They share the same birthday. Not because they were born on the same day, but because she has a small part of him inside her. “So on my birthday, she also has a small birthday party ,” says Gunawardena.
Senior Research Scientist at the Sri Lanka Institute of Nanotechnology (SLINTEC) and head of Research and Innovation Manju Gunawardena didn’t plan on donating a kidney at age 40. Ironically, when his friend and fellow researcher at the Peradeniya Agriculture Faculty was having kidney problems for over two years, he felt only natural to donate his kidney. In fact, ironically Gunawardena and both the recipient and her husband were doing kidney related research together.
Gunawardena explained that being in kidney research they were trying to safeguard people with kidney disease and knowing that she was going through dialysis two to three times a week gave him enough reason to donate his kidney. “Life is uncertain,” said Gunawardena. “We all have to go at one point. It’s great if we can do something good before we go. Besides, if you have a kidney problem, the chances are that both your kidneys would be affected. It wouldn’t help even if you have two kidneys. A human can live on 50 per cent of one kidney.”
At the Blood Bank they tested whether his kidney was a match for her. And it was also natural for the Professor in surgery Mandika Wijeyaratne to cut him up.
“Due to the stigma attached to organ donation, doctors prefer related donors, as they suspect that donations made by non related donors are always financially motivated,” explained Kidney Transplant Support Foundation (KTSF), Founder Chairman Ajit F. Perera.
However, the Kidney Transplant Support Foundation has been working to remedy the exclusive ‘related donor’ requirement, giving the opportunity for those who harbour a genuine desire to donate their kidney.
KTSF’s latest achievement is procuring the approval for all interested individuals to get the Donor Symbol in all future driving licences. The National Transport Medical Institute (NTMI) and four key branches, namely Werahara, Kegalle, Kandy and Gampaha presently entertain requests from all applicants who are interested in getting their Donor Symbols on their driving licences. A directive has already been sent to launch this initiative country wide.
A Medical Certificate from the National Transport Medical Institute is mandatory for anyone who wishes to obtain a driving licence. “Any applicant who applies for a driving or riding licence can express his or her wish to be an organ donor when obtaining the medical certificate and that in turn, will be included in the driving licence issued by the Department of Motor Traffic”, said Perera.
Perera has also got the Police on board. The IGP and the DIG-Traffic has circulated this information to all stations across the country directing them to be vigilant when visiting the scene of a fatal accident or near fatal accident so that they can check the driving licences and pass on the information to the hospitals where the victims are sent.
“With over 2500 road deaths each year, if organs can be harvested from at least five per cent of the cases (125 deaths), that’s a lot. Each cadaver translates to two kidneys, a liver and eventually – in the years to come – a heart, not to mention so many other tissues that can be harvested. Multiply this by a 125,” says Perera.
Lethargy of authorities
But in reality Perera complains that even the NMTI is indifferent to this cause, with some doctors not even bothering to register applicants.
Although the KTSF was set up in 2009 and the infrastructure for a database was strengthened by distributing 20 computers among major hospitals the staff usually express a general lack of enthusiasm, according to Perera.
“Registration procedure has to be carried out by a doctor. But many doctors didn’t show interest, because there was no money to be made,” said Perera.
“When a person is diagnosed with a kidney problem doctors try to play God.”
Perera charged that patients faced with death would do just about anything the doctor says and the doctors call all the shots and said the Ministry of Health has shown little interest in registering potential donors.
“The Cadaveric Transplant Programme was launched with the backing of the WHO in 2010, but to this day it has been inactive,” said Perera. “Right now I’m just a middleman connecting potential donors with people who need organs.”
Ideally ICU records every brain death and every surgeon and nephrologist is alerted through the system. But the lethargy of the medical professionals in government hospitals have reduced Perera to disdain.
Due to the lack of enthusiasm from hospitals Perera has all but given up on the system initially laid for the National Organ Donor Programme.
But he has an extensive network of trustworthy medical professionals who get his emails containing details of any new live donor he registers. “If we get a match from a patient who needs a kidney I contact the donor,” says Perera who gives priority to pediatric hospitals such as the Lady Ridgeway.
How to donate?
Any individual interested in donating their kidney while alive can call 0722247236. Potential donors are expected to sign a consent form, which requires information on the civil status, number of children, next of kin and medical history. A history of blood sugar and pressure prevents one from donating, according to Perera and the KTSF ascertains whether the donor’s intensions are genuine. “There are many practical difficulties to donating,” explained Perera. “Even though some people have genuine intentions of donating, their loved ones often stand in the way.”
Perera explained that although cadaveric transplants or donating after death is an option, live donations are most effective, with a 95 per cent success rate.
The ideal cadaveric donor is a patient who has been pronounced dead, explained Perera. “A brain dead person should be on a ventilator where the kidney and heart are alive. This is the ideal situation to harvest organs. Otherwise the organ will be rejected by the body.”
Perera complained that some doctors without waiting for an ideal match, shoot up patients with strong immunosuppressants to prevent rejection. He charged that such doctors do it for money and charge as much as one million rupees for a transplant surgery.
“Bones, skin, eye sclera and pericardium can be harvested from deceased donors,” said Sri Lanka Eye Donation Society, Human Tissue Bank Manager Hemaka de Mel. There are over 250 branches island-wide and interested individuals can register online by visiting ntb.mobitel.lk or call them on 011 2692051, 011 2698040 and 011 2698043.
Eyes can be donated up to four hours after death and tissue can be donated up to 12 hours after death. He said that the age of the donor is not a matter of consideration. “Tissue can be harvested from any donor below age 70. But those with viral, fungal or bacterial infections; HIV 1 and 1 and Hepatitis B and C infected donors are excluded. Individuals with wounds on the body are also excluded as it could lead to septicemia,” said De Mel.
De Mel explained that there are no compatibility issues with transplanting the Cornea of the eye and can be used by anyone. The most harvested is the knee joint from which a lot of tissue can be derived. He revealed that the Human Tissue Bank gives priority to cancer patients and children and doctor referrals for urgent cases.
Colombo University Professor of Surgery Mandika Wijeratne said there are two types of donors; deceased donors and living donors. “Among deceased donors there are two types. Those whose hearts are beating but declared brain dead, and those whose heart has stopped”, explained Prof Wijeratne who said that when the heart stops beating blood circulation stops damaging organs. “Consequently, organs must be harvested as soon as possible,” he said.
“But being on life support is not equal to being brain dead. To confirm brain death, brain function has to be tested twice over. There have been no instances of recovery from brain death,” said Wijeratne. He also pointed out that people also confuse brain death with coma, the lay term for which is unconsciousness.
The National Institute for Nephrology Dialysis and Transplantation spoke of the need to combat the myth of those who have suffered brain death, especially brain stem death, becoming alive and getting back up, by way of public awareness.
Consultant in Medical Administration and Director of the Institute, Dr. Rathnasiri A. Hewage said that as a result 750 kidneys in conditions suitable for donation for transplantation go to waste every year.
There are deceased donors whose hearts beat and there are deceased donors whose hearts do not beat. In the latter, their kidneys have to be harvested within 30 minutes of death.
In such cases, only the cornea of the eye can be donated (as it does not require much of a supply of blood to survive) and the body can be donated to a medical faculty according to Dr. Hewage.
“In the case of deceased donors whose hearts beat, this is because the heart is receiving oxygen. This is because of the presence of an in-built pacemaker,” he remarked.
In people who have suffered head injuries, they may become unconscious or slip into a coma. When the brain swells and keeps on swelling, and the pressure goes up inside the skull, the heart cannot pump blood to the brain, and due to the loss of the blood supply, respiration stops. When the heart receives no oxygen, the heart dies, and due to the lack of blood and oxygen, other organs too die. Brain death and brain stem death means that the individual is dead and the death is permanent.
It has to be diagnosed and confirmed by two groups of doctors. Immediately subsequent to brain death and brain stem death, liquefaction starts. The junior staff and labourers however believe that the deceased is alive as his or her heart is beating.
“In an intensive care unit, if the deceased is on a ventilator, the lung will provide oxygen to the heart and in this manner the heart can survive for three to four days or even up to a week,” he explained.
In the event of brain death and brain stem death, while in a coma, organs can be retrieved via operation.
Dr Hewage said that there are 5000 new chronic kidney diseases of unknown etiology patients per annum who require kidneys for transplantation.
Who can donate
When it comes to a donor, blood groups of donor and recipient must match. Both living and deceased donors are tested for diseases such as HIV, hepatitis and cancer. The point is to eliminate transferable risk. Dead donors are sparse.
“Sri Lanka depends heavily of living donors. Taking all precautions to ensure the health of the donor is imperative,” said Prof Wijeratne.
It must also be ascertained whether the potential donor is psychological fit to make the decision. “The informed consent of the donor is imperative,” reiterated Wijeratne.
Organs of donors with high blood pressure and sugar are harvested, provided the organs are not damaged. In fact, organs of donors as old as 65 to 70 and as young as 20 to 25 can be transplanted. But Wijeratne admitted that the doctor community have qualms about transplanting organs from donors younger than 20.
International legal regimes
The 44th World Health Assembly adopted a resolution in 1991 which developed nine guiding principles concerning transplants including the donation of organs or tissues for transplantation to the sick and the dying from deceased or living persons.
The principles were for the purpose of addressing commercial trade of human organs for profit and the exploitation of the economic needs of donors or relatives as such acts contravened the Universal Declaration of Human Rights and the spirit of the constitution of the World Health Organization.
Commercial trade includes commercial trafficking of organs involving transactions of purchase and sale, giving money, compensation or reward and receiving such and also including human trafficking.
The first principle states that organs may be removed from the dead for the purpose of transplantation if any legally required consent is obtained in prior, or in the absence of any reason to believe that the deceased objected to such.
The second bars physicians who determined the death from direct involvement in organ removal, transplantation procedures and the care of potential recipients.
The third observes that consenting donors should be free of undue influence and pressure being brought to bear on them. They must also be made to understand the health risks, benefits and consequences resulting from donation.
Also, paragraph three of the guidelines proposed by the Council of The Transplantation Society in 1985, concerning guidelines for the distribution and use of organs from cadaver sources and living unrelated donors, notes that active solicitation of living unrelated donors for profit and coercion and improper inducements to donate, is unacceptable.
Expenses incurred in donation, organ recovery, preservation, supply and loss of work earnings, damages sustained following the removal procedure or preceding examination can be reimbursed through a social security or insurance scheme.
Elsewhere, there are various measures taken to regulate transplants.
Sri Lankan legal provisions
One such locally available measure involves the legal instrument of the Transplantation of Human Tissues Act No. 48 of 1987, Section 17 of which criminalizes the sale, dealing or disposal of a body, part or tissue.
In the case of the removal and use of eyes of deceased individuals for the purpose of transplantation, such a thing is dealt with by the Corneal Grafting Act No. 38 of 1955.
Further, General Circular No. 01 – 37 issued in 2010 by the Ministry of Health sought to deal with organ donation in re-deceased to donor transplantation and laid down procedures and guidelines to be followed when retrieving organs from a deceased who is hooked on to ventilatory support systems (cases of brain death) for purposes of potential donation.
Medical research too relies on the donation and use of organs and tissues. Ethical review committees of medical faculties and hospitals are the decision makers in this regard. Legal standards applicable to research and tissue retention must be considered when making such calls.
Coroners and judicial medical officers too conduct inquests and autopsies, where bodies, body parts and tissues are retained. The Code of Criminal Procedure Act No. 15 of 1979 applies in this instance.