Abstract
This year is our nation’s Jubilee year, but perhaps few would have known that within 5 years of gaining independence as a sovereign nation, Singapore would have performed its first kidney transplant from a deceased donor, in 1970 at the Singapore General Hospital (SGH). The name of the first kidney transplant recipient was Doreen Tan, who was then a 30-year-old housewife, and she received a kidney from a 20-year-old national serviceman, Yee Kwok Tong, who had died a few hours earlier and whose mother gave consent for organ donation. The transplant, funded by a $1800 grant from the National Kidney Foundation was carried out on 8 July 1970 at the Bowyer Block of SGH by Dr Chan Kong Thoe, then head of the University of Singapore Department of Surgery, and the surgical procedure took 3 hours. Within 10 days of the surgery, the kidney transplant started to produce urine, and by September Doreen was discharged from the hospital. 1 It was a remarkable achievement for a third-world nation at that time, and what was more amazing was that Doreen lived a fruitful and long 22 years before dying on 19 March 1992 from sepsis. At the time of her death her renal function was still normal, with a serum creatinine of 86 μmol/l.
Since that historic event, renal transplantation in Singapore has progressed by leaps and bounds over the last 45 years. Shortly after the establishment of the first Department of Renal Medicine at SGH in 1973, the first living kidney donor transplant was performed, on 31 July 1976 when, for the first time at SGH, a recipient received a living kidney donor from his brother. Then, the first living kidney donor transplant from an unrelated or spousal donor was performed, on 13 December 1993. Over the next two decades, kidney transplantation at SGH became more complicated as recipients had more comorbidity or were at higher immunological risk for rejection (Table 1).
Kidney transplant milestones at the Singapore General Hospital.
Despite these rapid advances over four decades, renal transplantation in Singapore has been hampered by shortages of kidney donors. Early attempts at improving donor supply were unsuccessful. For example, Singapore’s first organ procurement legislation, called the Medical Therapy, Education and Research Act (MTERA), was an opting-in law that was passed in 1972. Unfortunately, this did not improve the kidney transplant rate, which was occurring at an average rate of three per year. 2 Due to the low rates of deceased donor kidney transplantation, the living kidney donor transplant program was set up in 1976 at SGH. This resulted in an average rate of 12 living kidney donor transplants being performed per year, but this was still insufficient to meet the demands of a growing population of patients with end-stage renal failure (ESRF). 3 To further increase donor supply, a trans-Pacific organ-sharing program was also started in 1983 to 1987 to import unplaced American and Canadian kidneys from deceased donors. Though this program provided 33 additional kidneys to Singaporeans, the 1-year graft survival was extremely poor at 27.3%, which was likely attributable to the prolonged cold ischemia times (50–73 hours) and the high degree of HLA mismatches. 4
Up to 1987 transplant volumes remain low, with only 149 living and 97 deceased kidney donor transplants performed in Singapore. As a result, the Human Organ Transplant Act (HOTA) was introduced, which was an opting-out legislation that effectively increased the pool of potential donors by more than 50-fold, from 45,202 organ pledgers under MTERA, to more than 3 million donors under HOTA. 4 Unfortunately, this did not translate to an expected increase in kidney transplant rates in Singapore. In the United States Renal Data System Report 2013, Singapore was listed as the country with the fifth largest incident rate of ESRF but also with one of the smallest kidney transplant rates at 17.7 per million population. 5 One of the reasons for the poor yield from HOTA was that there was a low actualization organ donor rate from the intensive care units. 5
As Singapore celebrates its 50th year of independence, we also celebrate the remarkable transformation of the healthcare landscape, which includes the rapid development of first world-level transplantation services where we are able to perform a comprehensive range of different types of transplants (Table 1). Furthermore, we produce extremely good outcomes, with a recent report showing that our long-term 10-year graft survival rates (deceased donor 65.9% and living donor 79.4%) at SGH are higher than those reported for Europe (56%) and the United States (46%).6,7 Despite our superior outcomes, we have not been able to make significant progress in improving donor supply for transplantation. As a result, as of July 2015 at SGH, there remained 294 patients who were waiting for a deceased donor kidney transplant, and an average of only 19 kidney transplants were performed per year over the last 5 years.
There needs to be a paradigm shift in the approach to improving the transplantation rate in Singapore. We have already explored legislative and clinical approaches to improve access to kidney transplantation but these approaches have largely failed. What is critically needed is a nation-wide program to increase awareness and education of kidney donation and transplantation among Singaporeans. For example, researchers from the kidney transplant program at SGH have conducted large-scale surveys to understand the needs for transplant-related education.8,9 In one survey of 1384 members of the general public, it was revealed that only 32.8% were familiar with HOTA, whereas another survey of 1460 respondents revealed that only 48.4% were willing to become living kidney donors, with over 85% fearing surgical risks and poor health consequent to donation. It seems only logical that transplant healthcare in Singapore should place greater emphasis on education and outreach activities that will improve understanding and acceptance of kidney donation and transplantation. Indeed, we are at a crossroad where we need to embark on a paradigm shift in increasing transplant rates in Singapore. This is even more urgent with an aging population and the continued dependence on resource-heavy hemodialysis as a preferred mode of renal replacement therapy. When Singapore celebrates its 100th birthday in 2065, it is hoped that the nation will by then have established a vibrant transplant society, culture and healthcare system.