Cadaver Transplantation

Dr (Mrs) Rasika Sirsat

Transplantation is currently considered

an accepted treatment modality for

patients with end stage organ failure where therapy with drugs or restorative
surgery is not feasible. Approximately, 25 different organs and tissues including
kidney, heart, lung, liver, pancreas, bone, cartilage, bone marrow, skin and cornea
can

be

transplanted.

This

is

due

to

important

break

throughs

in

immunosuppressant drugs and tissue typing. More than 1 million people world
wide have benefitted from successful

organ transplantation.

Of these kidney

transplant results have been the most gratifying. With improvement in results, the
demand for human organs for transplantation has increased. The source of donor
organs are living related donors (LRD), living un-related donors (LURD), cadaver
non heart beating donors (NHBD) and cadaver heart beating donors (HBD). Most of
cadaver transplanted kidneys are obtained from brain dead donors with functional
circulation.

Brain death can occur due to spontaneous intracranial hemorrhage,

head trauma, cerebral ischemia or primary cerebral tumours.

Brain death can be diagnosed at the bedside by performing various tests in
patients in whom the cause of coma is known and those who do not have severe
hypothermia (< 35oC) and have not received neurodepressor drugs, neuromuscular
blockers and anti-cholinergic drugs.
**BOX Neurological examination to demonstrate Brain death are
Absence of oculomotor/photomotor reflex
Absence of corneal reflex
Absence of facial movements
Absence of spontaneous muscle movements
Absence of oculo-vesitibular reflex
Absence of gag reflex

Absence of cough reflex

Absence of spontaneous breathing determined by Apnea test.
Apnea test: Patient is put on FiO2 of 100% for 20 minutes while still on the
ventilator. Thereafter ventilator is disconnected and patient is put on 6L/minute of
O2. Serial arterial blood gas are checked until PCO2 > 60mm Hg with PO2 around
100 mm/Hg.

Watch for movements of diaphragm if there is no spontaneous

respiration that indicates an absence of brain stem respiratory centre function.

These tests are repeated and confirmed after 6 hours. Only then the patient can be
declared as Brain dead. These tests are to be performed by 4 medical practitioners
(Neurosurgeon, Physician,

Neurologist, Intensivist) as per Transplantation of

Human Organs Act (TOHA) 1994.

Brain death is explained to relatives by the

treating physician after the first set of tests are performed.

The transplant co-ordinator can then counsel the close relatives regarding organ
donation. Once close relatives give written consent for organ donation, organs can
be retrieved after declaration of brain death following the second set of test to
confirm Brain Death.
The Zonal Transplant Co-ordinating Center (ZTCC) is informed about a potential
Cadaver donor. The ZTCC is a city based organisation who co-ordinate all activities
for organ procurement, maintainenance of a computerized central registry of
potential recipients and allocates organs as per the criteria laid down. The aim of
ZTCC is to provide impartial and effective organ distribution. The prospective 2
recipients for kidney transplant are called as per criteria laid down by ZTCC. It is
essential that a person who registers for a cadaver transplant keeps some funds
aside in the eventuality of being called for a transplant surgery.

The recipient

should also follow up regularly, at the center where he is registered so that the
nephrologist is aware of his/her medical fitness for surgery.

The suitability of donor organ is checked by performing a Lymphocyte cross

match.

If negative the recipient can proceed for Transplant. If the lymphocyte

cross is positive the recipient next on the list is considered for the transplant,
provided lymphocyte cross match is negative. The shortage of organs can be
expanded by including non-heart beating donors (NHBD) i.e. organs are retrieved
only after heart stops functioning. The main issue with NHBD is higher rate of
delayed graft function compared with that associated with heart beating brain dead
donors. However at 3 months graft function is not significantly different between
the two.
Most of the kidney transplants performed in India are from live donors. For
those patients who do not have an option of related kidney transplantation, the only
option is to wait for a cadaver kidney. The Human Organ Transplantation act was
passed in 1994 following which a few cadaver transplants have been carried out all
over India. In Maharashtra, the first cadaver transplantation after the act was
performed on the 27th of March 1997, thereafter about a hundred and fifty more
have been performed up to date.

So far about 1200 cadaver transplants have been

carried out in India far short of what is required. This is in spite of 8500 fatal road
traffic accidents per year. Per city about 8 to 10 brain dead patients would be there
at a time, however, the conversion rate is less than 19%. This is due to multiple
factors like poor infrastructure for quick and safe transportation of accident victims,
lack of ventilatory facilities, ignorance, failure to convince the near relatives to
donate organs, indifferent attitude of health care professionals and lack of organ
sharing agencies.

India spends 1.5% of GNP on health care. End stage kidney

disease (ESKD) treatment has extremely low priority as compared to population

control, eradication of communicable disease, nutritional program, etc. hence
government funding for renal replacement treatment is a miniscule amount. Very
few ESKD patients are reimbursed by their employers, while others rely on their
family and charitable organizations for funds.

Public unawareness, religious

sentiments, family pressures all contribute to bringing down the number of actual
organ retrieval from potential cadaver donors.

In Spain organ procurement system has been professionalized.

The organ

procurement team is responsible for the whole organ donation process from donor
identification to organ retrieval and they are accountable for their performance,
there are 127 such teams. Their organ donation rate has more than doubled over
the last one decade and the percentage of multi-organ retrieval has soared from 35
to 83% enabling a 3-fold rise of possible solid organ transplant.
Currently, organ shortage is the main obstacle to the full development of transplant
programme. It is possible to increase the cadaveric organ donation rate and also
promote living donation. It is still possible to improve graft survival rates and thus
reduce the need for re-transplantation.