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Deceased Donor Liver Transplantation at Apollo Hospital Chennai

Apollo Hospitals, Chennai, performed the first deceased donor multi-organ retrieval and the first liver transplant in the country on December 24, 1995. Five deceased donor liver transplants were performed between 1995 and 1997 but subsequently slackened. Meanwhile liver transplantation was on the way to becoming an established procedure for the treatment of end-stage liver disease in the country. Almost all the transplants being performed at that time were living donor liver transplants. In 2007, a new team comprising Dr. Anand Khakhar and Dr. Anand Ramamurthy joined Apollo Hospitals, Chennai with a mandate from the visionary Chairman of the Apollo Hospitals Group, Dr. Prathap C. Reddy to establish the first liver transplant program in Southern India.

We believed that the ideal system would be one where both, deceased as well as living donor liver transplants would be performed. It was clear from the beginning that existing systems in the west for organ donation could not be directly implemented and that it would require adaptation to the unique sociocultural economic and healthcare environment encountered here. A big difference here was that deceased donation was largely driven by the energy of the transplant programs.

A systematic approach to recognition and declaration of brain death, maintenance and optimization of potential donors, grief counseling and obtaining consent for solid organ donation was established.Declaration of brain death was encouraged and protocols for evaluation and maintenance were laid down in our ICU’s. The primary physician informed the family about brain death and the concept of organ donation was introduced. An intensivist(medical coordinator)would coordinate with the primary physician, relatives and 2 doctors from a government-approved panel for testing and certification and obtaining consent for brain death.A nurse coordinator was entrusted with the task of building a rapport and bereavement counseling of the next of kin as we observed that they were more likely to trust and respond to a caregiver than a social worker. We travelled across the state, addressing doctors regarding issues about brain death, organ donation and liver transplantation through forums like the Indian Medical Association, Association of Physicians of India among others. We also conducted meetings to increase public awareness through social and corporate organizations. A big revelation for us was that there were people who wanted to donate but was unaware of the procedure and the eligibility.



American-Liver-Foundation

These efforts started showing results and in 2008, 2009 and 2010 the number of deceased donations were 13, 24 and 28 respectively. As the numbers of liver transplants started increasing the state government took cognizance and between September 2008 and February 2009 passed 8 Government Orders (GO) that laid down ground rules for declaration of brain death, retrieval, allocation and sharing of organs between centers. Scientific advisory sub-committees constituted of medical experts from the field were established to fine tune organ specific rules regarding recipient listing, organ allocation and other issues arising from time to time. The government also encouraged organ donation by recognizing and felicitating donor families. One such event, namely the decision of a doctor couple to donate the organs of their son in September 2008 was highlighted and contributed in a big way to encourage organ donation. The print media also played an important role in creating public awareness and acknowledging organ donation by articles highlighting deceased donations and transplantation. Contrary to popular belief deceased donation has cut across barriers of socioeconomic status. We have encountered exemplary donation by illiterate, daily wage labourers as well. Our youngest donor was 6 years old and the oldest used liver came from a 70-year-old donor.An interim analysis of potential donors at our hospital over a period of 4 months from May to September 2010, revealed a 44% conversion rate (15 out of 34 families). This reflects the maturity of the system and the commitment of our coordinators. Of significance is that only 4 (12%) families refused consent after counseling by the transplant coordinators.

Most of the patients coming for liver transplant in our hospital arrange their own financial resources, which are in most cases limited. We are cognizant of the fact and take special care to ensure that they are judiciously utilized. We are conservative in our approach to marginal livers, which are likely to have higher chances of delayed function or non-function. One reason is that the supply of donors is limited and unpredictable and a super-urgent listing does not guarantee organ availability. The second reason is that the costs would escalate and even those recipients who manage to put together resources for one transplant would find it difficult to pay for two transplants. We moved some potential donors from outside Chennai to our hospital and retrieved organs for transplantation to minimize cold ischemia time. All shared livers were harvested using the hospital ambulance for surface transport or commercial airline services. On occasions when no direct air link was available a stopover and change of flight and a combination of road and air was used. No liver was rejected due to logistic constraints.

Our work speaks for itself. The numbers of deceased donors have increased over the years. We performed 200 DDLT’s till December 2012. The majority of them continue to be generated at ournetwork hospitals. Public awareness is increasing and will ensure that organ donations continue to increase. The future lies in creation of independent organ procurement organizations that, like in the west coordinate the identification, maintenance and distribution of organs.

FAQ's

  • What are the symptoms of chronic liver disease?

    The symptoms of liver disease are not specific. Early on, one may notice low energy levels, easy fatigability and poor appetite. But these symptoms are common in afflictions of several organ systems. The liver has a large reserve capacity. Till about 70% to 75% of this reserve is lost, there may not be any signs or symptoms.
    • Beyond this there may be fluid accumulation in the abdomen called ascites or swelling over dependant areas of the body like the legs.
    • Bleeding into the gastrointestinal tract may manifest as vomiting of blood or passage of black, tarry stools called melena.
    • Accumulation of toxic substances in the body normally filtered out by the liver particularly ammonia may lead to disruption of sleep pattern, forgetfulness, slowing or slurring of speech, inappropriate speech or even loss of consciousness in advanced cases.
    • Jaundice in Chronic liver disease is generally a late feature and tends to be less severe except in certain variants of liver disease
  • Is it treatable by medicines?

    Because over 70% to 75% of the liver is already damaged and replaced by scar tissue by the time signs and symptoms become evident, the process is not reversible by medication. In certain early cases, the process of further injury and scarring can be contained and rarely, even reversed by medication. In such cases the need for a liver transplant can be deferred or obviated. However, the treating doctor will decide whether you have such a condition and will monitor you during the treatment process.
  • Which are the common causes of chronic liver disease in India?

    Infection with Hepatitis B, Hepatitis C and alcohol are the common causes of liver disease in the adult population in our country. However, 1 in every 5 patients will have chronic liver disease where despite an extensive, no cause can be found. Infants and children present with chronic liver disease commonly due to congenital errors of metabolism.
  • When should one consult a transplant surgeon or a transplant centre?

    As soon as one is diagnosed with chronic liver disease or develops symptoms related to liver failure as outlined above a visit to a transplant centre is desirable. They have experience in treating patients with liver failure and recommend liver transplant at the appropriate time. One of the common problems faced is late referral of patients, usually when all medical treatment has failed. In such a situation, they usually develop problems related to medication such as renal failure due to diuretic use or they are too sick to undergo the transplant procedure. One has to remember that the transplant operation itself is a major procedure and a certain minimum level of fitness is necessary to undergo a liver transplantation.
  • What are the tests needed to determine fitness for liver transplantation?

    The work up is performed either as an outpatient or after admission. The process takes 4 to 5 days and investigations are performed in a staged manner. The first part of the testing determines the cause and severity of the liver disease and the second part is a detailed evaluation of other organ systems like the heart, lungs and the kidneys to rule out concomitant disease that may require correction prior to or even preclude transplantation in rare cases.
  • What is the success rate of liver transplantation?

    Liver transplant has an 86% to 92% success rate world wide. The outcome is directly related to the condition of the patient at the time of transplantation i.e. sicker patients tend to have poorer outcomes. With constant refinement of the process and a cumulative experience of over 1000 such procedures in our team, we have been able to achieve a success rate comparable to the best centers worldwide.
  • Will transplant patients be able to lead a normal life after transplantation?

    Yes, all patients return to their work after 12 weeks of discharge from the hospital depending on the nature of their work. People with office or desk jobs return to work earlier than those with physically demanding jobs. There is no restriction on routine activities like eating, exercise or sexual relations. All patients will have to take certain medicines that suppress the immune system and prevent rejection of the new liver for their lifetime. These medications will be reduced over time, especially after the first year. Especially during the first three months and to an extent during the first year patients are asked to avoid crowded places or proximity to patients with known infection like a cold. They are not required to wear masks at home or while going out after discharge.
  • What is the cost of a transplant operation?

    The average cost of a liver transplant operation performed anywhere in India would be roughly Rs. 22-25,00,000 for an adult and 18-20,00,000 for a child. However, it would also depend on the nature of disease causing liver failure and the preoperative status of the patient. The cost remains the same whether a deceased or a living donor is used. This is a fraction of the cost at which liver transplant is performed anywhere across the world. Subsequently, the medication to prevent liver rejection costs between Rs. 8000 and 10,000 a month in the first year and between Rs. 6000 and 8000 thereafter.
  • How is a liver obtained for transplantation?

    Liver transplant can be performed either using a part of the liver from a living donor or from a brain dead cadaver whose family has consented to donate organs. In India, by law the living donor has to be related to the recipient family. The hospital and/or a state authorization committee who will verify documents and interview them in person to ensure that there is no coercion or trading involved will ascertain this. The advantage of a living donor liver transplant is that the operation can be planned and carried out after stabilizing and preparing the patient.
  • What is the alternative if there is no suitable living donor available?

    In case there is no donor from the family or a donor is found unsuitable for donation, a patient can list himself or herself for a cadaveric liver transplantation. This is a unique facility available at Apollo Chennai, which is the only centre in India performing both cadaveric as well as living donor liver transplantation. The patient will be put on a waiting list for their blood group after clearance as a transplant candidate. On receiving news of a suitable donor being available, the patient is called in for admission. The time available to reach the hospital is around 6 to 8 hours. Patients from out of station have to temporarily stay in Chennai till such time the transplant operation is completed.
  • What is the risk involved to the donor?

    Liver donation is a safe surgery; the worldwide reported mortality after donor surgery is 1 in every 200-300 such operations. Complications such as bleeding, infection and leakage of bile from the cut surface are low (about 10 to 12 in every 100 patients). Even on being given these figures, almost all donors still proceed with donation as it involves saving the life of a loved one. The donor is a healthy adult relative without any major systemic illness and a liver anatomy that is suitable for splitting. This is ensured by a detailed evaluation prior to accepting candidacy as a donor. There should be enough liver volume to meet the requirements of the recipient and ensure a safe remnant volume for the donor. A remnant volume of 30-35% is sufficient to meet the metabolic requirements of the donor in the postoperative period. In approximately 6 to 8 weeks time the liver regenerates to its original size both in the donor as well as the recipient. This regenerative capacity is unique to the liver allowing a part of the liver to be transplanted into another person. The recipient can be discharged from the hospital in about 6 to 7 days and can resume their day-to-day activities within a week. Depending on the nature of their work (desk job or physically demanding), they resume work by 6 to 8 weeks.