29 Sep-2023-Editorial

REFORM CAN ADDRESS INDIA’S KIDNEY TRANSPLANT DEFICIT

Overview of Kidney Transplant Scenario in India

India’s organ shortage when it comes to kidneys is alarming. In 2022, over two lakh patients needed a transplant, but there were only about 7,500 transplants (about 3.4%).

Due to the prevalence of diabetes, malnourishment, overcrowding and poor sanitation, there is a high prevalence of Chronic Kidney Disease (CKD) in India, affecting about 17% of the population.

CKD often leads to end-stage renal disease (ESRD). A kidney transplant is often the best treatment for ESRD. Specifically, transplant is often better than alternatives on almost all dimensions that matter: quality of life, patient convenience, life expectancy, as well as cost-effectiveness.

In contrast to India, the United States and other developed countries could carry out about 20% transplants. Notably, a significant portion of this gap is on account of more stringent regulations in India than a lack of medical facilities.

How to Obtain a kidney for transplant?

The first is to get a kidney from a deceased person. This is constrained due to a lack of donations, the particular conditions required on the nature of death, and the infrastructure needed to collect and store kidneys.

The second is to request a relative or friend to donate. However, donor and recipient have to be compatible in terms of blood type and tissue type.

The Third mode is kidney ‘swaps’: In kidney swap, let us take the example of two strangers, Sunita and Zoya, who need kidneys. Sunita’s spouse is incompatible with her, and Zoya has the same problem. However, if Sunita’s spouse is compatible with Zoya, and Zoya’s spouse is compatible with Sunita, swap donations are possible. In

The fourth mode is kidney chain: Let us look at the case of Sonu who is an altruistic donor donating his kidney with no expectation of a kidney in return. Sonu donates to Sunita (assuming compatibility), Sunita’s spouse donates to Zoya, and Zoya’s spouse donates to some other compatible person, and so on. It creates a chain of donations.

Kidney Transplants in India

Our research shows that there are barely any swaps and almost no chains in India. This is because of legal roadblocks. And this is a significant opportunity missed with terrible consequences.

Consider swaps:

Swap transplants are legally allowed in India with due permission, but only near-relatives are allowed as donor-recipient pairs.

Exceptions to this restriction are Kerala, Punjab and Haryana, where High Court judgments have recently allowed non-near-relative donor-recipient pairs after verification.

Problems with Swaps

Further, unlike national, regional, and State lists for direct transplant from cadavers (dead bodies), there is no national coordinating authority for swaps.

In India, there are almost no kidney chains:

First, in all States except Kerala, it is illegal to donate a kidney out of altruism. Thus, one cannot start a chain since one cannot donate without getting a kidney (for a family member) in return. And kidneys from the deceased or brain dead are only used for direct transplants, not for chains or cycles.

Chains better than Swaps

The lack of kidney chains is possibly an even bigger opportunity missed than swaps. In chains, each patient first receives a kidney and only then does their relative donate. Thus, chains, compared to swaps, involve significantly lower hospital resources and uncertainty for participants.

Needlessly harsh laws regulating swaps and chains have contributed to a proliferation of black markets for kidneys. ‘Selling a kidney’ to relieve financial distress is a mainstream reference.

At a slow pace

Reforms of kidney exchange laws have been slow. The Transplantation of Human Organs and Tissues Act 1994 set the ball rolling by recognising transplant possibility from brain-stem death.

In the 2011 amendment, swap transplants were legalised, and a national organ transplant programme was initiated. But the national network remained underdeveloped initially.

According to the Transplantation of Human Organs and Tissues Rules 2014, swap transplants are allowed only for near relatives.

The government’s recent reforms (February 2023) allow more flexibility in age and domicile requirements while registering to obtain an organ. But these reforms leave the fundamental issue of inadequate kidney supply largely unaddressed.

World perspective on Swaps and Chains

Australia, Canada, Israel, the Netherlands and the United States (among others) now allow altruistic donations. Spain and the United Kingdom have national-level registries for kidney chains and swaps. The U.S. has especially made progress in facilitating thousands of swaps and chains.

Spain even has international collaborations for kidney exchange. India’s real challenge, therefore, is to learn from and replicate such existing successful regulations to improve the lives of several thousands of citizens.

Conclusion

It is beneficial to allow and encourage altruistic donation, non-near relative donation for swaps, and to improve the kidney-exchange infrastructure.

Prelims Questions

Question on rules related to Swaps and Chains

Mains Questions

1. It is high time that India learns from the International best practices and implements the Kidney Swaps from non-near relatives and Chains in addressing the growing demand of kidney transplants in India. Discuss (150 Words) 10 Marks