All over the world, kidney disease and kidney failure are most prevalent in the poor and economically underprivileged. About 50,000 or more patients are on dialysis in Kerala for terminal kidney failure. Being on dialysis is never a permanent solution to kidney failure. Fraught with several complications and lethal infections the yearly mortality rate in the dialysis population is in excess of 20%. Many of them cannot pay for a kidney transplantation and immunosuppressants which are required indefinitely.
The Kerala government does pay a modest amount for each dialysis treatment. But the government does not do much to promote transplantation, which is less expensive in the long run than keeping people on dialysis. Not to mention the improved quality of life for dialysis patients if they can get a transplant. I believe it is within the governmental powers to promote deceased (cadaver) donor transplantation in the State, as long as the transplant procedure is ethically done adhering to scientific protocols. Like in neighbouring States, government subsidies for purchase of immunosuppressants will also be helpful.
Intensely confounding cadaver donor transplantation is the public’s mistrust of doctors, the healthcare system and the pronouncement of brain death. The definition of brain death is globally approved and followed by countries with some differences. But in Kerala, a few past irregularities in pronouncement of brain death that garnered negative publicity have been played up by misguided activism. Additionally, the Transplantation of Human Organs and Tissue Act of India, which all the States follow, is unnecessarily rigorous, often causing delays in harvesting of vital organs leading to compromised organ viability.
Mistrust of the idea of organ donation after brain death can be ameliorated if Kerala promotes ethical, transparent and well-defined steps in organ procurement and allocation. Kerala was once in the forefront of deceased donor transplantation but not anymore. The State is far behind Tamil Nadu and Karnataka. Deceased donor transplants are taking place routinely in these States. In fact, in 2024, Tamil Nadu has witnessed an average rate of almost one organ donation a day. In August 2023, Tamil Nadu received the award for the best State Organ and Tissue Transplant Organisation from the National Organ and Tissue Transplant Organisation. The Kerala government should increase the awareness of voluntary organ donation and donation after brain death.
After speaking with multiple doctors across the State, it appears that there is little interest on the part of doctors to pronounce brain death. Even if they follow well-defined procedures for declaring brain death, they are subjected to intimidation and lawsuits and consequent negative publicity. This leads to fewer organs being harvested from brain dead people. It is time the government steps in to break this impasse by authenticating methodical assessment of a prospective donor before organ donation.
Like in Tamil Nadu and Karnataka, Kerala government can demand and facilitate recordkeeping of patients on dialysis and a waiting list for kidneys and other organs, and update this list periodically. There is a prevailing assumption that the waiting list is bogus and those who are on the waiting list in Kerala are not going to get a chance to receive a kidney. Organ allocation algorithms can help in impartially deciding who gets the kidney when a deceased donor kidney becomes available. Lack of a robust deceased donor transplantation programme promotes commercial organ purchase, which only the well-to-do can afford, leaving the poor out.
Most tertiary government hospitals in Kerala do not have the capabilities to do more than one transplant surgery a month. If this can be improved, more deceased donor transplants can be done in government hospitals. At the same time, private hospitals have more resources to undertake organ transplants and these resources should not be wasted.
Like Tamil Nadu, Kerala might want to cap hospital charges that private hospitals levy from recipients of deceased donor transplants. Family members of potential organ donors often hesitate to consent to donation as the organs go to help patients in private hospitals, which charge exorbitant amounts from the recipients. Capping of the hospital charges where organ transplantation takes place as well as for the hospitalisation of the potential organ donor death may go a long way in increasing organ availability and rebuilding public trust.
There is a plethora of available medical, surgical, immunological, and organisational skills across the State. These skills should never be wasted, and apathy assuredly will.
(K.G. Prem Chandran is a consultant nephrologist, Des Moines, Iowa, U.S.)
