RENAL DATA FROM ASIA–AFRICA
|Year : 2018 | Volume
| Issue : 5 | Page : 1181-1187
|Expanding renal transplantation organ donor pool in Nigeria
Ademola Alabi Popoola1, Timothy Olusegun Olanrewaju1, Benjamin Olusomi Bolaji2, Tajudeen Olalekan Ajiboye3
1 Department of Surgery, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Department of Anesthesia, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin, Nigeria
3 Department of Accident and Emergency Unit, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin, Nigeria
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|Date of Submission||26-Jun-2017|
|Date of Decision||14-Aug-2017|
|Date of Acceptance||14-Aug-2017|
|Date of Web Publication||26-Oct-2018|
| Abstract|| |
Kidney transplantation is the gold standard for end-stage renal disease. All over the world there are several challenges preventing sufficient organ donation to meet the growing needs of patients on the waiting list. One major challenge which is common to most countries is the shortage of organs from willing living donors. Many countries, especially, the developed countries, have devised several models of expanding their donor pools to meet the growing needs of patients on the waiting list. Nigeria, a developing country has very low kidney transplantation rate even though some progress have been made in making the procedure feasible in about a dozen hospitals in Nigeria. One very major challenge has been the shortage of donor organ supply. This paper intends to proffer suggestions on how to expand the organ donor pool in Nigeria.
|How to cite this article:|
Popoola AA, Olanrewaju TO, Bolaji BO, Ajiboye TO. Expanding renal transplantation organ donor pool in Nigeria. Saudi J Kidney Dis Transpl 2018;29:1181-7
|How to cite this URL:|
Popoola AA, Olanrewaju TO, Bolaji BO, Ajiboye TO. Expanding renal transplantation organ donor pool in Nigeria. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2018 Nov 15];29:1181-7. Available from: http://www.sjkdt.org/text.asp?2018/29/5/1181/243946
| Introduction|| |
End-stage renal disease (ESRD) is a growing burden in Nigeria. The prevalence is unknown, but hospital-based studies between 1989 and 2011 show that ESRD constitute 3.6%–8.8% of hospital admissions.,,, It mostly affects the young and productive age group, with male preponderance and people are of low socioeconomic and educational status. A recent estimate indicates that the number of patients on dialysis increased from 780 to 1500 over 10 years (2004–2014). The prevalence of CKD (of which ESRD is the 5th in its staging) in few studies in the general population ranged between 11% and 27%.,,, The management of patients with ESRD in Nigeria is a huge challenge similar to other sub-Saharan African countries which are characterized by poor health infrastructures and weak health systems. The majority of patients are poor, and they often present late to the hospital and receive suboptimal care with associated poor outcomes. The contributing factors are inadequate and inequality in the distribution of dialysis centers, few active transplant centers, the high cost of care, poor funding and inadequately trained personnel., Despite the declaration of Istanbul on organ transplantation and tourism in 2008, the practice is still actively (although covertly) practiced in Nigeria. A significant number of patients with ESRD still travel to India or Pakistan for renal transplantation with mostly paid unrelated living donors. Most of these patients’ graft survive only for months to few years. Despite all these limitations, kidney transplantation has been possible in Nigeria in many centers. In our own reckoning, shortage of transplantable organs is the main limiting factor.
Expansion of organ pool in Nigeria would involve in the initial stage, encouraging more of living donor transplantation and then later to start to explore the goldmine of deceased donor program. The following are practical suggestions on how to improve organ donor pool, some of which have contributed to the success of the transplantation programs in other countries.
| Enlightenment Campaign|| |
A renewed efforts at public enlightenment campaign about the burden of ESRD and the importance of kidney transplantation is key to expand the donor organ pool either of living or deceased. The burden of kidney failure and treatment options should be clearly stated and the emphasis on kidney transplantation as the best treatment for ESRD. Furthermore, the relative safety of organ donation and the fact that one kidney is compatible with life should be stressed. This campaign must identify key opinion leaders in the society. Nigeria is a very religious country, and religion has significant impacts on major decisions in the country. The religious leaders’ understanding and support for the program will be a major drive, as their opinions are generally respected. Hence, adherents could be encouraged to consider live donation and also enlist on the deceased donor register when it becomes available in the country. The support of the political leaders and the legislators is also key in securing government supports for the program and in enacting the enabling laws for organ transplantations including a deceased donor program.
| Improvement in Sections of the Nigerian Health Bill 2014|| |
Nigeria has a Health Bill passed in the year 2014. The law has provisions for both living and deceased donation in Part VI sections 52–56. It, however, does not provide for deceased donor register nor does it define brain death. Therefore, a need for amendments that comprehensively address the issues around the definition of death; donor consent; the role of family and surrogate decision making; age limitation for organ donation; organ trade and donor compensation; and the organ procurement model. For cadaveric organs, a law is mandatory, given the sensitivity and culture of Nigerians about death and handling of the dead. The law should also prescribe the establishment of potential donor register and registration on a national database of potential donors. The Federal Road Safety Corp (FRSC) of Nigeria revealed in the year 2012 that at least 11 people died from road traffic injuries every day. Some of these had irreversible brain injuries and died in the hospitals after several hours to few days of hospitalization. These road traffic victims who died on arrival at the hospital could also serve as potential donors with good outcomes for the recipients as studies have shown that the outcome of transplantation from circulatory death deceased donor organs is comparable with transplantation of living donor organs.
| Role of Nigerian Transplant Society|| |
There is a need for strong advocacy for organ transplantation in Nigeria. The Transplantation Association of Nigeria (TAN), although still evolving, is best placed to do this. TAN needs to push for an all-inclusive law that regulates tissue or organ procurement, transfer and administration in the country and seeks for recognition to coordinate the training of transplant personnel such as the surgeons, physicians, nurses, organ procurement officers, and transplant coordinators. The transplantation society should work relentlessly to advocate for a comprehensive legislation which should define brain death, make provisions for potential donors’ registration and support for ESRD and other organ failure patients. A good example of professional group advocacy is the one by the Nigerian Pediatric Ophthalmology and Strabismus Society which championed the reduction in childhood blindness by working with other stake-holders steadfastly to get a bill passed for the prevention of childhood blindness in Kwara State of Nigeria. The extant law for organ transplantation as it in the signed National health bill requires a lot of inputs of the association working with other stakeholders to achieve legislations that meet the need for a robust organ transplantation practice in Nigeria.
Furthermore, TAN should advocate that government tertiary health Institutions should have adequate number of intensive care unit beds, thereby laying the foundation for a deceased donor program in the country. There is also a need to create a national cadre of transplant coordinators and transplantation orientation program for intensive care physicians, who are a major force in the expansion of the deceased donor organ pool in the Spanish model. TAN must also develop a program that is based on high moral and professional standards. This program must only accommodate personnel with integrity so that the program will gain the confidence of the society. Any breech of integrity will set the program back significantly. It must be based on a high sense of sincerity and every officer that would be involved in the organ donation and allocation processes must instill confidence in the program so that the public would be motivated to register on the donor registry. Lack of sincerity and transparency on the part of operatives of the program will worsen public acceptability of organ donation and transplantation. A story of public trust betrayer in Germany, affected the transplantation rate by as much as 40%.
| Development of Regional Transplant Centers in Nigeria|| |
There are many public hospitals that are involved in kidney transplantation across the country. In some geopolitical regions (each region has 5–7 states), there are up to three centers [Table 1]. In Lagos state in the southwest region, there are two centers. Majority of these centers carry out few transplantations in a year and months apart. This is tantamount to the dissipation of limited resources and energy. The existing transplant centers in the country could be merged into regional centers. Such regional centers should be funded sufficiently by the government to have adequate facilities for transplantation. These regional centers should serve as referral centers and should be from among the already existing transplant programs with the requisite personnel. In addition, these centers must have a trauma center and a well-managed intensive care unit (ICU). These ICUs in addition to the emergency rooms of the hospital will serve as sources for deceased donors. The centers should be encouraged to commence deceased donor programs as soon as all legal issues have been sorted out. It must have a set of well-motivated ICU physicians as Delmonico et al have recognized that the ICU physicians have great roles to play. This is further corroborated by the Spanish model where one of the key points in the success of this model is the roles of ICU physicians who also serve as liaison officer for the transplant program or as transplant coordinators.
Each center must be able to carry out tissue typing and crossmatch, estimation of blood levels of immunosuppressant drugs, and renal biopsy in-house. The centers must have good dialysis centers. There would be a need for training and retraining of the staff of the regional transplant centers, and the country needs to develop a model for her transplantation program by understudying various models of countries with great successes. When these regional centers are well grounded, they could start daughter centers in other states in the regions. These regional centers should be expected to grow into training and support centers for soon to be established transplant centers in their respective zones or catchment areas.
Furthermore, there would be the need for capital investment for the procurement of laboratory equipment to enable each center to do cross-matching, viral studies, should have specialized operating theater equipment and equipment for organ perfusion, e.g. double balloon triple lumen catheters; ventilators and perfusion machines. The centers should also have skills improvement laboratories, where skills can be honed on animal models.
| Development of Deceased Donor Registration|| |
A deceased donor register is paramount to a successful deceased donor program. For a new program the “opt-in” system should be started with. Citizens should be encouraged to get listed through several public enlightenment activities. The national donor register data could be hosted on existing national data platforms such as the national drivers’ license database, national identity card database, the mobile telecommunication companies’ data base. These databases are preexisting and are accessible throughout the country. The decision as to whether to be a potential donor or not should be included in the registration for the services on these platforms. This registration should be stress-free and legalization of this decision should be worked out. In New Zealand, the applicants for driver’s license at the time of application. The applicants should mandatorily state whether they would like to be donors or not. A combination of one or two of these platforms could be used to ensure wider coverage beyond what one platform could do. Example of such is the combination of the national identity card data base, which is likely to continue to have an expanding database because of government’s decision to make it mandatory for many transactions which most citizens get involved in; and the database of the telecommunication companies. A Transplant Coordinator (TC) at a transplant center could be given access to the part of the database of the platform which deals with the prospective donor’s decision whenever the situation arises while maintaining the integrity of the primary database. The TC could source for the prospective donor’s decision from the national platform using items found on the donor as of the time of accident such as mobile phones, national ID card, automated teller machine card. Furthermore, the name of the contact of the next of kin should be retrievable from this database in porder to obtain family consent on time while the organs are still transplantable.
The patients on the waiting list should be properly registered and DNA typing of all the patients on the waiting list should be on the database which could be regional or national, and these information will be used to select the most suitable recipient for the available organs.
| Incentives to Donors|| |
Direct payment for donated organ have been admitted to be unethical worldwide and widely condemned by many countries. Although, there is a formal condemnation of payment for organs, the markets actually thrive, especially, as a significant component of transplant tourism. Unfortunately, altruistic donations have not been sufficient to take care of patients with ERSD on the waiting list. In the USA, about 17 patients died each day while waiting to be transplanted. The New York Times reported that although human organ trafficking is outlawed in nearly every country, illegal transactions in organs are widely available through vendors in countries such as China, India, Russia, and South Africa. Several of these factors such as the shortage of altruistic donation; thriving of black markets with exploitation of donors by the middlemen and the unlikelihood of the involvement of ethically minded top range professionals, in black market transplantation make the donors and recipients, the losers and the black marketers, the gainers.
The call for compensation has been strengthened by the experiences in countries that have legalized a form of donor compensation. For example, Iran has a system of legalized and regulated donor compensation and this country has reported the elimination of the transplant waiting list. Many more countries have recently legally introduced some forms of compensation or reimbursements to the donors. These countries have experienced significant expansion of the organ donor pools, examples are Saudi Arabia, Israel, and Singapore. Matas et al reported that a wait time of over five years, induces death on the waiting list of 7% annually.
In Nigeria, several forms of encouragements which could include giving recognition to potential deceased donors by a stepwise increase in the level of honor based on the number of years an individual has been on the donor register. For example, a prospective potential donor who has been listed on the donor register for a minimum of five years could have the opportunity to use rapid/fast track access during boarding at the airport and one who has been enlisted for a minimum of 10 years could have premium points when seeking employments or appointments with government agencies; or could been given tax breaks; discounted or free insurance premiums, and life insurance. Donors on the register for upward of 20 years should be nationally recognized. This could be in the medals or certificates. Furthermore, if a potential donor who has been on the register for at least 10 years comes up with organ end-stage disease, he should be given premium placement on the waiting list for transplantation. A potential donor who has been enlisted for at least 10 years, could in every 10 years of being enlisted transfer his privilege to a blood relation who is an ESRD patient on a waiting list. If the potential donor himself is assessed not to likely be in need of organ transplantation in a foreseeable future. In Nigeria, many transplantations are done abroad and are virtually all from living donors. The fact that about 200 living donor transplantation have been carried out in Nigeria means with more willing donors, the transplantation rate is likely to increase. A legalized and regulated payment to unrelated donors may increase the willingness of donors. A government agency should coordinate this and strive to eliminate unwholesome practices and ensure transparency of the transactions while confidentiality is respected. The payment to be made could be paid by the family of the organ recipients, or subsidized by the government in part or in full. The roles of middle-men should be completely eliminated. In addition to the direct payment, life and health insurance should be instituted for the live donors. The payment could also be made to the next of kin of the deceased donors or scholarship may be given to the dependants of deceased donors.
| Working with Strategic Partners|| |
The collaboration with the Federal Road Safety Corps (FRSC, https://frsc.gov.ng/) is important. The FRSC in Nigeria is responsible for driver’s license issuance so it could be involved with the donor registration as it is in New Zealand. The Corps members also serve as paramedics on Nigerian roads and are one of the bodies that are involved in the transportation of accident victims to the hospital. The collaboration will support the training of some members of the FRSC to be able to administer first aids and to transfer severely injured victims safely, including those that may have irreversible head injury to the hospital for consideration for organ donation. The Nigerian police should also be involved in this collaboration. Social activities and religious leaders are very important in this collaboration.
The success of transplantation cannot be achieved without the support and cooperation of certain partners. These include pharmaceutical companies, the Federal Road Safety Corp members, and the Nigerian Police Force. The pharmaceuticals company should be encouraged to start local production of immunosuppressant drugs to make them available, genuine and affordable, especially when the market demands increase from improved transplantation rate.
| Conclusion|| |
End stage organ failure is a global public health issue but its outlook is worse in the developing countries including Nigeria. Organ transplantation offers the best treatment option for these patients and this is well established in many developed countries, but organ availability is a global concern. Strategies to improve organ pool include incorporation of deceased donor program and provision of incentive to potential donors. Organ transplantation is generally less developed in sub-Saharan Africa, and in Nigeria. Deceased donor transplantation offers the opportunity to expand donor pools to improve transplantation rates which have been remarkably successful in many developed and some developing countries. The establishment of a deceased donor transplantation program in Nigeria and other sub-Saharan African countries will involve a comprehensive review of the existing legislations, the commitment of the government and the transplantation society, support of political, community and religious leaders and partnership with other relevant government agencies and private organizations.
Conflict of interest: None declared.
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Dr. Ademola Alabi Popoola
Department of Surgery, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin
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