Plotting transplant outcomes

A rare case of organ transplant failure highlights the need for outcome registries in India
In a rare instance in Mumbai last month, the organs of a 59-year-old brain-dead patient, that were harvested and transplanted, failed in all the three recipients. One of them, a 32-year-old being treated for renal failure, died within 48 hours while the recipient of the other kidney, a 60-year-old, died within a fortnight. The recipient of the liver, a 73-year-old woman, had to undergo a second transplant operation soon after. The strange and unexpected outcome has raised a series of questions for the medical fraternity, which is now conducting a clinical investigation. The case also brings into focus the absence of outcome registries in India that can help understand the quality of life after transplant and the rate of mortality.

Rare instance

“Such cases are an uncommon phenomenon. But they do occur and are reported from across the world,” says Dr. Avinash Supe, head of the technical committee that has been appointed by the Zonal Transplant Coordination Centre (ZTCC), Mumbai, to probe the case. “We are analysing if something went wrong in the [transplantation] process or there was an immunological problem which went unnoticed. In preliminary investigations, we have found that the retrieval and transplants were carried out carefully with all the protocols in place,” Dr. Supe says. “To validate our findings, we are taking assistance from nearly 12 experts from India, the United Kingdom and the United States.” Hyper-acute rejections in organ transplants are said to occur within minutes or hours of the donor organ being transplanted in the recipient. But doctors are refraining from terming the Mumbai case as a hyper-acute rejection. “Usually, hyper-acute rejections occur when the recipient is sensitised to the donor’s antigens [molecules capable of producing antibodies in the host]. But it is highly unlikely for this to happen in all three recipients,” says Dr. Bharat Shah, a Mumbai-based nephrologist who is also the general secretary of the ZTCC. “This is a rarest of the rare case.” A common condition observed in all the three recipients after the transplant was a fall in blood pressure and disseminated intravascular coagulation (DIC), which leads to the formation of blood clots throughout the body. Doctors say that when a kidney is rejected, it turns blue and does not make any urine. However, in both the kidney recipients, the kidney had made some urine before the complications began. Dr. Sunil Shroff, of the Multi-Organ Harvesting Aid Network (MOHAN) Foundation, says that rare instances of failures should not affect the organ transplant programme in any way. “There are always certain factors in the donor, something inherent, which may go undiscovered,” he explains, citing a case in the U.S. where all recipients developed hydrophobia and died of rabies after receiving an organ from the same donor. In 2009, a 33-year-old man in Mumbai died of Guillain-Barré Syndrome (GBS), the same auto-immune disorder that his 17-year-old brain-dead kidney donor had died of.

What data show

In 2017, there were close to 800 cadaver organ donations in India. Nearly two lakh people require kidneys, but only 8,000 manage to procure one. Similarly, more than 85,000 people require a liver, but only about 2,500 manage to get a transplant. The country also records a high number of live organ donations as compared to deceased organ donations. With the formation of the National Organ and Tissue Transplant Organisation (NOTTO) and the Regional Organ and Tissue Transplant Organisation (ROTTO), there may eventually be a push to report survival data to registries. “Outcome registries should have been there by now. Hopefully, the government will make it a requirement,” says Dr. Shroff. “If we start now, we will have robust data in the next five years.” In the West, organ transplants are highly regulated, as the performance of hospitals is analysed and licences renewed based on such data.

“It is ideal to maintain the registry for the success rate and survival rate complications after transplant. However it requires resources to maintain that,” says Dr. Suresh Rao K.G., who heads the Cardiac Critical Care and Cardiac Anaesthesia, Fortis Malar Hospital in Chennai. The hospital maintains survival data that comes handy for various scientific meetings.
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