Kidney failure is a major healthcare problem, and transplanting a new kidney is sometimes the only medical solution. Less than 10% patients with kidney failure undergo a kidney transplant with a family donor and 1% do so with a kidney from a deceased donor (someone who has died and their organs have been donated). The rest of the patients with kidney failure remain on dialysis because they do not find a deceased donor, don’t have a family donor, or the family donor that they do have is incompatible.
The deceased donation and transplantation program in our city and our country is yet to come of age and become a powerful organ resource for these patients. It is now 15 years since the inception of this program in Mumbai, and yet organs from deceased donors still form less than 10% of all transplants performed here. In the west, this forms 90% of the transplants.
Several practical hurdles cause this shortage of transplantable organs. While every attempt is being made to correct this situation, there is a need to explore other avenues to minimise this shortfall. Therein lays the role for a mathematical match-making approach as an additional avenue for a solution to this problem.
If you’ve been advised a kidney transplant by your nephrologist and are not able to go ahead because your prospective kidney donor has a blood group that does not match, then a swap transplant could be the solution for you.
ASTRA (Apex Swap Transplant Registry)
In January 2011 the Apex Swap Transplant Registry (ASTRA) was launched by the Apex Kidney Foundation. Since its inception 250 donor-recipient pairs have registered for a swap transplant.
40 kidney transplants have been completed successfully, with 10 kidney transplants in process. ASTRA leverages the principle of a database and mathematical modelling to find a solution for the problem of organ shortage. It is based on the principle of paired exchange or ‘swap’.
Kidney exchange or ‘swap’ is a simple barter system. It is a ’give and take’ deal between two pairs of people, each pair consisting of a giver and a taker, where each pair benefits by receiving a suitably matched organ. In this simple barter framework, it is possible to maximise returns exponentially when the pool is large and complex algorithms for exchange are built into it. A swap pair consists of a recipient (patient) and a donor (a family member). These pairs are such that they cannot ordinarily donate an organ to each other. This could happen because of blood group incompatibility or a tissue incompatibility. Such pairs register within the ASTRA database. ASTRA then runs an application based on a mathematical model and searches across the database for compatible pairs. It then generates simple binary donor recipient pairs or complex chain like the current domino.
What Exactly Happens During A Swap Transplant?
A Swap transplant involves an exchange of organs between two families, who cannot donate the organ to their own family member because of blood group mismatch. This is in a sense ‘paired exchange’.
This would minimize this shortfall of organs and increase transplant numbers legally. In this method there is a mechanism for organ sharing between two unrelated donor-recipient pairs.
Sheikh Family Shah Family
By doing a swap, two patients with kidney failure who in normal circumstances cannot undergo a transplant because of blood group mismatch within that family, can now go ahead with kidney transplantation.
Once there is a match, your nephrologist will be informed and your surgery will be done by your transplant team at the hospital of your choice. ASTRA will only generate compatible pairs, hand them over to the respective nephrologists and not do anything beyond this.
Swap Transplants Are Important For Certain Patients
Patients with kidney failure who have a family donor, but the blood groups are incompatible.
Patients with kidney failure who have a blood group compatible donor, but their lymphocyte cross-match is positive.
Patients with kidney failure who have a suitable donor within the family, but such a donor has tested positive for Hepatitis B or C. Such patients may enter the ASTRA to find a possible virus positive recipient so that the respective transplants can go through. Such pairs will have to however undergo mandatory liver tests to assess their liver function status as well as their suitability to give and receive a kidney.
Patients who have an elderly donor or a marginal donor with a compatible group can also register to get a donor who is better. For example – Mr Patel was on dialysis. His blood group is B. His father was a prospective donor. His blood group is O. He could have directly donated to his son, Mr Patel. But they registered for a swap transplant and get a relative young man to donate. While Mr Patel’s dad donated to someone else. This is possible if your marginal related donor’s blood group is O. Please consult your nephrologist or call us for explanation if you’re confused about the issue.
ASTRA is now 3 yrs old. Within this short period, 250 donor-recipient (D-R) units have registered within ASTRA across India and internationally. Altogether 65 transplantable pairs were matched; 40 swap transplants have been done; 10 of the others are in the process of completing formalities to undergo the transplant. There has also been an international swap generated from this database.
After two years of hard work and on the second attempt, India witnessed its first domino swap kidney transplant surgery in June 2013, made possible by ASTRA. The first attempt fell through when the chain (where only one patient-donor pairs was common), was disrupted by the death of one patient thanks to delays in getting permissions which did not come through on time. It took us 8 months to rebuild the chain. The Maharashtra government was very cooperative and five transplants were performed simultaneously. All the transplants were successful and the effort was huge. It involved the booking of 10 theatres in three hospitals and 40 senior doctors working together.
One of the patients was a roadside barber, they were of different strata and religions, and we are hopeful that the success of this will lead to many more domino kidney transplants in the future.
The exact role of ASTRA
You must understand that ASTRA is only a match-making agency. Once a patient is referred to the ASTRA, he would be registered and as soon as a possible swap match is generated by the database, this information would be conveyed to the two primary Nephrologists of the two patients. Further workup, assessment, legal formalities, organisation of the logistics of the transplant as well as the procedure of transplant would be the prerogative of these two nephrologists, in mutual consultation.
The ASTRA does not participate in the actual transplant surgery and is not liable for any of the events following the generation of the match.
What does ASTRA gain?
We gain nothing. It is a humanitarian effort. The charges to register are a nominal Rs. 200. There are no hidden costs. The more the people who register, the faster a match may happen.
The idea is to increase the number of living donor transplants successfully and legally. Our reward is the smile on the faces of those who have been given a new chance at life through ASTRA.
The author can be reached at firstname.lastname@example.org or at 09029938711