Human Organ Transplant Act

Indian parliament in July 1994 formulated HOTA to regulate transplant activities in India. This was necessitated by acts of selling and buying organs prevalent at the time and which had brought Indian medical system into disrepute all over the world.

This act immediately came into force in Goa, Himachal Pradesh, Maharashtra and Union Territories. This had to be ratified by various states before it could be applied to the rest of the country. Some of these states took a very long time before the act was applied.

In 2014, the act has been almost totally revised. The main aim of the act is to regulate all transplant activities, provide stringent punishment to offenders indulging in organ sales and traffic, clarify the confusing points in previous act and add grandparents to the list of near relatives. It also enhanced punishment to the offenders. This act also sought to encourage cadaver donation by various means.

This law further clarified the duties of Incharge in ICUs and made it mandatory for them to apply provisions of brain death and ask relatives if they are willing for cadaver donation in case a person had not prior to his death pledged to donate his organs.

This act also included nonmedical people (from police, judiciary, teaching professions etc) to become members of the authorizing committees. These committees decide whether a willing donor in case of living donor can donate his organs. These committees are also tasked with ascertaining financial position of the donors, motivation for donating an organ and seeing that organs are not sold or bought for transplant purposes. The committees also satisfy themselves in case of spouses that the donation is voluntary and without pressure.

The act provides for periodic review of the hospitals allowed to carry out transplant activity and publish their results of transplants undertaken by these. Various states have started their websites to regulate organ allocation and maintain a list of patients awaiting organ transplant.

The success of the act will depend on how meticulously and honestly the spirit of the act influences the transplant activity in the country.

MYTHS AND FACTS ABOUT KIDNEY DISEASE

Myth : All kidney diseases are serious and incurable

Fact : Most kidney diseases are treatable. Some are self-limiting and occur only once in a lifetime. Some progress towards renal failure but this progression can be slowed down if the disease is detected early. Even in late cases, treatment may help in reversing or slowing down the loss of kidney function.

Myth : only one kidney is affected by kidney diseases.

Fact : All medical diseases (high BP, diabetes, glomerulonephritis, nephrotic syndrome, poisonings, infections of urinary tract etc) affect both kidneys.

Some structural diseases like tumours, stones, abscesses, renal artery or vein clots, ureteral narrowings, may affect only one kidney.

Myth : I am passing enough urine. Hence my kidneys are not obstructed.

Facts : Most obstructions of the bladder and partial obstructions of the ureter  (stones or accidental ligation during surgery) cause more urine to be formed and passed. Only bilateral total obstruction or obstruction below bladder neck cause reduced urine output.

Myth : I am passing enough urine. Hence my kidneys are healthy and I do not require treatment or dialysis.

Fact : Some kidney disease cause decreased urine output or oliguria (< 400 ml urine/day). Most, however, are nonoliguric or Polyuric (urine output > 3000 ml/day). Even with normal or large urine production, waste material like acids, potassium, urea, creatinine and many more may not be excreted. A person then may require treatment at times dialysis as well.

Myth : Drinking more water will keep my kidneys healthy. This is the treatment for kidney diseases.

Fact : Usual water intake is well managed by thirst in healthy people. Drinking 2-3 litres of fluid may avoid some stone formations and urinary tract infections. Continuing to drink fluids when kidneys are failing or have failed may cause fluid in the lungs (pulmonary edema) or poor control of hypertension. The consequences may be deadly. Follow your doctors’ advice.

Myth : Dialysis once started is required life long.

Fact : In temporary or reversible renal failure, dialysis is required till kidney recovers. In CKD or ESRD with no reversibility, dialysis is required for emergency treatment of high potassium or fluid in the lungs. Maintainance dialysis for uremic symptoms, neuropathy, encephalopathy, pericarditis etc usually means either lifelong dialysis or renal transplant.

Hypertension in Dialysis Patients

Hypertension in Dialysis Patients I

About ½ of dialysis patients have high BP while on regular dialysis. A pre-dialysis BP > 140/90 mm Hg is required for the diagnosis of hypertension in this group.

Mortality, cardiovascular events including heart attacks, congestive heart failure, strokes are more common in hypertensive dialysis patients.

Systolic BP < 110 mm Hg Or >160 mm Hg is also associated with poor outcome in dialysis patients. Hence the BP has to be optimised and kept somewhere between these two limits.

Causes of high BP in dialysis population:

Expansion of body water and blood volume

Reduced blood supply to kidneys

Salt accumulation

High Calcium level

Thickened arteries

Preexisting essential hypertension

Increased sympathetic nervous activity

Poor water compliance

Poor drug compliance.

BP is measured before and after dialysis. For better overall BP, 24-hour ambulatory recordings are made.

Coming up Treatment of hypertension in the dialysis population.

Immunosuppression after Kidney Transplant

Immunosuppression after Kidney Transplant

The drugs are always taken on the advice of a physician experienced in dealing with transplants. Patients should never change doses on their own. Stopping of drugs may result in acute rejection and damage to or loss of the kidney. Usually three drugs are given. These are required to be taken lifelong.

The medicines may be Tacrolimus/ cyclosporine.

Older patients of functioning transplants may be on cyclosporine. These drugs are similar and called Calcineurin inhibitors. These drugs have a no of interactions with other drugs. Simultaneous intake of other drugs may increase or decrease the levels of these drugs.

Some common side efftects of CNI inhibitors are tremors, high BP, increase in urea and creatinine( due to kidney dysfunction) , swelling of the feet and high blood sugars. These also increase chances of infections.

Cyclosporine can also increase body hair, facial hair, or hair from the ears. This is called hirsutism and may be very unpleasant side effect in ladies. The dosage of these drugs are based on their blood levels which need to be checked periodically.

Azathioprine or mycophenolate.

These drugs are the other commonly used immunosuppressives. They may decrease blood cell formation (WBCs or RBCs or platelets or all three togather. They can also increase infections in the transplant recipient. Mycophenolate may cause abdominal cramps, diarrhoea or constipation.

These are expensive drugs and the blood levels are not easily available.

The interactions are fewer with other drugs.

Steroids

This is an important component of the immunosuppressive regime.

These drugs are started at very high levels in the 1st few days and rapidly reduced.

Though very effective in its action, these drugs are full of side effects. These drugs may cause weight gain, high sugars, high BP, dyslipidemias, behavioral disorders, hirsutism, rounding of the face, muscle weakness and sleeplessness. They can also cause bone weakness and increase chances of infections as do the other transplant medicines.

The drugs are always taken under medical supervision and sudden changes or stoppage of the drug may be catastrophic.