Apollo Hospitals, Chennai, performed the first deceased donor multi-organ retrieval and the first liver transplant in the country on December 24, 1995. Five deceased donor liver transplants were performed between 1995 and 1997 but subsequently slackened. Meanwhile liver transplantation was on the way to becoming an established procedure for the treatment of end-stage liver disease in the country. Almost all the transplants being performed at that time were living donor liver transplants. In 2007, a new team comprising Dr. Anand Khakhar and Dr. Anand Ramamurthy joined Apollo Hospitals, Chennai with a mandate from the visionary Chairman of the Apollo Hospitals Group, Dr. Prathap C. Reddy to establish the first liver transplant program in Southern India.
We believed that the ideal system would be one where both, deceased as well as living donor liver transplants would be performed. It was clear from the beginning that existing systems in the west for organ donation could not be directly implemented and that it would require adaptation to the unique sociocultural economic and healthcare environment encountered here. A big difference here was that deceased donation was largely driven by the energy of the transplant programs.
A systematic approach to recognition and declaration of brain death, maintenance and optimization of potential donors, grief counseling and obtaining consent for solid organ donation was established.Declaration of brain death was encouraged and protocols for evaluation and maintenance were laid down in our ICU’s. The primary physician informed the family about brain death and the concept of organ donation was introduced. An intensivist(medical coordinator)would coordinate with the primary physician, relatives and 2 doctors from a government-approved panel for testing and certification and obtaining consent for brain death.A nurse coordinator was entrusted with the task of building a rapport and bereavement counseling of the next of kin as we observed that they were more likely to trust and respond to a caregiver than a social worker. We travelled across the state, addressing doctors regarding issues about brain death, organ donation and liver transplantation through forums like the Indian Medical Association, Association of Physicians of India among others. We also conducted meetings to increase public awareness through social and corporate organizations. A big revelation for us was that there were people who wanted to donate but was unaware of the procedure and the eligibility.
These efforts started showing results and in 2008, 2009 and 2010 the number of deceased donations were 13, 24 and 28 respectively. As the numbers of liver transplants started increasing the state government took cognizance and between September 2008 and February 2009 passed 8 Government Orders (GO) that laid down ground rules for declaration of brain death, retrieval, allocation and sharing of organs between centers. Scientific advisory sub-committees constituted of medical experts from the field were established to fine tune organ specific rules regarding recipient listing, organ allocation and other issues arising from time to time. The government also encouraged organ donation by recognizing and felicitating donor families. One such event, namely the decision of a doctor couple to donate the organs of their son in September 2008 was highlighted and contributed in a big way to encourage organ donation. The print media also played an important role in creating public awareness and acknowledging organ donation by articles highlighting deceased donations and transplantation. Contrary to popular belief deceased donation has cut across barriers of socioeconomic status. We have encountered exemplary donation by illiterate, daily wage labourers as well. Our youngest donor was 6 years old and the oldest used liver came from a 70-year-old donor.An interim analysis of potential donors at our hospital over a period of 4 months from May to September 2010, revealed a 44% conversion rate (15 out of 34 families). This reflects the maturity of the system and the commitment of our coordinators. Of significance is that only 4 (12%) families refused consent after counseling by the transplant coordinators.
Most of the patients coming for liver transplant in our hospital arrange their own financial resources, which are in most cases limited. We are cognizant of the fact and take special care to ensure that they are judiciously utilized. We are conservative in our approach to marginal livers, which are likely to have higher chances of delayed function or non-function. One reason is that the supply of donors is limited and unpredictable and a super-urgent listing does not guarantee organ availability. The second reason is that the costs would escalate and even those recipients who manage to put together resources for one transplant would find it difficult to pay for two transplants. We moved some potential donors from outside Chennai to our hospital and retrieved organs for transplantation to minimize cold ischemia time. All shared livers were harvested using the hospital ambulance for surface transport or commercial airline services. On occasions when no direct air link was available a stopover and change of flight and a combination of road and air was used. No liver was rejected due to logistic constraints.
Our work speaks for itself. The numbers of deceased donors have increased over the years. We performed 200 DDLT’s till December 2012. The majority of them continue to be generated at ournetwork hospitals. Public awareness is increasing and will ensure that organ donations continue to increase. The future lies in creation of independent organ procurement organizations that, like in the west coordinate the identification, maintenance and distribution of organs.