April 7, 2007

liver transplants -high cost-low expertise

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Liver transplants plagued by high cost, lack of expertise

Rita Dutta – Mumbai

High cost and failure rate due to lack of professional expertise deal a crippling blow to more than half a lakh patients in India requiring orthotopic liver transplantations (OLT) every year. Experts highlight the need to address the issue at various levels including laymen and general practitioners alike as late referrals have restricted patients from availing successful liver transplants.

The gravity of the situation is reflected in the fact that while patients listed for OLT would not live beyond one to two years, not more than 10 OLTs are conducted annually and only around 100 patients have received transplant in India so far.

According to estimates, a 400-500 bed hospital, would have at least 100 patients dying of liver disease annually, who could have been saved by a transplant. Says Dr Gourdas Choudhuri, head of the department of gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, “In our institute, with 60 beds in gastroenterology, the mortality rate of admitted patients (2000 per year), most of whom are serious to critical, is around 10 per cent (200 deaths per year), of which 70 per cent (140 deaths per year) is due to liver failure. Most of them would be considered potential candidates for liver transplantation.”

A major bottleneck is the whopping cost of transplant, which ranges from Rs four lakh to Rs 25 lakh. The expensive UW solution, plasma fractioners, blood cell separators, blood bank support, prolonged ICU stay (from two weeks to a month) and immunosuppressants contribute to the cost.

Explains a consultant in surgical gastroenterology and specialist in hepato-biliary-pancreatic disorders and liver transplantation Dr Sudeep Shah of P D Hinduja Hospital, “The UW solution preservative costs Rs 20,000 a litre and one requires at least three litres of it. In addition is the cost of two supramajor surgeries, on the donor and the recipient. And at least 12 units of blood, platelets and fresh frozen plasma are to be kept ready for the surgery.” Reportedly, some hospitals hire chartered flights to get livers from other cities, adding another Rs four to Rs five lakh to the procedure.

According to managing director and liver transplant specialist of Hyderabad-based Global Hospital Dr K Ravindranath, lack of co-ordination between liver surgeon, liver specialist, anaesthesiologist, immunologist and lab medicine specialist has plagued liver transplantation. “With most specialists being attached to various hospitals, it’s difficult to bring them on one platform at the same time. The hospital management should be blamed for their short-sightedness regarding this,” said Dr Ravindranath, who has conducted 12 OLTs at Global Hospital, out of which 10 have been successful.

According to estimates, not more than 25 surgeons in India are trained to conduct liver surgery. Gangaram Hospital, Apollo Indrapastha and AIIMS in New Delhi, Global Hospital in Hyderabad, SGPGIMS in Lucknow, CMC-Vellore, SRMC and Stanley Medical College in Chennai, Jaslok Hospital and P D Hinduja Hospital in Mumbai conduct OLT.

Dr Sanjay Nagral, surgeon and liver transplant specialist, Jaslok Hospital, blames the lack of expertise on the part of medicos for patients not receiving OLTs. “OLT is not a regular surgical exercise. For conducting it, surgeons, physicians and anaesthesiologists need to receive special training from the US or the UK,” says Dr Nagral, who was in the team of surgeons which conducted a living-related liver transplant in India on a 14-year-old girl in 1998 at Jaslok Hospital.

OLT is technically difficult as it involves accurate dissection and suturing of several tissues from liver, blood vessels and bile ducts and needs two teams of surgeons and staff to work simultaneously, one on the donor and the other on the recipient. “A liver transplant is ten times more difficult than a heart or kidney transplant,” avers Dr Ravindranath.

Experts attribute lack of awareness among medicos and laymen alike for the less number of OLTs. Surgeons even complain of “lack of confidence” of physicians, GPs and gastroenterologists in referring patients for liver transplants to surgeons. “Physicians are not forthcoming about referring patients requiring liver transplant to us. And even if some are aware, they think it’s futile to inform patients about a technique which is not practiced widely,” rues Dr Nagral.

“Success breeds success and unless many liver transplants are performed, people will not have confidence and without confidence, we will not perform many,” says Dr Shah, who was in the team of surgeons which conducted a multi-organ transplant (kidney and liver) at Hinduja Hospital in January, 2004.

It’s to be noted that success rate of OLT in India is a modest 50 per cent in comparison with 80 per cent of the west. Many hospitals conducting OLT had initially recorded failures, indicating the complexity of the procedure. For instance, the first three liver transplants conducted at SGPGIMS four years ago, were not successful. For the remaining seven performed in the last one-and-a half year, the success rate has been around 50 per cent, informs Dr Choudhuri. According to Dr Ravindranath, around 50 per cent of the success of the transplant depends on the surgeons and the rest on the support services. “So, even if the surgeon conducts a successful transplant, improper support system can result in the patient losing his life,” says he. The life expectancy of 80 per cent of OLT patients is one year and 70 per cent for 10 years.“If the initial months after OLT are successfully passed, mortality rate is about 10 per cent in the next 10 years on an average.

Loss of the liver graft after the first year is less than five per cent and in a few cases, the original disease may relapse at some stage,” says Dr Shah.

Experts say that India would take a few more years to improve upon the success rate of OLT.

Others blame lack of networking between different hospitals for patients not receiving OLT. “Organ sharing is marred by regionalism. Though hospitals in Maharashtra have retrieval programme, they refuse to donate organs to other states,” laments an expert.

While the huge cost holds back patients from going to private hospitals, public hospitals do not evince interest because of the requirement of vast infrastructure. Says Dr Philip Abraham, a consultant gastroentrologist at P D Hinduja Hospital, “Public hospitals do not conduct OLTs as the infrastructure and costs involved for it can be utilised for treating a host of other ailments.”
Interestingly, medicos are hesitant about advocating live-related OLT than cadaveric, though both are permitted under the Transplantation Of Human Organs Act.
“In live-related donation, we are putting the life of the donor also at risk. That’s not ethical,” opines Dr Nagral. To which Dr Abraham adds that a surgeon should master OLT by cadaveric donation, before taking up live OLT.
They say the time has come for Indian hospitals to have a regular liver transplant programme as OLT costs abroad range from Rs 60 lakh to
Rs 80 lakh and listed Indian patients are not preferred over western patients abroad.

Suggestions to improve liver transplant

  • More NGOs should come forward to subsidise the cost.
  • Awareness-creation among medicos to make transplants available to the needy.
  • Networking and organ sharing between different liver transplant centres.
  • Setting up adequate life support systems in more hospitals for maintaining the haemodynamic status of the brain dead till emotional, social and medical preparedness for cadaver organ donation are also required.
  • Necessary changes in law and medical practice to ensure cadaver organ donation on time.
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