The Renal Transplantation issue

We have delayed and missed many opportunities before on renal transplantation. It is my fervent prayer that we do not do so again, that will be a great disservice to those in need of a transplant

After debates in the National Assembly recently, the ‘The Human Tissue (Removal, Preservation and Transplant) Bill’ (No. V of 2018) has been enacted.

The ‘Explanatory Memorandum’ is as follows:

The object of this Bill is to repeal the Human Tissue (Removal, Preservation and Transplant) Act and the Human Tissue (Removal, Preservation and Transplant) (Amendment) Act 2013 and to replace them by a new and revised legislation which provides a better legal framework for the removal, preservation and transplant of human tissue, other than blood, under appropriate medical supervision.

The new legislation, inter alia –

(a) provides that –

(i) no person shall donate any tissue, whether belonging to himself or to any other person, unless he obtains the approval of the Tissue Donation, Removal and Transplant Board;

(ii) no person, other than an authorised specialist, shall remove any tissue, or cause or permit any tissue to be removed from, the body of a person unless conditions are satisfied;

(iii) no person, other than an authorised specialist, shall perform a transplant;

(b) removes the current restriction applicable in the case of donation of tissue by living or deceased persons for the purpose of a transplant to the body of any other person; and

(c) provides that no removal of tissue, for the purpose of a transplant to an intended recipient, shall be allowed from the body of a person who is incapable, by reason of mental impairment, of agreeing to make a donation.

Both the 2013 and 2018 Acts are an emanation of the 2006 Act, which was the first piece of legislation that I was tasked to handle when I joined the Ministry of Health & Quality of Life as Chief Medical Officer in October 2006. Since I was involved in its revision from the beginning, I have thought it fit to highlight certain aspects of the renal transplantation issue for the understanding of lay citizens who may eventually be the recipients or donors of a kidney. This will be essentially about some of the principles involved in the process, the nitty-gritty needing to be worked out in due course based on preparatory work already undertaken in the course of revising the 2006 Act.

After the Board was constituted and began to meet nearly one year later (for reasons that I will not go into), it was found that there were some serious gaps. In the course of addressing them, technical assistance was sought from the WHO. Inter alia, an expert from France’s Agence de Biomedicine (rated as the best regulatory body in the world for human organ transplants), who was based in Reunion, was delegated and duly submitted her report. In fact she identified further gaps, which were taken care of in her report. Next there was a team from Marseille that came to look into the technical aspects, and it included a Mauritian specialist who had submitted a report some years earlier based on studies done in collaboration with the University of Mauritius.

For a successful tansplantation programme to take place, there must be:

1. Solid legislation;
2. Adequate infrastructure; and
3. Qualified personnel.

Legislation: So far in Mauritius, renal transplants that have been carried out have been between a recipient and a living related donor (except for one case). The major novelty in the new Act is that there is provision for donation from dead persons, that is, cadaveric donation.

At one time, the issue of allowing transplantation on Mauritian soil for foreigners (who would come with their donors) was flagged, at a time when there was no provision in the law for this. The current Act does not address the matter, so I presume that no foreigner will be allowed to travel to Mauritius for renal transplantation, because the major problem will be to establish the relationship between donor and recipient if they come from jurisdictions where civil status registration procedures are absent or weak.

As a matter of fact, since traffic in kidneys for transplantation is the major general problem concerning this type of donation, no ‘foreign’ donation should be allowed, as it will be impossible to control occult commercial trafficking in such cases.

Legislation must establish the specific criteria for donor competency and recipient eligibility. As far as the latter is concerned, as in all developed countries, this must include a cut-off age, besides other medical criteria, for example, those relating to the presence of other disease(s) i.e. comorbidity.

Further, the waiting list must be a coded one, and the anonymous donation made strictly according to the order on the list. The expert from the Agence de Biomedicine referred to above was very particular about this point, which was of crucial importance so as to prevent tampering with the waiting list by those in power, so neutrality in the donor-recipient framework was an absolute requirement.

Legislation must also make provision for establishing brain death, which is now required in all developed countries, and those doing so must have nothing to do with the two separate teams which are one, the team that removes the kidney from the donor and second, the team that will carry out the transplant, that is, puts the donated kidney in the recipient. So far in Mauritius, this was done by one and the same surgeon, a totally inadequate arrangement, and unacceptable. Having these two separate teams becomes all the more important now that cadaveric donations will be allowed.

Adequate infrastructure: Given the numbers that are involved, and that are likely to increase, we have reached the stage where we need a separate set-up for carrying out renal transplantation. In fact, a plan had already been prepared, and the proposed centre was to be built in the precincts of Jawaharlal Nehru Hospital, where there was land space available and identified. That plan has to be re-activated. In a Mauritius awash with money, that factor should not pose a problem. I recall that then the cost estimate for the proposed centre was Rs 50 million, and it will definitely have gone up, but not beyond our financial capability I would think.

However, I can think of another possibility that would speed up matters: Medpoint has a bed capacity of about 90, and already has the basic infrastructural requirements for carrying out operations. With a bit of lateral thinking, it is eminently possible to have both the Cancer Centre and the Renal Transplantation Center accommodated there with suitable modifications and additions.

There is another important matter: that of patients who undergo dialysis and who need what is called an arteriovenous or AV fistula (establishing a connection between an artery and a vein, usually done at the elbow) for that purpose. This a delicate but not difficult operation which had been carried out by the then two surgeons doing renal transplants, as also general surgeons in the five Regional Hospitals. And there was a waiting list of patients needing AV fistula.

For the general surgeons, it is an additional task that for one, they are not at all interested in and secondly, it cuts into their operating theatre time. Not only they should not be forced to do so, that would also go against the interest of patients. Besides, often these fistulae are accompanied by complications which general surgeons are not really trained to deal with.

The new infrastructure should make provision for all AV fistulas to be done at the new centre by transplant surgeons assisted by a dedicated team of trainee general surgeons preparing to become renal transplant surgeons.

However, dialysis should be continued on a decentralized basis at is the case at present.

The infrastructure should also include the full complement of laboratory facilities for carrying our both tissue typing and the other tests that are required in the management of the patients undergoing transplants.

Qualified personnel: These will of course include medical, nursing and paramedical staff. And here, we do not need to reinvent the wheel – the Marseille team had already offered to advise on and train staff need for such a centre. Besides, as they are also conversant with all the regulatory aspects, their expertise could additionally be tapped in this regard.

As mentioned at the beginning of this article, I have touched upon only a few salient points that would be of interest to concerned laypersons.

We have delayed and missed many opportunities before on renal transplantation. It is my fervent prayer that we do not do so again, that will be a great disservice to those in need of a transplant.

* Published in print edition on 1 June 2018

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