Kidney transplant in a globalizing world—Enrique Ona
abs-cbnnews.com | 07/01/2008 5:47 PM
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OPINION
By ENRIQUE ONA
Donors must be protected from any abuse. Just as important is to help these suffering and dying patients take access to the advances of medical science.
The issue of kidney transplantation and the use of living non-related donors especially to foreign recipients has been so muddled with misinformation, innuendos and aspersions to the country’s entire transplant program by some members of the local transplant community. They have been targeting, among others, the NKTI Transplant Program as an institution and me as the executive director and supposed "father of the derided organ donor program."
One must look back to the past to understand the unfolding events in kidney transplantation in our country today. Unlike in the US and other developed countries, through the years, kidney donors in the Philippines were mostly from living related donors (95%) and a mere 5% from deceased/cadaver donors despite all our efforts to work on the latter. The passage of the Organ Donor Act of 1990 legally recognized brain death and the legality of the organ donor card. This fact (difficulty of brain dead donation) is true in all developing countries including Japan and the reasons are manifold.
The shortage of donors in the US and all developed countries (except Spain) has resulted in a 5-8 years waiting time for patients who wished to be transplanted and the burgeoning costs of end-state renal disease or ESRD care ($2.5 billion annually in the US).
In Japan, the waiting time is indefinite because despite a legal recognition of brain death since 1997, only eight deceased donors have been retrieved.
At the same time, rapid advances in immunosuppression, the maturation of the surgical technique and overall improvement of care have markedly improved survival rate so that transplantation is now the preferred treatment for patients with ESRD compared to prolonged or life-long dialysis.
This has been shown by several comparative studies with regards to overall survival rate, long term costs and quality of life. This became clear globally as early as the late 1980’s and became more obvious in the 1990’s and more so today.
Evidence
Two important facts on living donors have become established. One, it is safe to be a living kidney donor – one lives a normal life in terms of life expectancy, sexual activity, with no or little danger of a higher incidence of hypertension and albuminuria.
Two, recipients with live donors have a significantly longer survival rate, compared to the best matched deceased donors
The above evidence-based medical facts have added to the tremendous demand of patients with ESRD to seek kidney transplantation as early as possible (pre-emptive), to look for a living donor beyond their family circle, and regardless of racial source.
In addition, the mounting demand for kidney transplantation has been exacerbated by the almost epidemic increase of patients with ESRD globally as a consequence of an "epidemic" of patients with Diabetes Mellitus and hypertension, the latter two being the most common cause of ESRD today.
Medical tourism
The past 5-10 years have also witnessed the development of "medical tourism" as exemplified by countries like India, Thailand and Singapore (but now world-wide) as improved hospital facilities in the less developed countries have attracted patients from developed countries where health care costs were expensive and unaffordable especially to those with no health insurance.
In 1999, a TV documentary exposed more than a hundred kidney transplants done in a private hospital from living non-related donors coming from the very poor section of the city, called BASECO in Tondo. This created a public uproar similar to what we have today, resulting in a Senate investigation, of which I had the difficult task of explaining and "defending" the practice.
Senator Juan Flavier instructed then Secretary Alberto Romualdez to create a body to which I was a member to come up with recommendations to stop this nefarious practice and come up with corrective measures. After several public hearings and meetings, it eventually resulted, after three years, in the passage of Administrative Order 124 in 2002, under the term of Sec. Manuel Dayrit.
Administrative Order No. 124 created the Philippine Organ Donation Program (PODP). The most important features of AO 124 were the following: separate accreditation of the transplant program (Kidney) from the hospital accreditation (the first in the country) and a 10% cap for foreign recipients in any transplant center.
Ethical debate
The year 2002 – 2007 must be reviewed to better understand our problems today, among which are:
1. The rapid world-wide demand for kidney transplants from all types of donors, deceased or living.
2. The program of "medical tourism" propagated by private hospitals to include kidney transplantation despite official pronouncements by the DOH to the contrary.
3. The ease of information dissemination through the Internet.
4. The rapid advances in transplantation beyond the HLA tissue types and better immunosuppression.
5. Poor governance, weakness and lack of clarity in certain parts of the previous AO 124.
6. The continuing global debate on the unresolved issue of donor compensation, assistance, gratuity or gift as differentiated from payment, sale or commerce for organ donors.
In the Philippines, reciprocating a favor with some gift or token of appreciation is an accepted cultural practice, not in the context of payment or commerce, but in the spirit of gratitude. Admittedly, this is often abused. If one was dying or in grave threat and a stranger offers help (on this instance, his kidney), are there guidelines on how one may reciprocate on this kindly act?
Responding to abuses happening in the US in the early years of kidney transplantation in 1987, the National Organ Transplant Act of the US was passed which forbids the receiving of any "valuable consideration" by the donor, deceased or living. This has been the hallmark of organ donation with varying modifications in other countries and the one supported by the WHO.
This has been the contentious issue of debate in the international transplant community of which no global consensus is forthcoming. In the late 1980’s, the US modified their position in accepting "emotionally related donors" such as husband and wife, fiancées and other persons that maybe emotionally affected if the recipient dies. In the last few years, the US has also accepted "exchange of donors" between unmatched pairs (living donors) and also accepted "removing disincentives" from donors by reimbursing expenses up to $8,000 dollars to volunteer living donors.
Help the suffering
It is true that the NKTI and the entire country’s kidney transplant program is predominantly a living donor program. This has been true despite long-term efforts to develop a deceased donor program.
The transplant program of the NKTI, with its excellent results comparable to that of the first world countries, has attracted patients internationally especially as the hospital achieved ISO-2002 certification six years ago. To say that our country attracts foreign recipients "only because they can easily buy cheap kidneys" is most unkind and undeserving of a reply.
Out of the 690 kidney transplants done in the Philippines in 2006, 158 (23%)of these were done for foreign recipients and in year 2007 a total of 1046 were done and 536 (51%) of these were done in the 13 private hospitals that strongly objected and ignored the 10% limit mandated by AO 124.
These number of transplants to foreigners including the flagrant abuses attracted world-wide attention and were reported by the Philippine Society of Nephrology (PSN) internationally putting us in the category of the abuses on organ trade with Pakistan, India, Turkey, Colombia, China and other eastern European countries.
Organ transplantation is a rapidly developing scientific endeavour which unfortunately is beset with various issues of moral, ethical and legal ramifications. This will even become more complex as we tackle issues on stem cell research and its medical applications, in-vitro fertilizations, implications of nanotechnology and other medical advances in the horizon.
We must try to keep an open mind and face these challenging fields with no malice, other than try to remember why we physicians are here for. Yes, donors must be protected from any abuse, respected and even honoured. Just as important is to help these suffering and dying patients take access to the advances of medical science today.
The author heads the National Kidney and Transplant Institute. These are excerpts from his speech read before the Board of Philippine Organ Donation and Transplantation, Office of the Secretary of Health, Manila on June 18.