By Dr Sunil P Shenoy
Consultant Urologist, AJ Hospital & Research Centre

Mangaluru, Sep 22: "I am confident that there truly is such a thing as living again, that the living spring from the dead, and that the souls of the dead are in existence." - Socrates

The Oxford Dictionary defines 'Cadaver' as 'a dead human body'. Medically, a 'Cadaver' is a corpse used for dissection and study. In the realm of human organ transplantation, 'Cadaver' refers to a brain-dead body with a beating heart, on life support systems. I dedicate this article to cadaveric donors and their families for their magnanimity to fellow humans, regardless of religion, caste and creed, in the face of extreme personal bereavement.

The operating room (OR) of a tertiary hospital in the city witnessed unusual activity that afternoon. A team of specialized surgeons arrived with their equipment on a chartered flight from a neighboring city to conduct the surgery. The patient was a cadaver. Following strict prescribed techniques, the liver, kidneys, heart, lungs, and both corneas were removed, preserved, and scientifically packed. One kidney was immediately transplanted into a matched recipient in the adjacent OR. Traffic police ensured a green corridor from the hospital to the airport to avoid delay in transporting the remaining organs. Several pre-matched recipients received the organs and got a new lease of life. It was death after death to medical science, life after death to the deceased, and life after life to the recipients.

While the demand for human organs to address the problem of end stage liver and kidney disease, failing hearts, blindness and so on, in India, runs into lakhs, the availability of suitable living donors remains abysmally low, at a few thousands. Cultural and religious inhibitions, fear and misunderstanding, and lack of public awareness restrict live organ availability. This demand-availability mismatch has led to clandestine organ trades, usually victimizing the poor. The Transplantation of Human Organs Act (THO) 1994 has regulated the system to a great extent. The problem of 'altruistic' unrelated donors (donating out of affection) taking advantage of loopholes in the Act for financial gains is still a vexing problem. Live related organ transplantation alone is inadequate to meet our burgeoning organ requirement.

We have a vast pool of potential organ donors among road traffic accident victims who reach the emergency with or subsequently progress to irreversible brain injury, neurologically defined as 'brain-dead'. Their hearts beat but the lungs need to be expanded by mechanical ventilatory support to maintain body oxygenation. Indeed, in developed countries, cadaveric donors far outnumber live related ones. A single donor can provide organs to nine recipients (two kidneys, two sections of the liver, pancreas, heart, lungs, and two corneas)The Transplantation of Human organs and Tissues Amendment Act 2011 specifically laid down the parameters for assigning brain death (declared twice with an interim gap of 6 hours) and empanelled a professional body to certify the same. The transplant team should not be involved with the brain death certification. A Zonal Co-ordination Committee maintains a registry of potential recipients with all data including blood group, duration of waiting period, age, place of origin etc with weightage to each criterion. The same committee oversees the organ retrieval team and decides the identity of the recipients.

Issues with consent: The social worker plays a pivotal role in counseling and motivating the relatives of the brain-dead patient for organ donation. The family should be given adequate time to decide, but within time constraints in preserving the donor organs on life support systems. Actual consent however, can be taken only after declaration of brain death. The possibility of the organs being found unsuitable for transplantation after retrieval should be explained. Coercion and financial appeasement are illegal. While the next-of-kin could give the consent, it is important to find out if any other siblings or close relatives have objections to the same.

Are all brain dead patients suitable for organ harvesting: It is important for the brain dead patient to have well functioning solid organs and no evidence of diseases like cancer(except for specific primary brain tumors), hepatitis and HIV. Exanguinating injuries and drugs used in critical care could compromise organ function and limit the feasibility of organ retrieval.

Conduct of organ harvesting: This should be done in an empanelled hospital by an independent organ retrieval team. The investigations done towards the conduct of the procedure should not be charged to the donor family. The surgical team should respect the appearance of the deceased after organ retrieval. A post mortem examination after the procedure is necessary by law, but should be expedited, respecting the sentiments of the bereaved family. The transplant recipient team should not be directly involved with the organ harvesting procedure but be ready to receive the organ for immediate recipient surgery. The identity of the recipient should be kept confidential. The retrieved solid organs should ideally be transplanted into the recipient within 6-8 hours of harvesting. Corneas can be preserved for longer periods.

The way forward: Creating public awareness through the media, NGOs, and healthcare professionals should be the cornerstone of our efforts. More healthcare institutions should have the organ retrieval and counseling infrastructure in place. Facilities for immediate cross-matching of donor and recipient should be available in all major cities. All waiting patients should be enrolled in a State or Zonal registry, with a transparent need based selection process. Road and air transport infrastructure should be improved for rapid transport of organs to recipient surgery centres. Behind all these should be, a political will to remove hurdles in organ donation, while maintaining strict vigil on illegalities that could surreptitiously creep up into such programs.

We have a colossal problem on our hands. The answer too is with us. When we pledge to donate our organs after death, we literally donate life. Say 'Yes' to organ donation.