Annual SAARC Oration 2024 A reflection of efforts to enhance the renal donor pool in Sri Lanka

Dr Seneviratne (right) with Dr. S. M. M Niyas, President - Sri Lanka College of Surgeons (middle) and Prof. Sunil Kumar Sharma Dhakal, President - SAARC Surgical Care Society (left)

Dr. Seneviratne delivering the annual SAARC Oration
Pixs by Kithsiri De Mel

Unlike dialysis, it is clear that kidney transplantation is the superior treatment option for kidney failure as it offers patients a significantly improved quality of life and better long- term survival.

 

Chronic Kidney Disease (CKD) has emerged as one of the leading health burdens in Sri Lanka, now recognised as a national epidemic. Given the multitude of prevailing communicable and non-communicable risk factors, it is estimated that approximately 150,000 patients are currently affected by CKD in the country. However,  due to poorly validated epidemiological data, lack of community-based studies and the use of non-standard ethics to collect data related to CKD, the actual number of patients may be significantly higher. Delivering the annual SAARC Oration organised by the Sri Lanka College of Surgeons in collaboration with the SAARC Surgical Care Society, Consultant Urologist, Transplant Surgeon and Clinical Lead – Department of Urology and Transplant at Sri Jayawardenepura General Hospital Dr. Lasantha Niroshan Seneviratne shed light on how the renal donor pool in a lower middle-income country like Sri Lanka could be enhanced.  

End-stage kidney disease and CKDu

Patients suffering from end-stage kidney disease can only survive with either dialysis or kidney transplantation. “Kidney transplantation can be facilitated through organs obtained by either living or deceased donors. In Sri Lanka, the only available form of deceased donor kidney transplantation is from brain-dead donors. In contrast, in many Western countries, donation after cardiac death is permitted following unsuccessful resuscitation efforts after cardiac arrest or as a part of end-of-life care under the withdrawal of life-sustaining treatment. Unfortunately, such practices have not yet been legalised in Sri Lanka. Unlike dialysis, it is clear that kidney transplantation is the superior treatment option for kidney failure as it offers patients a significantly improved quality of life and better long- term survival. Seventy years ago, a historic milestone was achieved with the first successful kidney transplant surgery, marking the beginning of a transformative era for individuals suffering from multi-organ failure,” Dr. Seneviratne said. 
Given the rapid environmental changes, it is not surprising that an estimated 6,000 patients suffer from end-stage kidney disease. Speaking further, Dr. Seneviratne said that from a global perspective, diabetes, hypertension and globular nephritis are the common etiological factors contributing to end-stage kidney disease in various regions in Sri Lanka. “In certain areas with a dominance of agricultural communities, endemic interstitial nephritis prevails. This condition known as Chronic Kidney Disease of unknown etiology (CKDu) has become a major health burden in specific rural populations. This form of CKDu has been observed in several other lower-middle-income countries and regions like Andra Pradesh in India, Egypt and Meso-America. However, this variant of disease is now emerging in various parts of the world as well.”

Economic burden of CKD

The management of CKD patients places a significant burden on Sri Lanka’s economic development. Dr. Seneviratne further said that the current annual allocation for the health budget, which is only 2% of the GDP is grossly inadequate. Sri Lanka provides free healthcare services to all citizens including dialysis and transplantation at public hospitals. However, patients seeking treatment at the private sector or Sri Jayawardenepura General Hospital must cover the cost of dialysis and transplantation. To assist low-income patients the government offers some support through the President’s Fund. The cost of donor transplantation at our hospital is around USD 3,000 which is significantly lower than the private sector. For patients who require dialysis thrice a week, the annual cost can be USD 5,300. Consequently, renal transplantation emerges as a more cost-effective solution for patients with end-stage renal disease in a low-income country like Sri Lanka. Additionally, long-term costs associated with maintaining a functioning graft are generally low, but the limited availability of dialysis in our country poses one of the greatest challenges in managing kidney disease which arises not only from shortage of dialysis machines and peritoneal dialysis fluid but also due to a lack of trained nurses and doctors. While dialysis is expensive and inaccessible to many patients, it can also place a significant financial burden on the country’s economy.” 

Unavailability of specialists

Sri Lanka experienced a major brain-drain, where many professionals left the country seeking greener pastures at the height of the economic crisis. What resulted is a dearth of specialists creating a void within the once-efficient and streamlined healthcare sector. He further said that the second major setback is the unavailability of specialists directly involved in living donor kidney transplantation and those indirectly involved in disease donation. “This includes professionals responsible for donor diagnosis and management in ICUs. Additionally, the limited availability of ICUs and High Dependency Unit facilities present another significant challenge. This shortage hinders the detection of deceased donors and complicates donor maintenance until organ retrieval. If we were confronted with these numerous challenges today, it is difficult to imagine the obstacles faced by our predecessors in 1985. The first successful living donor kidney transplantation was performed at a private hospital in Colombo; it took an entire decade for the same team to perform a deceased donor kidney transplant at the National hospital. By year 2000, two additional centers, the Kandy General Hospital and Sri Jayawardenepura General Hospital began offering kidney transplant services. Today, there are nine major centres and three low-volume centers in the government sector, performing transplant surgeries across Sri Lanka.” 

Scarcity of donors

Statistics collected over the last decade indicate that there had been more living donor transplantations (1975) when compared to deceased donor kidney transplantations (592). But according to Dr. Seneviratne, the primary challenge limiting the number of transplants remains the transiting of donor organs. Without donors there are no transplants. “One major setback is the difficulty in finding adequate number of donors, a challenge faced globally. The scarcity of organs results in many patients being added to the waiting list each day, further straining the system and forcing numerous individuals to endure a sub-optimal dialysis, sometimes once or twice a week instead of the recommended three times a week dialysis. To compound this issue, around 5-8% of patients on the waiting list die without receiving a donor kidney annually. The global recommendation for increasing the organ donor pool emphasised the importance of good governance and well-structured systems for organ donation and transplantation. Transparency in registries along with  mandatory auditing and quality evaluation must be an integral part of donation practices. However, it is essential for each country and institution to develop an individualised action plan tailored for their specific circumstances and realities. The challenges we faced in 2013 were multi-faceted. As a semi-government hospital these challenges were even more pronounced.”

A transformative journey

Achieving self-sufficiency in organ donation was a crucial milestone for Dr. Seneviratne and his team. This is why they embarked on a 10-year journey after identifying obstacles and leveraging support from local, national and international sources to meet international standards. “We began with a dedicated team of six professionals and gradually expanded our efforts, restructuring the existing living donor kidney transplant programme while simultaneously developing the deceased donor kidney transplant programme. As we progressed we made a significant contribution to the national programme benefitting from this collaborative relationship in a mutually advantageous manner.”
He further explained how living kidney donations were conducted voluntarily with the consent obtained in accordance with the donor in a four-stage clearance process. “The final approval was granted by an expert multidisciplinary team. The standard classical donor is a relative to the recipient. But on the other hand, deceased donor kidney transplantation is a complex process. It begins with the identification of the potential brain-dead donor followed by urgent retrieval of organs which typically occurs in an emergency situation. Transplantation is a coordinated, multidisciplinary teamwork. Time is of essence. All patients receive standard induction and maintenance therapy for those undergoing a second transplant or identified as having a high immunological risk. A desensitization protocol was implemented right across transplantation. Over the 10-year study period, we studied donor demography, peri-operative outcomes and post-operative complications. By the end of 2022, the Sri Jayawardenepura General Hospital had successfully performed 429 kidney transplants. In the first 12 years we conducted 126 transplants but over the subsequent 10 years, the number rose to 303 representing a 2.5 fold increase. In 2021, we became the number one transplant center in the country.”

Introducing laparoscopic donor nephrectomy

Donor nephrectomy is a significant, life altering event and it is crucial to minimise the surgical trauma that donors are likely to experience when undergoing a major surgery. Dr. Seneviratne further explained about traditional open donor nephrectomy which is performed through a flank incision resulting in a significant wound. “The length of the incision is typically twice the size of the kidney. As a result of this muscle-cutting incision, patients often experience substantial post-operative pain. The pain can lead to increased reliance on anesthetics, prolonged recovery and even chronic pain syndromes, ultimately diminishing the overall quality of life for the donor. Long term morbidity can be significant following open donor nephrectomy. Incisional hernias were common complications. The scar left by such large incisions can negatively impact the body image.  Therefore, a more effective technique was needed to minimise the morbidity and enhance the cosmetic outcomes to the donors, allowing them to reintegrate into society as ambassadors for organ donation.” 
This is why Dr. Seneviratne and his team initiated the laparoscopic donor nephrectomy service exclusively to all living donors. “With laparoscopic donor nephrectomy the donor retrieval incision is discreetly concealed beneath the clothing. Since 2013, we have been providing this service with the primary objective of encouraging more living donors to come forward. Following the introduction of this minimally invasive technique and its associated benefits we have been able to increase donor willingness. In 2015, we adopted a 3D technology for living donation procedures. The advanced technology provides a cinematic experience that enhance our understanding of the depth and angles during laparoscopic surgery. Laparoscopic donors experience shorter hospital stays compared to those undergoing open surgery. Long term complications were not observed in patients who have undergone laparoscopic donor nephrectomy and although two donor deaths were reported, neither was connected to the surgical procedure.”

Approaches to enhance the renal donor pool

Dr. Seneviratne further said that in a country like Sri Lanka, where the deceased donor programme is still at its infancy, renal donors with potentially unfavourable or medical surgical characteristics should not be excluded from donations. Complex donors defined as those over 60 years of age or even with minor controlled medical conditions were selected following extensive multidisciplinary team discussions. This approach was taken because recipients had no alternative options for more suitable donor kidneys. Amongst our donors, 24 were classified as medically complex donors. The oldest donor was 66 years. Additionally, 9 donors had a BMI of over 30 and three were classified as morbidly obese, the heaviest being 39.” 
“However, living, unrelated donors remain an underutilised resource and kidneys can also be donated by altruistic donors. Prior to 2013, the majority of our donors were first degree relatives. However, over the past decade there has been a five-fold increase in non-related donations. With the initiation of the deceased donor programme, a dedicated team was set up to harvest organs from deceased donors and facilitate transplantation. The first deceased organ harvesting at our hospital took place in 2016 followed by implantation of those kidneys into a recipient at our facility. To date we have successfully performed 68 kidney transplants from deceased donors at the Sri Jayawardenepura General Hospital. Over the past six years we successfully identified 27 potential organ donors of whom 20 were confirmed brain dead. We successfully harvested 34 kidneys receiving a similar number from the national organ retrieval system. In addition to kidney retrieval, we contributed to the procurement of livers and other tissues as part of multi-organ donation efforts. The organs and tissues were dispatched to other transplant centers for implantation and to the tissue bank for future use.”

One organ donor saves eight lives

The longer waiting lists for kidney patients are also due to the fact that many donors are unaware of multi-organ donation and brain death. Dr. Seneviratne said that this lack of knowledge is a key factor contributing to the country’s low deceased donor organ donation rates. In order to address this issue his team established the organ donation and transplantation foundation working together towards one shared goal of promoting deceased organ donation in the country. 
“One organ donor can save eight lives and donors have the potential to expand the kidney donor pool if kidneys from donation after cardiac death are being utilised. “Unfortunately, this group of donors hasn’t been tapped yet due to the absence of national regulations governing end of life care and the legal framework for deceased organ donations. For patients who are incompatible with their healthy living donors, kidney paired donation offers a viable alternative. This approach facilitates a paired exchange between donors coming to receive a compatible kidney, thereby enhancing a successful transplantation.”
 In conclusion, Dr. Seneviratne said that the future of transplantation should embrace innovative technologies such as fully robotic transplantation. He said that organ donation has to be recognised as a key quality indicator for the hospitals. “Resources have to be developed for optimal care in high volume transplant centres and organ donation should be promoted as a civic responsibility,” he said while acknowledging the unwavering dedication and commitment of individuals who have strived to make significant advances in the field of kidney transplantation in Sri Lanka.