Comment – Bold Policy Changes Are Needed to Meet the Need for Organ Transplantation in India

To the Editor: We read with interest the authors’ viewpoints1Shroff S, Gill JS. Bold policy changes are needed to meet the need for organ transplantation in India. Am J Transplant. 2021. https://doi.org/10.1111/ajt.16537.Google Scholar on what ails deceased donor transplantation (DDT) programs in India and their proposed solutions. We present our perspective on how living donor transplantation (LDT) programs service an unmet need in India, and suggest the way forward for DDT. The authors’ connotation that profit-driven impetus drives the growth of “revenue-generating private LDT centers,” and covertly discourages deceased donor transplants (DDT) is misleading. In this context, the cost of liver transplantation (LT) is overstated. At MILTRM, adult and pediatric LDLT cost 30 000, and 24 000 USD, respectively, and not 50 000 USD. The charges at other comparable world-class private hospitals, are similar; and in fact, a fifth to a tenth of that in Europe and the USA. LDT centers in India have made an invaluable contribution in saving lives, furthering innovation, excellence, training and research, and have put India on the global transplant map. The key reasons why DDT programs remain underdeveloped pan-India are socio-cultural impediments, significant regional variations in deceased-donor(DD) activity, inadequate state-backed awareness programs, and lack of enforcement of mandatory brain death declaration and required request. The service element at private hospitals is also under-recognized in the index paper. Of all LTs at our center, 20% (110 of 550 from 2018 to 2021) are not-for-profit for government-funded patients at 20 000 USD. Thirty-four of our last 100 pediatric LT were subsidized/funded by social initiatives. Clearly, families availing transplants in any of the above categories are not “rich.” We and other private hospitals leverage the expertise acquired in living donor liver transplantation (LDLT) in training government hospital transplant professionals and supporting their LDT and DDT programs. Twenty-two public hospital doctors received LT fellowship training at MILTRM over the past 5 years. We also support the LT program at AIIMS, Delhi (public hospital). Performing LDT in foreign patients with related donors from their own country, is not unjust. Further, foreigners do not deprive Indians of DD organs, which are only allocated to them if they cannot be placed for Indian recipients. In Tamil Nadu, in 2019, only 2/60 hearts, 3/48 lungs, and no livers or kidneys were allocated to foreigners.2TRANSTAN: Transplant Authority Government of Tamil Nadu, Government of Tamil Nadu. Statistics. https://transtan.tn.gov.in/statistics.php. Accessed June 25, 2021.Google Scholar Heart and lung transplant expertise is scarce, these teams have to be lauded, not castigated, for humanitarian efforts. NOTTO or its regional body places all DD organs,3NOTTO: National Organ & Tissue Transplant Organisation. https://notto.gov.in. Accessed June 25, 2021.Google Scholar and maintains a strict regulatory vigil on all transplants. We disagree with the narrative that, in India, the poor donate to the rich. This perspective is unfair to several internationally renowned institutions here and is not borne out by real-world data: 92.8% of DD in 2020 in Tamil Nadu2TRANSTAN: Transplant Authority Government of Tamil Nadu, Government of Tamil Nadu. Statistics. https://transtan.tn.gov.in/statistics.php. Accessed June 25, 2021.Google Scholar and 100% in 2019 in Mumbai (SK Mathur, President, Zonal Transplant Coordination Committee, personal communication, 2021)4Zonal Transplant Coordination Committee. Zonal Transplant Coordination. Cadaver organ donation details. https://www.ztccmumbai.org/data1.html. Accessed June 25, 2021.Google Scholar were at private hospitals. If private hospitals provide free transplants to the poor in exchange for more DD organs, it would tantamount to purchasing organs! Such allocation criteria are unethical. What is true is that the government must allocate more funds for transplantation, training, incentivizing faculty and DD awareness activities, as well as enforce brain death audits. This will improve DD rates and help build sustainable public transplant programs. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. AS Soin: Data analysis and interpretation, Drafting and final approval of the version to be published. R J Chaudhary: Data acquisition, drafting. A Rastogi, P Bhangui, A Gupta, K Yadav: Critical analysis. Data openly available as mentioned in references.