Kidney-paired donation to increase living donor kidney transplantation in India: Guidelines of Indian Society of Organ Transplantation – 2017
This month’s guest blog post is written by Dr. Vishwanath Billa, a Nephrologist and Transplant Physician at the Bombay Hospital Institute of Medical Sciences, Mumbai and a Professor of Nephrology at the Maharashtra University of Health Sciences. Dr. Billa is one of the authors of the Kidney Paired Donation Guidelines of Indian Society of Organ Transplantation – 2017, published in January 2018.
The release of the Kidney Paired Donation (KPD) guidelines by the Indian Society of Nephrologyearly this year is a significant step forward by the Society to formalize an activity that has been occurring in a limited and localized fashion across the country. These guidelines encourage this activity to become a comprehensive and coordinated national effort. The ability of paired kidney exchanges to provide quick transplant opportunities to easy to match pairs, as well as an alternate option for difficult to match kidneys has already been recognized.
While the guidelines have laid down the ground rules for this activity, understanding the concept and its implementation needs more than just ground rules. A paired kidney exchange program can be most successful when it functions as a single large database. The more the number of pairs in the registry, more are the opportunities for the pairs. This would mean that the multiple small such registries across the country need to merge into a single national database. From this centralized structure, there can be regional pairing as defined by patient geographies.
When the registry functions in this fashion and generates compatible pairs, my personal view is that donors should travel rather than the kidneys whenever a paired exchange takes place. Any step that can protect the function of the transplanted kidney in such an activity has to be adopted and adding the element of cold ischemia to a precious transplant does not add appeal.
The working of such a national registry has to reassure the Nephrology community that each of their registered pairs, when matched, would be transplanted by the registering Nephrologist alone. Involvement of the Nephrologists to register their incompatible donor- recipient pairs into the national registry would be effective only when they are convinced that by doing so they retain the opportunity to perform the transplant on their respective patients whenever matched.
The process of approval of paired kidney exchange transplants involves screening at the local hospitals followed by an interview by the Authorization committee. The process could get complicated when there is a long chain domino exchange planned or when the two pairs are registered at two distant centers. The insistence of the Authorization committee to individually interview each of the members of such an exchange poses huge logistic challenges. There is a need to evolve a procedure to address this challenge.
While manual allocation works when the size of the registry is small, it is imperative that a single national database needs to run on a computerized algorithm. Elimination of bias, assuring the best match to the patient, and quick matching are the tangible benefits of this approach. While the science of matching is standardized across the world, the philosophy of matching would vary from country to country based upon local laws, local culture, local economy and size of the country. There is a need to develop a local algorithm incorporating all these elements for a specific country.
For Nephrologists, there needs to be regulation (self or external) into choosing kidney paired donation over ABO incompatible transplants, especially for easy to match blood groups.
Dr. Vishwanath Billa,
Bombay Hospital and Medical Research Centre, Mumbai.