2.TRANSPLANTASYON 7. SUNUM
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Transcript of 2.TRANSPLANTASYON 7. SUNUM
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Liver Transplantation: Indianperspective
A.S. SoinHead of Department of Liver Transplantation
Sir Ganga Ram Hospital
New Delhi, India
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Mythology
Lord Ganesha
the oldest example of
(xeno) transplantation
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Ancient past
Sushruta
(Ahurveda
800 BC)
firstdescription ofhumangrafting NOSE JOB
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Plan
National perspective
Sir Ganga Ram Hospital experience
Development of Liver Transplant in India
Conclusion
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Organ donation and LTx inIndia: hard facts
1.1 billion population
HOTA (Legal Act) since 1994
4 regional OPOs (1 Govt, 3 NGO)
60 deceased donors per year: 2002-06 Livers used : 10-15 per year
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Need / rate of LiverTransplantation: India vs West
Region Rate of LTs
Developed West 12-32 per million
India 0.008per million
(58, 90 transplants in 2005, 2006)
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15
1015
2024 25
42
58
90
0
10
20
30
40
50
60
70
80
90
1995 1998 1999 2000 2001 2002 2003 2004 2005 2006
Liver Transplant in India:
annual trends
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Liver transplantation in India422 LTx in a total of 23 centres
138 DDLT and 284 LDLTNo. of transplants No. of centres
> 150 1
50-150 1 10-50 4
< 10 17
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Liver transplantation in IndiaLDLT : Total 284 Txs in 13 centres
No. of transplants No. of centres > 150 1 (SGRH)
50-100 1
10-20 2
< 10 9
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Sir Ganga Ram Hospital
SuperspecialityandResearchBlock
SGRH
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Located in theSuperspeciality andResearch Block
SGRH
The SGRH Liver TransplantUnit
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The SGRH Liver Transplant Unit
Specially designed
twin OTs Dedicated Liver
Transplant ICU
Liver HDU (step-down facility)
SGRH
Liver TransplantICU
LiverTransplant
OperationTheatre
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Patient group Survival (0.2-57 m)
(pt and graft)
LDLT 146/168 (87%)
ALL DONORS WELL (169/169)
SGRH experience: LDLT
results at a glance
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Patient and graft survival in 168
LDLTs
70
80
90
100
0 1m 3m 6m 12m 24m
Survival %
Time after transplant
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Live Donor Liver Transplantation:
SGRH Experience: 168 cases
169 Donors
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Donor Results Demographics
(n=169)
Age (years) 36.6y (21-57y)
Sex (M:F) 44:56
Weight (kg) 64.8 (48-90kg)
GRWR (%) 1.1 (0.6-3.7%)
R/L lobe 131/38MHV+ 102/131
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Intraoperative details
Operative time
(hours)
7.9 (5.30-11)
Transfusion
(units)
0.4 (0-8)
No transfusion 138/169 (82%)
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Postoperative course - donors
Survival 100%
Liver insufficiency None Intervention 5 pt. (CTdrain 3,
EBS 2)
Early re-operations 2 (bleed) Late re-operations 2 hernia repair
Hospital stay 7.8 d (6-18 d)
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Postoperative course - donors
Portal vein thrombus 1 (partial) Post op transfusions 5 Chylous ascites 1 Sepsis needing ICU 2 Bile leak 8 (5% - 2 BD stump,
6 cut surface) SAIO 2
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Donor follow - up
Mean 23 months (0.2 - 57 months)
Return to normal activity (4-7 weeks)
All doing well
Normal Liver function
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Live Donor Liver Transplantation:
SGRH Experience
Recipients
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SGRH LT series: aetiology(all LDLT patients, n = 168)
HCV, 53
Cholestatic Dis, 16HBV, 25
Crypto, 32
Ethanol, 17
FHF, 11
Non-cirrh
tumours, 3
Wilson's, 4
AIH, 6
Tyrosinemia, 1HCC withcirrhosis
34
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LDLT at SGRH: overview2002-07
Total * 168 Right lobes 130 Left lobes 37 Dual lobe 1(right + left)
Adult Adult right and left lobes 130 / 23 Pediatric left/right lobes 15 / 1
Elective 157
Emergency 11 (8%)*No re-transplants
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Patient characteristics
N= 168
Age: 39.2 years (1-70 years)
Sex: 116 M : 52 F
Childs Grade (159 CLD patients)Childs A B C
2 19 (14 HCC) 138
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LDLT: Intraoperative details
Operative time
(hours)
11.3 (5.8-25)
BloodTransfusion
(ml)
1650 (0-10110)
Additionalvascularreconstruction
Reqiured inalmost all
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Triple drug (Tac + Myco + steroid)
Extubation (mean, hrs) 10
Hospital stay (mean) 17.8 days (11-78)
Recipient post-Tx course
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Fulminant hepatic failure 10/11
Simultaneous liver and kidney Tx 1
for hyperoxaluria using two
separate live donors
Dual lobe transplant (right + left) 1
Moving ahead.
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Dual lobe transplant
Patients preop body weight 78 kg
Right liver weight 520 g
liver to body weight ratio 0.66
Left liver weight 252 g
liver to body weight ratio 0.32
Combined liver weight 772 g
Combined liver to body weight ratio 0.98
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Right and left livers looking healthy post-reperfusion and 15 days after LTx
Right liver Left liver
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Developing Liver Transplantation in India
Infrastructure Cost
Expertise
Expanding the donor pool
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Cost to company analysis of last 50 casesBasic cost of LDLT: 25000 USD in anuncomplicated case (60%)
Cost in remaining 40%: 38000 USD Who pays?
Self: private funds, collection by appeals, loanOthers: Govt / Tax payer, insurer, corporateemployer, Govt. employer, NGO, philanthropist,
pharmaceutical industry Solutions
Cost cutting generics, identical bl group ptsscheduled same week, cut down unnecessary testsIncrease funding by others esp. insurance
Developing Liver Transplantation: cost
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General problems Government Hospitals unable to launch a viable
programme yet
Still no foolproof mechanism to report all results tothe Health Ministry Cost private 40-50,000 USDollars
Solutions Incentives to team should be built into Govt
funding of LTx programmes Online registry - compulsory same day online
reporting into Health Ministry website Better insurance cover
LTx: problems in India
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LDLT Unregulated proliferation of centres
Cases by fly by night surgeons Under-reporting of donor deaths (4: 2 each in
North and South India only 1 reported inmedical literature, 2 in lay press)
Solutions Regional ceiling on number of centres Quality assurance - international guidelines for
infrastructure and expertise based onrecommendations of a National Professional Body
LTx: problems in India
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DDLT Rare operation ICU staff not geared up for donor
management OPOs kidney heavy livers wasted
would not even ask permission for liversretrieval to suit the convenience of kidney surgeons (liversurgeons come from outstation
Law - All hospitals with ICUs NOT accredited for multiorganretrieval (only transplant centres approved)
Health a state subject (27 states!) liver wasted if not placedin the state
Medico-legal cases (accidents/post surgical deaths) pvthospitals more active but no provision for PM or its waiver
Solutions: Non-govt OPO with Govt supportAmendments to law
LTx: problems in India
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Fulminant hepatic failure:logistics
Is informed consent / proper donorcounselling possible?
Transporting recipient
Quick donor work up
Extent of recipient work up
Abandoning attempt to transplant
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Fulminant hepatic failure:-worth it
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Conclusion
It has been possible to establish a viable livertransplant programme in India based on livingdonation
Development of new programmes should be based onan already working model and regulated by Govt.guidelines
Organ donation awareness, procurement andcoordination bodies must become active
All recipient / donor data to go into a National Registry Make LT affordable by cutting costs / better
insurance / Government programmes