2.TRANSPLANTASYON 7. SUNUM

8/14/2019 2.TRANSPLANTASYON 7. SUNUM

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Liver Transplantation: Indianperspective

A.S. SoinHead of Department of Liver Transplantation

Sir Ganga Ram Hospital

New Delhi, India


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Mythology

Lord Ganesha

the oldest example of

(xeno) transplantation


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Ancient past

Sushruta

(Ahurveda

800 BC)

firstdescription ofhumangrafting NOSE JOB


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Plan

National perspective

Sir Ganga Ram Hospital experience

Development of Liver Transplant in India

Conclusion


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Organ donation and LTx inIndia: hard facts

1.1 billion population

HOTA (Legal Act) since 1994

4 regional OPOs (1 Govt, 3 NGO)

60 deceased donors per year: 2002-06 Livers used : 10-15 per year


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Need / rate of LiverTransplantation: India vs West

Region Rate of LTs

Developed West 12-32 per million

India 0.008per million

(58, 90 transplants in 2005, 2006)


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15

1015

2024 25

42

58

90

0

10

20

30

40

50

60

70

80

90

1995 1998 1999 2000 2001 2002 2003 2004 2005 2006

Liver Transplant in India:

annual trends


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Liver transplantation in India422 LTx in a total of 23 centres

138 DDLT and 284 LDLTNo. of transplants No. of centres

> 150 1

50-150 1 10-50 4

< 10 17


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Liver transplantation in IndiaLDLT : Total 284 Txs in 13 centres

No. of transplants No. of centres > 150 1 (SGRH)

50-100 1

10-20 2

< 10 9


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Sir Ganga Ram Hospital

SuperspecialityandResearchBlock

SGRH


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Located in theSuperspeciality andResearch Block

SGRH

The SGRH Liver TransplantUnit


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The SGRH Liver Transplant Unit

Specially designed

twin OTs Dedicated Liver

Transplant ICU

Liver HDU (step-down facility)

SGRH

Liver TransplantICU

LiverTransplant

OperationTheatre


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Patient group Survival (0.2-57 m)

(pt and graft)

LDLT 146/168 (87%)

ALL DONORS WELL (169/169)

SGRH experience: LDLT

results at a glance


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Patient and graft survival in 168

LDLTs

70

80

90

100

0 1m 3m 6m 12m 24m

Survival %

Time after transplant


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Live Donor Liver Transplantation:

SGRH Experience: 168 cases

169 Donors


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Donor Results Demographics

(n=169)

Age (years) 36.6y (21-57y)

Sex (M:F) 44:56

Weight (kg) 64.8 (48-90kg)

GRWR (%) 1.1 (0.6-3.7%)

R/L lobe 131/38MHV+ 102/131


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Intraoperative details

Operative time

(hours)

7.9 (5.30-11)

Transfusion

(units)

0.4 (0-8)

No transfusion 138/169 (82%)


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Postoperative course - donors

Survival 100%

Liver insufficiency None Intervention 5 pt. (CTdrain 3,

EBS 2)

Early re-operations 2 (bleed) Late re-operations 2 hernia repair

Hospital stay 7.8 d (6-18 d)


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Postoperative course - donors

Portal vein thrombus 1 (partial) Post op transfusions 5 Chylous ascites 1 Sepsis needing ICU 2 Bile leak 8 (5% - 2 BD stump,

6 cut surface) SAIO 2


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Donor follow - up

Mean 23 months (0.2 - 57 months)

Return to normal activity (4-7 weeks)

All doing well

Normal Liver function


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Live Donor Liver Transplantation:

SGRH Experience

Recipients


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SGRH LT series: aetiology(all LDLT patients, n = 168)

HCV, 53

Cholestatic Dis, 16HBV, 25

Crypto, 32

Ethanol, 17

FHF, 11

Non-cirrh

tumours, 3

Wilson's, 4

AIH, 6

Tyrosinemia, 1HCC withcirrhosis

34


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LDLT at SGRH: overview2002-07

Total * 168 Right lobes 130 Left lobes 37 Dual lobe 1(right + left)

Adult Adult right and left lobes 130 / 23 Pediatric left/right lobes 15 / 1

Elective 157

Emergency 11 (8%)*No re-transplants


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Patient characteristics

N= 168

Age: 39.2 years (1-70 years)

Sex: 116 M : 52 F

Childs Grade (159 CLD patients)Childs A B C

2 19 (14 HCC) 138


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LDLT: Intraoperative details

Operative time

(hours)

11.3 (5.8-25)

BloodTransfusion

(ml)

1650 (0-10110)

Additionalvascularreconstruction

Reqiured inalmost all


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Triple drug (Tac + Myco + steroid)

Extubation (mean, hrs) 10

Hospital stay (mean) 17.8 days (11-78)

Recipient post-Tx course


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Fulminant hepatic failure 10/11

Simultaneous liver and kidney Tx 1

for hyperoxaluria using two

separate live donors

Dual lobe transplant (right + left) 1

Moving ahead.


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Dual lobe transplant

Patients preop body weight 78 kg

Right liver weight 520 g

liver to body weight ratio 0.66

Left liver weight 252 g

liver to body weight ratio 0.32

Combined liver weight 772 g

Combined liver to body weight ratio 0.98


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Right and left livers looking healthy post-reperfusion and 15 days after LTx

Right liver Left liver


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Developing Liver Transplantation in India

Infrastructure Cost

Expertise

Expanding the donor pool


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Cost to company analysis of last 50 casesBasic cost of LDLT: 25000 USD in anuncomplicated case (60%)

Cost in remaining 40%: 38000 USD Who pays?

Self: private funds, collection by appeals, loanOthers: Govt / Tax payer, insurer, corporateemployer, Govt. employer, NGO, philanthropist,

pharmaceutical industry Solutions

Cost cutting generics, identical bl group ptsscheduled same week, cut down unnecessary testsIncrease funding by others esp. insurance

Developing Liver Transplantation: cost


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General problems Government Hospitals unable to launch a viable

programme yet

Still no foolproof mechanism to report all results tothe Health Ministry Cost private 40-50,000 USDollars

Solutions Incentives to team should be built into Govt

funding of LTx programmes Online registry - compulsory same day online

reporting into Health Ministry website Better insurance cover

LTx: problems in India


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LDLT Unregulated proliferation of centres

Cases by fly by night surgeons Under-reporting of donor deaths (4: 2 each in

North and South India only 1 reported inmedical literature, 2 in lay press)

Solutions Regional ceiling on number of centres Quality assurance - international guidelines for

infrastructure and expertise based onrecommendations of a National Professional Body



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DDLT Rare operation ICU staff not geared up for donor

management OPOs kidney heavy livers wasted

would not even ask permission for liversretrieval to suit the convenience of kidney surgeons (liversurgeons come from outstation

Law - All hospitals with ICUs NOT accredited for multiorganretrieval (only transplant centres approved)

Health a state subject (27 states!) liver wasted if not placedin the state

Medico-legal cases (accidents/post surgical deaths) pvthospitals more active but no provision for PM or its waiver

Solutions: Non-govt OPO with Govt supportAmendments to law



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Fulminant hepatic failure:logistics

Is informed consent / proper donorcounselling possible?

Transporting recipient

Quick donor work up

Extent of recipient work up

Abandoning attempt to transplant


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Fulminant hepatic failure:-worth it


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Conclusion

It has been possible to establish a viable livertransplant programme in India based on livingdonation

Development of new programmes should be based onan already working model and regulated by Govt.guidelines

Organ donation awareness, procurement andcoordination bodies must become active

All recipient / donor data to go into a National Registry Make LT affordable by cutting costs / better

insurance / Government programmes

Documents

2.TRANSPLANTASYON 7. SUNUM