New Layout-Dt 14-2-2009 - final.pmd 2/14/2009, 5:16 PM 1

New Layout-Dt 14-2-2009 - final.pmd 2/14/2009, 5:16 PM1

2 From the Editor’s Desk

Dr. Reeta J. Dalal

3 Guest Editorial

Dr. Sudeep Shah

4 Cadaver Transplantation

Dr. Rasika Sirsat

8 Corneal Transplant

Dr. Nisheeta Agarwala & Dr. Pradyna

12 Heart Transplant

Dr. Kaushal Pandey

16 Frontiers of Immunosuppression

in Renal Transplant

Dr. Jatin Kothari

20 Liver Transplant

Dr. Sudeep Shah

24 Live Related Renal Transplant

Dr. Alan Almeida

30 Stem Cell Transplant (SCT)

Dr. Asha Kapadia

32 Lung Transplant -

Where does it stand today?

Dr. Manoj Agni

36 Short History of Organ Transplant

Dr. R. A. Bhalerao

38 Hinduja News

40 Welcome

Worldwide tens of

thousands of lives are

transformed by the miracle

of organ donation. Tissue

transplants e.g. skin,

cornea, bone-marrow,

vessels are invaluable. In

the last half century

transplant surgery has transformed from research

to life-saving surgery.

For every successful transplant there are

thousands who are on the waiting list and

probably die waiting to receive the graft. Organ

transplants are complicated by scarcity of organ

donors, various ethical and social issues.

In this issue Dr. Sudeep Shah, Liver Transplant

Surgeon at Hinduja Hospital has put together

articles from various specialities to give you an

‘Update on organ transplants’.

Dr. Reeta J. DalalConsultant Physician

From the

Editor’s Desk

Editorial BoardDr. Philip Abraham

Dr. Tester Ashavaid

Dr. C. BalakrishnanDr. Sudeep Shah

Dr. Gauri Mankekar

EditorDr. Reeta J. Dalal

Editor EmeritusDr. V. R. Joshi

Guest EditorDr. Sudeep Shah

PhotographyPramod Tandel

FROM THE EDITOR’S DESK / CONTENTS

2 2008 Vol 23 No. 1


Dr. Sudeep Shah

ORGAN TRANSPLANTATION IS one of the miracles of modern medicine. The ability

to replace failed organs has been dreamt about since the beginning of the last century.

However, with the greater understanding of the immune system and technical advances in

surgery, this became a reality in the 6th and 7th decades of the last century. The arrival of

more effective immunosuppression in the form of Cyclosporine radically improved the

results and in the eighties this treatment became established as the standard of care for

organ failure.

In this issue of the Newsletter, we highlight the indications and outcome for major organ

transplantation and also outline the procedure for cadaver organ donation.

Transplant is a reality now in tertiary care centers such as ours and we need to go forward

and build further. This is possible with greater awareness about organ donation. The gift

of life is the greatest that can be given as seen in the case study and we hope this issue will

serve to reinforce this.

DR. SUDEEP SHAH

Introduction toOrgan Transplantation

GUEST EDITORIAL

2008 Vol 23 Vol No. 1 3


TRANSPLANTATION IS CURRENTLY considered

an accepted treatment modality for patients with end

stage organ failure where therapy with drugs or

restorative surgery is not feasible. Approximately, 25

different organs and tissues including kidney, heart,

lung, liver, pancreas, bone, cartilage, bone marrow,

Cadaver Transplantation

skin and cornea can be transplanted. This is due to

important break throughs in immunosuppressant drugs

and tissue typing. More than 1 million people world wide

have benefitted from successful organ transplantation.

Of these, kidney transplant results have been the most

gratifying. With improvement in results, the demand for

Despite the immense benefits of successful organ transplant, the full

development of the transplant program is hindered by organ shortage.

By Dr. Rasika Sirsat

4 2008 Vol 23 No. 1


NEUROLOGICAL

EXAMINATION

TO

DEMONSTRATE

BRAIN DEATH

ARE

Absence of

oculomotor/photomotorreflex

Absence of

corneal reflex

Absence of facial

movements

Absence of

spontaneousmusclemovements

Absence of

oculo-vesitibularreflex

Absence of gag

reflex

Absence of

cough reflex

Absence of

spontaneousbreathingdetermined byApnea test.

human organs for transplantation has

increased. The source of donor organs are

living related donors (LRD), living un-

related donors (LURD), cadaver – non

heart beating donors (NHBD) and

cadaver – heart beating donors

following the second set of test to confirm

Brain Death.

The Zonal Transplant Co-

ordinating Center (ZTCC) is informed

about a potential Cadaver donor. The

ZTCC is a city based organisation who co-

CHECK LIST

MORE THAN 1 MILLION PEOPLE WORLDWIDE HAVE BENEFITTED FROM

SUCCESSFUL ORGANTRANSPLANTATION.“(HBD). Most of cadaver transplanted

kidneys are obtained from brain dead donors

with functional circulation. Brain death can

occur due to spontaneous intracranial

hemorrhage, head trauma, cerebral

ischemia or primary cerebral tumours.

Brain death can be diagnosed at the

bedside by performing various tests in

patients in whom the cause of coma is known

and those who do not have severe

hypothermia (< 35oC) and have not

received neurodepressor drugs,

neuromuscular blockers and anti-cholinergic

drugs.

The transplant co-ordinator can then

counsel the close relatives regarding organ

donation. Once close relatives give written

consent for organ donation, organs can be

retrieved after declaration of brain death

ordinate all activities for organ procurement,

maintainenance of a computerized central

registry of potential recipients and allocates

organs as per the criteria laid down. The

aim of ZTCC is to provide impartial and

effective organ distribution. The prospective

2 recipients for kidney transplant are called

as per criteria laid down by ZTCC. It is

essential that a person who registers for a

cadaver transplant keeps some funds aside

in the eventuality of being called for a

transplant surgery. The recipient should also

follow up regularly, at the center where he is

registered so that the nephrologist is aware

of his/her medical fitness for surgery.

The suitability of donor organ is checked

by performing a Lymphocyte cross match. If

negative the recipient can proceed for

Transplant. If the lymphocyte cross match is

“

BRAIN STEM DEATH IS IRREVERSIBLE ANDHAS BEEN RECOGNISED BY LAW SINCE 1995.“

“COVER STORY

2008 Vol 23 Vol No. 1 5


positive the recipient next on

the list is considered for the

transplant, provided

lymphocyte cross match is

negative. The shortage of

organs can be expanded by

including non-heart beating

donors (NHBD) i.e. organs

are retrieved only after heart

stops functioning. The main

issue with NHBD is higher

rate of delayed graft function

compared with that

associated with heart beating

brain dead donors. However

at 3 months graft function is

not significantly different

between the two.

Most of the kidney

transplants performed in

India are from live donors.

For those patients who do

not have an option of related

kidney transplantation, the

only option is to wait for a

cadaver kidney. The Human Organ Transplantation Act

was passed in 1994 following which cadaver transplants

have been carried out all over India. In Maharashtra, the

first cadaver transplantation after the act was performed

professionals and lack of

organ sharing agencies.

India spends 1.5% of GNP

on health care. End stage

kidney disease (ESKD)

treatment has extremely low

priority as compared to

population control,

eradication of

communicable disease,

nutritional program, etc.

hence government funding

for renal replacement

treatment is a miniscule

amount. Very few ESKD

patients are reimbursed by

their employers, while others

rely on their family and

charitable organizations for

funds. Public unawareness,

religious sentiments, family

pressures all contribute to

bringing down the number of

actual organ retrieval from

potential cadaver donors.

In Spain organ procurement system has been

professionalized. The organ procurement team is

responsible for the whole organ donation process from

donor identification to organ retrieval and they are

Apnea testPatient is put on FiO

2 of 100% for 20

minutes while still on the ventilator.

Thereafter ventilator is disconnected and

patient is put on 6L/minute of O2. Serial

arterial blood gas are checked until

PCO2 > 60mm Hg with PO2 around

100 mm/Hg. Watch for movements of

diaphragm if there is no spontaneous

respiration that indicates an absence of

brain stem respiratory centre function.

These tests are repeated and confirmed

after 6 hours. Only then the patient can

be declared as Brain dead. These tests

are to be performed by 4 medical

practitioners (Neurosurgeon, Physician,

Neurologist, Intensivist) as per

Transplantation of Human Organs Act

(TOHA) 1994. Brain death is explained

to relatives by the treating physician after

the first set of tests are performed.

on the 27th of March 1997, thereafter about a hundred

and fifty more have been performed up to date. So far,

about 1200 cadaver transplants have been carried out in

India, far short of what is required. This is in spite of 8500

fatal road traffic accidents per year. Per city about 8 to 10

brain dead patients would be there at a time, however,

the conversion rate is less than 19%. This is due to multiple

factors like poor infrastructure for quick and safe

transportation of accident victims, lack of ventilatory

facilities, ignorance, failure to convince the near relatives

to donate organs, indifferent attitude of health care

accountable for their performance, there are 127 such

teams. Their organ donation rate has more than doubled

over the last one decade and the percentage of multi-

organ retrieval has soared from 35 to 83% enabling a 3-

fold rise of possible solid organ transplant.

Currently, organ shortage is the main obstacle to the

full development of the transplant programme. It is possible

to increase the cadaveric organ donation rate and also

promote living donation. It is still possible to further

improve graft survival rates and thus reduce the need for

re-transplantation.

LACK OF PUBLIC AWARENESS, MISPLACED RELIGIOUSSENTIMENTS, FAMILY PRESSURES ALL CONTRIBUTE TO BRINGING

DOWN THE NUMBER OF POTENTIAL CADAVER DONORS.“

“

COVER STORY

6 2008 Vol 23 No. 1


Case Study By Dr. G. B. Daver

A 34 YEAR old lady- in the prime of her life struck down

by a stroke leading to brain stem death leaving behind a

grieving husband and child would in ordinary

circumstances be nothing more than a terrible tragedy.

However, the extraordinary act of generosity by the family

in intense grief transformed the lives of three unrelated

individuals.

Miss C was a young lady with kidney failure. She had

had so many dialysis that there was no further access to

her blood vessels to remove blood for purification. No

suitable relative was available to give her a kidney and

doctors were wondering what to do when her last open

access point would block. A kidney from a cadaver donor

was her only hope.

Mr P was a young man tired of life. Struck down by

kidney disease in his teens, he had already had a failed

transplant. Now, he was tethered to a dialysis machine

three times a week and unable to do anything productive;

his blood pressure swingig dangerously due to kidney

damage. A kidney from a cadaver donor was his only

hope.

Three happy recipients meet to remember the donor a month after the transplant

Mr D, an engineer in the prime of his life, struck down

by liver cirrhosis. He was unable to work and worried about

the future of his sons, aged 16 and 10. His wife was the

wrong blood group and he had no other relatives to donate

a part of their liver. He was on our waiting list for over a

year for a suitable liver donor. A liver from a cadaver

donor was his only hope.

On the day before Dassera 2007, the family of the

lady with severe brain damage leading to brain stem death

consented to donate her liver, kidneys and corneas after

realizing that she was lost to them forever. These organs

were useless to her but could transform three lives.

A team of surgeons commenced the procedure at 5

AM and surgeries carried on through the day and late

into the night. The recipients of the liver and two kidneys

were home 14 days after the operation.

Today all three recipients are back to a normal, productive

life, the nightmare years of their illnesses are behind them.

They realize that they are amongst the lucky few recipients

of a cadaver organ donation. Many more patients with end

stage organ failure wait for such a gift of life.

2008 Vol 23 Vol No. 1 7


CORNEAL TRANSPLANTThe cornea is the clear tissue covering the front of the eye. If the cornea

becomes cloudy or scarred, vision is markedly reduced or lost.

By Dr. Nisheeta Agarwala & Dr. Pradyna

FORTUNATELY, THROUGH THE medical miracle

of Corneal Transplants, sight restoration is possible.

More than 2 million Indians, a majority of them

children, suffer from corneal blindness and another

25,000 are added to that number every year. Since

there is no substitute for human tissue, the

transplantation process depends upon the priceless gift of

eye donation after death. To meet the requirements, eye

donation has to be increased several times and this is

possible only when the concept becomes a movement

and spreads to all families.

The decision to donate eyes is made by the family

8 2008 Vol 23 No. 1


members when a death occurs. The desire

to donate your eyes, should be conveyed to

the immediate family, during one’s

lifetime.Our eyes, can be recycled into the

priceless gift of vision for millions of our

corneally blind citizens instead of being

FACTS ABOUT

EYE DONATION

Donated eyes of

all ages can beused

Spectacle

wearers, andpeople sufferingfrom evendiabetes,hypertension orasthma candonate eyes.

Patients who have

undergonecataract surgerycan donate eyes.

Eyes can be

donated even ifthey have notbeen pledgedearlier.

Eye donation

gives sight to twocorneally blindpersons. Eyesare neverremoved from aliving person.

The process of

removing the eyesfrom the body ofthe deceased iscalledENUCLEATION.

CHECK LIST

buried or burnt. In the past people were not

aware of blood donation. They were

gradually educated and started donating

voluntarily. There is no shortage of potential

donors. All that is needed is the desire to

donate and a timely request so that the

closest eye collection services can be

contacted.

Corneal opacity due to infection

CORNEAL TRANSPLANTATION

The cornea is made up of 5 layers.

It can get opaque due to infections,injury,

following eye surgery, ageing and

degenerative changes. Conventionally, the

entire diseased central cornea is removed

and replaced with high quality transparent

corneal tissue from a donated eye. This is

called Penetrating Keratoplasty.

MORE THAN 2 MILLION INDIANS, A MAJORITYOF THE CHILDREN, SUFFER FROM CORNEAL

BLINDNESS AND ANOTHER 25,000 ARE ADDED TOTHAT NUMBER EVERY YEAR.“ “

If only superficial layers are opaque,

then those are replaced by Lamellar

Keratoplasty procedures and if the deep

layer is diseased then that is replaced by

Image is taken from Google

CORNEAL TRANSPLANT

2008 Vol 23 Vol No. 1 9


What Needs To Be Done?

• If there is a death in your family or friend circle, motivate the family

and call the nearest Eye Bank or dial 1919 (National & Local eye

donation helpline)

• Eyes are best removed within 6 hours of death

• The death certificate should be available.

• Switch off fans and place wet cotton / cloth over the close eyelids,

to keep eyeballs moist.

• Raise head with a pillow

• Most eye banks have a 24 hours response service, which receives

calls and sends a medical practitioner for the enucleation.

• The Eye Bank team will enucleate the eyes wherever the donor is,

at no cost

• The Eyes are removed without disfiguring the face

• Although it is only the corneas that are finally used, the entire eye

is removed and transported in special containers to the Eye Bank.

10 cc of blood sample is collected from the donor’s body for testing.

• The eyes will be evaluated and processed by trained Eye Bank staff

according to International standards.

• Eye Banks are non-profit organizations and the processed cornea

is supplied to qualified corneal surgeons.

• If the patients are identified with HIV infection, hepatitis B, C, rabies,

septicaemia or active leukemia, their corneas cannot be used for

transplantation.

NATIONAL & LOCAL EYE DONATION HELPLINE 1919

endothetial Keratoplasty

procedures. At our hospital

we have a 24 hour cornea

retrieval team – which will

conduct an enucleation

within the shortest period, for

any patient who passes away

in the hospital.

FOR REST OF

BOMBAY

Contact nearest Eye Bank or

Dial 1919 for prompt

response from an Eye

Donation Cell

CORNEAL TRANSPLANT

Donate Organs, Save Lives!After your life time, wouldn’t it make you happy to know that you can give a new lease of life to many other people?? One life can

give hope to many. But that’s only if you give the NOD to pledge your organs.

Organs Donation

1 . What is organ Donation?

Organ donation is the gift an organ to a person who needs a transplant. It’s a procedure in which a healthy organ is taken from

an individual who has died and transplanted into a person whose own organ is not functioning properly.

Donated organs give the recipients the opportunity of a longer and better quality of life

2 . Why is Organ Donation required?

Sometimes people suffer for irreversible organ failure and the only way they can recover or lead a normal life is to receive an organ

transplant.

3 . Is it legal ?

Yes it is legal. In India it is governed by the Transplantation of Human Organs Act (HOTA), 1994. This Act makes it mandatory

for institutions conducting transplants to register with an authority appointed by the state government. Many safeguards against

misuse have been built in the rules.

10 2008 Vol 23 No. 1


DONATE ORGANS, SAVE LIVES!

4 . Which organs and tissues can be donated?

Organs that can be transplanted are Kidneys, Heart, Liver, Lungs, Pancreas, Small Bowel, Cornea. Tissues like Heart Valves, Bone

and skin can also be donated.

5 . Do I need to be dead to donate an organ or tissue?

No, Blood and Bone marrow may be donated by live donors. Partial Liver & Kidney donation is allowed by law for blood relatives

of the recipient. For other organ donation, the person has to pronounced ‘brain dead’

6 . Are you sure I wil l be dead when they transplant my organs?

The Transplantation of Human Organs Act lays down criteria for determining brain steam death. The brain stem death tests must

be performed by four Doctors together, none of whom has anything to do with the transplant, and this must be done twice, with

a minimum gap of six hours. Such brain death can be declared only in institutions recognized by state appropriate authority.

7 . Will the doctors just let me die if they know I wil l be donating my organs?

No. Your doctors will take the utmost efforts to save your life. This is their first duty. If despite their efforts, the patient dies, only then

will the organs / tissues will be considered for donation. These doctors will not be involved with the organ transplantation, a

completer different set of doctors will take over for the further procedures.

8 . Can I donate if I die in an accident?

Yes if you are taken to the hospital in time and that hospital has capability for organ transplantation and is registered with the

state authority.

9 . Who will get my organs?

The recipient has to be on state waiting list for receiving organs and has to be compatible for that organ. If not, the next person

in waiting will be considered.

10. Will the Rich get priority in waiting list ?

No, the recipient has to be on state waiting list for receiving organs. Clinical criteria like blood group, immunological status, and

medical urgency are considered for the transplantation. There is no discrimination based on money colour, race and religion.

11. Will my family know who gets my organs?

No, the details of the recipient are not revealed to the donor family.

12. Will the recipient know my name and details?

No, the details of the donors are not revealed to the recipient.

13. Are there any religious objections to organ transplants?

All religions in India consider organ donation as an Act of Charity, Support it.

14. Can I specify to donate any specific organ and not any others?

Yes you can specify the same on your organ donation card.

15. Can I agree to donate to specific person and not to anyone else?

No. The recipient has to be on state waiting list for receiving organs. Organ donation is not accepted if it is conditional.

16. Is there any cost of donation to my family?

No, the cost is borne by the recipient’s family

17. How can I become a donor?

You simply have to fill up and sign the Organ Donor card that is attached. Please carry this card with you at all times.

18. Do I need to inform my family about my decision?

If you discuss you wish with your family they will be ready for the donation when the time comes and will be able to process the

donation faster.

19. Does organ donation cause any delay in funeral arrangement?

No, if consent for organ / tissue donation is given, the surgery is done immediately and there is no interference with the customary

funeral arrangement

20. Can I change my mind about organ donation?

Yes, simply tear your organ donation card.

21. Will I be paid for donating an organ?

No, the law does not permit commercial dealing in human organs.

22. Can I donate if have a medical condition?

The medical condition of the donor will be assessed at the time of organ donation. HIV and Cancer are specific conditions which

excludes people from donating.

23. Would there be an additional expense for donating organs?

No.

24. How can I be sure that the donated organs are safe and diseases free?

All potential donors’ blood is screened for ruling out transmitted dieses such as HIV and Hepatitis. The family of the potential

donor is kept informed of this requisite procedure.

25. Who can be a life organ donor?

Anyone 18 year of age and above can be a donor. Parents or Guardians consent will be required for any individual below 18 year

wishing to donate an organ.

2008 Vol 23 Vol No. 1 11


Heart TransplantHeart transplant surgery has come a long way in the last 40 years. However, due

to newer technology, the number of transplants performed each year is actually

falling. By Dr. Kaushal Pandey

HEART TRANSPLANTATION IS the most

satisfying surgical procedure for a Cardiac

Surgeon. A sick patient with a failing heart (not

expected to survive more than a few months) gets

wheeled into the operating room; three hours later

comes out into the ICCU with a new normal

functioning heart. For the surgical team it is just another

day at the office, but for this patient, it is new life. From

the epoch-making, first heart transplant in December

1967, heart transplant surgery has come a long way in

last 40 years. These forty years of heart transplant surgery

have been indeed tumultuous. There have been many

12 2008 Vol 23 No. 1


CHECK

LIST

highs, but numerous lows. Surgery now is

standard; but the yearly numbers are

actually falling. With newer technology

impacting our lives in more ways than one,

surgery of heart transplant has an

uncertain future. Sooner but not later,

totally implantable artificial heart (or assist

device) will make heart transplant surgery

obsolete.

First successful heart transplant surgery

was performed on 3rd December 1967 by

Dr. Christan Bernard. However the true

pioneer of Heart Transplant Surgery has

been Dr. Norman Shumway from Stanford

Medical Centre, U.S.A. His persistent and

untiring work on heart transplantation over

the decades has firmly established heart

transplant as a standard operation with a

significantly low peri-operative mortality

and satisfactory long-term results. Well over

60,000 heart transplant procedures have

been performed worldwide so far. At

present, less than 2700 heart transplants

are performed each year in the world and

these numbers are falling. The surgical

technique of this operation and the

associated problems have not changed

much with time. Problems of rejection

(both acute and chronic), susceptibility to

infection and long-term problems with the

transplanted heart have remained same

over the decades. The longest survivor of

RECIPIENT SELECTION:

Terminal Heart Disease

Brain death declared Age: New born – 60 yrs,Irremediable cardiac disease NYHA Class IV,Pulmonary Vascular Resistance < 6-8 Wood unitsor pharmacologically reversible

Reasonable physiological - normal function orreversible dysfunction of kidneys, liver, lungs, CNS

Psychosocial stability

No alcohol, tobacco or drug abuse

Absence of

• Active malignancy or infection

• Recent pulmonary Infarction

• Severe peripheral or cerebro vascular disease

Contraindications

Fixed pulmonary vascular resistance

Peripheral vascular disease

Acute malignancy

COPD /chronic bronchitis

Morbid obesity

ABO incompatibility

THE FIRST SUCCESSFUL HEART TRANSPLANTSURGERY WAS PERFORMED ON 3RD DECEMBER

1967 BY DR. CHRISTAN BERNARD.“

“HEART TRANSPLANT

2008 Vol 23 Vol No. 1 13


heart transplant has now

lived for over 28 years. Tony

Haesman from Washington

has worked as a salesman for

28 years. He had Heart

Transplantation at Stanford

and continues to lead an

active life.

SURGERY

Orthotopic

Hetrotopic (piggyback)

POST TRANSPLANT

CONCERNS

Immunosuppression

As in other solid organ

transplants

Transvenous myocardial

biopsy

• Internal jugular

approach

• 3-5 specimens

• weekly for the first 4

weeks

• grading system developed by Billingham

Coronary graft vasculopathy

Infection as in other solid organ transplants

MEDICAL COMPLICATIONS OF

CARDIAC TRANSPLANT

Cardiac

Ventricular dysfunction

Sinus node dysfunction

Tricuspid regurgitation

Allograft rejection

Allograft coronary artery disease

Decreased exercise tolerance

Non-cardiac, Non-infect ious

Renal insufficiency

Hypertension

Osteoporosis

Hyperlipidemia

Malignancy

Psychologic/behavioral/societal

Glucose intolerance

Pancreaticobiliary disease

Obesity

CARDIAC ALLOGRAFT REJECTION

Propensity decreases with time

Types

Donor Selection:• Only 10-20% of brain dead patients

with suitable hearts become donors;

cardiac transplantation is currently

limited by donor availability

• Age <45 (special exceptions)

• No pre-existent heart disease,

normal ECG, normal ECHO

• Few CAD risk factors

• No untreated acute infections

• Negative T cell cross match if panel

reactive antibodies 10% or greater

• Negative HIV. HbsAg, HCV

• No systemic malignancy

• No cardiac trauma

• Minimal pressure support

• ABO compatibility

• Size within 20%-50% of recipient

• Hyperacute • Acute

• Chronic (ACAD)

• Cellular • V a s c u l a r

(Humoral)

Diagnosis

• Endomyocardial

biopsy • Non-invasive

• Clinical

Treatment

ALLOGRAFT CORONARY

ARTERY DISEASE

Leading cause of death

> 1 year af ter

transplantation

Equivalent to:

• “Chronic rejection” in

renal allografts

• “Vanishing bi le

ducts” in hepatic

allografts

• “ B r o n c h i o l i t i s

obl i terans” in

pulmonary allografts

Prevalence of angiographically detectable disease

• 1 year: 10-2O%

• 5 years: 30-50%

HEART TRANSPLANT

THE LONGESTSURVIVOR OF HEART

TRANSPLANT HAS NOWLIVED FOR OVER

28 YEARS.

“ “

14 2008 Vol 23 No. 1


Functional Status Following Heart TransplantPost Transplant Functional Status

• 1 year follow up: 90% - no activity limitation, 8.5% -performs with assistance, 1.4%

total assistance

• 3 year follow up: 93.5% no activity limitation, 5.8% performs with assistance, 0.8%

total assistance

Post Transplant Work Status

• 1 year follow up: 29.2% working full time, 8.1% working part time, 47.7% not working,

15.0% retired

• 3 year follow up: 32.5% working full time, 8.5% working part time, 39.8% not working,

19.1% retired

Post Transplant Rehospital izat ion

• 1 year follow up: 57.5% no hospitalization, 9.2% hospitalization (not rejection not

infection), 11.4% (rejection), 14.8% (Infection), 7.1% (rejection + Infection)

Causes of Death afterTransplantation

Rejection

Infection

Technical

CNS

Malignancy

After First year

• Graft Atherosclerosis

• Infection

• Malignancy- Lymphoma

• Rejection

HEART TRANSPLANT

Surgery now is standard; but the yearly numbers are

actually falling. With newer technology impacting our lives

in more ways than one, surgery of heart transplant has an

uncertain future. Sooner but not later, totally implantable

artificial heart (or assist device) will make heart transplant

surgery obsolete.

2008 Vol 23 Vol No. 1 15

(Diagrams by Dr. Balkrishna)


Frontiers of immunosuppressionin Renal TransplantMaintenance immunosuppressive therapy is administered to all transplant

recipients to prevent acute rejection and loss of allograft.

By Dr. Jatin Kothari

Induction immunosuppressive strategies in renal transplantation

High dose conventional agents Antibody induction

Calcineurin inhibitor: Cyclosporine or tacrolimus Calcineurin inhibitor: Cyclosporine or tacrolimus

(lower doses than conventional agent strategy)

Corticosteroid Corticosteroid

Antimetabolite: Mycophenolate mofetil or Antimetabolite: Mycophenolate mofetil or

azathioprine azathioprine (lower doses than

conventional agent strategy)

Plus one of the following: .

ALG

ATG

OKT3

Anti-TAC: Daclizumab or basiliximab

16 2008 Vol 23 No. 1


EVALUATION

OF INDUCTION

PROTOCOL

REQUIRES

CONSIDERATION

OF THE

FOLLOWING

FACTORS:

Incidence and

severity ofdelayed allograftfunction orprimarynonfunctionincluding therequirement forand duration ofdialysis followingtransplantation.

Incidence of

acute rejection

Incidence, type,

and severity ofassociatedinfections

Long-term

allograft survivaland function

Mortality and

morbidity,Incidence andtype ofmalignancyduring long-termfollow-up

Cost including

length ofhospitalization

CHECK LIST

ALTHOUGH AGGRESSIVE

INDUCTION therapy offers clinical

advantages even in low-risk groups, such

a regimen produces the greatest benefits

in groups at high-risk for allograft

rejection which include pediatric patients,

African-Americans, recipients of kidneys

with prolonged cold ischemia time, and

those at h igh immunologic r i sk,

par t icu lar ly indiv iduals who are

presensitized. The sequential induction

regimen of thymoglobulin (or OKT3)

followed by cyclosporine or tacrolimus is

recommended in these high-risk groups.

MAINTENANCE

IMMUNOSUPPRESSIVE

THERAPY IN RENAL

TRANSPLANTATION IN ADULTS

Maintenance immunosuppress ive

therapy is administered to almost all

renal transplant recipients to help

prevent acute rejection and the loss of

the rena l a l logra f t . A l though an

adequate level of immunosuppression is

required to dampen the immune response

to the allograft, the level of chronic

immunosuppression is slowly decreased

over time (as the risk of acute rejection

decreases) to help lower the overall risk

of infection and malignancy; these risks

directly correlate with the degree of

overall immunosuppression. The type of

immunosuppression may also be varied

to decrease the risk of developing

chronic allograft nephropathy, the most

common underlying long-term cause of

a l logra f t loss . Convent iona l

maintenance regimens consist of a

combination of immunosuppressive

agents that differ by mechanism of

action. This strategy minimizes morbidity

and mortality associated with each class

of agent whi le maximiz ing overal l

effectiveness. Such regimens may vary by

t ransplant center and geographic

THE INTRODUCTION OF CYCLOSPORINE IN THEEARLY 1980S IMPROVED RENAL ALLOGRAFT

SURVIVAL BY APPROXIMATELY 15 PERCENT ATONE YEAR POST-TRANSPLANT.

“ “FRONTIERS OF IMMUNOSUPPRESSION IN RENAL TRANSPLANT

2008 Vol 23 Vol No. 1 17

THE LEVEL OF CHRONIC IMMUNOSUPPRESSIONIS SLOWLY DECREASED OVER TIME“

“


area.The major immunosuppressive agents that are

currently being used in various combination regimens

are corticosteroids (primarily oral prednisone),

azath iopr ine, mycophenolate mofet i l (MMF),

mycophenolate sodium (myfortic), Cyclosporine ,

Tacrolimus, Everolimus, and Rapamycin (sirolimus)

INVESTIGATIONAL IMMUNOSUPPRESSIVE

DRUGS IN CLINICAL RENAL

TRANSPLANTATION

The introduction of Cyclosporine in the early 1980s

improved renal allograft survival by approximately 15

percent at one year posttransplant. However, Cyclosporine

failed to enhance long-term graft survival because of the

inability to suppress the chronic and progressive loss of

functioning renal tissue arising from antigen dependent

and independent immunologic factors .The administration

of cyclosporine or tacrolimus may also exacerbate this

process because of direct nephrotoxicity . In addition,

renal transplant recipients are at risk for significant side

effects due to immunosuppression, including infection,

cardiovascular disease, hypertension, and malignancy.

These limitations constitute the rationale for the continued

development of new immunosuppressive agents.

MONOCLONAL ANTIBODIES — O KT3

remains the only non-humanized mouse antibody

licensed for the therapy of allograft rejection . However,

the administration of OKT3 is associated with frequent

and occasionally serious adverse effects.Since OKT3 is

a T cell mitogen, most of these symptoms are thought

to be mediated by T cell release of cytokines via CD3

binding. Other serious complications, arising from the

more intense immunosuppression, include infection and

an increased incidence of lymphoproliferative disease

Humanized OKT 3 — To reduce the s ide

effects and the antigenicity of murine OKT3, a non-

mitogenic “humanized” variant has been

developed . The humanized hybrid molecule

was engineered by transferr ing the

complimentary determining regions of OKT3

onto a human IgG framework and then

mutat ing single amino acids to reduce the

aff ini ty of the “humanized” ant i-CD3

monoclonal antibodies.

T10B9.1A monoclonal antibody — T10B9.1A

is a murine monoclonal antibody directed against an

epitope of the T cell receptor alpha/beta heterodimer .

Unfortunately, the development of human antimouse

antibodies with T10B9.1A occurs with the same

frequency as with OKT3 .

Anti-ICAM-1 antibodies — Several adhesion

molecules contribute to the interaction between T cells

and antigen presenting or target cells. One critical

adhesive receptor-counterreceptor combination is

leukocyte function-associated molecule-1 (LFA-1) and

intercellular adhesion molecule-1 (ICAM-1) .

Anti-LFA-1 an t ibod ies — phase I/ I I t r ials

evaluated two doses of efalizumab, a humanized anti-

LFA-1 antibody, plus maintenance therapy with either

full dose cyclosporine, mycophenolate and steroids or

half dose cyclosporine, sirolimus and prednisone . At

six months, patient and allograft survival were 97 and

95 percent, respectively.

Ant i -B7 ant ibody — Of the numerous

costimulatory pathways for T cell activation identified

thus far, that provided by the interaction of CD28 on

the T cell surface with its antigen presenting cell surface

ligands, B7-1 or B7-2 (CD80 and CD86, respectively),

has been most studied. T cell anergy and apoptosis

induced by T cell receptor signaling alone is prevented

by signaling through CD28.Phase III trials are currently

underway, which is evaluating Belatacept in a calcineurin

inhibitor free maintenance immunosuppressive regimen.

EVEROLIMUS — The efficacy and adverse effects

of Everolimus an immunosuppressive agent that is a

structural analogue of sirolimus, has been evaluated in

multiple studies . Dose levels up to 5 mg/day were well

tolerated; an increased incidence and severity of adverse

events, particularly thrombocytopenia and reversible

cholesterol elevations, were observed at a dose of 10

mg/day.

FINGOLIMOD (FTY720) — F ingo l imod

(FTY720) is a sphingosine analogue that functions as

an immunosuppressant by altering normal lymphocyte

homing patterns . This agent interferes with the exit of

lymphocytes from the thymus into the blood and from

the tissue of secondary lymphoid organs into the efferent

lymphatics. It may also reduce the risk of malignancy

after transplantation .

PHOTOPHERESIS — Photopheresis is a form of

extracorporeal photochemotherapy in which peripheral

lymphocytes are collected via apheresis and treated with

8-methoxypsoralen and ultraviolet light . The process

appears to downregulate act ivated T cel l

clones.Preliminary evidence suggests that photopheresis

may decrease the frequency of rejection in both cardiac

and renal transplant recipients.

FRONTIERS OF IMMUNOSUPPRESSION IN RENAL TRANSPLANT

18 2008 Vol 23 No. 1


2008 Vol 23 Vol No. 1 19

RESEARCH

Research

Patents:

‘Method and research tool for identification of mycobacterium along with detection of

drug resistance in mycobacterium tuberculosis complex’. Has been filed for patency to

Indian National Patent’s Office. The study was carried out by Shubadha Shenai under

the guidance of Dr Camilla Rodrigues and Dr Ajita Mehta.

Awards:

Shubadha Shenai won

– (i) Gold medal 2007 for best paper [Title : Development of a Reverse line blot

hybridization (RLBH) assay for species identification of mycobacteria and drug

resistant testing in M. tuberculosis complex. ] presented at the XXXIst at the Indian

Association of Medical Microbiologist.

– (ii) Best paper award in PhD category 2007 from the ‘Dhala’s Felicitation Fund’.

Dr Hari Talreja won the Burgis N. Khushetji Award in the Indian society of

Nephrology , Western chapter held at Raipur in sept 2007 for his paper; ‘Assesment

of currently available methods of GFR, need for a new marker (Cystatin C)? ’.

Annual Research Day was held on 12th April 2008. Best paper awards were given to

following papers:

– First prize: To Dr Dipika Agarwal for her paper ‘Prevalence of sleep disordered

breathing in patients with heart failure’

– Second prize: To Shubadha Shenai for her paper ‘Comparison of phenotypic&

genotypic methods of pyrazinamide susceptibility testing’ & to Rani Raghavan for

her paper For her paper ‘Genetic screening of cystic fibrosis gene in Indian patients’.

Mid Annual Research Day was held on 3rd November 2007. Best paper awards were

given to following:

– First prize: To Apurva Sawant for her paper ‘Prevalence of dyslipidemia in young

adult Indian population’.

– Second prize: To Jency Courien for her paper ‘Kikuchi-fujimoto disease :

A study of 25 patients.


LIVER TRANSPLANTATION IS, today, the only

curative option for end-stage liver disease. Dr

Thomas Starzl in the USA and Sir Roy Calne in the

UK who pioneered these surgeries in the 1960s

initially had success rates of 30%. However,

paralleling advances in immunosuppression,

Liver Transplant

anesthesia, intensive care and refining of surgical

techniques, survival of more than 80% have been

achieved.

CONTRAINDICATIONS

Systemic illnesses precluding anesthesia, untreated

Liver Transplantation has been gaining popularity due to its high success rate

and the fact that it is currently the only cure for end-stage liver disease.

By Dr. Sudeep R Shah

20 2008 Vol 23 No. 1


INDICATIONS FOR LIVER TRANSPLANTATION

Hepatitis C cirrhosis

Hepatitis B cirrhosis

Alcoholic liver disease

Cholestatic liver disease

• Primary sclerosing cholangiitis

• Biliary cirrhosis- primary and secondary

Autoimmune liver disease

Budd-Chiari syndrome

Metabolic disorders:

• Wilsons disease

• Haemochromatosis

• Oxalosis

• Alpha 1 antitrypsin deficiency

• Erythropoetic porphyria

• Hypercholesterolemia

• Familial amyloid polyneuropathy

Liver space occupying lesions:

• Polycystic disease

• Multiple adenomatosis

• Caroli’s disease

Fulminant liver failure

• Viral hepatitits (B, A, E)

• Drug toxicity

• Paracetamol overdose

• Halothane

• Wilson’s disease

In children:

• Biliary atresia

• Progressive familial intrahepatic cholestasis

• Metabolic disorders Criggler Najjar syndrome, Urea

cycle disorders

• Unresectable hepatoblastoma

LIVER TRANPLANT

2008 Vol 23 Vol No. 1 21

sepsis, AIDS and extrahepatic malignancy,

non neuroendocrine liver metastases, liver

angiosarcoma and cholangiocarcinoma

are considered absolute contraindications.

Hepatocellular Carinoma (HCC) beyond

the Milan criteria (> 5 cm tumour, >3

tumours each < 3cm), have survival

reduced by tumor reccurrence. HCC with

tumour thrombus in the portal vein. HBV

DNA positive patients have high graft loss.

Severe porto-pulmonary hypertension,

non-compliers with treatment and active

substance abusers are not considered.

IMMUNOSUPPRESSION AND

REJECTION

Only blood group matching is required

for liver transplantation. Though acute

rejection may occur in up to 50% of cases,

chronic rejection leading to graft loss takes

place in < 5% of transplants. Diagnosis

is suspected on altered liver function and

established by biopsy.

Lifelong immunosuppression is required.

Modern immunosuppression centers on

the use of calcineurin inhibi tors-

Tacrolimus (FK 506) or microemulsified

Cyclosporine A Levels are closely

monitored to limit toxicity. Steroids are

started in high doses and rapidly tapered.

In the majority of cases these can be

stopped by 3 months post operatively.

Episodes of acute rejection are treated by

pulsed steroids for 3 days. In rare cases,

severe rejection requires treatment with

anti lymphocytic globulin or OKT3.

Mycophenolate moefetil is used as an

adjunct, especially to reduce calcineurin

inhibi tor dose in case of renal

dysfunction.. Recently induction agents

such as anti IL2 receptor antibodies-

basiliximab and daclizumab and new

drugs rapamycin and sirolimus are also

being used.


POST OPERATIVE

COMPLICATIONS

Primary failure of graft

function is most feared-

occurring in 5% of cases.

The causes include poor

donor l iver qual i ty-

especially steatohepatitis.,

preservation injury and

hepatic artery thrombosis

(HAT), which almost

invariably requires

retransplantation. HAT

occurs in 5% of adult and

15% of pediatr ic

transplants. Portal vein

thrombosis is rarer,

occurring in 2%. Biliary

complications have been

called the Achilles’ heel of

liver transplantation and

occur in 12-30% of cases.

HAT may be associated

with this as the artery is the

main supply to the bile

duct. Corrective surgery is

often required.

Liver dysfunction due to

a small graft is a particular

problem of living related

transplant in case of small

donor graft. Failure to

establish adequate venous

outflow especially from

middle hepatic vein

branches of a right lobe

graft may lead to graft

congestion .

Infections owing to immunosuppression are the

common cause of morbidity and mortality. Besides

nosocomial organisms,

opportunistic infections of

note are cytomegalovirus

(CMV) which occurs as

fever, leucopenia and

colitis, hepatitis, pneumonia

or meningitis after the third

week. Prophylaxis is

instituted especially if the

donor has previous

exposure and recipient does

not. Viral and fungal

infections too are common.

Live vaccines should be

avoided post transplant.

Drug toxicity is a major

morbidi ty. Calcineurin

inhibi tors cause

h y p e r t e n s i o n ,

hyperl ipidemia and

diabetes. High levels are

nephrotoxic and may lead

to tremors, neuropsychiatric

changes and rarely,

convulsions. Cyclosporin

leads to hirsuitism and

gingival hypertrophy.

Mycophenolate causes

leucopenia and diarrhoea.

Rapamycin leads to retarded

wound heal ing. Drug

interactions are common

and complex, requiring

physicians to be careful

while adding new drugs.

Post t ransplant

l y m p h o p r o l i f e r a t i v e

disorders and skin cancers

occur in up to 7% of immunosuppressed patients.

Disease recurrence is a major issue, especially in

Donor Selection andProcedureThe donor may be a brain-stem dead

cadaver from whom the whole liver

may be retrieved, or a relative who is

fit, free of liver pathology and willing

to donate par t of the l iver. An

anatomical lobe or sector may be

removed amounting to 0.8 to 1% of

recipient body weight. Living donor risk

to life is estimated at <0.5% , with a

10% risk of major morbidity. The donor

l iver regenerates to near normal

volume.

Brain stem dead cadavers may not

provide a good quality liver if they have

poor hemodynamic stability, are on high

pressor doses, have fatty change, long

ICU stay or prolonged starvation.

Potential brain dead organ donors

require careful maintainance in ICU.

Cadaver livers may be divided along

anatomical planes to reduce size for

children or alternately split to provide

two grafts- a smaller left lobe for children

and right lobe for small adults, either in

situ or on the bench after retrieval.

The liver is perfused with University of

Wisconsin (UW) solution or Histidine-

tryptophan-ketoglutarate (HTK)

solution. The liver may preserve for upto

24 hours in UW and 15 hours in HTK

solution.

LIVER TRANPLANT

PARALLELING ADVANCES IN IMMUNOSUPPRESSION, ANESTHESIA,INTENSIVE CARE AND REFINING OF SURGICAL TECHNIQUES,

SURVIVAL OF MORE THAN 80% HAVE BEEN ACHIEVED.“

“

22 2008 Vol 23 No. 1


The Recipient ProcedureThe native liver is removed, a step that is difficult because of portal hypertension collaterals

and coagulopathy, and replaced by the donor liver, joining the vena cava, portal vein,

hepatic artery and bile duct. T-tubes or stents are occasionally employed across the biliary

anastomosis. In case of bile duct disease such as biliary atresia, a Roux loop of jejunum

is used. longer considered essential. The native vena cava is left in place in all living

related transplants and also in select cadaveric transplants.

Hepatitis C, where accelerated cirrhosis may occur in

up to 25% cases. Autoimmune hepatitis, primary

sclerosing cholangiitis and tumours may recur.

Recidivism causes graft loss in alcoholics.

PROGNOSIS

Modern transplant techniques offer a one year survival

of 80-90% and 5 year survival of 70-80% for

appropriately selected patients with chronic liver disease

undergoing timely transplants. The survival for fulminant

liver failure is marginally lesser. Living related and

cadaver transplant have similar survival rates.

INDIAN SCENARIO

Cadaver liver transplantation has been legally possible

since the Human Organ Transplant Act of 1994.

However, numbers have been limited. Various agencies

such as the Mohan Foundation (Chennai, Hyderabad),

Organ retrival banking organization (ORBO) (Delhi)

and Zonal Transplant Co-ordinating Center (ZTCC)

(Maharashtra) are involved in increasing awareness

for cadaver organ donation amongst physicians and

lay people. Living related liver transplant is offered in

some centers for those patients with suitable related

donors, with good results.

LIVER TRANPLANT

2008 Vol 23 Vol No. 1 23


Live Related RenalTransplantRenal transplantation is the best form of renal replacement therapy with live

related donor transplant being the solution of choice in End Stage Renal Disease

patients. By Dr. Alan Almeida & Dr. Ashwinikumar Khandekar

RENAL TRANSPLANTATION REMAINS the

best form of renal replacement therapy providing

better quality of life and survival compared to

dialys is. Contrary to common percept ion,

transplantation, in the long run, is a less expensive

option than dialysis, giving better rehabilitation. Live

24 2008 Vol 23 No. 1


WHO CANNOT

DONATE A

KIDNEY?

Following is a list of

conditions which

preclude renal

donation.

ABSOLUTEPsychiatric diseaseinterfering withability to consentActive drug oralcohol abuseEvidence of renaldisease (low GFR,urinaryabnormalities)Recurrent orbilateralkidney stonesCollagen vasculardiseaseDiabetes withkidneyinvolvementSevereHypertensionMalignancyActive infectionChronic activeviral infection(hepatitis B or C,HIV)Significant chronicliver diseaseCurrent pregnancy

RELATIVE

Age <18 or >65

years

Obesity (especially

BMI >35)

Mild or easily treated

hypertension

Single prior episode

of nephrolithiasis

Borderline urinary

abnormalities

CHECK LIST

CONTRARY TO COMMON PERCEPTION,RENAL TRANSPLANTATION, IN THE LONGRUN, IS A LESS EXPENSIVE OPTION THAN

DIALYSIS, GIVING BETTER REHABILITATION.“ “

LIVE RELATED RENAL TRANPLANT

THE FIRST SUCCESSFUL RENALTRANSPLANTATION WAS PERFORMED BETWEEN

IDENTICAL TWINS BY JOSEPH MURRAY IN 1954.“

“

Percent survival after living-related/cadaveric donor transplant and dialysis

Treatment 1 yr 2 yr 5 yr 10 yr

Type surv ival surv ival surv ival surv ival

Living-related donor

renal transplant 97.79 95.82 90.21 74.84

Cadaveric donor transplant 94.68 91.96 78.93 55.07

Dialysis 77.96 62.39 27.96 8.49

related donor transplant still remains the

solution of choice in End Stage Renal

Disease patients with the promise of

deceased donor (cadaver donor)

transplantation still not fulfil l ing its

promised growth.

HISTORY

The first successful renal transplantation

was performed between identical twins

by Joseph Murray in 1954. No

immunosuppression was used because

the donor was genetically identical to the

recipient. Transplantation grew with the

advent of newer immunosuppressive

agents such as azathioprine (1960). A

combination of steroids and azathioprine

soon became the s tandard

immunosuppressant reg imen for

t ransplants . Cyclospor ine became

available in the mid-80s, dramatically

reducing the incidence of acute rejection

and improving overall graft survival.

Mycophenola te mofe t i l (and

mycophenol ic ac id ) , tacro l imus,

sirolimus / everolimus and other agents

were added over the ensuing years. Not

only were newer drugs added but

biological agents to prevent or treat

rejection have evolved. The current day

s tandard t r ip le reg ime inc ludes

Mycophenola te , Tacro l imus or

Cyclosporine and steroids.

2008 Vol 23 Vol No. 1 25


AS PER THE EXISTING HUMAN ORGAN TRANSPLANT ACT 1994,ANY FIRST DEGREE RELATIVES OF THE RECIPIENT ( PARENTS,

SIBLINGS, CHILDREN) OR THE SPOUSE CAN BE AN ORGANDONOR PROVIDED THEY ARE BLOOD GROUP COMPATIBLE.

“ “LIVE RELATED RENAL TRANPLANT

26 2008 Vol 23 No. 1

OPTIONS FOR PATIENTS WITH END STAGE

RENAL DISEASE (ESRD)

Uremic symptoms arise in renal failure patients with a

creatinine clearance ≤ 10 mL/min with symptoms of

anorexia, nausea, weight loss, breathlessness, anemia

and somet imes reduced ur ine output being

predominant. Toxins, otherwise thrown out in the urine

by better functioning kidneys, accumulate in the

circulation in uremic patients,. This is the time that

the excretory function of the kidney need to be replaced

by the process of dialysis, either hemodialysis or

peritoneal dialysis. The synthetic functions viz.

production of vitamin D and the hormone erythropoietin

still need an external supplement in the form of

injections or tablets. Renal Transplant is a more

complete solution since a normal functioning kidney

is placed inside the recipient which carries out both

the excretory as well as the synthetic functions.

Sometimes, it may be prudent to do a transplant even

before the patient requires institution of dialysis and

is called a pre-emptive transplant (pre-empt the need

for dialysis).

WHO CANNOT HAVE A KIDNEY

TRANSPLANT?

Treatment options for patients with ESRD include

palliative care, hemodialysis, peritoneal dialysis, and

kidney transplantation. During the pretransplant

evaluation, patients are categorized as low, moderate,

or high risk based on surgical risk factors and comorbid

medical condit ions. Absolute and relat ive

contraindications to kidney transplantation are listed in

the table. Absolute contraindications include some types

of neoplastic disease, HIV infection, AIDS, some

infectious processes, some systemic diseases, and

irreversible vital organ failure. However, due to special

expertise and/or research protocols at individual centers,

pat ients with these contraindicat ions may be

transplanted, but this is not reflective of current practice

standards.

Contraindications to Renal Transplantation

Contraindication Absolute Relative

Cancer X

HIV positive/AIDS X

HCV infection X

HBV infection X

Morbid obesity X

Atherosclerosis X

Cardiac Disease X

Uncontrolled hypertension X

Smoking X

Unresolved psychosocial issues X

Active UTI X

Active tuberculosis X

Irreversible heart failure, XIrreversible lung failure XIrreversible liver failure X

Active systemic disease(ie, lupus, sickle cell

disease, Wegener’s disease) X

WHO CAN DONATE A KIDNEY?

As per the existing Human Organ Transplant Act 1994,

any first degree relatives of the recipient ( parents,

siblings, children) or the spouse can be an organ donor

provided they are blood group compatible. Blood group

[ABO] compatibility is the same as that in relation to

blood transfusion except that the Rh compatibility is not

required for renal transplant. Blood group ‘AB’ is a

universal recipient while ‘O’ is a universal donor. A

donor between 18 and 55 years of age would be

preferred, though at times, donors of older age may

also be accepted (biological age vs chronological age).

It is understandable that a kidney from an elderly donor

would have lower GFR (commensurate with the age-

related decline) and other associated co-morbidities.

WORK UP OF A DONOR

A donor is identified at a family conference and

undergoes detailed evaluation starting off with a detailed

history to rule out medical disorders that would preclude


Common side effects ofImmunosuppressives:• Cyclosporine can cause excessive

facial hair growth, gum hypertrophy,

hypertension, lipid abnormalities and

the drug itself is toxic to the kidneys

if the blood levels are high. It can

also affect the endocrine functions

of pancreas and lead to diabetes

mellitus.

• Azathioprine can cause bone

marrow suppression

• Mycophenolate causes selective

suppression of WBC production.

Loose motions are a common side

effect.

• Steroids side effects include truncal

obesi ty, hypertension, l ipid

abnormalities, cataracts, avascular

necrosis of femur head, muscle

weakness, osteoporosis and glucose

intolerance.

• Sirolimus and Everolimus can affect

wound healing, cause proteinuria

and in combination with

Cyclosporine or Tacrolimus affect

the kidney function.


2008 Vol 23 Vol No. 1 27

organ donation. After

an in-depth cl inical

examination, the donor is

subjected to laboratory

workup.

The first step is the

demonstration of blood

group compatibility (ABO).

I f the blood group is

compatible, the donor is

tested for renal functions

and any systemic condition

which might interfere with

organ donation or surgical

fitness. If the renal functions

are good and there is no

risk other than that

associated with an elective

surgery, only then the

prospect ive donor is

considered fit to donate.

The possibi l i ty of

transmitting an infection

should be ruled out by

performance of serological

tests. HIV seropositivity is a

contra-indication to renal

donation. Similar ly,

Hepatitis B or Hepatitis C

seropositive individuals

cannot donate to respective seronegative recipients. Any

active infection, especially urinary tract infection should

be completely treated prior to kidney donation. Specific

viral illnesses which are quiescent in a normal individual,

can become life threatening in an immunosuppressed

individual and need to be ruled out prior to donation.

These includes Cytomegalovirus (CMV) and Epstein -

Barr virus (EBV). An active infection can be ruled out

serologically by measuring IgM antibodies against these

viruses.

To quantify the donor’s renal functions, a 24 hr urinary

creatinine clearance is done or similar information may

be obtained by measuring the level of kidney function

on a nuclear medicine study (DTPA GFR). Surgical fitness

is largely decided by cardiovascular fitness followed by

the hepatic functions and respiratory i l lnesses

compromising lung functions. Finally the surgical

anatomy of blood supply to the kidneys needs to be clearly

delineated prior to surgery. This is done by either a

conventional renal

angiogram or Digital

Subtraction Angiogram

(DSA) or Computerized

Tomography (CT)

Angiogram depending on

availability.

HLA TEST AND

LYMPHOCYTE

CROSSMATCH

Human Leukocyte Antigen

(HLA) is a set of antigens

encoded by Major

Histocompatibility Complex

on chromosome 6. There

are two classes, class I and

class II. Class I includes

subgroups A, B and C and

class II includes subgroups

DR, DQ and others. Each

subgroup expresses two

alleles. Hundreds of such

alleles have been identified

and more are added every

few months. For Renal

Transplantat ion, the

subgroups A, B and DR are

considered important.

Identical twins will have

100% matching in these alleles. The other siblings can

have a 100% match (HLA identical), a 50% match

(haplo-identical) or a zero match between them. Parents

have a 50% match with their offsprings. Better the HLA

match, lesser is the immunosuppression required and

longer is the graft survival. Even though the HLA match

may be 100%, there are several other antigenic stimuli

which can incite an immunological response by the

recipient precipitating a graft rejection. This can be

tested by doing a lymphocyte crossmatch test where

donor lymphocytes are incubated with recipient serum

and if more than 10% of donor lymphocytes are destroyed

by recipient serum, it is designated as positive and a

transplant precluded at that stage and a search for

alternative donor initiated. This situation arises after

multiple pregnancies or donor specific transfusions.

WORKUP OF THE RECIPIENT

The workup is largely directed towards surgical fitness


THE OLD KIDNEYS ARE USUALLY PRESERVED SINCETHEY ARE HARMLESS AND CAN ACTUALLY CONTRIBUTE

SOME FUNCTION EVEN AFTER TRANSPLANT.“

“


and the viral illnesses mentioned above and have similar

implications as in the donor. Active infections including

UTI, dental abscesses, dental caries need to be ruled

out. In children, a common cause of renal failure is

abnormal bladder function. Bladder function needs to

be tested for its ability to accommodate and hold the

increased urine after transplant. If abnormal, a corrective

bladder surgery may be required.

TRANSPLANT SURGERY

Two surgical teams operate simultaneously on the donor

and the recipient. The donor kidney is placed in the

recipient’s iliac fossa outside the peritoneal sac. The

renal blood vessels are joined to the iliac blood vessels

and the ureter is joined to the bladder with a technique

designed to prevent reflux from the bladder into the renal

graft. The old kidneys are usually preserved since they

are harmless and can actually contribute some function

even after transplant. The additional surgery of removing

old kidneys can be avoided unless they are severely

infected or are too large and occupying the whole of

abdomen.

IMMUNOSUPPRESSION

Except in an identical twin, immunosuppression is

required to prevent rejection. This includes the

medicat ions l ike cyclosporine or Tacrol imus,

Mycophenolate (MMF) or Azathioprine along with

glucocorticoids. Newer, more potent drugs include

Sirolimus and Everolimus. If the HLA match is poor, an

‘induction’ agent is used in the form of monoclonal or

polyclonal antibodies against lymphocytes. These

medications are started a day or two prior to the surgery

and the antibodies are usually given just prior to the

surgery and after a fixed interval thereafter depending

on the drug used. The immunosuppression needs to

be continued life-long. These drugs need to be

monitored since the ‘therapeutic index’ is quite narrow.

Blood levels of cyclosporine and Tacrolimus are checked

routinely till the desirable level is achieved and thereafter

whenever the need is felt. Levels are also monitored for

Sirolimus and Everolimus. With the current day potent

immunosuppressants, graft life has increased at the cost

of increased risk of infections. Urinary Tract Infection

still remains the commonest infection followed by

bacterial pneumonia, viral illnesses like CMV and fungal

infections. Tuberculosis still remains a potent threat in

transplant recipients . A polyoma virus called BK virus

is becoming increasingly more recognized as a cause

for steady decline in graft function.

POST TRANSPLANT PERIOD

The transplant recipient requires close follow-up in the

post transplant period. The initial year is the most

important but the surveillance should continue lifelong

to ensure a long survival.

OUTCOMES OF RENAL TRANSPLANT

With potent immunosuppressive options available

today, graft survival has significantly improved. The

graft ‘half-life’ has increased to 12 to 15 years from a

previous 5 to 10 years. The outcomes are better with

complete HLA match (100%) compared to haplo-

identical (50% match) which in turn has better survival

than zero match. However, the outcomes are affected

by acute rejection episodes, severe infections,

recurrence of the native kidney disease in the graft

and cardiovascular diseases.

THE GRAFT ‘HALF-LIFE’ HAS INCREASED TO 12 TO 15YEARS FROM A PREVIOUS 5 TO 10 YEARS.“

“

28 2008 Vol 23 No. 1


UPDATE

To commemorate the 75th Birth Anniversary of Smt. Lalita Girdhar Hinduja on 1st November

2007, Hinduja Hospital took another step forward in the hi-tech world of modern medicate

to uphold the strong organization values of to improve patient safety and comfort,

inaugurated 8 new state-of-the-art operation theatres.

The new digitalized Operation Theatre complex is the first in many aspects in the country

and can match the best in the world. These theatres have been designed , keeping in mind

the surgeon, anesthetist, nurses and other OT personnel working requirements.

Highlights of this new OT complex:

• Guided Airflow Ventilation System (GAF): a patent technology for keeping

surgical site free of contamination.

• The Heat Ventilation and Air Conditioning Systems (HVAC): Each OT has it’s

individual Air Handling Unit (AHU) with independent temperature and humidity

controls. The first hospital to install the Digital Direct Control (DDC) for

management of pressurization of the complex, cleanliness of the various filtration

process based on room zoning, will greatly enhance the management of the air

quality with in the complex.

• Operating Lights: Light Emitting Diodes (LED) provides shadowless operating

light, excellent visualization, minimum heat generation and proper dissipation

with high light intensity.

• Integrated camera with LED lamps to capture crystal clear live images

• Simultaneous web telecasting of procedures.

New State-of-the-Art Operation Theatres

CONFERENCE AND SEMINAR

PLEASE VISIT www.hindujahospital.com/registration to register online

OR

VIEW PAST & FUTURE EVENTS.

2008 Vol 23 Vol No. 1 29


THE IDEA OF rebui lding a bone marrow

destroyed by radiation was born in the aftermath

of World War II and the subsequent nuclear arms.

First modern transplants started in 1957 in patients

with end stage leukemia.

Stem Cell Transplant (SCT)

INDICATIONS

The rationale for SCT differs for different diseases. Mainly,

it serves as:

• A rescue procedure after treatment with high dose

chemotherapy in certain malignancies

• As replacement therapy in patients with marrow

While Stem Cell Transplant has vast benefits, it is associated with a number of

complications, some of which may be life threatening.

By Dr. Asha Kapadia, Dr. Sachin V. Almel & Dr.Uma Dangi

30 2008 Vol 23 No. 1


failure or autoimmune disorders

• As a vehicle for gene therapy

• Possible strategy to establish tolerance

for solid organ transplants

TRANSPLANT PROCEDURE

In preparation for SCT, it is necessary to

“condition” the patient. The conditioning

regimens vary with the type of disease and

can be high dose chemotherapy, biologic

• Thrombocytopenia

• Infections

• Mucositis

• Venoocclusive disease

• Acute GVHD

• Graft failure

Late effects:

• Chronic GVHD

• Growth failure

• Infertility

DONOR

SELECTION

The choice of the

source of stem cells

depends on many

factors, importantly

the patient’s disease.

Depending upon the

source, transplant

can be –

Autologous -

source are

patient’s own

cells

Syngeneic –

donor is an

identical twin

Allogeneic –

• HLA identical

donor (related

/ unrelated)

• HLA non

i d e n t i c a l

donor (related

/ unrelated)

Xenogeneic –

different species

The stem cells are

either collected

from the bone

marrow; or the

peripheral blood

after treating with

growth factors.

therapy and radiation. The stem cells are

infused through a large bore central

venous catheter. Post transplant, the

engraftment depends on the source of the

stem cells and the use of G-CSF, usually

occurring at day 10 – 21.

COMPLICATIONS

SCT is associated with a lot of

complications, some of which may be life

threatening.

Early Toxicities:

• Neutropenia

• Cataracts

• Second malignancies

Transplant program at Hinduja Hospital

We have been doing Autologous

peripheral blood stem cell transplants’s

here at Hinduja Hospital for last 6 years,

mostly for malignant conditions viz.

mul t ip le myeloma and re lapsed /

refractory lymphomas. We have done

around 13 transplants so far, with good

results. We also plan to start Allogeneic

transplant at our centre in a short

while.

POST TRANSPLANT, THE ENGRAFTMENT

DEPENDS ON THE SOURCE OF THE STEM

CELLS AND THE USE OF G-CSF, USUALLY

OCCURRING AT DAY 10 – 21.“ “

CHECK LIST

STEM CELL TRANSPLANT

2008 Vol 23 Vol No. 1 31


INTRODUCTION:

TWENTY FIVE YEARS AGO the first successful

clinical lung transplant was performed and since

then lung transplantation has become the modality

of choice for a variety of end-stage lung diseases.

Lung transplant –Where does it stand today ?

This has essentially been due to the amazing advances

that have been made in the field through refinement of

surgical techniques and improved understanding of

transplant immunology and microbiology.

Approximately 1,400 transplants are performed

With refinement of surgical techniques and a greater understanding of

immunology and microbiology, the success of lung transplantation has increased

manifold. By Dr. Manoj Agni

32 2008 Vol 23 No. 1


worldwide each year. The operative

mortality rates are less than 10% and one

year survival is greater than 80% for most

diagnoses. Functional results are excellent

and durable. Post-transplant quality-of-life

25% predicted.

• Resting Hypoxia – PaO2 < 60 mm

Hg.

• Hypercapnia – PaCO2 > 50 mm

Hg.

studies demonstrate s igni f icant

improvement in the majority of patients.

Unfortunately, donor shortages continue

to limit the more widespread application

of lung transplantation. In order to address

this issue, marginal donors, living lobar

and split lung donor techniques have been

used clinically to increase the number of

donor lungs available.

FOR WHOM AND WHEN ?

• Emphysema due to chronic

obstructive pulmonary disease

or ααααα-1-antitrypsin deficiency

• Cystic fibrosis and

• Pulmonary f ibrosis.

• In the paediatric population,

cystic fibrosis and pulmonary

vascular disease are the prime

indications.

Referral guidelines:

• Endstage lung disease with l i fe

expectancy less than 1 - 2 yrs.

• Postbrochodilator FEV1 less than

DONOR LUNGS ISSUES

Ideal donors are ones with a

nonsmoking his tory, clear chest

radiograph, negative bronchoscopy and

good gas exchange (PaO2)/ (FIO2)

>300). Unfortunately, only 5–10% of

multiorgan donors have lungs that meet

these criteria

Donors aged less than 60 yrs are

preferable.

Contra indicat ions: ABO

incompatibil i ty between donor and

recipient, human immunodeficiency virus

positivity, active malignancies (outside the

central nervous system), and active

hepatitis infections remain absolute

contra indicat ions to donor lung

procurement.

Most adult lung transplants can

be conducted without the requirement

for cardiopulmonary bypass. Patients

with severe primary or secondary pulmonary

hypertension and paediatric patients need,

cardiopulmonary bypass.

SINGLE OR

DOUBLE LUNG

TRANSPLANT ?

ON OR OFF

BYPASS ?

General guidelines for

the selection of the

procedure are based

on the nature of the

original disease and

are as follows:

Double-lung

transplantation

• Cystic fibrosis

• Generalized

bronchiectasis

• Some patients

with COPD

Single-lung

transplantation

• Restrictive

fibrotic lung

disease

• Eisenmenger

syndrome with

reparable

cardiac

anomaly

• Some patients

with COPD

• Primary

pulmonary

hypertension

Heart- lung

transplantation

• Eisenmenger

syndrome with

irreparable

cardiac defect

• Pulmonary

hypertension

with cor

pulmonale

• End-stage

lung disease

with concurrent

severe cardiac

disease

CHECK LIST

LUNG TRANSPLANT

DONOR SHORTAGES CONTINUE TO LIMIT

THE MORE WIDESPREAD APPLICATION

OF LUNG TRANSPLANTATION.“

“

2008 Vol 23 Vol No. 1 33


AFTER ALL THIS,

HOW WELL DO THE

RECIPIENTS DO ?

Operative mortality and

long-term survival vary by

diagnosis, with emphysema

providing results somewhat

superior to more

challenging conditions

such as pulmonary fibrosis

and pulmonary

hypertension. The operative

mortality is usually around

5 - 10%.

Postoperative functional

resul ts are excel lent.

Fol lowing bi lateral

transplantat ion for

emphysema, the mean

FEV1

increases from a preoperative level of 16% of the

predicted value to 84% at 3 months. This improvement

in pulmonary function is maintained at 1 yr with a mean

FEV1 of 75% predicted. Among cystic fibrosis patients,

results are similar, with a preoperative FEV1 of 22%

predicted increasing to 68% predicted early

postoperatively and 70% predicted at 2 yrs.

Among more than 14,500 lung transplant recipients

on the ISHLT ( International Society of Heart Lung

Transplantation) Registry, overall 1-, 3- and 5-yr survival

is 76, 57 and 43% respectively. Among single lung

recipients, FEV1

at 5, 6 and 7 yrs after transplantation

was 75, 73 and 68% predicted respectively. Experience

with pulmonary hypertension has also been gratifying.

These patients have experienced immediate restoration

of normal right heart function and pulmonary

haemodynamics which persists over a 4-yr follow-up

period. Actuarial survival of paediatric recipients is

77% at 1 yr, 62% at 3 yrs and 55% at 5 yrs.

Improvement in quality of life is seen after the

transplant and usually becomes evident after 3–6

months. Mobility, energy,

sleep, activities of daily

living dependency level

and dyspnoea were reported

to be improved following

lung transplantat ion.

Pretransplant psychological

status appears to affect

post-transplant quality of life

and adjustment.

BILATERAL

LIVING-DONOR

LOBAR LUNG

TRANSPLANTATION

Bilateral living-donor lobar

lung transplantation is a

procedure for pat ients

considered too ill to await

cadaveric transplantation. In this procedure, right and

left lower lobes from two healthy donors are implanted

in the recipient in place of the whole right and left lungs,

respectively.

Because only two lobes are transplanted, it seems to

be best suited for children and small adults Furthermore,

since paediatric patients receiving living lobar

transplants experienced less BOS and better pulmonary

function than paediatric recipients receiving cadaveric

donor lungs, living lobar transplantation may be the

preferred method for children.

Dramatic improvement of

pulmonary hemodynamics is

confirmed by chest X-ray and

echocardiogram. The mean

pulmonary artery pressures can

decrease from 72 mmHg to 11

mmHg. A year postoperatively, the patient is in

excellent physical condition with a forced vital capacity

and FEV1 close to 90% of predicted.

What to watch out forpostoperatively – earlyand late ?

Reperfusion injury - Early lung

allograft dysfunction occurs in 15–20%

of cases.

Airway complicat ions

In fec t ions

Rejection - Most recipients experience

at least one episode of acute rejection

within the f i rs t year fol lowing the

transplant. Calcineurin inhibitors are

used in virtually all patients

Bronchiolitis obliterans syndrome -

BOS

LUNG TRANSPLANT

IN BILATERAL LIVING-DONOR LOBAR LUNG TRANSPLANTATION,

RIGHT AND LEFT LOWER LOBES FROM TWO HEALTHY DONORS

ARE IMPLANTED IN THE RECIPIENT IN PLACE OF THE WHOLE

RIGHT AND LEFT LUNGS, RESPECTIVELY.“ “

34 2008 Vol 23 No. 1


LUNG TRANSPLANT

Chest X-rays before (A) and after (B) receiving

LDLLT. (A) Before operation. Marked cardiomegaly

was present. (B) Three months after receiving

LDLLT. Well-expanded lobes filled the chest cavity,

leaving no detectable dead space without

cardiomegaly.

Survival af ter l iv ing-donor lobar lung

transplantation. After receiving a living-donor

lobar lung transplantation, 31 of 33 recipients

(94%) are currently alive for as long as

77 months.

Auto graft -Transplant of tissue to the same person e.g. Skingrafts, vessel grafts for CABG

Allo graft -Transplant from a genetically non-identical memberof same species e.g. human organ/ tissuetransplants.

Iso graft -Transplant to a genetically identical recipient e.g.identical twins

Xeno graft -Transplant from one species to another e.g. porcineheart valve transplant

Split Transplants -Donor organ (e.g. liver) may be divided betweentwo recipients.

Domino Transplants -This operation is performed for cystic fibrosis as bothlungs and heart are easier to transplant enbloc,recipients healthy heart is transplanted into someoneelse.

TYPES OF TRANSPLANTS

2008 Vol 23 Vol No. 1 35


AUTO SKIN GRAFTS have been in Mumbai since

1950 progress happened in improved knife blades,

electronic dermatome and meshing. Heterogenous

grafting did not succeed, as was expected. Skin

banking and culture are for the future.

SHORT HISTORY OF ORGANTRANSPLANT

Solid organ transplant of kidney first took place in

around 1965 – 66. It was performed by Dr. Pardanani,

under leadership of Dr. P. K. Sen in K.E.M. Hospital.

However organ performed for a few days, as powerful

immuno-suppressives were not available. Donation of

PROGRESS IN CITY OF MUMBAI - By Dr. R. A. Bhalerao

36 2008 Vol 23 No. 1


organ from cadaver was obtained by

obtaining affidavit from “cadaver” patient’s

relative, in presence of a Magistrate or JP.

Same process was used for cadaveric

donations of two livers and two hearts. Liver

transplantation was carried out by Dr. R. A.

Bhalerao and cardiac transplant by Dr. P. K.

Sen. The retrieval team was headed by

Dr. R. A. Bhalerao. However these efforts

were mainly supplemented by first successful

cardiac transplant in South Africa by

Christian Bernard. The liver transplants were

mainly technical success, cardiac transplants

worked for few hours. Further efforts got

dwarfed by some legal technical objections

pointed out by Dr. T. H. Ridani, the then

Dean of K.E.M. Hospital. One additional

cardiac transplant was done by Dr. K. F.

Dastur in Nair Hospital. Further cadaveric

transplants, had to wait till Human Organ

Transplantation Act, 1994. The first long

term successful cadaveric kidney transplant

was performed by Dr. Vatsala Trivedi,

Urologist from Sion Hospital, and since then,

L.T.M.G., K.E.M. Hospital and corporate

hospitals Jaslok and Hinduja Hospital are

in forefront of kidney and liver transplant

operations, with both cadaveric and live

related donor programme. ‘Selling’ of

kidneys, prosecutions, and public debates

have now brought the organ donations

programme to a new crisis with shrinking

cadaver organs rising demands and

‘morality ’ block by different segments

of society including press, police,

judiciary, doctors. Government being

involved in more ‘urgent’ national problems

the future looks unclear. The same happened

in ‘blood transfusion’ programme

where now voluntary donor programme is

replacing professional donor programme.

In Asian countries cadaveric donations

share additional social and religious

inhibitions, hence this slow progress appears

inevitable.

1. Dr. Ashwini Gandhi Bhalerao was awarded

the “Dr. Suresh Nadkarni Mitramandal

Award for the year 2006-2007” by the

Indian Medical Association, Maharashtra

State for her activities in the field of health

education through mass media, books on

health related topics and conducting lectures for public health

education.

2. Dr. Shusheel Kharbanda, resident

(urology) won the first prize in paper

presentation for a paper “PROLONGED

ILEUS POST RADICAL CYSTECTOMY:

CONSIDER TOBACCO”. The paper was

presented in Mumbai Urology Society –

Annual Meeting 2008, held at Lonavala between 4th – 7th July

2008.

3. Dr. Lancelot Mark Pinto, 3rd year Dip. N.B.

in Respiratory Medicine, won the second

prize for the South Asian Cochrane

Network Essay competition for Post –

graduate students in the health sciences

on the topic “BARRIERS TO EVIDENCE

INFORMED PRACTICE IN SOUTH ASIA

AND POSSIBLE SOLUTIONS” at the 2nd South Asian Regional

Symposium on Evidence Informed Health Care at the Christian

Medical College, Vellore on April 9th 2008.

AWARDS

SHORT HISTORY OF ORGAN TRANSPLANT

2008 Vol 23 Vol No. 1 37


PET SCAN

P.D.Hinduja Hospital and MRC recently installed the

second generation PET/CT in September 2007, an

advanced version of Discovery TM Ste from GE

Healthcare for the first time in India. The advantages

of this PET/CT scanner gives images that help doctors

to diagnose patients in early stages of cancer and

increase the prospect of preventive cure. It enables

the radiation oncologist to focalize the beam of

HINDUJA NEWS

38 2008 Vol 23 No. 1

Interactive Session by Dr. Phulrenu Chauhan

Abhijeet Sawant with his young fans

radiation to the active part of the tumor. This helps

the risk of radiation exposure to the neighboring

normal tissue. The machine has been used to perform

a whole body scan on a seven year-old patient.

CAMPS

12 Medical Camp were organised commemorating

the 75th anniversary year of L. G.H.

WORLD JUVENILE DIABETES DAY &

CHILDREN’S DAY

On 14th November, Hinduja Hospital organized a

camp for the juvenile diabetes on Children’s Day. More

than 60 diabetic children with their families joined in this

celebration. The chief guest for the day was Abhijeet

Sawant, India’s very first Indian Idol. The programme

included an electrifying tabla performance by the young

tabla artists, the Khan Brothers. Magic show performance

by Mr. Ashraf Khan and active participation from the


HINDUJA NEWS

2008 Vol 23 Vol No. 1 39

Dr. Kirtane felicitating Mrs. Vakil at the 2nd CochlearImplant Workshop

Demonstration of Intubation

Cornell, USA. A team of outstanding faculty members from

both the institutions provided an integrated view of

Emergency Medicine.

The highlights of this conference were hands-on –

experience with mannequins which is first of its kind in

India, especially flown in from USA. These mannequin

simulators helped develop an increasingly realistic physical

and procedural components to complement an already

high level of situational realism. The objective of this

conference was to establish a residency programme in EMS

Emergency procedure – Drawing of Femoral blood

children during the brief interactive session conducted by

Dr. Phulrenu Chauhan which included a quiz on juvenile

diabetes for educating and raising awareness among the

audience.

WORKSHOP

The P D Hinduja Hospital organized the 2nd Cochlear

Implant Update from 22 – 23 December, 07. The

Workshop was aimed at ENT surgeons, audiologists and

educators for the hearing impaired, keen to start their

own Cochlear Implant Programmes.

Recognizing the need for a wider awareness on

Cochlear Implants and the need for professionals to

understand the team approach required to make

Cochlear Implants a success, P D Hinduja National

Hospital, through this workshop, aimed to provide basic

information and training to the participants.

The workshop also felicitated Mrs. Meher K Vakeel,

a pioneer in the field of education for the hearing

impaired in India. Mrs. Vakeel, who has dedicated over

forty years of her life, to the education of the hearing

impaired is credited with establishing The Education

Audiology and Research Society, the first teacher training

course for the hearing impaired in India, an infant centre

for early diagnosis and parent guidance, and the

introduct ion of neonatal hearing screening

programmes. Among other accolades she is the recipient

of the prestigious ‘International Meritorious Service

Award” by the Alexander Graham Bell Association for

the Deaf, UK.’

CONFERENCE ON EMERGENCY

MEDICINE

On 14th & 15th November, Hinduja Hospital conducted a

workshop on Emergency Medical Services, in collaboration

with the Division of Emergency Medicine – New York

Presbyterian - The University Hospital of Columbia and

by sensitizing the medical fraternity to the nuances of EMS

as a practice in the developing countries.

To take the EMS dream further, P.D. Hinduja National

Hospital & MRC has taken a step towards developing

Emergency Medicine as an independent specialty in India.

Hinduja hospital has always been at the vanguard of

pre-hospital care development. A Policy program is

being developed for recommendation to the National

Knowledge Commission a high level advisory body, during

the meeting of the Dean and Heads of major institutions

from Mumbai apart from senior faculty on Emergency

Medicine from New York Presbyterian – The University

of Columbia and Cornell was held on the 13th of

November 2007.


WELCOME

Printed and Published by Marketing Department, P. D. Hinduja National Hospital & Medical Research Centre, Veer Savarkar Marg,

Mahim, Mumbai - 400 016 at SYNERGY CREATIONS , for free and private circulation. Editor : Dr. Reeta Dalal. Registered.

(The Publisher cannot be held responsible for errors or for any consequences arising from the use of the information

contained in this newsletter.)

Dr. (Mrs.) Chitra Madiwala has joined as the Consultant Histopathologist in the department of

Laboratory Medicine.

Dr. Madiwale completed her MD (Pathology) in 1988 from the University of Mumbai and fellowship

in Nephropathology from USA. She has over 22 years of experience having worked at G.S.Medical

College & KEM hospital - Mumbai and as an associate Professor at G.S. Medical College & KEM

Hospital.

Her areas of interest include nephropathology, gynecologic - pathology and orthopedic - pathology.

Dr. Sudhir Warrier has joined as a Consultant in Hand & Reconstructive Surgery, section of

Orthopedics.

Dr. Warrier did his MS (Orthopedics) in 1987 from Grant Medical College, University of Mumbai.

He has done fellowships from Gyeongsang National University, Korea; Okayama University, Japan

& Government Stanley Hospital, Chennai. He was awarded the Best Discourse Award at the XIIth

International Orthopedic Congress, Pakistan in the year 1997 and the Scholarship of Asia Pacific

Societies for Surgery of the Hand, Hong Kong in the year 2002.

Dr. Warrier is attached to Laud Clinic, Shushrusha Citizen Co-op Hospital & Jaslok Hospital. He is regularly involved in

training programmes across the country for the post-graduate students & practicing orthopedic surgeons through workshops

on Hand Surgery & External Fixation.

Dr. Pankaj Deshpande has joined as Consultant in Pediatric Nephrology, section of Pediatric

Medicine.

After completing his MD in pediatrics and 2 years in Pediatric Nephrology from Bai Jerbai Wadia

hospital for Children, Dr. Deshpande went to UK in 1996. He pursued his MRCP in Pediatrics in

1997 and post MRCP he specialized in Pediatric Nephrology in various centers' of excellence in UK.

He has worked as a Pediatric Nephrology Consultant at Southampton General Hospital, UK from

2001 to 2005.

He returned to Mumbai in 2005 and ever since then has been practicing as a pediatric nephrology consultant at MGM

Hospital, Lok Hospital, Kidney Speciality Group and Sai Child Care Centre.

Dr. Sharmila Ghosh has joined as the Consultant Haematologist in the Dept of Laboratory Medicine

Dr. Ghosh completed her MD in Pathology in 1995 from Kasturba Medical College. She was trained

in Hematology from St. Jude Hospital - US, in January 2008 and did advanced training in Bone

Marrow reporting, Flow Cytometry and FISH at the Royal Free Hospital - London in 2004. She has

also received training in Quality Systems e.g. ISO - 13000 from Tata Business Excellence.

Dr. Ghosh has expertise in Phase I to Phase IV Clinical Trials, entailing planning, resource utilization

and manpower management. She is skilled in planning and scheduling work, establishing systems,

setting goals and standards.

Dr.Ghosh has worked at Asian Institute of Oncology, Raheja Hospital and Tata Memorial Hospital in Mumbai and

Jamshedpur. Prior to joining us she had worked at SRL Ranbaxy Ltd. as a Consultant Hematologist.

Her area of interest is Hemato-Oncology.

Dr. Uday Limaye has joined as the Consultant in Interventional Neuroradiology, section of

Interventional Radiology (DSA) in the department of Imaging. He completed his DNB from Grant

Medical College and Sir JJ Group of Hospitals, Mumbai in 1995 and underwent specialty training

from world renowned Interventional Neuroradiology centres like Foundation Rothshield

Hospital,(France); Royal Perth Hospital, Australia and Haciteppe University, Turkey.

Dr. Limaye is the Associate Professor& Chief of Interventional Neuroradiology at Seth G.S.Medical

College & KEM Hospital; Mumbai .He has done pioneering work on Dural Venous Sinus thrombolysis,

which was adjudged as the best paper at the Eastern Neuroradiology Meeting, Toronto in 2005.

His areas of interest & expertise include intracranial stenting for Brain Aneurysms & Intracranial Artherosclerosis, Acute

Stroke Therapy & Endovascular management of Craniofacial Vascular Malformations.

WELCOME


Documents

New Layout-Dt 14-2-2009 - final.pmd 2/14/2009, 5:16 PM 1