The intensity of Non-Communicable Diseases (NCD) has been on the rise over the last several decades. Kidney diseases is most prevalent among the NCDs
In Bangladesh every year, 40,000 to 45,000 fresh patients are being affected by End Stage Renal Disease (ESRD). Poor people are affected more by ESRD due to suffering from skin disease in their childhood, smoking, adulterated food, unnecessary and wrong treatment, untimely treatment of diabetes and high blood pressure with other environmental factors.
The best treatment for ESRD is Kidney transplant. Dialysis has also equal benefit but it is very time consuming.
Gonoshasthaya Dialysis Centre is the biggest dialysis centre in the sub-continent. Every day, on an average 260 patients take dialysis service at the Centre. Ultra-poor patients get four-hour haemodialysis thrice a week for only Tk1800 and the poor patients pay Tk2400 for the same service.
Middle class patients pay Tk2500 while the fee is Tk3000 for rich patients. They can avail the service staying in a cabin paying Tk500 extra.
During a four-hour dialysis, each patient gets Random Blood Sugar (RBS) test and blood pressure test at least thrice and if necessary, remedial treatment is given free of charge. The wards are equipped with ventilator and cardiac monitor to provide quick treatment where applicable and there are separate oxygen boxes for each patient.
The ESDR patients who take dialysis have to take one Erythropoietin injection every week. The company-fixed price of the injection ranges from Tk2,000 to Tk5,000. Many patients need to be given blood once a month. They have to take medicines for diabetes and high blood pressure which costs about Tk30 to Tk35 daily.
If the 1982 National Drug Policy was properly implemented, the price of Erythropoietin injection and other medicines would have gone down by 50 per cent. Transplantation of kidney in ESDR patient is much more costly than in dialysis.
An ESDR patient can live a healthy life for 15 to 20 years if kidney is transplanted directly below the abdomen at a cost of Tk2 lakh to Tk2.5 lakh after collecting it from the body of a healthy person.
However, before the organ transplantation, blood group and tissue typing of the donor and recipient have to be matched. It costs about Tk 20,000 for tissue typing of both the donor and the recipient. If the kidneys are not of the same group, additional immune suppressant has to be taken by the patient regularly. It costs Tk20,000 to Tk25,000 per year.
After collecting organ from a Cadaver, it can be transplanted in a live ESDR patient's body within six hours. However, it has some technological problems. The result of transplantation of the organ collected from a Cadaver is not equal to that taken from a living donor.
Every year, more than one lakh kidneys are transplanted throughout the world and 60 per cent of those are collected from living donors.
First kidney transplantation
A kidney collected from a living donor was transplanted above the thigh of an ESDR patient for the first time in the USA in 1954. At that time, kidney transplant was considered as a medical miracle.
From the 1960s, the kidney collected from live donor's body started to be transplanted on the thigh and under the skin at the lower part of the recipient's abdomen. Then it was connected with the urinary bladder, renal artery and vein to internal iliac artery and vein. The transplanted kidney gets activated in a few minutes and the ESDR patient can urinate.
Proper completion of the full operation takes two to three hours.
Any healthy person can donate kidney and live a healthy and normal life. However, the blood pressure of the donor, protein count in his urine and functioning of the kidney should be examined every year.
Organ transplantation laws in different countries
In the USA, usually a healthy person aged between 18 to 70 years donate kidney in three ways: direct donation to a patient of his choice, non-directed donation as per the requirement of the hospital and Paired donation or trade donor (kidney from two donors transplanted to two ESDR patients) in case blood group does not match.
In Canada, any healthy and altruistic person can donate his kidney to an unknown person. If he wishes, he can donate a kidney, a part of his liver and a lobe of lungs. Using the body parts of live and dead donor, lives of 8 persons can be saved and quality of life of 75 sick persons can be improved.
A healthy citizen of any age can donate organ to any relative and un-related patients under the Human Tissue Act 2004 in UK's England, Wales and North Ireland and under the Human Tissue Act 2006 in Scotland. The use of the organs of the dead persons is legal if his relatives do not object to it.
In India, a patient's relatives can directly go to a hospital and donate organ. If a non-relative person wants to donate organ, he has to inform the State Authorizing Committee. The Committee gives its decision in 24 hours. An appeal can be made against its decision to the Central Authorizing Committee. There is scope for Swap Transplantation.
In Sri Lanka, a healthy person who is not patient's relative, can donate organ taking permission from the Ethical Committee of the Health ministry.
The Organ Transplant Act in Bangladesh is formulated in line with the Act in Pakistan. In Pakistan, organ donation to an unrelated person is not legal. But if an organ cannot be collected from a first degree relative, there is scope for collecting organ from a living or dead person after obtaining approval from Human Organ Transplant Authority. All organ transplantations has to be communicated to the National Monitoring Authority within 48 hours. If a person violates the rules, he can be given 10 years jail term or fined Rs15 lakh. In Pakistan, about 10 to 12 kidneys are transplanted every week. In 2008, the first kidney collected from a cadaver was transplanted for the first time at Sindh Institute of Urology Technology (SIUT). A cadaver kidney transplant was done at Islamabad in March 2010.
In Singapore, Thailand, Nepal and Myanmar, organ donation to non-relatives is illegal. Reform of the organ transplant act in Nepal is under process in line with that in the USA and Iran. Patients from other countries can avail the organ transplantation facility by submitting the certificate from own country's home or foreign ministry regarding relation between the donor and the recipient. Long live medical business!
Egypt is the only Muslim country where no law has so far been enacted regarding organ transplantation on the excuse of religion. The ulamas at Al Azhar University are of the opinion that if there is no adverse effect, the sharia doesn't prohibit organ donation by living persons. There is no objection to collect organ from dead persons as well. Trading in kidney is unethical and now law has been formulated to save the poor people from cheating.
In Saudi Arabia, transplanting kidney collected from cadaver into the body of living persons suffering from ESDR started in 1983. Transplantation of kidney, lungs, liver and heart bulbs from living persons started from 1994. Kidneys were successfully transplanted into the bodies of 267 living ESDR in 1997.
World's best organ transplant act in Iran
An ideal organ transplant law is in force in Iran. From 1967 to 1988, only living relatives could donate organ in Iran. Organ donation by brain dead donor started there in the year 2000. In 2005, the organs collected from 3421 living relatives, 15356 living nonrelatives and 823 dead bodies were transplanted in the diseased persons' bodies. Since 1988, all healthy organ donors are given special monetary reward in Iran. As a result, Iran is the only country in the world where there is no waiting List for kidney transplantation.
More than 50 per cent of all ESDR patients in the country have been living for over 15 years after receiving kidneys from living persons. The rest have been living healthy lives through taking peritoneal or haemodialysis.
Organ transplant law in Bangladesh
The scope of "Transplantation of Human Organs Act 1999", as amended in 2018, is very limited. This law violates fundamental human rights. The law does not have any provision for donation of organ by living nonrelatives.
The human life expectancy has increased in the country but the age limit for donor and recipient has been limited from 65 years to 70 years in Article 7/1 (kha) and 7/2 (ka). As there is no physician of professor rank in the district towns, formation of medical certification board is not possible under Article 9 (ka).
Collection of organ from a cadaver and its preservation is not easy in an under-developed country. Cadaveric national committee has been limited to Dhaka (Article 9/2/ka). In the act five, pages have been devoted to the Cadaveric Donation. The existing organ transplant act influences both donor and recipient to tell lies. The responsibility of determining the relation falls on the hospital authorities and the physicians. This law violates citizen's rights. There should be scope for donating organ by all healthy relatives or nonrelatives like those in the developed countries and Iran. The age limited for healthy donor and sick recipient should be raised to 90 years. However, the young age recipients should be given priority in getting organ transplantation.
Thirdly, there should be authorisation authority in all districts headed by a retired justice. He or she can be a member of parliament, a physician, a senior teacher, a journalist, a freedom fighter or a philanthropist. Three types of organ donation should be made legal: Patient's living relatives, living nonrelatives, altruistic, swap or paired donation. Only living persons can donate organ on the basis of this.
Fourthly, all organ donors should be given a minimum of Tk5 lakh as reward and providing treatment and other facilities to the donor on priority basis if necessary.
If the physician does not make shameful mistake or there's no evidence of negligence in transplantation procedure, cancellation of his registration is not logical.
In Bangladesh, 10,000 kidneys are transplanted every year. But every year only 200 to 250 ESDR patients get their kidneys transplanted. At Shyamoly's CKDU Centre, urologist Professor Dr Kamrul Islam alone performs 150 successful kidney transplantations every year. About 1500 ESDR patients go to India and Sri Lanka for kidney transplantation every year and each patient has to spend Tk30 lakh to Tk40 lakh for the purpose.
The rich go to the USA or Singapore for kidney transplantation. It costs them Tk1 crore to Tk3 crore. So Bangladeshi patients spend approximately Tk800 crore on kidney transplantation only. On the other hand, if each living donor is given Tk5 lakh reward, the government will have to spend Tk500 crore. It will save money of the ESDR patients and will reduce their sufferings. The country's money will be saved while its reputation will increase. The medical science will also improve.
Writ in Bangladesh High Court for organ transplant
The scope of the present law is very narrow. Donating organ to a relative or nonrelative voluntarily is a healthy citizen's fundamental right. Barrister Rashna Imam filed a writ petition in the court of Justice Nazrul Islam Chowdhury and Justice Khandaker Diliruzzaman on August 24, 2017 seeking redress in this effect. The court took opinion of seven kidney specialists. The specialists opined that the organ donation should not be made open to all. They said, the people from the lower class of the society will sell organs out of poverty.
Gonoshasthaya Kendra trustee Dr Zafrullah Chowdhury gave a differing opinion and informed the court that like donating money or property, organ donation is also a person's fundamental right. So the process of organ donation should not be kept limited among the close relatives, rather it should be opened to healthy nonrelatives.
However, there should be legal provision so that poor people are not affected. Except for Dr Zafrullah Chowdhury all other specialists are Nephrologists. They earn their livelihood through dialysis. The professional interest of the specialists who gave their opinion is related with this. The two honourable judges will deliver their verdict on the rule as to why Articles 2 (ga), 3 and 6 of the "Transplantation of Human Organs Act 1999" should not be declared as violation of the Constitution on December 5.
Organ transplantation at Gonoshasthaya Kendra
Kidney transplantation at Gonoshasthaya Kendra Nagar Hospital will start in March 2020. The work on two international standard operation theatres at the fourth floor of the Gonoshasthaya Kendra Nagar Hospital at a cost of more than Tk1 crore is ongoing. Same amount of money will be spent on buying modern equipment. Professor Magdi Yacoub of Royal London Hospital, his colleagues and renowned Indian heart surgeon Dr Devi Sethy's Narayana Hridayalaya are providing technological support. A team of surgeons from Royal London Hospital will provide training to the Bangladeshi physicians and they will perform five organ transplantations.
The poor patients will have to pay Tk1.5 lakh and the affluent patients Tk3 lakh for tissue typing of the donor and recipient, other tests, operation charge and cost for staying in the ICU, medicines and follow up.
Zafrullah Chowdhury is a founder and trustee of Gonoshasthaya Kendra and Professor Tauqueer Karim is a professor of Nephrology in the USA