It is refreshing to see that governments are finally recognising the problem.
Times of India Pune Edition 31st Aug 2012
Friday, August 31, 2012
Friday, August 24, 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.
Tuesday, August 21, 2012
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 .
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.
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.
Monday, August 20, 2012
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 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
- 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.
- HCV patients should abstain from alcohol and keep their weight in check
- Immunosuppression should be tightly monitored as excessive or pulse therapies can accelerate recurrence and hepatocyte damage
- 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
- After transplantation, they have to be extremely compliant with follow-up for early detection of recurrence
- Re-transplantation may be required in a significant proportion of patients after 5-20 years
Whole deceased liver transplant...classical
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.
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!
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.
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
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