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  • 1. Cadaver Organ Donation & Transplantation in Asia The Way Ahead Dr. Sunil Shroff Head of Department- Urology & Renal Transplantation,Sri RamachandraMedical College & Research Institution, Managing Trustee, MOHAN Foundation, Chennai [email_address]

2. Organ Shortage

  • Each day, about 60 people around the world receive an organ transplant, while another 13 die due to non-availability of organs.
  • Organ shortage the main limitation to saving lives of critically ill patients is due to individuals and their families not considering organ donation out of fear, ignorance or misunderstanding.

3. Cadaver Transplant in Asia The Road Ahead

  • Overview of Cadaver Transplants in Asia
  • Common Problems & Platforms
  • The Road Ahead

4. Overview of Asia

          • Asia World
  • Population 3.6 Billion6.4 Billion
  • No Of Countries 51 235
  • Land Mass 44,390,000 Sq.Km 6,233,821,945 Sq.Km
  • Life ExpectancyM 63 yrF 66yrs

5. Cadaver Transplants in Asia

  • Kidney
  • Liver
  • Heart
  • Heart Lung
  • Pancreas

Source: Asian Transplant Registry 6. PER CAPITA INCOME FOR ASIAN COUNTRIES( In US Dollars) Low Per Capita Income - 1000 Sri Lanka930 Armenia950 Indonesia810 Azerbaijan820 Georgia770 India540 Yemen520 Pakistan520 Mongolia 480 Vietnam480 Bangladesh400 Uzbekistan420 Laos340 Kyrgyzstan340 Cambodia300 Nepal240 Tajikistan210 Average Per Capita Income1000 Thailand2,190 Iran2,010 Kazakhstan1,780 Jordan1,850 Syria1,190 Turkmenistan1,120 China 1,100 Philippines1,080 No Data -Afghanistan-Bhutan, Palestine, Bahrain,Cyprus, Iraq, Qatar, UAE,Myanmar, Timor , Oman,Brunei,N.Korea High Per Capita Income2500 Japan 34,180 Hong Kong 25,860 Singapore21,230 Kuwait17,960 Israel16,240 S Korea12,030 Taiwan13,530 Saudi Arabia9,240 Lebanon 4,040 Malaysia3,880 Turkey2,800 Maldives 2,510 7. High per capita income & Successful Living Transplant Programmes Taiwan Saudi ArabiaLebanon MalaysiaTurkeyJapan Hong Kong SingaporeKuwaitIsraelS Korea 8. High per capita income & Cadaver Tansplant Programme Most of Asia is struggling with Cadaver Programme including regions withhighper capita Iran Lebanon KuwaitIsraelS Korea Japan Hong Kong Singapore Taiwan Saudi ArabiaMalaysiaTurkey 9. Kidney Tx Waiting List in Asia (2002)

  • Japan12,974
  • Taiwan 7000
  • Saudi Arabia 4248
  • Korea 4000
  • Pakistan - 1650
  • Hong Kong -1018
  • Singapore 666
  • Bangladesh - 125
  • Waiting Time
  • Taiwan 1.9 yrs
  • Korea 2.2 yrs
  • Hong Kong 4.3 yrs
  • Singapore 5.8 yrs
  • No Waiting list in Iran for Kidney Tx.

No figures available for China, India, Philipines, Indonesia 10. Transplant Expertise- Asia

  • Japan has - 352 transplant centres
  • Thailand - 27 kidney, 6 liver, & 6 Cardiac transplantation centers
  • Iran has 22 centres mainly kidneys
  • India has 110 centres for Kidney Tx5 centres Liver, 6 Cardiac.over 35 centres have undertaken cadaver transplants
    • Howeveronly 6 centres do cadaver Tx . regularly

11. Transplants - Japan

  • Kidney Transplant since 1964-15 113
  • Liver transplants since 1989-2411
  • Heart Transplants since 1998-17
  • Lung transplants since 1998-39
  • The organs have largely been obtained from living and to some extent from non-heartbeating donors

Ref: Shirakura -WHO/HTP/EHT/T-2003.1Ethics, access and safety in tissue and organ transplantation:Issues of global concern. Madrid, Spain, 6-9 October 2003 12. Cadaver Kidney Transplants in Asia

  • India, Taiwan, Korea, Thailand, Iran, Saudi Arabia and SingaporeRegularly are undertaking Kidney Cadaver Transplants
  • Taiwan, Thailand, Singapore follow the western model and run the programme almost on the same line
  • Japan is still struggling with the programme though their numbers are slowly rising
  • India is emerging as one of the Key players despite still struggling with the programme logistics
  • Very Little information from China is Available on their modus operandi

13. Cadaver Heart Transplants in Asia

  • Hong Kong, India, Japan, Malaysia, Saudi Arabia, Singapore and Thailand are doing Heart transplants
  • Taiwan and Korea do the maximum heart transplants in Asia

14. Cadaver Liver Transplants in Asia

  • Korea do the maximum living liver transplants and has high level of expertise in the field
  • 2,345 LTs (1,860 from the living donor and 485 from the deceased donor) were performed in 24 institutes from March 1988 to December 2004, although 5 institutes had performed more than 10 LTs per year.
  • Japan, Hong Kong, Taiwan similarly have expertise in living liver transplants
  • Four centres in India located at Hyderabad, Vellore and Delhi have fair expertise with liver transplants and emerging as the key players in the country.

15. Cadaver Kidney Transplants Scene in India

  • In past ten years approx. 1000 Cadaver organ transplants over 900 kidneys and 100 Livers and heart have been performed
  • Almost 40% of the cadaver transplants in India done in Tamil Nadu
  • Tamil Nadu Organ Sharing Network could become the role model for rest of the country

Approx.110 centres in India do kidney Tx.however only 25 to 30 centres do over 25 per year. 16. Historical Aspects Cadaver Transplantation - India

  • 1967 -First successful cadaver Kidney Transplant in India at KEM Hospital, Bombay
  • 1994 - First successful heart transplant done at AIIMS, N.Delhi
  • 1995 - First successful multi-organ transplant done at Apollo Hospital, Chennai
  • 1998 First Successful Lung transplant, Madras Medical Mission Hospital, Chennai
  • 1999 First Pancreas Transplant, Ahemdabad

17. Asian Countries Undertaking Transplants Kidneys alone (n-10)

  • Pakistan - K
  • Philippines K
  • Indonesia K
  • Malaysia K,
  • Iran K,
  • Israel K
  • Turkey K
  • Syria K
  • Malaysia K
  • Bangladesh K

Some of these countries have done (eg Pakistan) occasional liver or heart(eg Malaysia)transplant. 18. Asian Countries Undertaking MultiorganTransplants (n-9)

  • Hong Kong K, H, Li, H-L
  • India K, H, Li, H-L, P
  • Japan K, H, L, L, K-P
  • Korea- K, H, Li, L, K-P
  • People Rep China K, H, Li
  • Saudi ArabiaK, H, L, Li
  • Singapore K, H, L, Li
  • Taiwan K, H, H-L, Li
  • Thailand K, H, H-L, Li

Legend:K-Kidneys, K-P - Kidneys & Pancreas,H-Heart,L-Lung,H-L-Heart& Lung,Li- Liver 19.

  • Overview of Cadaver Transplants in Asia
  • Common Problems & Platforms
  • The Way Ahead

Cadaver Transplant in Asia The Road Ahead 20. Common Problems & Platforms

  • Incidence of organ failure in Asia
  • Public and Professionals Attitude to Brain Death & Organ Donation
  • Religion & Organ Donation
  • Legal Aspects
  • Media and Scandals
  • Reporting of Brain Death
  • Hospital Infrastructure
  • Trained Transplant Co-ordinators /Counsellors

21. Incidence of ESRD In Asians & Blacks

  • Black and Asian people arethree to four timesmore likely to develop end stage renal failure than white people
  • This rises toeight timesmore likely for older Asians
  • Diabetes five timesthe rate of the white population
  • Hypertension was at leasttwice the rate of the white population.

22. World Status of Transplants

  • Annual Number of kidney transplantations per million population (pmp) per year-
  • USA-52Predominantly Cadaver Donors
  • Europe - 27Predominantly Cadaver Donors
  • Asia -3Predominantly LivingDonors

In last 10 to 15 years the rate of both kidney an liver transplants have increased but heart has remained static. In 2000 approx. 15,000 kidneys were transplanted in each region . 23. Cadaver Donor Rates

  • The Cadaver donors per million population per year
  • USA -20.7
  • Europe -15.9
  • Asia -1.1
  • South America -2.6

24. Physicians Attitude to Organ Donation

  • Korean health professionals' attitudes and knowledge toward organ donation and transplantation .Kim JR, Elliott D, Hyde C. 2004 Mar;41(3):299-307.
  • There was alack of knowledge by Korean health professionalssurrounding brain death and the organ procurement process.
  • Participants' attitudes were mixed and somewhat negative, as they didnot regard brain death as true death

Korea Organ donation rate below 2 per million population per year. 25. Physicians Attitude to Organ Donation

  • Outmoded attitudes toward organ donation among Turkish health care professionals.Topbas M, Can G, Can MA, Ozgun S.Transplant Proc. 2005 Jun;37(5):1998-2000.
  • A large proportion of Physicians are indifferent to organ donation process.Reason cited for this were -
  • Lack of information regarding the donation process (28.7%),
  • Concerns about the sale of organs (22.1%),
  • Islamic religious beliefs (21.6%)

26. Public Attitude

  • Turkey(n=774)- 59.2% would consider donating organs
  • Pakistan(n 367) 59.9% Willing to donate their organs
  • Hong Kong-60.3% of the respondents were are willing to donate organs
  • Viet Nam -66% urban Vietnamese surveyed were willing to donate organs or tissues after death

Ref - Turkey- Ozdag N. EDTNA ERCA J. 2004 Oct-Dec;30(4):188-95 Pakistan - Artif Organs. 2005 Nov;29(11):899-905. Ashraf O, Ali S, Li SA, et alHong Kong -Yeung I, Kong SH, Lee J. Soc Sci Med. 2000 Jun;50(11):1643-54 Viet Nam - Hai TB, Eastlund T, Chien LA, Duc PT, Giang TH, Hoa NT, Viet PH, Trung DQ. 27. Public Attitude - Singapore

  • Social and cultural aspects of organ donation in Asia.
  • Woo KT. Ann Acad Med Singapore. 1992 May;21(3)
  • Important misconceptions and fears were
  • Fear of death,
  • Belief that removal of organ violates sanctity of decreased
  • Concern about being cut up after death,
  • Desire to be buried whole,
  • Dislike of idea of kidneys inside another person,
  • Wrong concept of brain death,
  • Idea of donation being against religious conviction

28. Public Attitude - China

  • Investigation of understanding and willingness of organ transplantation in young people in Beijing, Shanghai, Wuhan .Zhonghua Yi Xue Za Zhi. 1997 Jan;77(1):22-7.Liu Y, Lei H, Qiu F. China Foundation of Organ Transplantation Development, Wuhan
  • Cities of China
  • Young people have a better understanding of organ transplantation
  • Conventional attitudes and feudal habits are the major obstacle to the development of organ transplantation in China.

29.

  • Results of the Survey
  • Less than 50% overall positive response in favour of donating solid organs
  • 72% were willing for Eye donation and carry a Donor Card
  • All major religions were willing to consider organ donation

SURVEY ONPUBLIC ATTITUDETOWARDS ORGAN DONATION & TRANSPLANATATION Shroff S, Shankar R et al,Indian Medical Tribune, 1996 Public Attitude and Organ donation in India 30.

  • Request for EYES FIRST - SEE HOW FAMILY REACTS
  • Family WillingFamily Reluctant
  • Ask For Solid Organs Abandon Efforts
  • (Heart, Liver, Kidneys ..)
  • Inform Transplant Co-coordinator

Above protocol calledTHERAMACHANDRA PROTOCOLto askfor organs CONCLUSION -PUBLIC ATTITUDE SURVEY HOW TO ASK FOR ORGANS IN THE EVENT OFBRAIN DEATHPATIENT 31. Brain Death Law & Guidelines Optional 24 3 PCO 2 P A Indonesia Mandatory - A - 4 - DVO - P p P P P India Iran Optional A 1 PCO 2 P P Hong Kong Mandatory 24 3 DVO P P Georgia Optional A A A A A China Optional A 3 DVO P P Bangladesh Optional A A A A A Armenia Conf, Test Obv Time Physicians Apnea Test Guidelines Law Countires 32. Brain Death Law & Guidelines Optional 6 1 PCO 2 P A Taiwan Optional A 2 PCO 2 P P Singapore Optional A A DVO A A Vietnam Optional 6 3 DVO P P Thailand Optional 24 1 DVO P A Philippines Not known A A A A A Pakistan Mandatory 12 2 PCO 2 P P Malaysia Optional 6 1 PCO 2 P P Korea (S) Mandatory A 1 PCO 2 P P Japan Conf, Test Obv Time Physicians Apnea Test Guidelines Law Countries 33. Singapore - Legal Aspects

  • THE HUMAN ORGAN TRANSPLANT ACT (HOTA) OF 1987 Singapore
  • .. Kidneys can be procured from patients of road traffic accidents who have been declared brain-dead unless they haveOPTED OUT ( Presumed Consent)
  • (Muslims exempted)

34. Thailand - Legal Aspects

  • There is no law to directly govern transplant procedures in Thailand.
  • The Medical Council is responsible in regulating human organ transplantation . They decide the criteria from time to time.
  • Medical Council in Thailand determines whether any punitive action should be taken against the doctors

35. India Legal Aspects

  • Transplantation of Human Organs Act, 1994
  • Aims
  • Regulate removal, storage and transplantation of human organs for therapeutic purposes
  • To prevent commercial dealings in organs
  • Recognise Brain Death

36. RELIGIOUS & CULTURAL ASPECTS

  • Religion plays major role in promoting Organ Donation.
  • Major religions in Asia Pacific include -
    • Islam
    • Buddhism
    • Christianity
    • Hinduism
    • Sikhism
    • Judaism

37. Religion and Organ Donation

  • Common thread that binds all religions of the world
    • Saving of life overrides all objections
    • There is no religion that is against organ donation
    • What holds back is cultural reservations-
      • Ignorance of the process of organ donation,
      • Fear of mutilation,
      • Lack of emotional support at time of tragedy,
      • Fear that organs will be sold or used only by the rich
      • Mistrust of hospitals and health professionals
      • Myths

38. Religious Attitude to Donation

  • ChineseAmericans are influenced by Confucian values, and to a lesser extent, Buddhist, Daoist spiritual beliefs
  • -associate an intact body with respect for ancestors or nature.
  • The subjects were most willing to donate their organs after their deaths 1 stto close relatives , then in descending order
  • distant relatives, people from their home country and strangers
  • Influence of religious and spiritual values on the willingness of ChineseAmericans to donate organs fortransplantation . Wilbur Aaron Lama & Laurence B McCulloughb . Clinical TransplantationVolume 14Issue 5Page 449 - October 2000 doi:10.1034/j.1399-0012.2000.140502.x

39. Buddhism & Organ Donation

  • The attitude of Buddhism is in perfect agreement with organ and tissue donation; and in Buddhist Scriptures there are stories where donation of tissues have been referred to as an act of charity earning merits
  • - The Late Dr Hudson Silva

World renowned success of the Eye Donation Society of Sri Lanka led by late Dr. Hudson Silva: target of 40,000 eyes procurement reached in May 1999. Gujarat in India has high number of eye donations (Jains) gets 4000 corneas - highest in India. 40. Buddhism & Organ Donation

  • Predominantly Buddhist Countries
  • Sri Lanka
  • Thailand
  • Vietnam
  • Myanmar
  • Less Dominant
  • Korea (30%)
  • Singapore (30%)

41. Buddhism & Organ Donation

  • Even in countries where Buddhism is less dominant
  • Singapore and Korea - Buddhists are main source of tissue donors.
  • Success of NUH Tissue Bank in Singapore, entirely due to strong support by Buddhist Community. All donors Buddhists.

42. Muslims & Organ Donation

  • Muslims the most controversial group -
  • Koran does not forbid tissue donation
  • Koran states that if by not transplanting an organ or tissue, the person will die, then it is permissible to donate . It is allowed for an emergency to save life.
  • Different interpretations by different religious leaders, ustazs and ulamas
  • Muslims must bury the body as soon as possible after death the sooner the better usually less than 8 hours.

43. Muslims & Organ Donation

  • Predominantly
  • Saudi Arabia
  • Iran
  • Iraq
  • Kuwait
  • Turkey
  • Pakistan
  • Bangladesh
  • Malaysia
  • Brunei
  • Indonesia (Secular-PANCASILA)
  • Less Dominant
  • China (200 million)
  • India
  • Singapore (20%)

44. Muslims & Organ Donation

  • Each country has its own MUFTI -religious official appointed by Govt to deal with Islamic matters
  • FATWAS are religious rulings made by Fatwa Committee as official stand by Govt. on various issues.
  • Fatwa Committee chaired by MUFTI includes prominent religious leaders, lawyers, doctors and other members of public
  • Fatwas are not legal binding .

45. Muslims & Organ Donation

  • Fatwas declared in several countries
  • Saudi Arabia : 1985 - permit both living related and cadaveric donation of organs
  • Pakistan,
  • Bangladesh,
  • Malaysia - 1995
  • Indonesia

46. CULTURAL PRACTICES OF MUSLIMS

  • Despite Fatwas Muslims reluctant to donate organs
  • God created them whole. They prefer to return to him whole.
  • Many Muslims bury amputated limbs, foreskin from circumcision, amnion from delivery.
  • Not religious requirement but cultural practice. Not all Muslims do this

47. Christianity- Organ Donation

  • Predominantly -
  • Philippines
  • Less Dominant
  • Singapore (30%)
  • Korea (30%)
  • Malaysia
  • India

No bar to organ donation -Shortage of Donors in Philippines, Singapore and Koreadue to cultural factors. 48. Christianity- Organ Donation

  • STATEMENT BY POPE JOHN PAUL II
  • Full support of organ and tissue donation concluded with words of Jesus narrated by evangelist and physician LUKE:
  • give, and it will be given to you;good measure, pressed down, shaken together, running over, will be put into your lap (Luke 6 : 38).
  • We shall receive our supreme reward from God according to the genuine and effective love we have shown to our neighbour.

49. Hinduism and Organ Donation

  • Predominantly
  • India
  • LESS DOMINANT
  • Sri Lanka (