India’s kidney transplant deficit

India’s kidney transplant deficit

Why in the News?

India’s organ shortage has increased alarmingly, for which government’s recent reforms (February 2023) allow more flexibility in age and domicile requirements while registering to obtain an organ.

Kidney transplantation in India:

1. There is a high prevalence of chronic kidney disease (CKD) in India, affecting about 17% of the population, due to
   1. the prevalence of diabetes, malnourishment
   2. overcrowding and poor sanitation
2.  CKD often leads to end-stage renal disease (ESRD), for which kidney transplant is often the best treatment in terms of almost all dimensions that matter: 
   1. Quality of life, patient convenience, life expectancy, as well as cost-effectiveness
3. In 2022, over two lakh patients needed a transplant, but there were only about 7,500 transplants (about 3.4%). 
4. The United States and other developed countries carry out about 20% transplants compared to India.
5. Stringent regulations in India is the main cause for the gap in transplants.
6. Ways to obtain a Kidney by the Patient:
   1. Get a kidney from a deceased person.
      1. It is constrained due to a lack of donations, the particular conditions required on the nature of death, and the infrastructure needed to collect and store kidneys.
   2. To request a relative or friend to donate.
      1. However, compatibility in terms of blood type and tissue type, between the donor and recipient acts as a constraint.
   3. Kidney ‘swaps’
   4. Kidney ‘chains’

Need for change in regulations:

1. Kidney exchange regulations, though required to encourage kidney exchange across family units, change is required to bolster two innovative kidney exchange methods: kidney ‘swaps’ and kidney ‘chains’.
2. India has barely any kidney swaps and almost no chains due to legal roadblocks.

   1. 

      Swap transplants are legally allowed in India with due permission, but only near-relatives are allowed as donor-recipient pairs. 
   2. If a recipient’s donor is not a near relative (such as spouse, parents), she and her donor cannot participate in a swap.
   3. Exceptions to this restriction are Kerala, Punjab and Haryana, where High Court judgments have recently allowed non-near-relative donor-recipient pairs after verification.
   4. But it is legal for a recipient’s non-near-relative to donate to him/her.
   5. Therefore, there are double standards across swaps and direct donations are questionable.
3. Lack of national coordinating authority for swaps unlike that available for national, regional, and State lists for direct transplant from cadavers.
4. There are no kidney chains in India, as it is illegal (except in Kerala) to donate a kidney out of altruism. 
   1. A chain cannot be started since one cannot donate without getting a kidney (for a family member) in return.
   2. Also, kidneys from the deceased or brain dead are only used for direct transplants, not for chains or cycles.
   3. Kidney chains involve significantly lower hospital resources and uncertainty for participants, as each patient first receives a kidney and only then does their relative donate.
   4. This is better than swaps where families demand nearly simultaneous operations of all donors and recipients since no one wants to lose a kidney without gaining one. 

5. Stringent have led to a proliferation of black markets for kidneys.
   1. It majorly involves ‘Selling a kidney’ to relieve financial distress.
   2. black markets endanger participants as these operations are conducted without due legal and medical safeguards.
6. The Transplantation of Human Organs and Tissues Act 1994:
   1. It recognises transplant possibility from brain-stem death.
   2. In the 2011 amendment, swap transplants were legalised.
   3. A national organ transplant programme was initiated. 

Way forward:

1. Laws for swaps to make them on a par with direct donations is necessary.
2. Inadequate kidney supply largely unaddressed.
3. Sufficient precedents have been set globally can be adopted
   1. Australia, Canada, Israel, the Netherlands and the United States (among others) now allow altruistic donations. 
   2. Spain and the United Kingdom have national-level registries for kidney chains and swaps.
   3. Spain even has international collaborations for kidney exchange.