Organ allocation model for India - who gets the organ?

Dr.Sunil Shroff,

Managing Trustee, MOHAN Foundation (Multi Organ Harvesting Aid Network)

Prof. and Head of the Department, Urology & Renal Transplantation

Sri Ramachandra Medical College & Research Institution, Chennai - 600116

www.mohanfoundation.org

 

Organ allocation is an important aspect of a multi-organ deceased donation programme. In a vibrant programme no one institution can retrieve and possibly keep all organs for itself. The principles of sharing needs to be dynamic and may require changes from time to time depending on the need of the programme. The following  are the guiding principles to establish a successful sharing network   

        Organs are scarce and can save lives. Due to their scarcity all organs should be utilized to save lives of the needy patients.

        The principle of sharing should be based on the best matched organ goes to the most needy patient.  

        The long term objectives of sharing hospitals should be on Give and Take principle.

        Sharing principles should apply for all the available organs.

        The larger the pool of waiting- list, better the matching of the organ.

        Organs should first be matched using blood group followed by HLA (especially for kidneys) along with age, gender and geographical  proximity.

        Organs donated from children should generally go to paediatric  age group patients to ensure  that they best match in size but, when  there are no suitable recipients, organs can go to adult patients.

        Regular auditing of shared numbers and their results need to be accounted and discussed to further evolve the system. 

 Equitable organ distribution is an important component of any organ sharing - state or national network.  The logistics of the flow of organs depend on the following factors in most programmes including India  

        The maximum acceptable ischemia time of the organ.

        The waiting list of the hospitals for various organs  among the participating hospitals in the city & state.

        The participating hospitals contribution to the programme - Gives and takes or only takes

        The waiting list of the hospitals for various organs among the participating hospitals in the neighbouring states.

        The transport logistics between cities

        Affordability of the recipient / participating programme in the organ sharing network

Acceptable Ischemia time Usually 4 hours for heart, 12 hours for liver and 24 to 48 hours for kidneys are acceptable cold ischemia time.

Waiting list The waiting list for heart is non-existent in India due to the programme being limited to a few select institutions. The kidney waiting lists are long and in any organized programme in a state it is seldom likely to leave that state. Over the last two years the waiting list for liver has grown due to many hospitals participating in the programme.

Participating  Hospitals contribution to the programme Gives and takes or only takes A hospital which only expects to receive from the programme and not give back to the sharing system can pose to be problem in kidney sharing due to the long waiting lists.  This is not so when the organ concerned is heart due to the few takers for the organ.

Sharing between states- This can work out again on give and take principle.

Transport logistics - Hearts are best shared within the same city. However recently a heart was flown from Bangalore to Chennai and transplanted but required chartered flights and polices help to minimize the ischemia time. This type of sharing is an exception rather than rule.

Livers and kidneys on the other hand can be shared between various states and examples from the past includes organs getting transported from Chennai to N.Delhi,  Chennai to Hyderabad and Bangalore to Chennai   

From the above examples interstate sharing of livers and kidneys are routinely possible in our country.

However besides the time of transportation Cross match time has to be kept aside for kidneys and liver when considering transportation from one place to another.

Affordability of recipient or programme If an organ can only be transported by chartered flights the cost can be high and these costs would need to be borne by the programme or the recipient.

Organ Sharing Network evolved by MOHAN Foundation for Tamil Nadu and Andhra Pradesh 

In the past 8 years the Foundation through its sharing network has shared over 410 kidneys, heart and livers between 18 hospitals and has also sent organs as far as to N.Delhi from Chennai. It has worked on the principle that all organs should be utilized and not be wasted. More recently it has noticed that in both the above states the donation has been coming spontaneously from family members.  

Mission statement Organs should be treated as national resource and No Organs should be wasted.

 The guiding principles of sharing has been simple and is as follows-

1.      There should be no wastage of organs that can save a persons life

2.      Organs should not flow from the poor, who will be the most common donors, to the rich

3.      Organs should be shared in an efficient manner with mechanisms that can be quickly set into motion.

4.      A patient awaiting transplantation will not be allowed to register with two hospitals simultaneously.

5.      It will be the responsibility of the participating hospitals to update details of the patients in their care, so that the ranking and allocation will be appropriate.

General Guidelines before putting patients on waiting list for cadaver organs

1.      A common waiting list of recipients from all hospitals wishing to undergo cadaver organ  transplant should be maintained on a centralized secure web-based system.

2.      Before putting patients on waiting list the transplant clinician should ensure:

a.      That patient is aware that merely by having the name on waiting list does not guarantee that the organs would be available.

b.      The patients should be counselled about cadaver organ donation and transplant programme. They should ensure that they are contactable at any given time of the day or night and would be prepared to arrive at the transplant centre. Not complying would mean that they would lose their turn on waiting list.

c.      If they are not available for a period of time they should inform the concerned hospital who should deactivate the patient. Not informing the hospital would mean them losing their turn on the waiting list. 

d.      The short and long term graft outcomes should be briefly discussed with the patients and their relatives.

            Allocation Criteria

1.      The retrieving hospitals get to keep one kidney, heart and liver if they have the recipient sharing and the one kidney goes to common pool.

2.       If the organ is retrieved from a non-transplanting centres all organs come to the common pool and allocation goes as per the waiting list.

In the MOHAN organ sharing network no kidneys were shared with other states but livers were often flown out of the state. However on two occasions kidneys were received from FORTE in Bangalore to Chennai.      

To make this whole process seamless the MOHAN network developed a web-based waiting list and organ matching software and its demo version is available  on www.mohanfoundation.org/inos.  

The problems that were encountered in the network are as follows

1.      Displeasure from hospitals that gives more organs and receive less from other participating  hospital.

2.       Refusal to share kidneys.

3.      Lack of uniformity in the use of perfusion fluid and method of retrieval.

4.      Cost sharing some delays in settling bills between sharing hospitals.

5.      Lack of takers for heart this is the most common wasted organ in the programme.

6.      Lack of trained personnel to counsel for organs. 

Last year the sharing network and principles have been further enlarged due to the active participation of the Department of Health of Tamil Nadu and these principles have been further strengthened. 

Organ Sharing Network model adopted by Tamil Nadu

1.      A multi-organ recipient takes precedence over all others on the regular waiting list.

2.      Sharing of organs retrieved from cadaver donors in Government Institutions. The Priority for organ allocation is as follows-

 Govt. Hospital  where organ retrieved has first priority to the -

Liver, heart, one kidney

Other kidney allocated to the general pool in the priority sequence below

a.      Combined Govt. Hospitals list within the state

b.      Combined Private Hospitals list within the state

c.      Govt. Hospitals outside state

d.      Private Hospitals outside state

e.      Foreign national registered in Govt. / Private hospital within and then outside state

3.      Sharing of organs retrieved from Private Transplant Centres. The Priority for organ allocation is as follows-  Private Hospital where deceased is located  gets priority for  Liver, heart, one kidney  .

Other kidney allocated to the general pool is distributed on the following priority sequence -

a.      Combined Govt and Private Hospitals list

b.      Govt and Private Hospitals outside state

c.      Foreign national registered in Govt / Private hospital within and then outside state.

4.      Organs retrieved  from Non-Transplanting centre The order of priority is as follows -

a.      Combined Govt. Hospitals list within the state first gets first priority for the organ.

b.      Combined Private Hospitals list within the state gets the next priority for the organ.

c.      Govt. Hospitals outside state

d.      Private Hospitals outside state

e.      Foreign national registered in Govt. / Private hospital within and then outside state

5.      Patients on urgent list (liver, heart, lungs) supersede standard list and hospital misses its regular turn on the Rota. Examples include for Liver Sharing -

a.       Hepatic Artery Thrombosis following a liver transplant.

b.      Primary graft failure

c.      Fulminant hepatic failure.

Examples for heart Patient waiting with

Left Ventricular Assist Device

Intra-aortic Balloon Pump

To participate in the system all hospitals need to send their waiting lists to a central co-ordinating body in the state. No system of sharing is perfect and all systems ever since the principles of sharing were drawn up have had some gaps. In India, where  the deceased donation takes place only in  a few hospitals,  a simple sharing system on the lines of the above laid out principles can help all the programmes in the country.