Brouhaha over intestinal transplantation......scattering the chaff

There has been a lost of discussion regarding intestinal transplantation in the context of the victim of the brutal gang-rape in New Delhi recently. Irate protestors, politicians, armchair philosophers and all the usual suspects have been clamouring for 'severe punishment' read 'mutilation', 'torture' and 'death' for the perpetrators of this heinous crime. Some members of the medical fraternity have shockingly and appallingly joined voice with their irresponsible and impulsive suggestions for painless 'mutilation' of the accused forgetting that as professionals they are sworn not to do anything to harm a human being.

Media and medical fraternity have been fairly verbose and prosaic in describing the medical condition of the victim with frequent and graphic updates regarding her condition with the need for intestinal transplantation being thrown-in fairly frequently for good measure. There have also been 'ill-disguised' attempts at garnering fifteen minutes of fame and scoring brownie points in certain quarters provoking comments like 'harvesting the rapists intestines to help the victim' among the less informed and emotional public. There have also been sane and sage voices of reason appearing as well but these have been largely drowned out by the raucous cacophony on part of the rabble-rousers. The medical-media circus has culminated in the shifting the ill-fated victim outside the country to an institution that has 'multi-organ transplant facilities' and 'infrastructure' to help the victim recover despite contradicting reports regarding her condition varying between 'repeated cardiac arrests' to 'extremely critical' and critical but stable' depending on which version you choose to believe. The government itself has contradicted itself on the current condition of 'Nirbhaya', 'Amanat' or 'Jane Doe' depending on what you choose to call her .... (why they could not use her first name however boggles my imagination).

As a responsible medical professional privileged to understand the facts, I feel beholden to try and scatter the chaff regarding intestinal transplantation to provide some scientific perspective to the muddled situation created by contradicting and confusing inconsistent statements.

Intestinal failure occurs when there is insufficient surface area of small intestine to digest and absorb nutrients to meet the demands of the body entirely through enteral route. This usually occurs when large parts of the intestine are lost due to massive removal at one sitting or repeated removals. Traumatic injury is a rare cause of intestinal failure. Patients with intestinal failure have massive diarrhoea, dehydration and nutritional deficiencies due to inability to absorb water, fat, protein and vitamins all of which have to be supplemented through the intravenous route (parenteral) for survival. Parenteral nutrition needs to be delivered through large central veins using indwelling catheters.

The intestine has significant but not infinite potential to compensate for loss of length by increasing absorptive mechanisms and allow nutritional independence through a series of intrinsic changes called 'intestinal adaptation'. Extent of adaptation depends on various factors including the residual length, which part has been resected, presence of large intestine, blood supply as well as general health and age of the patient. It is generally believed that the ileum has higher potential to adapt than the jejunum. Most authorities agree than when less than 50cm small intestine is left behind, it is extremely unlikely that the patient will ever be able to be free for parenteral nutrition.

Long term parenteral nutrition has several consequences including line infections, clotting of veins, nutritional deficiencies, fluid overload, hyperglycaemia and development of progressive liver dysfunction any or all of which are life threatening. More importantly this severely impacts the quality of life of the patient and imposes significant costs. Successful transition to home-based and night time parenteral nutrition is not possible in all cases.

Intestinal transplantation is offered to those who fail all attempts at rehabilitation or develop complications of parenteral infections like repeated line infections, fungal infections or who develop extensive clotting of veins precluding continuation of parenteral nutrition or severe liver dysfunction. In the latter case combined liver and intestinal transplantation can also be necessitated.

INTESTINAL TRANSPLANTATION IS NEVER AN EMERGENCY!
Somehow this fact though mentioned in the current context has been drowned out.
What a patient with massive loss of intestine acutely needs is to be kept free from infection and provided optimal fluid volume, electrolytes and nutrients to compensate for loss of intestinal function. It is important that dehydration, electrolyte disturbances and hypotension be avoided as these can further compromise the ability of the residual intestine or even be fatal. Unless the status of the patient can be optimised and rehabilitation on parenteral nutrition achieved there is no question of performing an intestinal transplant in the future.

Intestinal transplant like any transplant requires a donor organ. This may be a deceased (brain-dead or cadaver) donor or a live donor. The former is preferred due to the ability to provide larger length and inherently larger vessels to join. It is not possible to transplant just anyone's intestine. The donor should be 30-50% of the patient's size ( to allow intestine to fit), be of same or compatible blood group and ideally should be HLA matched. SO ASKING FOR HARVESTING THE RAPIST'S INTESTINES MAY NOT BE OF ANY HELP TO THE VICTIM.

Results of intestinal transplant have been improving but are not yet as good as liver or kidney transplant. This is because the intestine is a hollow organ loaded with bacteria and has much larger population of immune cells (lymphocytes ) in its wall than other organs that make it prone to infection and more likely to incite an immune response (rejection) when transplanted. Intestinal transplant is much more resource intensive in the intermediate to long term rather than solid organ transplant. Despite improvement in critical care, infection control and anti-rejection therapy results of intestinal transplantation are 50-65% at 1 year on average ( 70-80% at the best centres) and at 3 years between 40-50% (55-60% at best centers).  THEREFORE UNLESS THEY ARE WILLING TO PROVIDE LIFELONG FREE CARE, A POPULIST OFFER TO FUND AN INTESTINAL TRANSPLANT FOR THE VICTIM IS ONLY WINDOW-DRESSING.

I have the greatest sympathy for the victim's plight and empathise with the outrage it has generated. However while we condemn the incident in the strongest terms and our heart goes out to the victim, it will do us no favour or credit to lose sight of the medical facts!

Will the trickle become a flood

Man donates organs of son knocked down by railway pole - The Times of India on Mobile

After their death, these Kerala villagers want others to live - Hindustan Times

After their death, these Kerala villagers want others to live - Hindustan Times

What a great gesture!

While this fantastic move is inspirational, it may remain at best symbolic.

Head injuries account for about 10-30% of deaths from road traffic accidents. Most of these fatalities are in the age group of 15-45 years, where organ damage from disease is unlikely.Poor infrastructure, trauma and ambulance services mean that only a small fraction of these individuals would reach a hospital in time or in a condition for their organs to be usable.

Unless parallel attempts are made to improve trauma and ambulance services across the country, such salutary initiatives are unlikely to make a dent in the dismal organ donation scenario.

Caveat lector.....Not everything in the papers is fact....Journalist heal thyself!

To manage organ donation well, a course in transplant coordination - Hindustan Times

The accompanying graphic (Hindustan times Delhi 24th September) totally misrepresents the situation regarding organ donation in the city of Delhi. I wish the reporter had taken the trouble to verify the numbers she was getting from her 'sources'. Caveat lector (reader beware) would be my advice. I am sure the reporter meant well, but the figures mentioned could lull the readers into some utopian fantasy and complacency.

If the numbers were true, particularly those at AIIMS, all transplant surgeons and physicians would be clapping their hands in a rapturous delight. These numbers while still far below what is needed, would herald a happy change in the embarrassingly depressing 'real' situation in India.

It is a welcome development that Delhi doctors are being trained in transplant coordination by experts from Barcelona. The province of Catalunya in Spain, where Barcelona lies, has the distinction of the highest organ donation in the world about 35 per million ( It is 25 per million in US and only 0.04 in India). The province of Catalunya is a torchbearer in the field of organ donation and whatever we can imbibe from their protocols will be welcome to shed our title of being a 'selfish nation'. However blindly aping their system is unlikely to work because they have a great penetration of socialised medicine paid for by state insurance while India is struggling with social medicine even in primary care. We will have to take inspiration from them and find locally applicable solutions to shed this dubious distinction.

The plan being worked out indicates that the powers that be have taken initiative to a felt need in the society, but this alone is unlikely to yield dividends. The strategy has to be multi-pronged and should simultaneously target education, legislation, professional training and societal change. A good staring point would be to take measures to restore faith of society in initiatives of the powers that be in looking after their welfare. Unless this faith is restored, we will be hard pressed to change the status quo no matter what rosy hyperbole is presented in the press.

Special 'mirror image' donor saves two in death

Recently a brain dead 49 year old donated his kidneys that could end up saving two precious lives. The supreme gesture should be saluted like every such noble gesture for community benefit. This donor had an anatomical anomaly called situs inversus totalis.

Situs inversus is an anomaly where the organs are placed in mirror image position from their typical orientation (situs solitus). Situs inversus may occur in various levels with total inversion being called situs inversus totalis the more common form is right sided heart (dextrocardia) with situs solitus.

Situs inversus totalis is usually a benign condition though about 20% are associated with Kartegener's syndrome ( infertility, respiratory disease and situs inversus).

Situs inversus being rare causes an unfamiliar surgical environment for the surgeons who may have never encountered such anatomy during their training. When an deceased organ donor has situs inversus it may pose minor problems and the surgeon has to constantly be aware of the altered anatomy to avoid inadvertent injury to vital structures.

When a living donor has situs inversus it can be problematic to position the graft particularly the right lobe which has to be placed in the left side of recipient. This can lead to angulation of the graft that can compromise its outflow by causing kinking. There are few such reports in literature requiring innovative methods like placement of tissue expanders to prevent angulation.

Cadaveric whole liver may need to be rotated 180 degrees to facilitate tension free vascular anastomosis.

Surgeons in the history of liver transplantation have had to innovate frequently to successfully use scarce donor organs successfully.

Ganesha Chathurti.... celebrate the God of Transplantation

According to Hindu mythology, the elephant headed son of Shiva and Parvati is the first recipient of a transplant although it was a xenotransplant ( from non identical species).

According to the story, Ganesha was asked by his mother Parvati not to allow anyone to enter the house while she bathed. When Shiva, Parvati's husband and father of Ganesha, sought to enter the house he was prevented from doing so by Ganesha siting his mother's orders. The enraged Shiva sent several of his minions to force Ganesha to allow him entry but all these were sent packing by the obedient Ganesha. Blinded by rage, Shiva attacked Ganesha and beheaded him for his impertinence. Seeing this Parvati was livid and threatened to curse the Gods for causing the death of her son. In order to placate Parvati, the celestial physician asked the Gods to fetch the head of the first animal they came across which turned out to be an elephant. The elephant head was transplanted onto Ganesha's body and he was given an elixir to drink which may have been a potent immunosuppressant to prevent rejection of the xenograft.

The iconic depiction of Ganesha is the head of an elephant on a pot bellied body which some have likened to the fat deposition resultant from steroid induced immunosuppression.

Ganesha's vehicle the mouse 'Mooshak' has been compared by some to the importance of mouse models in transplant related research.

Although all these could well be considered myths or a figment of a fertile imagination by agnostics and disbelievers, hindu literature is replete with such miracles that today are considered achievable by modern medicine.

In a lighter vein, one of my fellow transplant surgeons commented that Ganesha did not receive the head of an elephant but an elephant received the body of a human being! This made Ganesha the first human organ donor and not transplant recipient!!

The Social Network....will it provide the tipping point for organ donation?

Facebook, social media can boost organ, tissue donation

Social networking sites today connect millions even billions of people across the world.

They provide an uninhibited and egalitarian environment that transgresses caste, colour, class, creed and national barriers for person to person interactions. Such interactions have not been possible in the history of the human race.

Social networking sites have amply demonstrated their prowess in being instruments of social change. The Arab Spring protests globally and the Anna Hazare movement locally have bear poignant testimony to the fact that these sites can provide 'the tipping point' to a undercurrent of discontent brewing in people regarding their surroundings and their way of life.

The study referred to in the article revealed that a simple survey regarding willingness to donate organs on a popular social networking site saw a significant spike in donations which then subsided. This indicates that only persistent messages and motivation can sustain this trend.

I hope this provides the much needed tipping point to the sad organ donation story in this country

Kudos Mumbaikers.....What about Delhi ke dilwaley

Two more cadaver donations in city

Its very encouraging to see the increased rate of organ donations in the city of Mumbai. Its laudable to note that the city that never sleeps has a conscience that has awakened.

Now will Delhi ke dilwaley find it in their heart to make this noble gesture?

Watch this space

Rally to simplify organ donation by Mumbaikers

The wait for a donor’s organ - Indian Express Mobile

The people's movement begins. Let us hope it opens eyes all over the country.

An unselfish act....Kudos and solemn homage.

http://www.business-standard.com/generalnews/news/ganga-ram-trust-chairman-gives-new-life-to-3-even-in-death/54194/

Kudos and homage to the late Shri Tej Ram, Chairman of the Sir Ganga Ram Trust may his soul rest in peace.

Following a massive stroke at the age  of 88, Shri Tej Ram was deemed to have no brain stem function. His family honouring his life-time wish agreed to donate his organs without any fanfare and to not-so privileged individuals. The liver and kidneys have been transplanted into three needy individuals who otherwise were staring at near certain death due to advanced organ failure.

This selfless and honourable act from a person of high-standing in society comes as a breath of fresh air in an environment that has been sullied by greed, avarice and moral corruption restoring faith in the humanity that is the very essence of the human race.

Let us take a moment to bow and pay our solemn homage to Shri Tej Ram whose last human act has immortalised him. He continues to live in the three individuals can now look forward to a healthy life thanks to him.

I hope such individuals will continue to stand out as paragons of virtue to inspire more and more people and their families towards such selfless acts . 

Transplant coordination: what it really means...it's no mean feat!

The Transplantation of Human Organs Act mandates that hospitals who undertake organ transplant have a designated transplant coordinator but is quite silent on what role that individual is required to play in the transplant process.

The person appointed as transplant coordinator should be either a registered nurse, a medical graduate or a social worker who has been preferably trained in transplant coordination. Some universities and foundations run such accredited courses in India. However few working coordinators have such training in practice.The transplant coordinator usually ends up being reduced to a secretary, business manager or propaganda specialist. Without training even medical doctors are unable to understand the intricacies of the transplant process so their coordination is symbolic at best.

The transplant coordinator should act as the advisor, counsellor, friend and confidante of the patient and the family. Ideally the coordinator should facilitate the preparation, logistics of the operation and ensure smooth transition from hospital and domiciliary care. Listing and prioritisation of patient on the list for a cadaveric transplant is also the role of the coordinator. The coordinator should liase with the organ distribution network and help in selection of the deceased donor in conjunction with the retrieval team and hospital. The coordinator should frequently be available to update the family and answer any questions.Once discharged the coordinator should maintain records of the status of the patient, schedule follow up visits and ensure compliance with medication, investigation and rehabilitation. To sum up the coordinator should be the bridge between the patient and the transplant physicians and surgeons. Doing all this is no mean feat.

Rapid action......let's do the same for the other absurd rules

Absurd organ donation rule on kitchen-sharing dropped

Postmortem can be done after organ retrieval, suggests DGHS

Two significant  news reports in the Times of India that could impact organ donation scenario in this country significantly

It appears that the rule for not so near relatives proving that they have shared the same kitchen for more than 10 years with the recipient to be a live donor is unlikely to be incorporated in the amendment to the  Human Organ Transplant Rules.

Several absurd rules and conventions have entered the organ donation stage. I have personally known officials from authorisation committee ask for a 'same womb' certificate to be furnished when a sibling is donating to another. I have found this quite drole not to mention unnecessary. Who on earth could issue such a certificate? Birth certificates or school certificates or government documents where parents names are entered should suffice. Unfortunately nobody has gone over this absurdity with a critical eye.

The focus should be on facilitating donations while keeping a sentinel to deter inducements and impersonation. Like all laws in this country, the spirit of the law is salutary but it's letter needs a lot of modification.

The second news item that is of great relevance to the deceased donor situation is the suggestion of the Director General of Health services that post-mortem could be done after organ retrieval.

Brain stem death usually occurs in two situations : following trauma or following a cerebrovascular accident. With India's killer roads, motor vehicular accidents account or a large quantum of head injuries that present to trauma centres.  While this is a sad situation and cries out for improvement in roads and helmets, since most of these individuals are younger and active, their uninjured organs are likely to be in excellent shape and hence transplantable.When the injury is severe and brain death supervenes, even if consent for organ donation is provided by the next of kin, once of the major hurdles to organ donation comes in the form of performance of the medicolegal post mortem. Since post-mortem is not possible outside government institutions and medical colleges, having a forensic pathologist present during the organ retrieval (as mandated by rules currently) can be a logistical nightmare. This is due to understaffing of forensic departments, lack of motivation and sometimes rank callousness.

This suggestion to use technology like CT or MRI to image organs before retrieval or obtain samples of required organs during retrieval if a forensic pathologist  is a welcome proposal and is likely to simplify organ retrieval in medico-legal cases significantly. A post-mortem can always be performed after retrieval if needed.

This suggestion if accepted will allow timely retrieval of many more transplantable organs and save lives.

Organ donation rules....need for transparency not toughening

The Times of India on 4th September 2012 has reported a proposal by the ministry of health to amend rules in the organ transplant act to include 'not so near' relatives.

Suggested modalities to establish the relationship with live donor include

1. Old photographs of donor and recipient together
2. Staying together and sharing same kitchen for more than 10 years
3. Establishment of relationship between donor and recipient by a senior embassy official (for foreign nationals)

Greater caution has been recommended in case of female donors.

To the best of my knowledge, this is anyway a standard practice today and in camera interviews of donor and relatives are the norm in most if not all authorisation committees. 

Having had significant experience in this field, what I believe we in India are lacking is the spirit of the law. As an insider, I can safely vouch that the letter of the law is followed to the 't' wherever I have had the occasion to study the system.

What I think needs to be strictly followed and enforced is

Donor to be evaluated and counselled by medical team who is not treating the recipient. This will avoid any potential conflict of interest.

Counselling of the donor privately and offering a medical opt-out in case of his/her refusal to donate. this will avoid pressure from family.

Donor advocacy team consisting of social worker and physician to be present during the authorisation committee meeting. 

Until deceased donor organs are available to meet the need, living donation will be the need of the hour. Rather than make it difficult to donate by tightening rules and norms, what should be insisted on is greater transparency, dissipation of information, detailed counselling, donor advocacy and avoidance of coercion or inducement in any form.

Wake up call

It is refreshing to see that governments are finally recognising the problem.

Times of India Pune Edition 31st Aug 2012

Will state governments all over the country follow suit?

Cadaver organ donations in India have been at an embarrassingly low level of 0.02 per million as opposed to between 5-30 per million in the western world. More appropriately called 'deceased' organ donation has been allowed in India since 1995 when the Transplantation of Human Organs Act of 1994 was passed by parliament and ratified by most state assemblies.

Since health is a subject on the concurrent list of the Indian constitution, any changes or rules under this act can be applicable only when the concerned state takes the initiative to frame these rules.

Repeated and persistent efforts by doctors, patient groups and NGOs to get states to frame rules to simplify and facilitate process of organ donation for all concerned have until now fallen on deaf ears. The state of Tamil Nadu has been the obvious exception with rules having been simplified paving the way for a spurt in donation and transplantation of hundreds of livers, kidneys as well as some heart and pancreata. Other states until recently haven't followed suit.

The above article from the Times of India, Mumbai on 22nd August is a welcome move but one can't help thinking the state has woken up from its slumber after the recent much publicised death of a prominent leader from that state. Whatever has been behind this, this effort if taken to its meaningful conclusion will benefit thousands of people with end stage organ failure waiting expectantly for organs that more often than not did not come in time to be of use.

Let us hope more states are awakened by this movement.

Partial or whole liver transplant

Improvement in outcomes in the 1980s led to increased acceptance and widening of indications for liver transplantation across the western world.
The demand for organs persistently exceeded the supply of organs leading to death of patients while waiting for an organ.
Advances in liver surgery by the late 1980s made it possible to divide the liver into functionally independent viable parts along specific planes. This sowed the seed of partial grafting. Almost concurrently this concept was applied to splitting whole livers from deceased donors either in vivo or ex vivo and to living donors. European surgeons who had access to deceased organs could split organs to benefit two patients usually an adult and a child . In Asia, partial grafts from
Living donors were used initially in children and subsequently into adults as well. In US and Europe progress in splitting also was extended to doing a full right-left split of the deceased donor liver.
There is no doubt that a whole liver graft is the gold standard for adult liver recipients. Partial grafts from deceased and split donors have been used over three decades and in almost all situations with equivalent results. As long as liver cell quality is good,hepatocyte mass is adequate and ischemia time is kept low, partial liver transplant in an experienced center provides results equivalent to whole liver transplant .

Liver transplantation for children: no child's play

Children when they need liver transplantation present challenges different from adults.

Common causes for end stage liver disease in children depend on age but biliary cirrhosis due to extrahepatic biliary atresia, metabolic disorders like Wilson disease, liver resident enzyme defects and autoimmune disorders are more common than viral hepatitis. Almost one fifth of those who need transplantation have acute liver failure.

Most deceased donors being adults, children are rarely able to receive a whole organ. Partial grafts obtained by reducing or splitting a deceased donor organ or a living donor are usually the only grafts available.

Liver disease has a profound impact on physical, psychosocial and intellectual development in children. If liver transplantation is needed it should be performed as early as possible to take advantage of catch-up growth and avoid interference with schooling.
Parents have to be extremely motivated to work in conjunction with the transplant teams to ensure compliance with instruction particularly as the child grows and the baton of responsibility passes on from parents to the child.

Liver transplantation for hepatitis C: the hidden truth

Hepatitis C related chronic liver disease is an important cause of decompensated cirrhosis in patients who need liver transplantation in south-east asia, europe, africa and north america. Although anti-viral treatment for hepatitis C in the form of Pegylated interferon and ribavarin are fairly effective in achieving virological response in those who do not have genotype 1 of the virus, patients who already have liver dysfunction at the time of diagnosis or those that have ascites or severe hypersplenism are unable to complete the course of therapy or need dose reductions. Even those who attain virological response may relapse.
Patients with HCV related cirrhosis who undergo liver transplantation usually have significant viral loads at the time of transplant and treating them with interferons to reduce this level is often impractical and can be poorly tolerated. Unlike for hepatitis B there is no effective vaccination or immunoglobulin to protect against recurrence of HCV infection in the transplanted liver. As of now patients with HCV should clearly understand that HCV infection will recur in all the transplanted livers. In fact, HCV virus can be identified in the liver within hours of transplantation. The timing and outcome of HCV related damage to the liver after transplantation is different and is related to factors in the following cartoon.

Patients with concurrent obesity and significant alcohol intake or HIV infection are at a higher risk of accelerated HCV recurrence and damage. 

Active surveillance and protocol liver biopsy to detect early HCV related inflammation in the transplanted liver cells followed by supervised therapy is the only way to mitigate the progression to fibrosis in the transplanted liver. The transplanted liver cells are more susceptible to viral damage due to the immune-suppressive state. While some studies have suggested that cyclosporine has anti HCV action as compared to tacrolimus among the immune-suppressive agents, this has not been proven conclusively. Undetected and inappropriately treated, HCV recurrence can lead to cirrhosis and end stage liver disease within months to a few years. Despite adequate treatment, sustained virological response may not be achieved in all patients and these may develop recurrent cirrhosis and become candidates for a re-transplant after a variable period of 5-20 years. In fact ,most re-transplantations across the western world are performed for this indication.

Patients with HCV therefore should bear in mind the following before undergoing liver transplants

1. Unless there is concurrent liver tumor within the liver, kidney dysfunction or other life-threatening complication, liver transplant should be delayed as far as possible.
2. HCV patients should abstain from alcohol and keep their weight in check
3. Immunosuppression should be tightly monitored as excessive or pulse therapies can accelerate recurrence and hepatocyte damage
4. They should discuss with their transplant centres and preferably not accept deceased organs from older donors (>65 years) that are fatty or have cold ischemia of more than 6 hours 
5. After transplantation, they have to be extremely compliant with follow-up for early detection of recurrence
6. Re-transplantation may be required in a significant proportion of patients after 5-20 years 

Whole deceased liver transplant...classical

The classical whole deceased donor liver transplant is a time honored surgical technique from the early days of liver transplantation. Although most centers around the world have all but abandoned this technique in favour of the more recent 'piggyback' technique, it is worth mentioning here for the sake of  the non physician readers.
In the classical technique after the division of the blood vessels that take blood into the diseased liver of the patient ( hepatic artery and portal vein), the inferior vena cava below and above the liver is clamped and the diseased liver is removed along with the retrohepatic inferior vena cava. The whole donor liver is then sewn in the following sequence: supra hepatic vena cava-donor suprahepatic vena cava, infra-hepatic vena cava-donor infrahepatic vena cava, portal vein to donor portal vein and hepatic artery to donor hepatic artery.

Stages of liver damage

Liver transplantation for acute liver failure: look before you leap

Acute liver failure is a devastating syndrome leading to development of rapid development (within 26 weeks) of jaundice, coagulopathy and hepatic encephalopathy or coma in patients without history of liver disease. Acute liver failure is an medical emergency associated with significant healthcare costs, resource utilisation, morbidity and mortality. Even in the modern age, it carries a mortality of close to 30%. Successful management depends on early identification of cause and cause directed therapy, timely access to high level intensive care management and organ support and timely application of liver transplantation in those unlikely to respond or unresponsive to best medical care. Liver transplantation has single handedly improved survival in acute liver failure from less than 50% in the 1960-1980 to a respectable 70-75% after the 1990s.
To be effective and efficient, liver transplant should be performed "never too early but never too late". Early transplant deprives the patient from a chance of spontaneous recovery of liver function and exposes him (and even a family donor) to a needless risk and operation as well as condemns the patient unnecessarily to lifelong medication and immunosuppression with all the associated problems. Too late transplant reduces the chances of recovery and increases the morbidity and mortality of the procedure.
It is therefore critical to identify the window in which medical management does seem to be improving condition but before the onset of infection, cerebral oedema or multi-organ failure .
Reams have been written on how to identify this window and there is still some debate. Most clinicians utilise a combination of clinical and laboratory criteria in deciding which patients are unlikely to improve without liver transplantation. The criteria commonly used are the King's college criteria, MELD/PELD score or Clichy criteria. The parameters most often used to decide are the degree of encephalopathy, prothrombin time, bilirubin, arterial ammonia and lactate levels. In small children with rapid development of coma monitoring of intracranial pressure may help identify those that could recover after liver transplantation. It must be remembered that these criteria are not infallible and are at best 80-85% accurate in determining prognosis ie 10-15% patients who meet these criterial may still recover spontaneously without transplant.
From a patient's point of view, it is important not to panic but to ensure timely transfer to a liver transplant facility since transferring patients with severe encephalopathy who need ventilator can lead to acceleration of brain swelling and death. Liver dialysis though widely popularised about a decade ago, seems to do little more that allow patients to wait longer for transplantation although there are anecdotal reports of spontaneous recovery in drug or toxin induced conditions.

While time is of the essence, a mad rush in deciding regarding liver transplantation particularly for a living donor is never prudent. All attempts should be made to get all the information, even seek more opinions if needed. It is undoubtedly a gruelling decision and there is a lot of pressure all around but you must look before you leap!

Vilasrao Deshmukh's death rakes up a pressing issue

Brain death is not a psychiatric condition but a situation where there is severe and irreversible damage to the brain stem ( an area of the brain that controls the vital functions like breathing spontaneously). This damage usually results from injury to the brain or due to massive bleeding due to a stroke or tumour.Not all patients in coma are brain dead. Such a person cannot breathe on his own an

d is unable to synchronise functions. Tests to detect the presence of this condition are very elaborate and accepted over last five decades. For a period of time after brain death ( hours-days) the heart continues to pump blood and hence organs like kidneys, lungs, liver,intestines and pancreas remain functional. During this period these organs can be retrieved with consent from the family by a surgical procedure and transplanted to save lives of others whose own organs have failed. The procedure to retrieve is a surgical procedure done in an operation theatre under anaesthesia and hence the individual is kept pain free. Such an individual in any case is unable to experience pain or sensation due to functional disruption of connection between the spinal cord and the brain. The law to this effect is in existence since 1994.Although it is typically Indian to highlight an issue only when a celebrity or politician is involved, it does not take away the fact that this is a real issue. Ask those people who have someone jn their family on dialysis or with liver disease. Rather than deride the process or the context, the need of the hour is to propagate information and shore up the legal and administrative machinery to ensure just and timely implementation of the existing rules

Organ donation .... Cheating death with generosity

Brain stem or brain death is a state following severe brain injury due to injury or stroke where critical functions of the brain mainly the ability to initiate spontaneous respiration, maintain consciousness and coordinate body functions are irreparably damaged. In this state circulation to organs is maintained, the heart is beating but meaningful life has already ceased . Eventually due to loss of coordination all systems including the heart will shut down in a matter of days. Brain death can be reliably diagnosed based on simple bedside tests once the cause of brain injury is known. Inability to elicit spontaneous respiration after withdrawal of ventilator indicates a positive apnoea test. Other tests include the caloric test and doll's eye that indicate loss of brain stem reflexes. These tests performed by a panel of clinicians or brain specialists are sufficient to declare brain death. However to remove any doubt the tests are repeated on two occasions separated by at least 6 hours before declaration. Additional tests like EEG or cranial Doppler are merely supportive and not necessary to diagnose brain death from a medical or legal standpoint. Once brain death is declared all systems can be supported using artificial devices to keep blood supply into organs intact for some time.During this period, these organs can be extracted and transplanted into patients whose organs have failed.the liver, kidneys, intestines, pancreas, heart, lungs and other tissues can all be used to save several lives when they are no longer of use to the brain dead individual. These organs will live in the recipients long after the donor has passed. Can there be a better way to cheat death?

Living donation ... A kiss of life

Patients with advanced liver disease who need early transplantation are often lost due to complications while they are waiting for a donor liver. In such circumstances a living donation from a near and dear one can serve as a kiss of life. Several terminally ill patients have been salvaged by this precious gift from their loving family

Clotting disorders in liver disease

Blood clotting is one of the main mechanisms by which bleeding is spontaneously controlled. This involves mainly three components : platelets, clotting factors and fibrinolytic factors. A stable effective clot is formed when platelets are adequate in number and function, clotting factors are available in adequate quantity and fibrinolytic mechanisms are downregulated. In liver disease particularly cirrhosis any or all of these mechanisms may be deranged. Bleeding may be a result of low platelet count or function, reduced synthesis of clotting factors ( mainly II, VII,IX and X) as well as excessive production of fibrinolytic factors( protein C,S and tissue plasminogen activator). Elevated pressure in splanchnic vessels resulting from portal hypertension makes them more liable to rupture under minimal stress or spontaneously. Curiously in some cases coagulation may be hyperactive leading to thrombosis due to overproduction of procoagulants or deficiency of fibrinolytic factors. Monitoring and maintenance of coagulation is critical in patients with severe liver disease particularly during surgery or liver transplantation. Massive blood transfusion is associated with a poor prognosis in the short and long term and hence irrational blood and component therapy has fallen into disrepute. Germane and need based timely blood or component therapy can salvage difficult situations while avoiding the effects of massive transfusions. Most centres now apply real-time point-of-care coagulation monitoring to guide their component therapy as opposed to lab report based correction. While reproducibility between different systems is lacking the clinical correlation has been encouraging. In fact one of the major successes in liver transplantation surgery has been the reduction of blood loss which has played a significant role in improving the safety and success of the procedure.

Review article written by me for Indian Journal of Surgery

Liver transplantation for hepatocellular carcinoma is a controversial and oft debated issue. The debate revolves around utility i.e. expected gain to the recipient of the liver graft in terms of survival after transplantation as opposed to the same graft being offered to someone without a tumor and equipoise i.e. whether the risk of transplant and its aftermath is lower than the risk of other therapies. In Asian countries and India since a living donor graft is the most common liver graft used, there is a double equipoise to be satisfied. Not only does the patient require to have a good expectation of survival but the advantage to the patients has to be significant enough to justify the risk albeit minimal to the living donor. How to select such patients before transplant remains an area of great interest and investigation. This and other issues have been addressed in my article based on my experience and the current published literature on the subject.

Is the world about to end? Mayans and other doomsday diatribes

Written history is replete with doomsday predictions relating to the end of the world as we know it. Everyone waits for the current one regarding 2012 to fizzle out. However if you ask me humanity has died long ago. It died the moment the human race started taking pride in developing weapons to annihilate themselves several times over. There is no other example of such sheer lunacy in the living world, where the self-preservation is the primary goal of any species. And we call ourselves intelligent!We might as well be cannibals.

Somebody is obviously goofing on the job or else the reset button would have been pressed long ago.