Liver Transplantation: Indian

perspective

A.S. Soin
Head of Department of Liver Transplantation
Sir Ganga Ram Hospital
New Delhi, India
 Mythology

Lord Ganesha
the oldest example of
(xeno) transplantation
 Ancient past
Sushruta
(Ahurveda
800 BC)
first
description of
human
grafting –
NOSE JOB
 Plan

 National perspective
 Sir Ganga Ram Hospital experience
 Development of Liver Transplant in India
 Conclusion
 Organ donation and LTx in
India: 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
 Need / rate of Liver
Transplantation: India vs West

Region Rate of LTs

 Developed West 12-32 per million

 India 0.008per million
(58, 90 transplants in 2005, 2006)
 Liver Transplant in India:
annual trends
90 90
80
70
60 58
50
42
40
30 25
24
20 20
15
10 10
5
0 1
1995 1998 1999 2000 2001 2002 2003 2004 2005 2006
 Liver transplantation in India

422 LTx in a total of 23 centres

138 DDLT and 284 LDLT
No. of transplants No. of centres
 > 150 1
 50-150 1
 10-50 4
 < 10 17
Liver transplantation in India

LDLT : Total 284 Txs in 13 centres

No. of transplants No. of centres
 > 150 1 (SGRH)
 50-100 1
 10-20 2
 < 10 9
SGRH

Sir Ganga Ram Hospital

Super
specia
lity an
d Rese
arch B
lock
 The SGRH Liver Transplant
SGRH

Unit

 Located in the
Superspeciality and
Research Block
 SGRH

The SGRH Liver Transplant Unit

Liver
 Specially designed Transplant
twin OTs Operation
Theatre
 Dedicated Liver
Transplant ICU
 Liver HDU (step-
down facility)
Liver Transplant
ICU
 SGRH experience: LDLT
results at a glance

Patient group Survival (0.2-57 m)

(pt and graft)

LDLT 146/168 (87%)

ALL DONORS WELL (169/169)

 Patient and graft survival in 168
LDLTs

100

90
Survival %

80

70
0 1m 3m 6m 12m 24m
Time after transplant
Live Donor Liver Transplantation:
SGRH Experience: 168 cases
 169 Donors
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 131/38
MHV+ 102/131
Intraoperative details

Operative time 7.9 (5.30-11)

(hours)
Transfusion 0.4 (0-8)
(units)
No transfusion 138/169 (82%)
 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)
 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
 Donor follow - up

 Mean 23 months (0.2 - 57 months)

 Return to normal activity (4-7 weeks)

 All doing well

 Normal Liver function

Live Donor Liver Transplantation:
SGRH Experience
 Recipients
SGRH LT series: aetiology
(all LDLT patients, n = 168)

Tyrosinemia, 1
HCC with
AIH, 6
cirrhosis
Wilson's, 4 34
Non-cirrh
tumours, 3
FHF, 11
HCV, 53
Ethanol, 17

Crypto, 32 Cholestatic Dis, 16

HBV, 25
 LDLT at SGRH: overview
2002-07
Total * 168
 Right lobes 130
 Left lobes 37
 Dual lobe 1(right + left)

 Adult 152
 Adult right and left lobes 130 / 23
 Pediatric left/right lobes 15 / 1

 Elective 157
 Emergency 11 (8%)
*No re-transplants
 Patient characteristics

 N= 168
 Age: 39.2 years (1-70 years)
 Sex: 116 M : 52 F
 Child’s Grade (159 CLD patients)
Child’s A B C
2 19 (14 HCC) 138
LDLT: Intraoperative details

Operative time 11.3 (5.8-25)

(hours)
Blood 1650 (0-10110)
Transfusion
(ml)
Additional Reqiured in
vascular almost all
reconstruction
 Recipient post-Tx course

Triple drug (Tac + Myco + steroid)

Extubation (mean, hrs) 10

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

 Moving ahead….

Fulminant hepatic failure 10/11

Simultaneous liver and kidney Tx 1

for hyperoxaluria using two
separate live donors

Dual lobe transplant (right + left) 1

 Dual lobe transplant
Patient’s 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
 Right and left livers looking healthy post-
reperfusion and 15 days after LTx

Right liver Left liver

Developing Liver Transplantation in India
 Infrastructure

 Cost

 Expertise

 Expanding the donor pool

Developing Liver Transplantation: cost

 Cost to company analysis of last 50 cases

Basic cost of LDLT: 25000 USD in an
uncomplicated case (60%)
Cost in remaining 40%: 38000 USD
 Who pays?
Self: private funds, collection by appeals, loan
Others: Govt / Tax payer, insurer, corporate
employer, Govt. employer, NGO, philanthropist,
pharmaceutical industry
 Solutions
Cost cutting – generics, identical bl group pts
scheduled same week, cut down unnecessary tests
Increase funding by “others” esp. insurance
 LTx: problems in India

General problems
 Government Hospitals unable to launch a viable
programme yet
 Still no foolproof mechanism to report all results to
the 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

 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 in
medical literature, 2 in lay press)
 Solutions
 Regional ceiling on number of centres
 Quality assurance - international guidelines for
infrastructure and expertise based on
recommendations of a National Professional Body
 LTx: problems in India

 DDLT
 Rare operation – ICU staff not geared up for donor
management
 OPOs “kidney heavy” – livers wasted
would not even ask permission for livers
retrieval to suit the convenience of kidney surgeons (liver
surgeons come from outstation
 Law - All hospitals with ICUs NOT accredited for multiorgan
retrieval (only transplant centres approved)
 Health a state subject (27 states!) – liver wasted if not placed
in the state
 Medico-legal cases (accidents/post surgical deaths) – pvt
hospitals more active – but no provision for PM or its waiver

 Solutions: Non-govt OPO with Govt support

Amendments to law
 Fulminant hepatic failure:
logistics

 Is informed consent / proper donor

counselling possible?
 Transporting recipient
 Quick donor work up
 Extent of recipient work up
 Abandoning attempt to transplant
Fulminant hepatic failure:
-worth it
 Conclusion

 It has been possible to establish a viable liver

transplant programme in India based on living
donation
 Development of new programmes should be based on
an already working model and regulated by Govt.
guidelines
 Organ donation awareness, procurement and
coordination bodies must become active
 All recipient / donor data to go into a National Registry
 Make LT affordable by cutting costs / better
insurance / Government programmes