HYDERABAD: Sixty eight-year-old Arumugam* joined the transplant waitlist for a liver in March this year. Six months down the line, with the pandemic having rewritten the norms of organ donation and transplant, he is still waiting. His daughter says that they have been lucky to have not had any need for emergency care, making the wait relatively easier. While they have had no trouble accessing the medicines he needs, they have not been able to frequent the hospital for a few treatments that require intravenous administration. While hundreds of patients in the state await different organs, quite a few who needed immediate intervention didn’t survive the wait. With cadaver transplants coming to a complete halt in a majority of the hospitals, this is true for most of the country.
Lockdown scare
Mukesh, transplant coordinator at Velammal Medical College Hospital and Research Institute, Madurai, says his hospital has lost three patients since the start of the nationwide lockdown. “We usually identify at least two patients a month for cadaver organ donation. In March, we did three. But since April (with the exception of one patient in June), we haven’t done any. Liver patients are in a dire state. Kidney patients are now dependent on dialysis (but it increases their expenses). We have nearly 100 patients awaiting a kidney and ten to fifteen desperately in need of a liver transplant,” he reports. These are the numbers from just one hospital in one city in Tamil Nadu.
Providing some numbers at the state level, Dr Joy Varghese, director of Hepatology and Transplant Hepatology, Gleneagles Global Health City, says, “In Tamil Nadu, TRANSTAN (Transplant Authority of Tamilnadu) controls all cadaver organ donation programmes. Normally, a minimum of ten to fifteen cadaver organ donations happens every month. However, since March, entire Tamil Nadu has generated only four cadaver organ donations,” he offers.
This significant drop in numbers affects not only those awaiting transplant surgery but several aspects of the medical ecosystem. “At least five-six people directly benefit from one cadaver organ donation; this covers the patients who get the organs (heart, kidney, liver, etc.) directly. Indirectly, it could benefit a lot more patients for we preserve the blood vessels of the cadaver after removing the major organs. This can be stored even for six months. This can be very useful in surgeries, when there are complications like thrombosis (clot in a blood vessel),” he explains.
Paused by pandemic
All this has not been without reason. With the nature of the virus and the way it spreads being so unpredictable, forcing the medical community to rethink protocols and guidelines on a daily basis, transplant doesn’t come easy. The priority had been to keep the patients safe, especially given that a transplant surgery would call for use of immunosuppressants (drugs or medicines that lower the body’s ability to reject a transplant organ), making the patient more vulnerable to infections. Even living organ donations had been put on hold.
Dr Sunil Shroff, transplant surgeon and managing trustee of non-profit organisation called the Mohan Foundation, says the priorities have changed for the medical community. “The hospitals are quite busy with COVID. Patients and doctors are fearful of it. That’s why the rate of organ donation has come down everywhere. Not just in India, in other countries also to some extent. That is but natural because these things are bound to happen whenever there is a calamity or disaster,” he points out. But the fraternity has not been idle. Dr Sunil, the president-elect of Indian Society of Organ Transplantation, says they worked together with the National Organ & Tissue Transplant Organisation (NOTTO) to draw up the guidelines for organ donation-transplant — which donor to accept and the precautions to follow during the procedure et al.
Hurdles and risks
By the start of June, several states in the country had cautiously reopened cadaver organ donation. While the numbers are nowhere near normal, there are still plenty of things that can go wrong or make transplants a lot more complicated, it looks like. The first hurdle is, of course, the COVID test. Mukesh breaks down the process for us. “Normally, organ recovery and transplant takes 15-20 hours. Since the pandemic, the first step has been to get the COVID test results of the donor and his/her family. This procedure itself takes a minimum of seven-eight hours. Only then can we confirm the availability of the particular donor. At the same time, we have to test the recipient and his/her family as well; the back recipient and family too have to be covered. This is for the local organs (organs that go to patients in the same hospital). For example, when we get a potential donor in the hospital, we take the liver and one kidney. The heart, lungs, sometimes the pancreas, and the second kidney, would go to the sharing hospital; it’s usually hospitals in Chennai. Since the pandemic, we have not allowed other hospitals to travel here for these organs. For people coming from other districts could be a risk for our patients. All this is a very big challenge for the hospitals,” he explains.
What more, the lockdown initiated as a response to the pandemic itself seems to have worked against organ donations but not in the way you would expect. For cadaver organ donations, the patient has to be declared brain dead; this means that the brain is no longer functional and will never be so again. In such a condition, the other organs can survive for several hours if the blood circulation is maintained by means of CPR (cardiopulmonary resuscitation) or ventilators (if the patient is at a hospital). Most hospitals’ source of brain dead donors had been road accidents. With people safely at home during the lockdown, naturally, there haven’t been that many trauma cases, he reasons.
Terms & conditions
Limping back to the transplant game, hospitals lead with extreme caution. With COVID in the picture, that involves a lot of testing, isolation and quarantine. But all of it — safeguarding the patient and protecting the huge team involved in the surgery — is a huge process, points out Dr Varghese. “Here, at Gleneagles, there is a separate operation theatre for transplant surgeries. The ICU (intensive care unit) adjacent to this theatre is also reserved for these patients. The team — of doctors, supporting staff and technician — are also exclusive to this duty. After the surgery, the team would be in home isolation until the next surgery, the following week. During this period, they have specific protocols and precautions to follow. In case any of them test positive between surgeries, they are removed from work and cannot return till they get a clearance from the Infection Disease Consultant. Naturally, all doctors, and donors and recipients and their attendants are all tested for COVID,” he explains. These protocols have been put in place for emergent living donor transplants. Since the pandemic, the hospital has decided to perform the surgery only if the patient cannot survive without it. They have done 14 of them between
March and July.
These terms and conditions differ from hospital to hospital and one state to another. For those still waiting for such reprieve, that it hasn’t been easy is an understatement. TANKER Foundation, an organisation in the service of the underprivileged with kidney ailments, has had many people under its care benefitting from transplants. For the patients already facing many challenges in terms of access and affordability, COVID has turned out to be yet another big one. “A lot of our patients — 40 to 50 of them over the past few years — have had a kidney transplant. Over the COVID period, all transplants had been stopped. Also, kidney failure patients are more vulnerable,” recounts TANKER’s managing trustee Latha Kumaraswami. It’s dialysis that has kept many of their patients going, even if it means they have to overcome their fear of the coronavirus and visit a hospital for the procedure.
Counselling patients during such a difficult period, when you have little else to offer in the place of a transplant, is certainly not easy, chips in Dr Shroff. “The one who is waiting, who requires an organ does require an organ. The ones waiting for the heart and the lungs are the more desperate category; that’s one area where you can’t do much. You provide them with hope and pray, to be honest,” he shares.
Community efforts
Meanwhile, there has been no dearth of awareness efforts. MOHAN Foundation has kept up its programmes — from online concerts to webinars — right up to the Organ Donation Week (that concluded on August 13 — the day popularly misconstrued as Organ Donation Day, which actually falls on November 27). In Kolkata, a fledgling organisation by the name Live Kingsize Die Kingsize has been furthering the cause of organ donation. While the organisation may only be two months old, its co-founder Shruti Mohta has been at it since 2016. She has managed to reach out to hundreds of people with the organ donation pledge, routinely organising myth-busting panel discussions. She has also acted as the bridge between doctors and families making the decision to donate the organs of a loved one.
With the organ donor card not having any legal binding, it comes to the family being aware of the concept, the individual’s decision and accepting their role in making it happen, she points out.
Even as the medical community scrambles to keep up with the virus, Dr Shroff points out that this situation here is quite unprecedented, at least where organ donation and transplant are concerned.
Ask him when was the last time they have faced such challenges and he goes, “Never. Even internationally — I’ve asked my colleagues — nobody has faced this kind of challenge. The good thing about the Nipah outbreak was it was immediately controlled in Kerala. Even when we had SARS, it was contained very fast and quite restricted to a few countries; very few cases spilled over. The problem with coronavirus is that it has been unpredictable. It’s also because we’ve still not understood the natural history of this virus.” Even the guidelines they drew up for organ donation and transplant have been revised twice already; it’s bound to be dynamic in the coming months and years too. And there’s plenty to be learnt about transplants for COVID positive patients.
Despite all this, there is reason to give patients hope, he says. “This will recede and get back to normal. It is not the end of the road; everything is in place and doctors are rearing to go as soon as the virus recedes a little bit. These activities differ from place to place. With the curve not being uniform in our country, perhaps the patient can move to a state that is doing the transplant they require,” he suggests.
*Name changed