Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper.

Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries. In India, majority of deceased donations happen following brain death (BD). While existing legislation allows for DCDD, there have been only few reports of kidney transplantation following DCDD from India. This document, prepared by a multidisciplinary group of experts, reviews international best practices in DCDD and outlines the path for DCDD in India. Ethical, medical, legal, economic, procedural, and logistic challenges unique to India have been addressed. The practice of withdrawal of life-sustaining treatment (WLST) in India, laid down by the Supreme Court of India, is time-consuming, possible only in patients in a permanent vegetative state, and too cumbersome for day-to-day practice. In patients where continued medical care is futile, the procedure for WLST is described. In controlled DCDD (category-III), decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Families that are inclined toward organ donation are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. In donation following neurologic determination of death (DNDD), if cardiac arrest occurs during the process of BD declaration, the protocol for DCDD category-IV has been described in detail. In DCDD category-V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the ICU. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and techniques, such as normothermic regional perfusion (nRP) and ex vivo machine perfusion, has been provided. The outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for successful execution of DCDD in India are described. How to cite this article: Seth AK, Mohanka R, Navin S, Gokhale AGK, Sharma A, Kumar A, et al. Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper. Indian J Crit Care Med 2022;26(4):421-438.

Organ commercialism, trafficking and transplant tourism.

The gap between demand and supply of organs continues to widen worldwide, encouraging transplant commercialism. While solid organ commerce is most prevalent in impoverished countries, commercialisation of body parts such as tissues is prevalent in economically developed countries. A number of international legal instruments and transplant societies define, condemn, and criminalise these practices and have issued statements related to organ commercialism. In contrast, limited attention has been paid to illicit and unethical activities associated with the procurement and clinical use of tissues. In India, The Transplantation of Human Organs (Amendment) Act, 2011, has taken multiple measures to combat organ and tissue commerce and as a result the number of such instances seems to be on the decline. However, the fight against unethical organ procurement through the internet and the social media is challenging and requires the cooperation of global bodies. Keywords: Organ trade, Declaration of Istanbul, tissue commerce, organ transplants, transplant tourism.

Heart transplantation in India-looking back as we celebrate 25 years of the transplant law.

India's heart transplantation programme is the number one programme in South Asia with an average heart transplantation rate of 0.2 per million population (pmp) versus the global average of 1.06 pmp (2016-2018). The deceased donation rate was 0.67 pmp in India in 2018. The law which made it possible has completed 25 years. In the first 5 years, after the law was passed, less than 50 hearts had been transplanted. The foundation for the deceased donation programme was laid through the creation of an 'Organ Sharing Network' in the year 2000 by Multi Organ Harvesting Aid Network (MOHAN) Foundation, a non-governmental organisation in Chennai. The role of the Health Department of Tamil Nadu in streamlining the deceased donation process in 2008-2009 changed the course of the programme. The heart transplantation programme evolved due to a handful of committed hospitals from the private sector. The challenge was in the identification and certification of brain death, and this continues to be the main reason for the low donation rate. The referral government hospitals, which usually receive traumatic head injuries that result in brain death, seldom possess the infrastructure or financial autonomy to start a transplant programme. Hence, expensive transplants like heart and liver have catered to the needs of the economically affordable class mostly. To improve the donation rate will require innovative thinking by taking steps such as strengthening the national programme and creating cross-subsidy formulas in organ sharing so that the less affordable too have access to such surgeries. To showcase the success of the programme, it is also imperative to start a heart transplant outcome registry to study the short- and long-term outcomes.