare subsidies, and establishing transparent allocation systems can go a long way in addressing the organ shortage crisis,” opined Dr Kristen.
“The current situation of kidney transplants in India is much better than what it was a decade ago but remains hugely inadequate to the existing need. It has been estimated that there were 3,595 kidney transplants in 2013 which almost tripled to 9,834 by 2022,” opined Dr Rammohan Sripad Bhat, Director – Institute of Nephrology, Kauvery Hospitals, Bangalore.
The outlook
Organ donation needs to be fast-tracked by creating more awareness among the general public. Though kidney organ donation has seen some uptick, there is a long road ahead before India can compete with other developed nations.
