Tête-à-Tête With Dr. Priyadarshi Ranjan, Transplant Surgeon

-Madhav Bansal 1st year, IMS & SUM Hospital, Bhubaneswar

Dr. Priyadarshi Ranjan is an extraordinary Transplant Surgeon based in Chandigarh. An alumni of King George’s Medical College, Lucknow ; PGIMER Chandigarh and having done his Fellowship from the coveted John’s Hopkins Comprehensive Transplant Centre, He is reputed for his innovative and dynamic surgical capabilities and outstanding results and is also commonly perceived as the “kidney man of India”. Dr. Ranjan is currently the Chief of Urology and Kidney transplantation at Fortis Hospital, Mohali and is the founder Director of Kidney Transplantation Program in the same hospital.

He has performed Pediatric Kidney Transplant, Double or Triple Vessel Kidney Transplants, ABO Incompatible Kidney Transplant and Swap Kidney Transplant. He has been featured in the Limca Book of Records twice, once for harvesting a tumor bearing kidney and the next time for performing a Kidney Transplant Surgery on 160-kg-heavy Mr. Ruldu Singh (heaviest patient in India to successfully receive a kidney transplant). He has also been credited with performing the first twin Cadaver Kidney transplantation in the state of Punjab.

He is one of the few specialist Urological surgeons across the globe who conducts both donor and recipient surgeries himself single handedly during kidney transplant operations for his patients

(Dr. P. Ranjan in Conversation with Madhav Bansal)

1. The first organ transplant in India happened back in 1965. So how far have we reached today according to you?

In India we have made immense progress in the field of organ transplantation. It started with the kidneys, but now we have gone into heart transplant, liver transplant, skin transplant, hand transplant, cornea transplant, pancreas transplant, intestinal transplant, so there has been a lot of progress in terms of transplantation both in the medical front as well as in surgical front. The techniques & medicines have evolved as well as the results and the survival of the patient and the organ has become tremendously successful.

2. You are perceived as the ‘Kidney man of India’. What encouraged you to enter this very field of Kidney Transplantation after your MCh in Urology?

I always wanted to be a cardiac surgeon when I was at your stage of MBBS. I thought that cardiac surgeons are the most skillful, most daring and the most challenging surgeons. So in my MS, I started my preparation for cardiac surgery and then when I was posted in the CTVS unit, I came to know that Urology is the most sought after branch by all the surgery PG’s and I started preparing for it. I never thought of coming into transplant, but then Urology has two important aspects in the background, one is that it gives you a very rewarding kind of  job in which you can do a lot of endoscopic surgeries ,and secondly the scope is very high- from lower urinary tract , prostate , bladder to kidney surgeries to transplantation. During my MCh I had three months of posting in transplant surgery. We had exposure to transplant surgeries and then once I joined Sanjay Gandhi PGI, Lucknow as a faculty, from there I started picking up transplantation and developing interest in the field. Transplantation per se is a very exciting, interesting and bold branch because it needs a lot of blood vessels to be anastomosed, a lot of suture handling, so transplant gives you a kick from inside. It gives you next level satisfaction.

3. According to you does knowledge about transplantation lack among the citizens of our country? How do we motivate them? What steps can be taken to make organ donation as far-reaching a program as blood donation?

Education and public sensitization are two important steps to encourage organ donation. Basically, India is a developing country and the level of education is still not at par with the western world. Organ donation has a lot to do with the level of literacy and the sensitivity of people. We are a country with 130-135 billion being the population but still our organ donation rates are very low because people are not literate. They are not sensitized about organ donation, and they don’t know the impact of it. Their religious misbeliefs interfere like in Hindus or many other sects; they believe that if one donates his organs, he or she isn’t born with those organs in the next birth.

4. In India where does altruism stand in Organ donation?

True altruism is in which the person who is going to offer his organ as a living donor does not know who this organ is going to go to. There is no compensation in return. There is no attachment to the recipient. The only reason why he or she is donating is for his own self and to give back to the society. Altruism unfortunately is not allowed in India at this point of time. Altruistic donors are not encouraged. There have been a few incidents in which the court or the appellate court authority have given permission for this but still altruism is quite a distant concept in India. Here, we are fighting with commercialization in organ donation. We are fighting with a lot of hitches in the system, like lack of proper infrastructure for the process of organ donation. Maybe after a couple of decades altruism will become a reality, but at this point even if it does become a reality, there will be a lot of money exchange, commercialization and organ commerce which might create panic and a very wicked situation in the country. You might have seen the movie Andhadhun (laughs), so you realize how messy situations can turn up.

5. How bad is the current shortage of organs? Does this vary for different Organs?

Absolutely! We get organs hardly for 1/10th of our patients. So 90% would still die in want of an organ. It takes hardly 30 minutes to harvest a kidney laparoscopically and fortunately for us in Urology, there are 2 kidneys so the donor goes home on the third or fourth day. Vis-a-Vis other organs such as liver which is one in the body. So liver has to be split in living donor transplantation. Whereas in the transplant of pancreas, heart and intestines, these organs can only be taken post-mortem, once the patient is brain-dead. So kidney is by far the most commonly donated organ. The number of kidney transplants is close to 10,000 in our country and most of the kidney donors are living, related donors either emotionally related or genetically related. In liver transplant, there is less number of living donors, but the organ shortage is absolutely similar to kidney shortage.

6. What is the Legal framework, Issues and challenges of Living organ donation in India? Are current laws under the THOA Act succinct in regulating the process or do you think some reforms are needed? What are the organizations in India and the world that regulate organ sharing?

The Indian law, which is called the Human Organ Transplant Act of India came into existence in 1994, there have been amendments, latest taking place in 2014. The aim of the law is to prohibit any kind of organ commerce. So the law says that the loved ones such as parents, siblings, spouse, grandparents or grandchildren are the people who can donate an organ. If there is any other person who is donating the organ to a distant relative or an emotionally related person then that person has to undergo a scrutiny and an interview through a government appointed authority in which the authority will assess whether there is any kind of organ commerce or not. Based on their emotional bonding and strength the committee gives the permission that this donation is out of love and affection. So this is the current existing law.

In USA there is an organization called the United Network for Organ Sharing (UNOS) which predominantly focuses on deceased donor organ donation (Only 30% of patients in the US will have a living donor vis-a-vis India where 95-98% of the program constitutes living donors, we have a very primitive deceased organ donation program)

There is a definite waiting list, which is maintained. There has to be a very high level of transparency in maintaining that waiting list. People should not pay money to get an organ, so that is the basic function of UNOS. Similarly in India, We have got the NOTTO which stands for National Organ and tissue transplant organization.  So, NOTTO is that body which decides the distribution and sharing of organs but still there are a lot many changes which we need in the law to promote organ donation such as encouragement of swap organ donation, altruistic donation or non-directed donation. There are challenges in many fronts which need to be addressed in the current laws in organ donation.

7. What are the hurdles you face in receiving the organ on time? How successful is the Organ donation network in India?

If we talk of living donation per se, the greatest hurdle is of blood group incompatibility. So normally as for blood donation ‘AB’ is a universal recipient and ‘O’ is a universal donor.

There are a lot many patients who will have either ‘A’ blood group or ‘B’ blood group and their donors have the reverse blood group. So then technically a transplant cannot be performed. This is the greatest problem which we have. The second problem is of sensitization in which the patients develop antibodies against the organ – antibodies against a cell marker called the human leukocyte antigen (HLA). So these are called as sensitized patients and they are not able to receive a transplant despite having a living donor.

Both these problems can be very well addressed by a swap transplant program. This is an extremely good program. I’m a great proponent of a swap transplant. But the legal formalities, hurdles, clearances and permissions are too elaborate for a swap transplant. It takes practically two to three months to mature a patient into a waiting list or to get a surgery done after he registers for a swap. If we could smoothen the process by legal rules, like there are certain clauses in the law such as the requirement of NOC. Since health is a state policy, so every state has a different guideline or directive. We struggle a lot at the level of State NOCs. The elaborate paperwork is sometimes what we grapple with and many times patients lose their lives being stuck in this loop. If the system was more nationally unified a lot many patients would be able to get an organ and we would be able to extend the benefits of transplantation to a larger population.

8. What is the procedure for a person to get enlisted as a potential donor? Give us your views on whether India lacks in a uniform governing system to monitor organ procurement and transplantation.

What is the opt-out system of organ donation?

The procedure would be- the person should go to a registered transplant hospital, express the desire, get the donor card signed and then go ahead with organ donation. So he should tell his family members or the next of kin that if something, God forbid happens to him, they should donate his organs. The consent can be withdrawn by the family at any point of time. It is still not legally bound despite an expressed consent by the deceased. The decision can be vetoed.  There are so many real time hurdles, which make it practically impossible like some logistical issues, delay in performing the last rites by the family, the deceased being a resident of a remote region leading to delays, etc. Also, there are many legal, ethical as well as financial dilemmas the patient’s families have.

Either we have a law like Spain/Portugal wherein everybody is an organ donor except if he or she has opted out of the system.

So in the Opt-Out Model, anybody who dies in a road traffic accident is considered as a national property, the body of the deceased is in the hands of the law. It is not given to the next of kin. So the government will decide where the organs will go. The person will have to give the organs; there is no rule of consent of the family, until and unless that patient has opted out. You have to fill a specific form for opting out. If you opt out of that system, you are deprived of many privileges and perks from the government, so there are very less number of people who decide to opt out. So that is the basis of a very successful deceased donor program. Our country should adopt the opt-out system, but it will come with a lot of political or legislative enforcement and sensitization.

In India too, like many other nations, the mention of an organ donor should be there on the driving license as it is one of the most readily available legal documents especially when a person is subject to a road mishap.

9. What are the expenses involved in the organ procurement by the recipient? How can Transplant Surgery reach out to the ordinary man who can’t afford it?

Transplant is available both in the government sector as well as the private sector. The government sector expenses compared to private sector expenses are maybe half, so if you spend say 3 lakh Rupees in a government hospital for the transplant you will spend 6 lakhs in a private hospital. Transplant is accessible to a common man except those people who are so poor who can’t even afford immunosuppression which costs around 10,000 -15,000 Rupees a month. So one of the indications of not doing the transplant in a person is who is not able to afford these medicines. Unless the government takes up and there is some kind of health insurance for all the citizens and they are able to bear that cost then only the situation will improve. In addressing solutions to the problem of access to organ transplantation, it is important to focus on the full scope of the problem in both its pre- and post-operative aspects. In the context of organ transplantation, justice requires both equal access to organs and equal access to the medications needed to maintain those transplanted organs. The financial burdens associated with access to post-transplant medications can be significant.

10. Keeping in mind the current situation, how difficult is it to perform an organ transplant during the COVID 19 pandemic & how can it be made safer?

As COVID is a new disease, we are struggling to make transplants safe during this pandemic.  We have to keep ourselves safe as well as ensure the safety of the transplant.  We have not stopped organ transplant program during the current times of COVID – 19, but every day the level of precautions and the level of the scare involved is increasing. A lot many people are at risk and a lot of challenges are there but still we are able to do those transplants which are life-saving at this point of time. So we are tailoring our OT list in such a way, so that we do less number of patients and place those patients first in the list who are really sick and won’t survive without a transplant.

In my cohort, close to a thousand to twelve hundred patients, I haven’t seen any of the transplant patients developing COVID. The reason could be that they are put on steroids which in a way inhibits the inflammatory response. Plus, the educated transplant population is quite aware and they take all the necessary precautions. And then COVID can happen to anybody, we need to always be on a war-footing and also we can’t let unfortunate souls die waiting for a transplant because of COVID.

11. I’ve heard about the e i-Kidney app that you have launched. Tell us more about it.

This app is run pan India. Anybody across the country can register on that app. When the person has got a donor who is willing to donate but the blood group is not matching, he registers on this app free of cost. On the background, this data comes to us. So every week one of our coordinators will sit and analyze that data and start making pairs. Pairing is in terms of age similarity and the kind of region they belong to, so we try to make pairs so that they have least differences culturally, geographically as well as physically and we are able to give the benefit of a successful transplant to both the families.

12. What are the guiding lines that you follow in your profession and also, can you share some of your insights about this field for the budding transplant surgeon in the making?

As you grey your hair in surgery, you realize that we have to respect Mother Nature. Doing a transplant is hardly an hour’s job; more important is the surgical decision-making. Is the patient fit to undergo a transplant? Will I be able to achieve a successful outcome in that transplant or not? What is the best time to take this patient for a transplant? Whether at all is he going to benefit with a transplant or not?

I think a quote which I religiously follow in my practice of transplantation is to listen to Mother Nature and feel somebody else’s life.

We have to be sensitive to the feelings and the kind of pain the patients are going through.

Once we start feeling that pain, once we start putting ourselves into that situation and empathizing, many things become clear. In a lot many places Mother Nature will guide you.

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