Lara Adejoro
A consultant nephrologist and kidney transplant physician at the Lagos State University Teaching Hospital, Ikeja, Dr Theophilus Umeizudike, speaks with LARA ADEJORO on the rules guiding organ harvesting and transplants.
Can you explain what organ donation and harvesting entail?
This implies that there is a donor and someone who needs the organ. In kidney transplantation, this is done for someone whose two kidneys have failed. When the two kidneys fail, many abnormal things happen to the body, except the person is undergoing dialysis, and he will not be fit to undergo a kidney transplant.
In Nigeria, what we have done so far is a living donation for kidney transplantation. What we do in our centre and many centres in Nigeria is that a person who is undergoing dialysis will bring a donor. We advise such arecipient to bring their relatives as potential donors so that the Human Leukocyte Antigen cross-match will be a good match. We have many people undergoing dialysis in Nigeria and other countries.
HLA matching is one of the key determinants of a successful transplant outcome, hence the need to have a good matching. Poor HLA matching will lead to organ rejection in the body of the recipient. If the HLA doesn’t match, the recipient has to bring another donor and that is why we advise that the donor should be a family member.
What are the ethical guidelines for organ donation and harvesting in Nigeria?
There is a Nigerian National Health Act which means that organ donation and harvesting should be done in a regulated way and should follow the Istanbul declaration.
In 2008, there was an Istanbul declaration that regulates organ transplantation worldwide. The nutshell of the declaration is that as much as possible, there should not be any inducement to get an organ from a prospective donor.
In other climes where this is more regulated, there is a regulatory organisation that coordinates both the deceased and living organ donations.
For a deceased’s organ donation, the deceased would have given prior consent to their organs being harvested after their death; it is easy to make such organs available for people on the waiting list. So, where it is regulated, people on dialysis have a waiting list, and once somebody dies in a hospital and the deceased person’s HLA matches theirs, they are called up. Within a few hours, the transplant operation will take place. This is also applicable for other organ transplants, whether heart, liver, lung, or pancreas.
Usually, preference is given to children because they are expected to live longer, rather than older adults. Other considerations will be the blood group matching that of the donor, and if the recipients have other conditions that will not enable them to survive for many years after the transplant. Such poor health conditions include severe heart disease, chronic liver disease, and dementia; there is no need to give such a person an organ as their life expectancy is short.
Is organ donation and harvesting allowed in Nigeria?
It is done in Nigeria but the government is not regulating it strictly. It’s more like centres set up their guidelines and protocol based on the NHA.
So most centres will follow their guidelines or protocol to select suitable donors and recipients. Most centres try to ensure there is no financial inducement for the donor, there is a need to get an affidavit from the court that there was no exchange of funds between the recipient and the donor. After establishing altruism on the part of the donor and other investigations have been conducted, then kidney transplantation can take place
In the meantime, we don’t have regulations for deceased donations, just like in most parts of Africa. The deceased donation happens only in South Africa.
What are the rules guiding it?
It is the NHA that is guiding what we do as medical practitioners. The law states that you cannot take someone’s organ without the person’s consent. The donor must be 21 years and he or she is counselled on the 0.05 per cent risk of the person having some morbidity or mortality. The donors are screened to rule out any kidney disease, hypertension, diabetes, HIV, hepatitis B or C and they don’t have any other disease that may preclude them from being a donor. Organ donation and harvesting should be completely voluntary.
In our centre, we ask an independent physician to see the donor and the recipient so that there is no form of inducement. Then we will run several tests on the potential donor and be sure that they are okay before the person can donate his or her kidney.
What is the medical stand regarding the organ business in the country?
Some people walk into the hospital and say they want to donate their kidneys and want to be paid and we discourage them from such. We do not get involved in such a business.
Most doctors don’t subscribe to it, we usually tell people to get their relations who can donate and if they don’t have a willing or suitable family member, they can look for a friend who can willingly donate. Because the organ business happens in some hospitals doesn’t make it right.
What are the implications for the donor or recipient?
Before somebody donates a kidney, aside from establishing they have two functional kidneys, he or she would be screened thoroughly to rule out any other illness that may preclude the donation. Many donors do well after kidney donation, but some studies from Europe show that some 15-20 years after donating a kidney, some donors may develop hypertension or kidney disease.
In Nigeria, we have not been able to completely study donors over that period because kidney transplantation in Nigeria is barely about 20 years old. It is not in every clime that donors are routinely followed up.
In our centre, we do our best to encourage the donor to come back for follow-up after one month, six months, and yearly. The person who receives the kidney transplant is our patient for a lifetime because we need to monitor him or her, be sure the new kidney is working perfectly, and ensure they use their medications.
What are the precautionary measures the donor and recipient should take before a transplant can take place?
After donating a kidney, the donor is advised to live a healthy lifestyle as he now lives with one kidney. Salt consumption should be reduced because excessive salt consumption may increase blood pressure. We encourage them to exercise, maintain a healthy weight, avoid cigarettes and herbal remedies, and if they need to see a physician, they should go to a good hospital. Living with one kidney is not impossible, they just need to live healthily and avoid anything that can put their kidney at risk. They should not take any medication without seeing a doctor.
For the recipient, for the first few months after the transplant, we discourage them from going out or travelling but can travel after three months. They are also advised to maintain good hand hygiene and home hygiene and avoid buying food from the roadside. They must continue to take the anti-rejection medications every day and keep up with regular clinic visits.
Is there a shortage of organ donation in the country and how bad is it?
There is a shortage of organ donations everywhere in the world whether for living or deceased donors and that is why there is a waiting list. What has been done in advanced countries is to do what is called ‘Opt-out,’ which means that anybody alive has to indicate on their driver’s license that they don’t want their organs harvested after death. If the person doesn’t opt out, it means that when the person dies, with the consent of the relations, their organs can be harvested and given to people who need specific organ transplantation.
Some countries in Europe have done it and it is helping them in increasing the donor pool. This also applies to the lungs, eyes, liver, intestine, cornea, and other organs that can be transplanted. In Iran, the government operates a system where potential kidney donors are paid a stipulated amount.
Likely, many of the people donating are not well-to-do or very educated and they want to donate their organs for a fee. A few years ago, we did a study in Nigeria and found that less than 30 per cent of our dialysis patients can continue the treatment for one year. This is because it is capital intensive and much fewer of that number can afford a kidney transplant as this is equally expensive. There is a shortage of kidneys in every country of the world and people on the kidney transplant waiting list spend an average of three to four years before getting deceased kidney transplantation.
In those climes, those people on dialysis are advised that they can bring a relation who can donate to them and that removes them from the waiting list.
When can one say organ donation or harvesting is illegal?
It is illegal when you are paying someone to donate a kidney. This illegality thrives in our country because there is no regulation of the process. There is no government regulatory body overseeing organ transplantation. To have a regulatory body, takes political will and funding. If you want to do such a thing, you must be able to offer people alternatives when you are bringing up such regulations. There should be robust health insurance that can pay for dialysis and kidney transplantation. It is not rocket science, it happens in South Africa. If not, people will continue to take advantage of the poor.
Is there a regulatory body for organ donation in the country?
Yes and no. Each centre doing kidney transplants regulates itself but there is no central body coordinating it. Each centre, based on its guidelines and protocols decides what they want to do. It is not everybody who is doing dialysis that will need a transplant. Some people have acute kidney injury; this is a reversible condition in which their kidneys fail and they need some dialysis sessions or need medications to help their kidneys recover.
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