A single brain-dead donor can potentially save eight lives by donating major organs: kidneys, lungs, liver, heart, pancreas and small intestine
It has been 16 years since the start of kidney transplant services in Nepal. Transplantation significantly improves outcomes and quality of life for End Stage Kidney Disease (ESKD) patients compared to dialysis. Nepal has a robust system for organ transplantation from both living and brain-dead donors. More than 50 brain deaths are said to occur per month at different hospitals in Nepal. However, various factors still hinder brain dead organ donation efforts.
Brain death is defined as the death of the brain stem, marked by irreversible damage to the receptive and responsive functions of the brain. A single brain-dead donor can potentially save eight lives by donating major organs: kidneys, lungs, liver, heart, pancreas and small intestine.
The Coordination Unit for the Brain Death Donation Programme is situated in Dudhpati, Bhaktapur, within the building of the Shahid Dharmabhakta National Transplantation Centre (SDNTC). However, it operates autonomously and allocates a kidney or liver to the person who gets the highest score.
Brain death declaration, organ donation and transplantation are emergency services requiring the staff to work 24/7, including on public holidays and festivals, without any leave. SDNTC has full-time staff dedicated to the co-ordination of living donor kidney and liver transplantation.
In Nepal, 10 kidney transplants and three liver transplants have been done from brain-dead donors, accounting for just 1.3 per cent of all transplants. Hospitals must report brain death cases to the coordination unit for potential organ donation and transplantation. Five successful brain death organ donations have occurred from Kantipur Hospital (in 2074 BS), Ganeshman Singh Memorial Hospital (in 2075), Nepal Korea Hospital (in 2075), Annapurna Neuro (in 2079), and Madhyapur Hospital (in 2079).
The Brain Death Coordination Unit has also received brain death notifications from Blue Cross Hospital, Patan Hospital, National Trauma Centre, Dirghayu Guru Hospital and Research Centre, Medicare Hospital, Police Hospital, Upendra Devkota Memorial Neuro Hospital, and Surkhet Provincial Hospital. Notably, major hospitals in the capital are absent from this list. Despite over 50 brain deaths occurring monthly in Nepali hospitals, the coordination unit is not being informed consistently.
Here are some examples of brain death declaration cases. A 24-year-old man from Sindhuli, who suffered a serious head injury after falling from a jeep, was declared brain dead after treatment proved unsuccessful. It was hard to explain to the family members about organ donation after brain death. With additional counselling by a social worker from Sindhuli for eight hours, the family finally agreed to donate the organ. As a result, two patients received kidney transplants from this deceased donor. In another case, the family members of a 72-year-old brain-dead patient in a hospital in Lalitpur were aware about these matters due to which the organ donation process went more smoothly.
Recently, a senior anesthesiologist in Lalitpur reported a brain death case. The coordination unit staff rushed to the hospital, and after seven hours of consultation, the nieces of the deceased agreed to donate the organs. However, the wife objected, and the donation attempt was unsuccessful. In another incident, a senior neurosurgeon from the National Trauma Centre informed the coordination unit about a brain death case resulting from a road traffic accident. The evaluation committee included a representative from the hospital management, a forensic expert and a police officer. However, the police officer lacked experience with brain death organ donation procedures, which led to delays as he took time to understand the necessary rules and regulations. This incident highlights how lack of knowledge among the stakeholders can delay brain death declaration and organ donation, often making organ retrieval impossible from unstable brain-dead.
Over the past seven years, counseling families of brain-dead patients has been our primary challenge. Convincing grieving relatives to donate organs is difficult, and the hospital management sometimes rejects the process even when families consent. Key barriers thus include limited public awareness, religious beliefs, infrastructure gaps and family consent difficulties.
Raising public awareness is crucial for organ donation from the brain dead. SDNTC has led various campaigns, including walk-a-thons, health camps, football matches, interaction programmes, workshops and conferences. Despite legal requirements, many hospitals are unaware of the need to inform the coordination unit about brain deaths, so the unit conducts weekly promotion programmes in hospitals. Introducing organ donation and transplantation into the 9th or 10th-grade health education curriculum is in progress. Discussion with transport ministers indicates that a law is needed to include organ donation in driver's license applications.
Providing facilities, relief packages, treatment and travel expenses, and insurance for families of brain-dead donors can enhance the programme. The Centre offers Rs 50,000 to the donor hospital and Rs 100,000 to the donor families. The programme could be more effective if family members received partial or complete health insurance and if support such as scholarships was provided to the donor's children.
With active support from all sectors, 80 per cent of all transplants in Nepal could come from organ donation after brain death, similar to other Western countries. We are open to discussion to ease the process and make it widely available, ensuring no Nepali dies due to a lack of organs. Nepal could become self-sufficient in organ transplantation.
Dr Shrestha is a senior kidney and liver transplant surgeon at the SDNTC, Bhaktapur
