THE DEBATE  ON ALLOCATION

 The two problems that eternally confront cadaver transplantation surgery are availability of organs and how those organs should be allocated-should it be to the person who has waited the longest, the persons who is sickest, the youngest or the oldest? Should it be region, state or country wide allocation – in that order or the reverse? The questions are endless but what emerges is a need to have discussions, frame ground rules and establish criteria for allocation. The cadaver programme in India is still in its infancy. But as the programme grows and if organs are not to be wasted, it will become necessary for the organs to be shared between the different transplantation centres in our country. And that would mean establishing extremely clear allocation criteria.

ALLOCATION SCENCE IN THE UK

According to Mr. C. J. Rudge, Consultant Transplant Surgeon in UK even though cadaveric renal transplantation has been done in the United Kingdom for well over three decades there are still major problems - problems that limit the supply of such organs and lead to difficulties in determining the most appropriate method for allocation of the kidneys that are available. The allocation of organs is governed by two primary aims which to some extent are mutually incompatible.

Firstly, to maximise the outcome achieved from every single kidney that is transplanted. It has been show that only three categories of HLA matching can influence transplant survival. If there is 0 HLA mismatches the best result are achieved. Intermediate results are found with 1 HLA A locus mismatch, or 1HLA B locus mismatch, or 1HLA + 1 HLA B mismatch. All other degrees of HLA matching are associated with somewhat inferior results, the actual degree of mismatching being non- significant. These three groups are called “0 mismatch “, "favourable match" and "the rest" respectively and give one year graft survival of 88%, 83% and 79%. Under a new National Kidneys Sharing Scheme agreed by all transplant units in the UK and brought into effect on July 1^st 1998, both kidneys from a donor are offered nationally if there are from a donor  are “0 mismatch” patients available. If not, one kidney offered nationally for a “favourable match” recipient, the other is used by the local transplant unit that retrieved the kidney. If there are no “0 mismatch” or "favourable match" patients, both kidneys are used locally and allocated according to local criteria.

The second aim is to try, as far as possible, to give every patient waiting for transplant an equal opportunity of receiving a kidney, and to take into account a number of other factors. A points based system has been developed that is used when two or more patients are equally matched for a given kidney, and can be used as the basis for local allocation if there are no “0 mismatch” or “favourable match” patients. The system benefits patients who have been waiting longer, have more uncommon tissue types, are younger and are closer in age to the donor; several other factors are also taken into account.

ALLOCATION DEBATE IN USA

In the U.S.A., there is a big debate on as the government wants a new system for allocating donated organs. Right now, when an organ becomes available, it is offered first to the neediest person in one of 63 local regions. If no one in the area qualifies, then it is offered to one of the 11 multistate regions. If still unclaimed, the organ is finally offered to the rest of the nation. The new regulation proposes that the organ be allocated to the sickest person in the whole country, first. Those who want the new rule implemented say that the inefficiencies of the old regulation cost as many as 300 lives each year. Opponents of the new rule say that the system could drive up costs. Sicker patients require expensive follow - up care than average patients do, and they have a lower overall chance of survival. And so the debate goes on.

A BEGINNING IN INDA

What is the scene in India? FORTE, Foundation for Organ Retrieval and Transplant Education a registered Trust based in Bangalore had a Workshop on November 21^st &22^nd 1998 on “Organ Procurement and Co-ordinating Organisations”. The workshop was co-ordinated by Mrs. Rebecca Thomas, Hon.Secy of FORTE. Various issues were discussed at the workshop – brain death, grief counselling, donor motivation, the need for non-hospital based organ procurement organisations, awareness programmes and of course allocation. What emerged from the discussions was the need to have a larger donor pool so that there are more chances of a match and less wastage of organs. Organ sharing is the key and if it is to be a nationwide programme the government also needs to get involved.

Hospitals in Chennai have already been sharing organs in an informal way when the retrieving hospital did not have a suitable recipient. Now, the hospitals in Bangalore recognised under the “THO” Act have decided to share organs as per previously agreed allocation criteria. Right now, the allocation criteria framed  for kidneys only are based on “maximum survival of the transplanted organ for the most worthy amongst waiting recipients." A points based system similar to that being followed abroad has been evolved by FORTE, details of which are given below:

1. IMMUNOLOGICAL 

6    AG match                    50        High   PRA                  10

5    AG match                    40        ABO Identical               5

4    AG match                    30     

3    AG match                    20                                          

2    AG match                    15        Maximum                    65       

2. PERIOD OF WAITING                   

< 2 months                   0          2-6 months                   5

 6-12 months                   10          Add per year                 5

                                                    Maximum                    20

3. LOCATION OF RECIPENT (Dialysis Unit)

Within city                     5          within state                  0

 Outside state               -5          maximum                   5  

 4. AGE GROUP

0-4                                0          5-9                               5

10-49                           10          50-50                           0

> 60                             -5          maximum                    10

A beginning has been made but one has to tread carefully. And as Mr. Rudge put it, “Cadaveric organs are a national resources – the transplant community has a responsibility to the nation at large and to the donor’s family in particular to ensure that the organs are allocated fairly, equitably and in a manner that maximises the potential benefits.”