Decoding organ transplants with Dr Harsha Jauhari

According to a study, India’s organ transplantation landscape in 2019 showcased a remarkable dedication to saving lives through living donors and solid-organ transplants. The majority of living donors stepped forward as kidney donors, contributing a significant total of 8613 donations, followed by liver donors with 1993 contributions. Additionally, India’s transplantation infrastructure is growing at a steady pace, with 550 registered transplant centres operating under state-appropriate authorities, accompanied by 140 Non-Transplant Organ Retrieval Centres.

Dr Harsha Jauhari

To discuss this journey and the process of organ donation in detail, THIP Media spoke to Dr Harsha Jauhari, MBBS, MS, FRCS, FICS, FAIS. Awarded with Dr B C Roy National Award in 2016 by the President of India, Dr Jauhari is one of the leading experts in the field of organ transplantation in India. In 2004, Delhi High Court appointed him as a member of a high-powered committee responsible for reviewing the provisions of the Transplantation of Human Organ Act, 1994. He also has been the Advisor for Organ Transplantation to the Ministry of Health & Family Welfare, Government of India since 2014. Here are some excerpts from the discussion:

What are the most common and the least common organs harvested in India?

Live donors are a common source for kidney and liver transplants, while organs obtained from deceased donors are relatively rare. Among transplants from deceased donors, kidney and liver transplants are the most prevalent, whereas intestinal and lung transplants are not very common. Over time, there has been an increase in heart transplants compared to the past.

Which organs and tissues can be donated while a person is alive, which can be donated after death?

Although it is occasionally possible to obtain skin tissue from a live donor, other types of tissues are typically not obtained in this manner. Deceased donors can provide organs like eyes, bones, skin, blood vessels, and nerves. Composite tissues, such as hands, feet, or toes, can also be taken from them. These are examples of organs and body parts that can be obtained from a deceased donor.

What are the risks of an organ transplant surgery for both the receiver as well as the donor?

Recipients of organ transplants often face a multitude of complications and comorbidities including diabetes, hypertension, kidney failure, anaemia, etc., among others. Doctors treat them and improve their overall condition to make them as fit for the transplant surgery as possible. However, it is not feasible to maintain them at such a level of fitness for an extended period. Many patients with kidney and liver problems also face the challenge of fulminant hepatitis. In such critical scenarios, their chances of survival without a transplant within the next few days are slim. This urgency holds true for heart and lung patients as well. While there are inherent risks involved, they are carefully evaluated and calculated. In the cases of kidney transplants, survival is as good as any other operation.

When it comes to donors, it is essential that live donors are in a healthy state by definition. Extensive investigations and assessments are conducted to ensure their suitability. Our obligation towards the donor is even greater because their initial health is intact. We cannot compromise their well-being in order to improve someone else’s health. This is precisely where the law plays its role. Our responsibility towards the recipient involves treating them and enhancing their condition. Simultaneously, we have a duty to the donor to ensure their continued good health post-surgery. Therefore, doctors are very careful throughout the process.

Can age and blood group compatibility be a factor for organ donation?

Till a few years ago, blood group compatibility used to pose significant challenges. However, we have made significant progress in routinely crossing the blood group barrier, especially for kidney and liver transplants. Remarkably, the outcomes of such procedures are virtually as good as those with the same compatible blood groups.

Nowadays, people can donate at the age of 65 and 70 years as long as they are fit. The assessment of their fitness level is a professional judgement made by their healthcare provider. Therefore, as long as potential donors maintain good health, age does not significantly impact their ability to donate. Similarly, individuals of any age can receive organ donations based on thorough evaluations conducted by medical experts to ensure their overall health.

If people have certain health conditions, can they donate organs?

Many people with hypertension or diabetes may fall into the category of ‘marginal donors’. These conditions commonly emerge after the age of 40. Therefore, we take a calculated risk if no other donor is available. It is worth noting that individuals who have successfully overcome cancer and have been in remission for two to three years can also serve as donors. Likewise, individuals who have undergone procedures such as hysterectomy, mastectomy, gallbladder surgery, or even appendicitis can still be deemed fit for organ transplantation. In recent times, we have witnessed an increasing number of such marginal donors, and they are doing fine.

In case of cancer survivors donating organs, do you think that there can be fear among the recipients that they might also get cancer?

Certainly, individuals may experience fear in such situations. Nevertheless, I would like to emphasise here that the professionals carrying out these processes are very diligent with it and provide comprehensive guidance to the patients. Additionally, numerous checks, rechecks, and counter checks are in place to ensure that nothing is handled casually or overlooked.

If an organ donor dies, what are the steps that family members can take to harvest their organs? Also, what is the time frame within which that decision to donate has to be made?

There are two kinds of disease donors. One is brain stem death and the other is cardiac death. If a person stops breathing, their heartbeat also stops. If this happens at home, it doesn’t leave any scope of doing anything at that point, except for donating corneas. In such a situation, the team can come home and take the cornea. This is because by the time the process is started, it gets too late to retrieve any other organ, as the rest of the organs remain deprived of oxygen and cannot be removed or used as a result.

In the cases of brain stem death, the diagnosis cannot be done at home. These cases are either road traffic accidents or accidental deaths, electrocutions, etc. Therefore, they have to be admitted to the hospital. There are eight separate examinations before you can declare someone brain-dead. After this, the transplant coordinators get in touch with the patient’s family.

All this has to take place in centres which have been designed accordingly. Now we have widened it from being transplant activity of donor and recipient at transplant centres. We now have an NTORC (Non-Transplant Organ Retrieval Centre). Any hospital that is a trauma centre or has got ICU and some beds and a good OT can be declared a donor centre. If a brain-dead person comes in, someone will go there and help declare the brain death. The organs can be removed from there and then moved to the transplant centre.

Do all the states have NTORC centres?

The authority is there, the concept is there, the difficulty is to try to involve a nursing home or a good hospital in this. The aftermath of a donation can be demanding, resembling a battlefield the following morning. Motivating these institutions to participate becomes crucial, as their incentive is often limited to some publicity. Thus, we are making concerted efforts nationwide, particularly targeting the trauma centres established by the government in major cities. Additionally, the objective is to facilitate transplant activities in every medical college across the country. This requires the initial step of establishing dedicated departments of transplantation medicine. Currently, efforts are underway to train professionals in organ retrieval techniques to ensure a widespread availability of skilled personnel.

What are the legalities associated with organ donation in India? And what would you suggest if it’s a very complicated chain of events?

The law has intruded upon this particular facet of medical care. Earlier the first introduction of the law was to prevent commercial trade of any organs in 1994. The concept of brain stem death was included in that at the time. After that in 2004, we revised it and had the new amendments that brought in a whole lot of things. I was one of the people in a very high-powered committee appointed by the Delhi High Court. One of the changes was that every hospital has to be registered. They must have transplant coordinators, and each hospital has to have a website. The decisions have to be taken in such a way that everything is transparent. We set up an organisation, which is now called NOTTO (National Organ Tissue and Transplant organisation).

We also introduced the concept of the National Organ Transplant Programme. This programme sets the infrastructure training. We also have the concept of required requests. So, if someone dies in a hospital, often their family members blame the doctors involved for the death of their loved one, whether they were responsible or not. In such a situation, if a doctor at the hospital goes up and asks for organ donation, the situation can get out of hand. Therefore, we came up with this concept of required request. There are sign boards that are put up all over saying that the doctor on duty is required by law to ask for the organs. You are free to say yes or no. This made a lot of difference because when families are sitting outside and seeing the patient inside, they read all these things. It makes an impact. We are now trying to move for the ‘uniform declaration of death’.

A doctor who has just been registered can go up and certify somebody dead, if the heart and lungs have stopped working. Whereas for a brain stem death, you need four senior doctors in India who examine independently following a checklist. This process is repeated again after six hours. Only then can they declare someone brain dead. The list of documents that the doctors are required to maintain during this process is very lengthy. In cases of organ donation, people are supposed to move around with a huge stack of documents every time. So, we are trying to bring in a single document explaining the identity of the deceased and the causes of death. The rest of documentation can be kept in the hospitals except a single piece of paper that can be taken to the banks, or for permission or to the registrar’s office.

Myth or Fact

Organ and tissue donation mutilates the body. Is it a myth or a fact?

It is a myth. Organ or tissue donation will not result in mutilation of the body.

Anyone can be an organ donor. Myth or Fact?

Yes, in 99.9 percent cases, people can become organ donors.

Only the heart, liver and kidneys can be donated. Myth or Fact?

No. A person can donate about 8 organs and any number of tissues.

If the ICU doctors know that the patient is an organ donor, they won’t work hard enough to save the patient. Myth or Fact?

This is totally wrong. It doesn’t matter whether the patient is an organ donor or not, they will be treated in the same way as any other patient, putting their survival and well-being on priority.

Organ donation will make the body look ugly. Myth or fact?

For a live donor, now with laparoscopic surgery, you get a few punctures here and there. And the retrieval and transplant of the organ is carried out in a very cosmetically acceptable way, for both the donor and the recipient as well. In the case of a deceased donor, you have an incision which is closed in the abdomen or the chest. If the bones are taken out, splints are put in. There are artificial lenses that have been put (if one wants) in the cases of eye donation. There is no mutilation of the body.

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