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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA–AFRICA  
Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1441-1449
Organ donation for transplantation in Bangladesh


The Center for Heritage Education Bangladesh, Savar, Dhaka, Bangladesh

Click here for correspondence address and email

Date of Web Publication4-May-2022
 

   Abstract 


Organ transplantation is a treatment of modern medicine and technology that saves the lives of hundreds and thousands of medically suitable end-stage organ failure patients. The first successful kidney transplantation from living-related donors in Bangladesh was successfully performed in 1982 and regularly from 1988. This was then followed by deceased cornea in 1984, and liver and bone marrow from living-related donors in 2010 and 2014 respectively. The Human Organ Transplantation Act was first passed by the parliament of Bangladesh in1999, allowing both brain death donation and living-related donor transplantations. Before the legislation of 1999, religious approval (fatwa) from religious leaders was obtained that acknowledged brain death donation and allowed deceased donation for transplantations. The existing act was revised in January 2018. From 1982 to 2017, only 1791 kidney, six liver, and 25 bone marrow transplantations were carried out from living-related donors. Deceased transplantations have not been started yet in Bangladesh. Only 5500 deceased corneas have been used for transplantation purposes. There are long-standing concerns about the lack of transplantation of the vital organs from deceased donors in Bangladesh and its impact on the increasing demand for procuring organs from living donor. On the other hand, living-related donors are very scarce. Numerous vital organ failure patients are often forced to buy organs from poor people. It creates an illegal and unethical market in human organs in Bangladesh.

How to cite this article:
Siraj MS. Organ donation for transplantation in Bangladesh. Saudi J Kidney Dis Transpl 2021;32:1441-9

How to cite this URL:
Siraj MS. Organ donation for transplantation in Bangladesh. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 25];32:1441-9. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1441/344765



   Introduction Top


Bangladesh, as a country, gained independence in 1971. Bangladesh (147,570 km2 of land area) is bordered by India to the west, north and east, and shares a small border with Myanmar in the southeastern hilly areas of the country.[1] Bangladesh is the 8th most populous (164 million) and 10th most densely populated country (1116/km2) in the world. Muslims account for 89%, Hindus for 10%, and other religions such as Buddhists and Christians make up the remaining 1%. Nearly 65% of the population still lives in rural areas of Bangladesh. Like many other countries, organ transplantation in Bangladesh is largely guided by socio-cultural and economic characteristics. Organ transplantation care in Bangladesh has steadily developed, but is still in its primary stage.[2],[3] Providing care to an end-stage organ failure patient is still a less emphasized area for the country of Bangladesh. The per capita Gross Domestic Product (GDP) of the national budget has increased in recent years (from US$ 27% in 2012 to US$ 37% in 2015) but the government only spends less than 3% of its GDP on the health sector.[4] Article 19(2) of the Bangladeshi constitution states that “the state shall adopt effective measures to remove social and economic inequality between men and women and to ensure the equitable distribution of wealth among citizens and of opportunities to attain a uniform level of economic development throughout the republic.”[5] The government is constitutionally committed to providing basic healthcare services and medical requirements to its people (article 15).[5] The government thus uses most of the healthcare budget for priority areas in healthcare including the provision of clean drinking water, sanitation, population control, prevention of communicable and infectious diseases, and family planning.[6]

Bangladesh’s healthcare system is hierarchically structured, top to bottom. At the top, the Ministry of Health and Family Welfare is positioned and offers policy suggestions for the two directorates of health services and family planning. Upon receiving policy suggestions, the Directorate General of Health Services and Directorate General of Family Planning implement such policies through hospitals and healthcare institutes throughout the country. The healthcare service delivery system is top-down, starting from national to district, sub-district and finally union and ward levels. This system provides promotive, preventive and curative care for outdoor and indoor patients at different levels including primary, secondary and tertiary.[6] Primary healthcare services are usually provided by the sub-district-, union- and ward-level hospitals and clinics in rural areas; secondary services by district hospitals, and secondary and mostly tertiary level services are provided by hospitals and institutes located at divisional and in capital cities. Besides, publicly funded medical college hospitals and institutes provide healthcare services. However, the government hospitals and clinics always remain over-crowded as most of the treatment, drugs, and medications are supposed to be provided free of charge or at minimal charges whereas privately funded hospitals are costly, aiming to provide treatment for the affluent sections of the country and are unaffordable for the vast majority. Due to the limited resources, tertiary-level healthcare service such as organ transplantation still does not rank as a top priority for the Bangladeshi government. In 2015, the World Bank declared Bangladesh as a lower-middle-income country, aspiring to be a middle-income country by its 50th independence anniversary in 2021. The World Bank’s Country Partnership Framework (2016–2020) continually supports Bangladesh to achieve the vision of reaching its middle-income status by its golden jubilee in 2021. The annual per capita GDP has significantly increased and it was US$ 1698 in 2018. The government is expected to allocate the required funds and resources to healthcare,[7] especially organ transplantation in Bangladesh. However, this review presents a unique summary of organ donation for transplantation in Bangladesh and explores the obstacles that hinder establishing an organ transplantation program in the country.


   Organ-related Diseases Top


The exact incidence and prevalence rate of end-stage organ failure is unknown because there is still no national registry in Bangladesh. The prevalence rate of chronic kidney disease is 18 million.[8] The incidence and prevalence rate is probably much higher than that reported by different sources as there is no comprehensive study or reliable data. Around 20 million people currently suffer from kidney diseases and another half-million are suffering from corneal diseases.[9] Of the 20 million kidney disease patients, nearly one million face end-stage kidney failure while 400,000 die annually due to failure to receive dialysis or transplants.[10] Around 18 million people are suffering from hepatitis B and C - the leading causes of liver failure, five million from diabetes, and another half-million are suffering from rheumatic heart disease.[11] Fifty-four kidney patients die each day, due to failing to receive transplants in Bangladesh[12] while approximately 22 patients die every day awaiting a transplant in the US[13] and 16 in European countries.[14] An estimate suggests that only 130 vital kidney failure patients can obtain organs compared to an estimated demand of 5000 annually.[2]


   Resources and Infrastructure in Organ Transplantation Care Top


The development of human organ transplantation in Bangladesh is relatively new.[11] The Department of Nephrology was first created in 1973, while the Department of Urology was first established as recently as 1981 (Bangladesh Renal Association and International Society of Nephrology, 1999). There are few public and private hospitals in Bangladesh which have the setup for organ transplantation services. Bangabandhu Sheikh Mujib Medical University (BSMMU), the National Institute of Kidney Diseases and Urology (NIKDU), Dhaka Medical College Hospital (DMCH), and Chittagong Medical College Hospital (CMCH) are the government centers for transplantation whereas the Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Kidney Foundation Hospital (KFH), Center for Kidney Disease and Urology Hospital (CKDUH), Apollo Hospital Dhaka, Lab Aid Specialized Hospital, Anwar Khan Modern Hospital, IbnSina Hospital, Japan-Bangladesh Friendship Hospital, Popular Medical College and Hospital (PMCH) and United Hospital have transplantation services in private settings within the country. The Combined Military Hospital (CMH), Dhaka has recently started transplantation services in public settings. Among the private hospitals, the KFH and CKDUH offer dialysis and transplantation services at low cost. From 1982 to 2003, there was only one kidney transplantation center but now there are 10 centers performing transplantations across the country.[15]

The cost of transplantations in private hospitals is much higher than in public hospitals. Transplantation surgery and post-operative care for two weeks in public hospitals such as BSMMU and NIKDU costs nearly US$ 2500 but it ranges between approximately US$ 4000 and US$ 8000 in private hospitals.[15] In addition to this, private hospitals also charge extra fees for medications. The cost for transplantation surgery in the Kidney Foundation Hospital is comparatively lower than the other private hospitals at about US$ 3000).[7] Public hospitals are always overcrowded; poor people are often denied access to receiving transplantation services. On the other hand, organ transplantation in privately funded hospitals is costly; most people do not have access to these services in the country. Only a few public officials have health insurance and a few in private settings.[16] The majority of people in Bangladesh still live in rural areas; they are also unable to pay higher costs for transplantations. Only a few people can afford the high costs of organ transplantation. As a result, many poor organ failure patients are unable to pay these charges and they finally die without receiving organ care.

Organ transplantation care and its services are remarkably inadequate for the vast number of organ failure patients. At present, only 200 nephrologists and nearly 100 urologists are available in the whole country of Bangladesh and only a few of them can do transplantations among the 100 urologists and the vast majority (70%) of them work in public hospitals and institutes.[15],[16]


   Living Organ Donation for Transplantation Top


The first successful living-related kidney transplantation was performed at the then Institute of Postgraduate Medicine and Research (now Bangabandhu Sheikh Mujib Medical University) in October 1982. However, regular kidney transplantations from living-related donors in this hospital have been continuing since 1988. Most organs, especially kidneys, are transplanted in CKDUH, BSMMU, BIRDEM, and KFH. Only very few kidneys are transplanted yearly at the publicly funded institute, NIKDU. From 1982 to 1988, kidney trans-plantations were almost stopped due to the increasing organ business. From 1988 to 2000, a total of 458 renal transplantations were performed of which 280 were for males and 178 were for females. Of them, 280 patients (64%) received living related and 178 patients (36%) received living unrelated donor organs and all living unrelated donor transplantations except spousal donors were performed abroad.[17] The sale of living organs in hidden markets thrives in Bangladesh as there was no law in the early years of organ transplantations. In order to curb organ trade, the Human Organ Transplantation Act (HOTA, 1999) was first passed by the parliament of Bangladesh and published in a Gazette on April 13, 1999. This act applied to the removal of organs both from deceased and living donors for transplantations. It approved the removal of organs, not only the kidney, heart, liver, pancreas, bone, asthimajja, eye, skin, and tissue, but also any other organs or parts of the body which are transplantable (section-2a). Before the legislation of 1999, a fatwa (religious approval) was obtained from religious leaders in Bangladesh that recognized both living and brain death criteria and allowed living persons and brain death donors to donate organs for transplantations.

According to the 1999 Act, a close relative can only donate his/her organs to save the lives of other close relatives. These include first- and second-degree blood relatives and spouses only. The first-degree blood relatives are the father, mother, adult brother and sister, and adult son and daughter, the second-degree relatives by blood are uncles and aunts from the paternal and maternal sides. Spouses include husbands and wives. Apart from these close relatives, nobody was allowed to donate organs legally. In January 2018, a few stipulations of the existing act were revised and approved by the government. The Act which was revised in 2018 redefines the term “close relatives” and adds third-degree blood relatives as potential donors in addition to the existing donors. Third-degree blood relatives are the grandparents, grandchildren, and first cousins. The stipulation of the new act also adds that anybody can donate their bone marrow and cornea to anyone else but other organs or body parts are to be donated only among the close relatives listed in the donors list in the act. This act does not allow the selling of organs or receiving financial benefits for exchanging organs. It also completely bans advertisements for the purpose of selling organs (section 9).

After the 35 years of initiation of organ transplantations (1982–2017), a total of 1791 kidneys had been transplanted in Bangladesh [Figure 1].[18] Among these kidneys, 520 were transplanted at CKDU, 515 at BSMMU, 425 at Kidney Foundation, 127 at BIRDEM, 80 at PMCH, 39 at United Hospital, 35 at NIKDU, 15 at Apollo, four at DMCH, and 2 at CMCH. In the United States, by comparison, a total of 39,717 life-saving transplantations were performed in 2019 while 23,401 were kidneys.[19] Due to the inadequate transplantation infrastructure and facilities, organ scarcities, and high cost of transplantations, only two to three per million patients remain alive on kidney replacement therapy in Bangladesh.[20]
Figure 1: The number of kidney transplantation performed in different hospitals (1982–2017).
CMCH: Chittagong Medical College Hospital, DMCH: Dhaka Medical College Hospital, NIKDU: National Institute of Kidney Diseases and Urology, PMCH: Popular Medical College and Hospital, BIRDEM: Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, BSMMU: Bangabandhu Sheikh Mujib Medical University, CKDU: Center for Kidney Disease and Urology Hospital.


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Liver transplantations have slowly begun in recent years. The first liver was successfully transplanted on June 3, 2010, at the BIRDEM and one year later, the second successful liver transplantation was performed on August 6, 2011, at the same hospital in Bangladesh.[2] As of today, a total of six liver transplantations have been successfully performed in the country.[18] The liver transplantation has been stopped for the last few years. The first bone marrow transplantation center was inaugurated at DMCH in October 2013 and the first bone marrow transplantation was carried out successfully on March 10, 2014, at this hospital.[21] A total of 25 bone marrow transplantations from living-related donors have been successfully performed in Bangladesh.[21] Despite liver and bone marrow transplantation from live-related donors having already started in Bangladesh, kidneys are still the main transplantable organs in the country.


   Deceased Organ Donation for Transplantation Top


Deceased transplantation has a great potential in a majority Muslim society of Bangladesh, as the religious rulings (fatwa) and the HOTAs (section-5, 1999 and 2018) both allow the removal of organs from “brain death” donors for transplantations. But unfortunately, this practice is still virtually absent in the country, whereas organs from deceased donors are always considered the main source of organs in many developed countries. For example, in the United States there were almost 11,900 deceased donors in 2019 while there were only nearly 7,400 living donor transplantations in Bangladesh (UNOS). Deceased organ transplantation has even been successfully started in many Muslim majority countries such as Turkey, Saudi Arabia, and Iran.[22] Deceased donation in most developed countries is nearly 25%–30% resulting in 90% of organs for transplants coming from deceased donors.[23] As deceased organs do not fulfill the supply in light of the huge demand for transplantable organs in developed countries, living donors are thus reasonably allowed to donate organs for transplantation.[24] But the practices are robustly different in many Muslim majority societies, especially in South Asian Muslim societies such as Bangladesh and Pakistan. Although few deceased corneas have been transplanted in Bangladesh, other non-redundant organ transplants such as kidney, liver, heart, and pancreas have not been started yet. This practice is also virtually absent in Pakistan. The HOTA, 2010 of Pakistan allows deceased donors to donate organs for transplantations but the practice is still not satisfactory.[25],[26] The majority of Pakistanis have some socio-cultural misconceptions in regard to deceased transplantations.[25] Deceased transplantations have even been started in neighboring India and Sri Lanka. Although several attempts have been made to initiate a deceased organ transplantation program in Bangladesh, it has somehow failed. For example, in April 2002, Dr. Badrudozza Chowdhury, the former President of the People’s Republic of Bangladesh, inaugurated the first kidney donation bank which was intended to collect kidneys from deceased donors. However, this bank is not currently in operation.[11] With the help of a Korean transplantation team, Bangladeshi physicians are currently ready to perform deceased transplantations in BSMMU, BIRDEM, KFH, DMCH and CMH if brain death donors are thought to be available and their families are in agreement.[27]

Cornea transplantation began in Bangladesh as early as 1984.[28],[29] Sandhani National Eye Donation Society (SNEDS), a charity-based eye donation center which was established in 1977 with the initiative of DMCH medical students, has started its campaigning about posthumous eye donation in Bangladesh. Their activities include promoting posthumous eye donation as well as handling the collection, preservation, and utilization of human eyes spread out in different public medical hospitals in the country. However, around 7.5 million Bangladeshis suffer from blindness and of them, a total of 5, 26, 000 people are suffering from corneal diseases.[28] From 1984 to 2017, more than 5500 corneas from deceased donors were transplanted and currently, about 500 corneas are transplanted annually.[29] The SNEDS team generally collects corneas from voluntary deceased donors diagnosed with brain death in different hospitals. But most of the deceased corneas are collected by the 28 SNEDS team from unclaimed dead bodies.[28] A few notable Bangladeshis have donated their dead bodies but intended it to be for medical education and research purposes.[30]


   Potential Deceased Donors and Recipients Top


A total of 56,000 people have died in the 84,000 road traffic accidents that have occurred in the past 21 years in Bangladesh.[31] In recent years, an average of 6000–8000 people die annually in road accidents in Bangladesh[32] and most of them are diagnosed as having undergone brain death, which means that the country annually has approximately 4000–5500 potential deceased donors. [Figure 2] shows the annual number of deaths by road accidents in Bangladesh from 2016 to 2019. These numbers are enormous and may fulfill the needs for all organs for transplantation. On the other hand, there are about 500 ICU beds in different public hospitals of Bangladesh where an average of 20–25 critical patients are declared brain dead every day.[27] These brain dead patients would be the potential donors for transplantations and thus the lives of many end-stage organ failure patients, especially the lives of 5000 annual kidney failure patients, could be saved.
Figure 2: The number of deaths by road accidents (2016–2019).

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   Obstacles Top


The obstacles to living donations for transplantations in Bangladesh are mainly donor scarcity, the high cost of immunosuppressive drugs, frequent post-transplantation infection, lack of awareness among the people and patients, compliance with drugs, and lack of organized follow-up care.[15] Obstacles to introducing a deceased transplantation program include the lack of interest among transplantation physicians, lack of training of transplantation coordinators, lack of a proper ICU setup, and lack of mass awareness.[15] In addition there is a lack of required infrastructural facilities and resources, lack of motivation among transplant physicians and the masses, high cost of immunosuppressive drugs, and orientation regarding deceased transplantations.[6] The main obstacle to introducing a deceased transplantation program in Bangladesh, I believe, is the unwillingness of transplant physicians regarding deceased transplantations. Secondly, Bangladeshis fear disfiguring the dead body of their loved one as they perceive harming the dead body of relatives as wrongdoing and wrongdoers will be punished on the Day of Final Judgment (Quran, 14:23,43). Despite the many socio-cultural misconceptions, deceased transplantation programs have already been established in many Muslim majority countries such as Iran.[33],[34],[35],[36] Although some socio-cultural perceptions in regard to deceased donations have hindered the Iranian government to establish a successful deceased transplantation program,[37] the government has recently diverted funds from its living unrelated transplantation program to deceased transplantations.[38] Thus, the annual rate of deceased donation is found to be higher than living donations in Iran.[39] The Iranian living organ transplantation program is ethically controversial[16] but the government of Bangladesh may take lessons from the Iranian deceased transplantation program and apply reasonable and justifiable measures in introducing such program in Bangladesh.


   Conclusion and Recommendations Top


The high illiteracy rates among the poor, and unwillingness and reluctance of the government are the major problems for establishing successful organ transplantation programs in Bangladesh. As there is no national organ transplantation database in the country, establishing a national online database in the 21st century is a timely demand of the people. Organ transplantation hospitals and institutes even do not have permanent registry systems because governments as well as organ transplantation hospitals are somehow unwilling to establish a permanent registry system in the country. There is even no campaign strategy to increase mass awareness of organ donation for a transplantation program in the country. On the other hand, deceased organ transplantation programs are virtually non-existent in the country. Living donors are also not available from within families. As a result, the demand for transplantable organs outstrips supply. The families of organ failure patients, especially kidneys, want to save the life of their relatives and they are somehow forced to buy organs from poor people in hidden markets. The study concludes that starting a successful deceased organ donation program for transplantation may resolve the current scarcity of organs in the country and thereby organ business will be stopped. At the same time, organ transplantation facilities need to be available for the public. As the resources are very limited, especially in Bangladesh, this study recommends that required resources in terms of finance, manpower, infrastructure, costly medical equipment, and medications should be subsidized as many people are suffering from end-stage organ failure. Organ transplantation physicians, nurses, and coordinators should be well-trained regarding the procurement, preservation, and transplantation of human organs, especially the collection and preservation of deceased organs. More organ transplantation hospitals and units should be established and ICU facilities should be extended. A comprehensive mass awareness program regarding organ transplantation should be introduced throughout the country. People, especially those who live in rural areas, have to be aware of their socio-cultural misconceptions regarding organ donation. As a result, potential donors will be found and increase in number so that the lives of a number of end-stage organ failure patients can be saved or improved which will ensure better healthcare outcomes and protect poor people from selling their organs in hidden markets.

Conflict of interest: None declared.



 
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Correspondence Address:
Md Sanwar Siraj
The Center for Heritage Education Bangladesh, Savar, Dhaka
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.344765

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    Abstract
   Introduction
    Organ-related Di...
    Resources and In...
    Living Organ Don...
    Deceased Organ D...
    Potential Deceas...
   Obstacles
    Conclusion and R...
    References
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