Nephrologists cry foul over Govt’s circular on kidney transplant

Rita Dutta - Mumbai

Now, permission for every unrelated kidney transplant would entail the presence of a nephrologist along with donor and recipient in front of the authorisation committee of the Directorate of Medical Education and Research (DMER), the proceedings of which are to be video recorded. According to the government resolution dated 12th September, 2005, (a copy of which is with this reporter) the decision was taken in the authorisation committee meeting held on 6th September. The cost of the video-audio recording will have to be borne by the patient.

Quite obviously, the DMER circular has nephrologists up in arms. Members of Mumbai Nephrology Group, an association of over 30 Mumbai-based nephrologists, have decided to write to the chairman of DMER questioning the practicality of a nephrologist’s presence in front of the authorisation committee.

Nephrologists feel that the regulation is “unfair and demotivating” and stretching their role too far. Fumes Dr Bharat Shah, consultant nephrologist, Lilavati Hospital, “Where do we have the time to wait for hours at the authorisation committee office located at St George Hospital and go through the multiple rounds of interviews? We are here to treat patients and not to establish identities.”

After a circular last year stating to haul up neurologists and nephrologists in case of a foul play in organ transplant, the recent circular has stoked the simmering differences between nephrologists and The Maharashtra Confederation For Organ Transplantation (MCFOT), a body constituted by the government to implement the Transplantation of Human Organs Act (TOHA), 1994.

Avers Dr Jatin Kothari, consultant nephrologist and transplant physician, P D Hinduja Hospital, “Why are nephrologists being targeted, when transplant is a group activity involving transplant co-ordinator, social worker, urologist, nephrologist and anaesthesiologist?” Agrees Dr Raman Kumar Malik, senior nephrologist, Hiranandani Hospital, “Why is the government trying to make a scapegoat of us? We do send our reports to authorisation committee through the hospital committee.”

Where do we have the time to wait for hours at the authorisation committee office located at St George Hospital and go through the multiple rounds of interviews? We are here to treat patients and not to establish identities. Dr Bharat Shah Consultant Nephrologist Lilavati Hospital

Nephrologists feel the presence of a physician or a surgeon is not required in establishing the identity of the donor and the recipient in front of the authorisation committee as the local authorisation committee of the hospital verifies case papers of the donor and the recipient before sending it to authorisation committee. According to Dr Bhupendra Gandhi, consultant nephrologist, Jaslok Hospital, “It is not a difficult task to identify genuine cases of unrelated donors, as 90 per cent of kidney transplant cases are referred by nephrologists, who see relatives of the patient come to visit him during the two to three months of the patient undergoing dialysis. The rest ten per cent are referred by urologists.”

Dr Gandhi, who is also the co-ordinator of Mumbai Nephrology Group, defines the role of a nephrologist: “Our role is to identify patients who qualify for kidney transplants, check whether the donor kidney is of good quality, the donor is having normal health and over all look into the success of the transplant surgery. We can’t play legal guardians.”

Do others associated with transplant feel that nephrologists are being targeted? Reasons Dr Umesh Oza, urologist, Bombay Hospital, “Probably, nephrologists have been asked to verify as in most cases the work-up (medical examination) of the donor and recipient is done by them.” He, however, feels that government should either ask the physician or surgeon, whoever has done the work-up or call for the representative from the hospital committee. Echoes Pushpa Goel, transplant co-ordinator, P D Hinduja Hospital, “Ideally, a representative from the hospital committee should be asked to certify.”

Agrees Jyoti Nagda, secretary, Narmada Kidney Foundation, “Why is the government questioning the evaluation report sent by hospitals? It would be very difficult for nephrologists to find time to go to the authorisation committee office.”

The stringency is indubitably aimed at cleansing the malpractices that rocked kidney transplant last year. A renowned nephrologist from Bombay Hospital was also arrested for indulging in malpractices, but later released on bail.

“The proceedings will be video-taped, so that the evidence of testimony of the donor and recipient can be kept, in case the donor later claims that he was duped,” says an expert.

Are these restraints having any positive impact on the organ transplant programme? No, transplants have plunged considerably because of all these restrictions, rue nephrologists. Most hospital authorities reported a 20 to 50 per cent decline in kidney transplant in comparison with last two years. P D Hinduja Hospital, which was conducting 50 transplants every year around two years back, is conducting not more than 20 transplants a year now, revealed hospital authorities. Same with Jaslok Hospital, which has witnessed a decline of 40 transplants per year, from around 70 transplants two years back. Bombay Hospital, which was conducting more than 40 transplants per year before is now doing only around 12.

The reasons for the decline are myriad. Hospital committees have now become more stringent with the government shifting screening of related transplant to hospitals. Earlier, while hospitals had to give only medical records of the donor and the recipient, now hospitals have to look into an array of issues. “We have to do the tissue matching, check the authenticity of claims of being related through multiple interviews and consult a medico legal expert on the whole issue. Besides, with so much stringency about unrelated donor, many patients have stopped coming,” explains Dr Oza. Additionally, a major chunk of patients trickling to Mumbai hospitals from outside Mumbai have now stopped coming with the mushrooming of transplant centres in areas outside Mumbai.

The victims are patients, who have to be continued on dialysis. “Kidney transplant has many advantages over dialysis. A patient has to come for dialysis two to five times a week, but the quality of life is not as good as that of transplant. I feel miserable for patients undergoing the suffering,” mourns Dr Oza.

The MCFOT is not ready to buy the story. On conditions of anonymity, an MCFOT member, says, “Why can’t private hospitals do substantial number of transplants, when KEM hospital has done 25 kidney transplants in the last nine months, in comparison with a few cases before.” The MCFOT is miffed with nephrologists requesting to conduct “urgent transplants”. “Kidney transplant can never be urgent. A patient can always be put on dialysis in case of an emergency,” says the MCFOT member.

We are taking sufficient steps to bridge the gulf between nephrologists and MCFOT. We often sit with nephrologists to clarify their doubts. Dr Vidya Acharya Member MCFOT

The hurdles in communication between nephrologists and MCFOT was never more obvious. More often than not, MCFOT letters for nephrologists do not reach them, as they fail to get forwarded by hospital chiefs. “In many cases, nephrologists refer letters to authorisation committee, when it is meant to appropriate authority and vice versa. They do not know the difference between the two bodies,” says an insider.

Explaining the difference between the two bodies, Dr Suganthi Iyer, medico legal expert, Zonal Transplant Co-ordination Committee, (ZTCC), says, “While an appropriate authority lays down guidelines and recognises transplant centres and reviews licenses of the centres after every five years, authorisation committee gives permission to conduct transplant.” She, however, holds that nephrologists know the difference between the two terms. The MCFOT is also alarmed by the sharp decline in report from authorised organ transplant centres on related organ transplantations, after the government revised the TOHA, 1994 last year. As reported in May issue of Express Healthcare Management, the onus of screening related donors was shifted from the government to individual hospitals, whereby hospitals were asked to constitute their individual committee to screen related donors, but requested to submit the report of permission of the donor and post-operative report to the appropriate authority of the government.

“Of the 28 authorised organ retrieval and transplant centres in Maharashtra, not more than eight centres are filing their kidney transplant data. Hence, we have decided to issue circulars to chief of hospitals,” says the MCFOT member.

Previously, like the state of Gujarat, the Maharashtra government screened both related and unrelated donor. “This caused long delays, forcing us to ask hospitals do the screening,” explains the official.

Nephrologists had opposed the move then, accusing the government of shirking responsibility.

With over 1,00,000 patients with end stage renal failure requiring transplant and only three per cent receiving them, is the MCFOT taking some steps to address the roadblocks? According to Dr Vidya Acharya, member, MCFOT, “We are taking sufficient steps to bridge the gulf. We often sit with nephrologists to clarify their doubts.” To address the issue of MCFOT letters not reaching nephrologists, she said, “ Earlier, while we were sending letters meant for nephrologists to the deans, now we have decided to send them to additional municipal commissioners and municipal commissioners.”

The silver lining in all this confusions, perhaps, is the significant decline in unrelated organ transplantations. “From over 100 unrelated transplants last year, this year so far, we had only around 20. This is a healthy trend as unrelated donation spawns commercial donation and its associated malpractices,” says Dr Acharya.

rita@expresshealthcaremgmt.com