new layout-dt 14-2-2009 - final.pmd 1 2/14/2009, …...wrong blood group and he had no other...
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New Layout-Dt 14-2-2009 - final.pmd 2/14/2009, 5:16 PM1
2 From the Editor’s Desk
Dr. Reeta J. Dalal
3 Guest Editorial
Dr. Sudeep Shah
4 Cadaver Transplantation
Dr. Rasika Sirsat
8 Corneal Transplant
Dr. Nisheeta Agarwala & Dr. Pradyna
12 Heart Transplant
Dr. Kaushal Pandey
16 Frontiers of Immunosuppression
in Renal Transplant
Dr. Jatin Kothari
20 Liver Transplant
Dr. Sudeep Shah
24 Live Related Renal Transplant
Dr. Alan Almeida
30 Stem Cell Transplant (SCT)
Dr. Asha Kapadia
32 Lung Transplant -
Where does it stand today?
Dr. Manoj Agni
36 Short History of Organ Transplant
Dr. R. A. Bhalerao
38 Hinduja News
40 Welcome
Worldwide tens of
thousands of lives are
transformed by the miracle
of organ donation. Tissue
transplants e.g. skin,
cornea, bone-marrow,
vessels are invaluable. In
the last half century
transplant surgery has transformed from research
to life-saving surgery.
For every successful transplant there are
thousands who are on the waiting list and
probably die waiting to receive the graft. Organ
transplants are complicated by scarcity of organ
donors, various ethical and social issues.
In this issue Dr. Sudeep Shah, Liver Transplant
Surgeon at Hinduja Hospital has put together
articles from various specialities to give you an
‘Update on organ transplants’.
Dr. Reeta J. DalalConsultant Physician
From the
Editor’s Desk
Editorial BoardDr. Philip Abraham
Dr. Tester Ashavaid
Dr. C. BalakrishnanDr. Sudeep Shah
Dr. Gauri Mankekar
EditorDr. Reeta J. Dalal
Editor EmeritusDr. V. R. Joshi
Guest EditorDr. Sudeep Shah
PhotographyPramod Tandel
FROM THE EDITOR’S DESK / CONTENTS
2 2008 Vol 23 No. 1
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Dr. Sudeep Shah
ORGAN TRANSPLANTATION IS one of the miracles of modern medicine. The ability
to replace failed organs has been dreamt about since the beginning of the last century.
However, with the greater understanding of the immune system and technical advances in
surgery, this became a reality in the 6th and 7th decades of the last century. The arrival of
more effective immunosuppression in the form of Cyclosporine radically improved the
results and in the eighties this treatment became established as the standard of care for
organ failure.
In this issue of the Newsletter, we highlight the indications and outcome for major organ
transplantation and also outline the procedure for cadaver organ donation.
Transplant is a reality now in tertiary care centers such as ours and we need to go forward
and build further. This is possible with greater awareness about organ donation. The gift
of life is the greatest that can be given as seen in the case study and we hope this issue will
serve to reinforce this.
DR. SUDEEP SHAH
Introduction toOrgan Transplantation
GUEST EDITORIAL
2008 Vol 23 Vol No. 1 3
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TRANSPLANTATION IS CURRENTLY considered
an accepted treatment modality for patients with end
stage organ failure where therapy with drugs or
restorative surgery is not feasible. Approximately, 25
different organs and tissues including kidney, heart,
lung, liver, pancreas, bone, cartilage, bone marrow,
Cadaver Transplantation
skin and cornea can be transplanted. This is due to
important break throughs in immunosuppressant drugs
and tissue typing. More than 1 million people world wide
have benefitted from successful organ transplantation.
Of these, kidney transplant results have been the most
gratifying. With improvement in results, the demand for
Despite the immense benefits of successful organ transplant, the full
development of the transplant program is hindered by organ shortage.
By Dr. Rasika Sirsat
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NEUROLOGICAL
EXAMINATION
TO
DEMONSTRATE
BRAIN DEATH
ARE
Absence of
oculomotor/photomotorreflex
Absence of
corneal reflex
Absence of facial
movements
Absence of
spontaneousmusclemovements
Absence of
oculo-vesitibularreflex
Absence of gag
reflex
Absence of
cough reflex
Absence of
spontaneousbreathingdetermined byApnea test.
human organs for transplantation has
increased. The source of donor organs are
living related donors (LRD), living un-
related donors (LURD), cadaver – non
heart beating donors (NHBD) and
cadaver – heart beating donors
following the second set of test to confirm
Brain Death.
The Zonal Transplant Co-
ordinating Center (ZTCC) is informed
about a potential Cadaver donor. The
ZTCC is a city based organisation who co-
CHECK LIST
MORE THAN 1 MILLION PEOPLE WORLDWIDE HAVE BENEFITTED FROM
SUCCESSFUL ORGANTRANSPLANTATION.“(HBD). Most of cadaver transplanted
kidneys are obtained from brain dead donors
with functional circulation. Brain death can
occur due to spontaneous intracranial
hemorrhage, head trauma, cerebral
ischemia or primary cerebral tumours.
Brain death can be diagnosed at the
bedside by performing various tests in
patients in whom the cause of coma is known
and those who do not have severe
hypothermia (< 35oC) and have not
received neurodepressor drugs,
neuromuscular blockers and anti-cholinergic
drugs.
The transplant co-ordinator can then
counsel the close relatives regarding organ
donation. Once close relatives give written
consent for organ donation, organs can be
retrieved after declaration of brain death
ordinate all activities for organ procurement,
maintainenance of a computerized central
registry of potential recipients and allocates
organs as per the criteria laid down. The
aim of ZTCC is to provide impartial and
effective organ distribution. The prospective
2 recipients for kidney transplant are called
as per criteria laid down by ZTCC. It is
essential that a person who registers for a
cadaver transplant keeps some funds aside
in the eventuality of being called for a
transplant surgery. The recipient should also
follow up regularly, at the center where he is
registered so that the nephrologist is aware
of his/her medical fitness for surgery.
The suitability of donor organ is checked
by performing a Lymphocyte cross match. If
negative the recipient can proceed for
Transplant. If the lymphocyte cross match is
“
BRAIN STEM DEATH IS IRREVERSIBLE ANDHAS BEEN RECOGNISED BY LAW SINCE 1995.“
“COVER STORY
2008 Vol 23 Vol No. 1 5
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positive the recipient next on
the list is considered for the
transplant, provided
lymphocyte cross match is
negative. The shortage of
organs can be expanded by
including non-heart beating
donors (NHBD) i.e. organs
are retrieved only after heart
stops functioning. The main
issue with NHBD is higher
rate of delayed graft function
compared with that
associated with heart beating
brain dead donors. However
at 3 months graft function is
not significantly different
between the two.
Most of the kidney
transplants performed in
India are from live donors.
For those patients who do
not have an option of related
kidney transplantation, the
only option is to wait for a
cadaver kidney. The Human Organ Transplantation Act
was passed in 1994 following which cadaver transplants
have been carried out all over India. In Maharashtra, the
first cadaver transplantation after the act was performed
professionals and lack of
organ sharing agencies.
India spends 1.5% of GNP
on health care. End stage
kidney disease (ESKD)
treatment has extremely low
priority as compared to
population control,
eradication of
communicable disease,
nutritional program, etc.
hence government funding
for renal replacement
treatment is a miniscule
amount. Very few ESKD
patients are reimbursed by
their employers, while others
rely on their family and
charitable organizations for
funds. Public unawareness,
religious sentiments, family
pressures all contribute to
bringing down the number of
actual organ retrieval from
potential cadaver donors.
In Spain organ procurement system has been
professionalized. The organ procurement team is
responsible for the whole organ donation process from
donor identification to organ retrieval and they are
Apnea testPatient is put on FiO
2 of 100% for 20
minutes while still on the ventilator.
Thereafter ventilator is disconnected and
patient is put on 6L/minute of O2. Serial
arterial blood gas are checked until
PCO2 > 60mm Hg with PO2 around
100 mm/Hg. Watch for movements of
diaphragm if there is no spontaneous
respiration that indicates an absence of
brain stem respiratory centre function.
These tests are repeated and confirmed
after 6 hours. Only then the patient can
be declared as Brain dead. These tests
are to be performed by 4 medical
practitioners (Neurosurgeon, Physician,
Neurologist, Intensivist) as per
Transplantation of Human Organs Act
(TOHA) 1994. Brain death is explained
to relatives by the treating physician after
the first set of tests are performed.
on the 27th of March 1997, thereafter about a hundred
and fifty more have been performed up to date. So far,
about 1200 cadaver transplants have been carried out in
India, far short of what is required. This is in spite of 8500
fatal road traffic accidents per year. Per city about 8 to 10
brain dead patients would be there at a time, however,
the conversion rate is less than 19%. This is due to multiple
factors like poor infrastructure for quick and safe
transportation of accident victims, lack of ventilatory
facilities, ignorance, failure to convince the near relatives
to donate organs, indifferent attitude of health care
accountable for their performance, there are 127 such
teams. Their organ donation rate has more than doubled
over the last one decade and the percentage of multi-
organ retrieval has soared from 35 to 83% enabling a 3-
fold rise of possible solid organ transplant.
Currently, organ shortage is the main obstacle to the
full development of the transplant programme. It is possible
to increase the cadaveric organ donation rate and also
promote living donation. It is still possible to further
improve graft survival rates and thus reduce the need for
re-transplantation.
LACK OF PUBLIC AWARENESS, MISPLACED RELIGIOUSSENTIMENTS, FAMILY PRESSURES ALL CONTRIBUTE TO BRINGING
DOWN THE NUMBER OF POTENTIAL CADAVER DONORS.“
“
COVER STORY
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Case Study By Dr. G. B. Daver
A 34 YEAR old lady- in the prime of her life struck down
by a stroke leading to brain stem death leaving behind a
grieving husband and child would in ordinary
circumstances be nothing more than a terrible tragedy.
However, the extraordinary act of generosity by the family
in intense grief transformed the lives of three unrelated
individuals.
Miss C was a young lady with kidney failure. She had
had so many dialysis that there was no further access to
her blood vessels to remove blood for purification. No
suitable relative was available to give her a kidney and
doctors were wondering what to do when her last open
access point would block. A kidney from a cadaver donor
was her only hope.
Mr P was a young man tired of life. Struck down by
kidney disease in his teens, he had already had a failed
transplant. Now, he was tethered to a dialysis machine
three times a week and unable to do anything productive;
his blood pressure swingig dangerously due to kidney
damage. A kidney from a cadaver donor was his only
hope.
Three happy recipients meet to remember the donor a month after the transplant
Mr D, an engineer in the prime of his life, struck down
by liver cirrhosis. He was unable to work and worried about
the future of his sons, aged 16 and 10. His wife was the
wrong blood group and he had no other relatives to donate
a part of their liver. He was on our waiting list for over a
year for a suitable liver donor. A liver from a cadaver
donor was his only hope.
On the day before Dassera 2007, the family of the
lady with severe brain damage leading to brain stem death
consented to donate her liver, kidneys and corneas after
realizing that she was lost to them forever. These organs
were useless to her but could transform three lives.
A team of surgeons commenced the procedure at 5
AM and surgeries carried on through the day and late
into the night. The recipients of the liver and two kidneys
were home 14 days after the operation.
Today all three recipients are back to a normal, productive
life, the nightmare years of their illnesses are behind them.
They realize that they are amongst the lucky few recipients
of a cadaver organ donation. Many more patients with end
stage organ failure wait for such a gift of life.
2008 Vol 23 Vol No. 1 7
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CORNEAL TRANSPLANTThe cornea is the clear tissue covering the front of the eye. If the cornea
becomes cloudy or scarred, vision is markedly reduced or lost.
By Dr. Nisheeta Agarwala & Dr. Pradyna
FORTUNATELY, THROUGH THE medical miracle
of Corneal Transplants, sight restoration is possible.
More than 2 million Indians, a majority of them
children, suffer from corneal blindness and another
25,000 are added to that number every year. Since
there is no substitute for human tissue, the
transplantation process depends upon the priceless gift of
eye donation after death. To meet the requirements, eye
donation has to be increased several times and this is
possible only when the concept becomes a movement
and spreads to all families.
The decision to donate eyes is made by the family
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members when a death occurs. The desire
to donate your eyes, should be conveyed to
the immediate family, during one’s
lifetime.Our eyes, can be recycled into the
priceless gift of vision for millions of our
corneally blind citizens instead of being
FACTS ABOUT
EYE DONATION
Donated eyes of
all ages can beused
Spectacle
wearers, andpeople sufferingfrom evendiabetes,hypertension orasthma candonate eyes.
Patients who have
undergonecataract surgerycan donate eyes.
Eyes can be
donated even ifthey have notbeen pledgedearlier.
Eye donation
gives sight to twocorneally blindpersons. Eyesare neverremoved from aliving person.
The process of
removing the eyesfrom the body ofthe deceased iscalledENUCLEATION.
CHECK LIST
buried or burnt. In the past people were not
aware of blood donation. They were
gradually educated and started donating
voluntarily. There is no shortage of potential
donors. All that is needed is the desire to
donate and a timely request so that the
closest eye collection services can be
contacted.
Corneal opacity due to infection
CORNEAL TRANSPLANTATION
The cornea is made up of 5 layers.
It can get opaque due to infections,injury,
following eye surgery, ageing and
degenerative changes. Conventionally, the
entire diseased central cornea is removed
and replaced with high quality transparent
corneal tissue from a donated eye. This is
called Penetrating Keratoplasty.
MORE THAN 2 MILLION INDIANS, A MAJORITYOF THE CHILDREN, SUFFER FROM CORNEAL
BLINDNESS AND ANOTHER 25,000 ARE ADDED TOTHAT NUMBER EVERY YEAR.“ “
If only superficial layers are opaque,
then those are replaced by Lamellar
Keratoplasty procedures and if the deep
layer is diseased then that is replaced by
Image is taken from Google
CORNEAL TRANSPLANT
2008 Vol 23 Vol No. 1 9
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What Needs To Be Done?
• If there is a death in your family or friend circle, motivate the family
and call the nearest Eye Bank or dial 1919 (National & Local eye
donation helpline)
• Eyes are best removed within 6 hours of death
• The death certificate should be available.
• Switch off fans and place wet cotton / cloth over the close eyelids,
to keep eyeballs moist.
• Raise head with a pillow
• Most eye banks have a 24 hours response service, which receives
calls and sends a medical practitioner for the enucleation.
• The Eye Bank team will enucleate the eyes wherever the donor is,
at no cost
• The Eyes are removed without disfiguring the face
• Although it is only the corneas that are finally used, the entire eye
is removed and transported in special containers to the Eye Bank.
10 cc of blood sample is collected from the donor’s body for testing.
• The eyes will be evaluated and processed by trained Eye Bank staff
according to International standards.
• Eye Banks are non-profit organizations and the processed cornea
is supplied to qualified corneal surgeons.
• If the patients are identified with HIV infection, hepatitis B, C, rabies,
septicaemia or active leukemia, their corneas cannot be used for
transplantation.
NATIONAL & LOCAL EYE DONATION HELPLINE 1919
endothetial Keratoplasty
procedures. At our hospital
we have a 24 hour cornea
retrieval team – which will
conduct an enucleation
within the shortest period, for
any patient who passes away
in the hospital.
FOR REST OF
BOMBAY
Contact nearest Eye Bank or
Dial 1919 for prompt
response from an Eye
Donation Cell
CORNEAL TRANSPLANT
Donate Organs, Save Lives!After your life time, wouldn’t it make you happy to know that you can give a new lease of life to many other people?? One life can
give hope to many. But that’s only if you give the NOD to pledge your organs.
Organs Donation
1 . What is organ Donation?
Organ donation is the gift an organ to a person who needs a transplant. It’s a procedure in which a healthy organ is taken from
an individual who has died and transplanted into a person whose own organ is not functioning properly.
Donated organs give the recipients the opportunity of a longer and better quality of life
2 . Why is Organ Donation required?
Sometimes people suffer for irreversible organ failure and the only way they can recover or lead a normal life is to receive an organ
transplant.
3 . Is it legal ?
Yes it is legal. In India it is governed by the Transplantation of Human Organs Act (HOTA), 1994. This Act makes it mandatory
for institutions conducting transplants to register with an authority appointed by the state government. Many safeguards against
misuse have been built in the rules.
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DONATE ORGANS, SAVE LIVES!
4 . Which organs and tissues can be donated?
Organs that can be transplanted are Kidneys, Heart, Liver, Lungs, Pancreas, Small Bowel, Cornea. Tissues like Heart Valves, Bone
and skin can also be donated.
5 . Do I need to be dead to donate an organ or tissue?
No, Blood and Bone marrow may be donated by live donors. Partial Liver & Kidney donation is allowed by law for blood relatives
of the recipient. For other organ donation, the person has to pronounced ‘brain dead’
6 . Are you sure I wil l be dead when they transplant my organs?
The Transplantation of Human Organs Act lays down criteria for determining brain steam death. The brain stem death tests must
be performed by four Doctors together, none of whom has anything to do with the transplant, and this must be done twice, with
a minimum gap of six hours. Such brain death can be declared only in institutions recognized by state appropriate authority.
7 . Will the doctors just let me die if they know I wil l be donating my organs?
No. Your doctors will take the utmost efforts to save your life. This is their first duty. If despite their efforts, the patient dies, only then
will the organs / tissues will be considered for donation. These doctors will not be involved with the organ transplantation, a
completer different set of doctors will take over for the further procedures.
8 . Can I donate if I die in an accident?
Yes if you are taken to the hospital in time and that hospital has capability for organ transplantation and is registered with the
state authority.
9 . Who will get my organs?
The recipient has to be on state waiting list for receiving organs and has to be compatible for that organ. If not, the next person
in waiting will be considered.
10. Will the Rich get priority in waiting list ?
No, the recipient has to be on state waiting list for receiving organs. Clinical criteria like blood group, immunological status, and
medical urgency are considered for the transplantation. There is no discrimination based on money colour, race and religion.
11. Will my family know who gets my organs?
No, the details of the recipient are not revealed to the donor family.
12. Will the recipient know my name and details?
No, the details of the donors are not revealed to the recipient.
13. Are there any religious objections to organ transplants?
All religions in India consider organ donation as an Act of Charity, Support it.
14. Can I specify to donate any specific organ and not any others?
Yes you can specify the same on your organ donation card.
15. Can I agree to donate to specific person and not to anyone else?
No. The recipient has to be on state waiting list for receiving organs. Organ donation is not accepted if it is conditional.
16. Is there any cost of donation to my family?
No, the cost is borne by the recipient’s family
17. How can I become a donor?
You simply have to fill up and sign the Organ Donor card that is attached. Please carry this card with you at all times.
18. Do I need to inform my family about my decision?
If you discuss you wish with your family they will be ready for the donation when the time comes and will be able to process the
donation faster.
19. Does organ donation cause any delay in funeral arrangement?
No, if consent for organ / tissue donation is given, the surgery is done immediately and there is no interference with the customary
funeral arrangement
20. Can I change my mind about organ donation?
Yes, simply tear your organ donation card.
21. Will I be paid for donating an organ?
No, the law does not permit commercial dealing in human organs.
22. Can I donate if have a medical condition?
The medical condition of the donor will be assessed at the time of organ donation. HIV and Cancer are specific conditions which
excludes people from donating.
23. Would there be an additional expense for donating organs?
No.
24. How can I be sure that the donated organs are safe and diseases free?
All potential donors’ blood is screened for ruling out transmitted dieses such as HIV and Hepatitis. The family of the potential
donor is kept informed of this requisite procedure.
25. Who can be a life organ donor?
Anyone 18 year of age and above can be a donor. Parents or Guardians consent will be required for any individual below 18 year
wishing to donate an organ.
2008 Vol 23 Vol No. 1 11
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Heart TransplantHeart transplant surgery has come a long way in the last 40 years. However, due
to newer technology, the number of transplants performed each year is actually
falling. By Dr. Kaushal Pandey
HEART TRANSPLANTATION IS the most
satisfying surgical procedure for a Cardiac
Surgeon. A sick patient with a failing heart (not
expected to survive more than a few months) gets
wheeled into the operating room; three hours later
comes out into the ICCU with a new normal
functioning heart. For the surgical team it is just another
day at the office, but for this patient, it is new life. From
the epoch-making, first heart transplant in December
1967, heart transplant surgery has come a long way in
last 40 years. These forty years of heart transplant surgery
have been indeed tumultuous. There have been many
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CHECK
LIST
highs, but numerous lows. Surgery now is
standard; but the yearly numbers are
actually falling. With newer technology
impacting our lives in more ways than one,
surgery of heart transplant has an
uncertain future. Sooner but not later,
totally implantable artificial heart (or assist
device) will make heart transplant surgery
obsolete.
First successful heart transplant surgery
was performed on 3rd December 1967 by
Dr. Christan Bernard. However the true
pioneer of Heart Transplant Surgery has
been Dr. Norman Shumway from Stanford
Medical Centre, U.S.A. His persistent and
untiring work on heart transplantation over
the decades has firmly established heart
transplant as a standard operation with a
significantly low peri-operative mortality
and satisfactory long-term results. Well over
60,000 heart transplant procedures have
been performed worldwide so far. At
present, less than 2700 heart transplants
are performed each year in the world and
these numbers are falling. The surgical
technique of this operation and the
associated problems have not changed
much with time. Problems of rejection
(both acute and chronic), susceptibility to
infection and long-term problems with the
transplanted heart have remained same
over the decades. The longest survivor of
RECIPIENT SELECTION:
Terminal Heart Disease
Brain death declared Age: New born – 60 yrs,Irremediable cardiac disease NYHA Class IV,Pulmonary Vascular Resistance < 6-8 Wood unitsor pharmacologically reversible
Reasonable physiological - normal function orreversible dysfunction of kidneys, liver, lungs, CNS
Psychosocial stability
No alcohol, tobacco or drug abuse
Absence of
• Active malignancy or infection
• Recent pulmonary Infarction
• Severe peripheral or cerebro vascular disease
Contraindications
Fixed pulmonary vascular resistance
Peripheral vascular disease
Acute malignancy
COPD /chronic bronchitis
Morbid obesity
ABO incompatibility
THE FIRST SUCCESSFUL HEART TRANSPLANTSURGERY WAS PERFORMED ON 3RD DECEMBER
1967 BY DR. CHRISTAN BERNARD.“
“HEART TRANSPLANT
2008 Vol 23 Vol No. 1 13
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heart transplant has now
lived for over 28 years. Tony
Haesman from Washington
has worked as a salesman for
28 years. He had Heart
Transplantation at Stanford
and continues to lead an
active life.
SURGERY
Orthotopic
Hetrotopic (piggyback)
POST TRANSPLANT
CONCERNS
Immunosuppression
As in other solid organ
transplants
Transvenous myocardial
biopsy
• Internal jugular
approach
• 3-5 specimens
• weekly for the first 4
weeks
• grading system developed by Billingham
Coronary graft vasculopathy
Infection as in other solid organ transplants
MEDICAL COMPLICATIONS OF
CARDIAC TRANSPLANT
Cardiac
Ventricular dysfunction
Sinus node dysfunction
Tricuspid regurgitation
Allograft rejection
Allograft coronary artery disease
Decreased exercise tolerance
Non-cardiac, Non-infect ious
Renal insufficiency
Hypertension
Osteoporosis
Hyperlipidemia
Malignancy
Psychologic/behavioral/societal
Glucose intolerance
Pancreaticobiliary disease
Obesity
CARDIAC ALLOGRAFT REJECTION
Propensity decreases with time
Types
Donor Selection:• Only 10-20% of brain dead patients
with suitable hearts become donors;
cardiac transplantation is currently
limited by donor availability
• Age <45 (special exceptions)
• No pre-existent heart disease,
normal ECG, normal ECHO
• Few CAD risk factors
• No untreated acute infections
• Negative T cell cross match if panel
reactive antibodies 10% or greater
• Negative HIV. HbsAg, HCV
• No systemic malignancy
• No cardiac trauma
• Minimal pressure support
• ABO compatibility
• Size within 20%-50% of recipient
• Hyperacute • Acute
• Chronic (ACAD)
• Cellular • V a s c u l a r
(Humoral)
Diagnosis
• Endomyocardial
biopsy • Non-invasive
• Clinical
Treatment
ALLOGRAFT CORONARY
ARTERY DISEASE
Leading cause of death
> 1 year af ter
transplantation
Equivalent to:
• “Chronic rejection” in
renal allografts
• “Vanishing bi le
ducts” in hepatic
allografts
• “ B r o n c h i o l i t i s
obl i terans” in
pulmonary allografts
Prevalence of angiographically detectable disease
• 1 year: 10-2O%
• 5 years: 30-50%
HEART TRANSPLANT
THE LONGESTSURVIVOR OF HEART
TRANSPLANT HAS NOWLIVED FOR OVER
28 YEARS.
“ “
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Functional Status Following Heart TransplantPost Transplant Functional Status
• 1 year follow up: 90% - no activity limitation, 8.5% -performs with assistance, 1.4%
total assistance
• 3 year follow up: 93.5% no activity limitation, 5.8% performs with assistance, 0.8%
total assistance
Post Transplant Work Status
• 1 year follow up: 29.2% working full time, 8.1% working part time, 47.7% not working,
15.0% retired
• 3 year follow up: 32.5% working full time, 8.5% working part time, 39.8% not working,
19.1% retired
Post Transplant Rehospital izat ion
• 1 year follow up: 57.5% no hospitalization, 9.2% hospitalization (not rejection not
infection), 11.4% (rejection), 14.8% (Infection), 7.1% (rejection + Infection)
Causes of Death afterTransplantation
Rejection
Infection
Technical
CNS
Malignancy
After First year
• Graft Atherosclerosis
• Infection
• Malignancy- Lymphoma
• Rejection
HEART TRANSPLANT
Surgery now is standard; but the yearly numbers are
actually falling. With newer technology impacting our lives
in more ways than one, surgery of heart transplant has an
uncertain future. Sooner but not later, totally implantable
artificial heart (or assist device) will make heart transplant
surgery obsolete.
2008 Vol 23 Vol No. 1 15
(Diagrams by Dr. Balkrishna)
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Frontiers of immunosuppressionin Renal TransplantMaintenance immunosuppressive therapy is administered to all transplant
recipients to prevent acute rejection and loss of allograft.
By Dr. Jatin Kothari
Induction immunosuppressive strategies in renal transplantation
High dose conventional agents Antibody induction
Calcineurin inhibitor: Cyclosporine or tacrolimus Calcineurin inhibitor: Cyclosporine or tacrolimus
(lower doses than conventional agent strategy)
Corticosteroid Corticosteroid
Antimetabolite: Mycophenolate mofetil or Antimetabolite: Mycophenolate mofetil or
azathioprine azathioprine (lower doses than
conventional agent strategy)
Plus one of the following: .
ALG
ATG
OKT3
Anti-TAC: Daclizumab or basiliximab
16 2008 Vol 23 No. 1
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EVALUATION
OF INDUCTION
PROTOCOL
REQUIRES
CONSIDERATION
OF THE
FOLLOWING
FACTORS:
Incidence and
severity ofdelayed allograftfunction orprimarynonfunctionincluding therequirement forand duration ofdialysis followingtransplantation.
Incidence of
acute rejection
Incidence, type,
and severity ofassociatedinfections
Long-term
allograft survivaland function
Mortality and
morbidity,Incidence andtype ofmalignancyduring long-termfollow-up
Cost including
length ofhospitalization
CHECK LIST
ALTHOUGH AGGRESSIVE
INDUCTION therapy offers clinical
advantages even in low-risk groups, such
a regimen produces the greatest benefits
in groups at high-risk for allograft
rejection which include pediatric patients,
African-Americans, recipients of kidneys
with prolonged cold ischemia time, and
those at h igh immunologic r i sk,
par t icu lar ly indiv iduals who are
presensitized. The sequential induction
regimen of thymoglobulin (or OKT3)
followed by cyclosporine or tacrolimus is
recommended in these high-risk groups.
MAINTENANCE
IMMUNOSUPPRESSIVE
THERAPY IN RENAL
TRANSPLANTATION IN ADULTS
Maintenance immunosuppress ive
therapy is administered to almost all
renal transplant recipients to help
prevent acute rejection and the loss of
the rena l a l logra f t . A l though an
adequate level of immunosuppression is
required to dampen the immune response
to the allograft, the level of chronic
immunosuppression is slowly decreased
over time (as the risk of acute rejection
decreases) to help lower the overall risk
of infection and malignancy; these risks
directly correlate with the degree of
overall immunosuppression. The type of
immunosuppression may also be varied
to decrease the risk of developing
chronic allograft nephropathy, the most
common underlying long-term cause of
a l logra f t loss . Convent iona l
maintenance regimens consist of a
combination of immunosuppressive
agents that differ by mechanism of
action. This strategy minimizes morbidity
and mortality associated with each class
of agent whi le maximiz ing overal l
effectiveness. Such regimens may vary by
t ransplant center and geographic
THE INTRODUCTION OF CYCLOSPORINE IN THEEARLY 1980S IMPROVED RENAL ALLOGRAFT
SURVIVAL BY APPROXIMATELY 15 PERCENT ATONE YEAR POST-TRANSPLANT.
“ “FRONTIERS OF IMMUNOSUPPRESSION IN RENAL TRANSPLANT
2008 Vol 23 Vol No. 1 17
THE LEVEL OF CHRONIC IMMUNOSUPPRESSIONIS SLOWLY DECREASED OVER TIME“
“
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area.The major immunosuppressive agents that are
currently being used in various combination regimens
are corticosteroids (primarily oral prednisone),
azath iopr ine, mycophenolate mofet i l (MMF),
mycophenolate sodium (myfortic), Cyclosporine ,
Tacrolimus, Everolimus, and Rapamycin (sirolimus)
INVESTIGATIONAL IMMUNOSUPPRESSIVE
DRUGS IN CLINICAL RENAL
TRANSPLANTATION
The introduction of Cyclosporine in the early 1980s
improved renal allograft survival by approximately 15
percent at one year posttransplant. However, Cyclosporine
failed to enhance long-term graft survival because of the
inability to suppress the chronic and progressive loss of
functioning renal tissue arising from antigen dependent
and independent immunologic factors .The administration
of cyclosporine or tacrolimus may also exacerbate this
process because of direct nephrotoxicity . In addition,
renal transplant recipients are at risk for significant side
effects due to immunosuppression, including infection,
cardiovascular disease, hypertension, and malignancy.
These limitations constitute the rationale for the continued
development of new immunosuppressive agents.
MONOCLONAL ANTIBODIES — O KT3
remains the only non-humanized mouse antibody
licensed for the therapy of allograft rejection . However,
the administration of OKT3 is associated with frequent
and occasionally serious adverse effects.Since OKT3 is
a T cell mitogen, most of these symptoms are thought
to be mediated by T cell release of cytokines via CD3
binding. Other serious complications, arising from the
more intense immunosuppression, include infection and
an increased incidence of lymphoproliferative disease
Humanized OKT 3 — To reduce the s ide
effects and the antigenicity of murine OKT3, a non-
mitogenic “humanized” variant has been
developed . The humanized hybrid molecule
was engineered by transferr ing the
complimentary determining regions of OKT3
onto a human IgG framework and then
mutat ing single amino acids to reduce the
aff ini ty of the “humanized” ant i-CD3
monoclonal antibodies.
T10B9.1A monoclonal antibody — T10B9.1A
is a murine monoclonal antibody directed against an
epitope of the T cell receptor alpha/beta heterodimer .
Unfortunately, the development of human antimouse
antibodies with T10B9.1A occurs with the same
frequency as with OKT3 .
Anti-ICAM-1 antibodies — Several adhesion
molecules contribute to the interaction between T cells
and antigen presenting or target cells. One critical
adhesive receptor-counterreceptor combination is
leukocyte function-associated molecule-1 (LFA-1) and
intercellular adhesion molecule-1 (ICAM-1) .
Anti-LFA-1 an t ibod ies — phase I/ I I t r ials
evaluated two doses of efalizumab, a humanized anti-
LFA-1 antibody, plus maintenance therapy with either
full dose cyclosporine, mycophenolate and steroids or
half dose cyclosporine, sirolimus and prednisone . At
six months, patient and allograft survival were 97 and
95 percent, respectively.
Ant i -B7 ant ibody — Of the numerous
costimulatory pathways for T cell activation identified
thus far, that provided by the interaction of CD28 on
the T cell surface with its antigen presenting cell surface
ligands, B7-1 or B7-2 (CD80 and CD86, respectively),
has been most studied. T cell anergy and apoptosis
induced by T cell receptor signaling alone is prevented
by signaling through CD28.Phase III trials are currently
underway, which is evaluating Belatacept in a calcineurin
inhibitor free maintenance immunosuppressive regimen.
EVEROLIMUS — The efficacy and adverse effects
of Everolimus an immunosuppressive agent that is a
structural analogue of sirolimus, has been evaluated in
multiple studies . Dose levels up to 5 mg/day were well
tolerated; an increased incidence and severity of adverse
events, particularly thrombocytopenia and reversible
cholesterol elevations, were observed at a dose of 10
mg/day.
FINGOLIMOD (FTY720) — F ingo l imod
(FTY720) is a sphingosine analogue that functions as
an immunosuppressant by altering normal lymphocyte
homing patterns . This agent interferes with the exit of
lymphocytes from the thymus into the blood and from
the tissue of secondary lymphoid organs into the efferent
lymphatics. It may also reduce the risk of malignancy
after transplantation .
PHOTOPHERESIS — Photopheresis is a form of
extracorporeal photochemotherapy in which peripheral
lymphocytes are collected via apheresis and treated with
8-methoxypsoralen and ultraviolet light . The process
appears to downregulate act ivated T cel l
clones.Preliminary evidence suggests that photopheresis
may decrease the frequency of rejection in both cardiac
and renal transplant recipients.
FRONTIERS OF IMMUNOSUPPRESSION IN RENAL TRANSPLANT
18 2008 Vol 23 No. 1
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2008 Vol 23 Vol No. 1 19
RESEARCH
Research
Patents:
‘Method and research tool for identification of mycobacterium along with detection of
drug resistance in mycobacterium tuberculosis complex’. Has been filed for patency to
Indian National Patent’s Office. The study was carried out by Shubadha Shenai under
the guidance of Dr Camilla Rodrigues and Dr Ajita Mehta.
Awards:
Shubadha Shenai won
– (i) Gold medal 2007 for best paper [Title : Development of a Reverse line blot
hybridization (RLBH) assay for species identification of mycobacteria and drug
resistant testing in M. tuberculosis complex. ] presented at the XXXIst at the Indian
Association of Medical Microbiologist.
– (ii) Best paper award in PhD category 2007 from the ‘Dhala’s Felicitation Fund’.
Dr Hari Talreja won the Burgis N. Khushetji Award in the Indian society of
Nephrology , Western chapter held at Raipur in sept 2007 for his paper; ‘Assesment
of currently available methods of GFR, need for a new marker (Cystatin C)? ’.
Annual Research Day was held on 12th April 2008. Best paper awards were given to
following papers:
– First prize: To Dr Dipika Agarwal for her paper ‘Prevalence of sleep disordered
breathing in patients with heart failure’
– Second prize: To Shubadha Shenai for her paper ‘Comparison of phenotypic&
genotypic methods of pyrazinamide susceptibility testing’ & to Rani Raghavan for
her paper For her paper ‘Genetic screening of cystic fibrosis gene in Indian patients’.
Mid Annual Research Day was held on 3rd November 2007. Best paper awards were
given to following:
– First prize: To Apurva Sawant for her paper ‘Prevalence of dyslipidemia in young
adult Indian population’.
– Second prize: To Jency Courien for her paper ‘Kikuchi-fujimoto disease :
A study of 25 patients.
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LIVER TRANSPLANTATION IS, today, the only
curative option for end-stage liver disease. Dr
Thomas Starzl in the USA and Sir Roy Calne in the
UK who pioneered these surgeries in the 1960s
initially had success rates of 30%. However,
paralleling advances in immunosuppression,
Liver Transplant
anesthesia, intensive care and refining of surgical
techniques, survival of more than 80% have been
achieved.
CONTRAINDICATIONS
Systemic illnesses precluding anesthesia, untreated
Liver Transplantation has been gaining popularity due to its high success rate
and the fact that it is currently the only cure for end-stage liver disease.
By Dr. Sudeep R Shah
20 2008 Vol 23 No. 1
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INDICATIONS FOR LIVER TRANSPLANTATION
Hepatitis C cirrhosis
Hepatitis B cirrhosis
Alcoholic liver disease
Cholestatic liver disease
• Primary sclerosing cholangiitis
• Biliary cirrhosis- primary and secondary
Autoimmune liver disease
Budd-Chiari syndrome
Metabolic disorders:
• Wilsons disease
• Haemochromatosis
• Oxalosis
• Alpha 1 antitrypsin deficiency
• Erythropoetic porphyria
• Hypercholesterolemia
• Familial amyloid polyneuropathy
Liver space occupying lesions:
• Polycystic disease
• Multiple adenomatosis
• Caroli’s disease
Fulminant liver failure
• Viral hepatitits (B, A, E)
• Drug toxicity
• Paracetamol overdose
• Halothane
• Wilson’s disease
In children:
• Biliary atresia
• Progressive familial intrahepatic cholestasis
• Metabolic disorders Criggler Najjar syndrome, Urea
cycle disorders
• Unresectable hepatoblastoma
LIVER TRANPLANT
2008 Vol 23 Vol No. 1 21
sepsis, AIDS and extrahepatic malignancy,
non neuroendocrine liver metastases, liver
angiosarcoma and cholangiocarcinoma
are considered absolute contraindications.
Hepatocellular Carinoma (HCC) beyond
the Milan criteria (> 5 cm tumour, >3
tumours each < 3cm), have survival
reduced by tumor reccurrence. HCC with
tumour thrombus in the portal vein. HBV
DNA positive patients have high graft loss.
Severe porto-pulmonary hypertension,
non-compliers with treatment and active
substance abusers are not considered.
IMMUNOSUPPRESSION AND
REJECTION
Only blood group matching is required
for liver transplantation. Though acute
rejection may occur in up to 50% of cases,
chronic rejection leading to graft loss takes
place in < 5% of transplants. Diagnosis
is suspected on altered liver function and
established by biopsy.
Lifelong immunosuppression is required.
Modern immunosuppression centers on
the use of calcineurin inhibi tors-
Tacrolimus (FK 506) or microemulsified
Cyclosporine A Levels are closely
monitored to limit toxicity. Steroids are
started in high doses and rapidly tapered.
In the majority of cases these can be
stopped by 3 months post operatively.
Episodes of acute rejection are treated by
pulsed steroids for 3 days. In rare cases,
severe rejection requires treatment with
anti lymphocytic globulin or OKT3.
Mycophenolate moefetil is used as an
adjunct, especially to reduce calcineurin
inhibi tor dose in case of renal
dysfunction.. Recently induction agents
such as anti IL2 receptor antibodies-
basiliximab and daclizumab and new
drugs rapamycin and sirolimus are also
being used.
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POST OPERATIVE
COMPLICATIONS
Primary failure of graft
function is most feared-
occurring in 5% of cases.
The causes include poor
donor l iver qual i ty-
especially steatohepatitis.,
preservation injury and
hepatic artery thrombosis
(HAT), which almost
invariably requires
retransplantation. HAT
occurs in 5% of adult and
15% of pediatr ic
transplants. Portal vein
thrombosis is rarer,
occurring in 2%. Biliary
complications have been
called the Achilles’ heel of
liver transplantation and
occur in 12-30% of cases.
HAT may be associated
with this as the artery is the
main supply to the bile
duct. Corrective surgery is
often required.
Liver dysfunction due to
a small graft is a particular
problem of living related
transplant in case of small
donor graft. Failure to
establish adequate venous
outflow especially from
middle hepatic vein
branches of a right lobe
graft may lead to graft
congestion .
Infections owing to immunosuppression are the
common cause of morbidity and mortality. Besides
nosocomial organisms,
opportunistic infections of
note are cytomegalovirus
(CMV) which occurs as
fever, leucopenia and
colitis, hepatitis, pneumonia
or meningitis after the third
week. Prophylaxis is
instituted especially if the
donor has previous
exposure and recipient does
not. Viral and fungal
infections too are common.
Live vaccines should be
avoided post transplant.
Drug toxicity is a major
morbidi ty. Calcineurin
inhibi tors cause
h y p e r t e n s i o n ,
hyperl ipidemia and
diabetes. High levels are
nephrotoxic and may lead
to tremors, neuropsychiatric
changes and rarely,
convulsions. Cyclosporin
leads to hirsuitism and
gingival hypertrophy.
Mycophenolate causes
leucopenia and diarrhoea.
Rapamycin leads to retarded
wound heal ing. Drug
interactions are common
and complex, requiring
physicians to be careful
while adding new drugs.
Post t ransplant
l y m p h o p r o l i f e r a t i v e
disorders and skin cancers
occur in up to 7% of immunosuppressed patients.
Disease recurrence is a major issue, especially in
Donor Selection andProcedureThe donor may be a brain-stem dead
cadaver from whom the whole liver
may be retrieved, or a relative who is
fit, free of liver pathology and willing
to donate par t of the l iver. An
anatomical lobe or sector may be
removed amounting to 0.8 to 1% of
recipient body weight. Living donor risk
to life is estimated at <0.5% , with a
10% risk of major morbidity. The donor
l iver regenerates to near normal
volume.
Brain stem dead cadavers may not
provide a good quality liver if they have
poor hemodynamic stability, are on high
pressor doses, have fatty change, long
ICU stay or prolonged starvation.
Potential brain dead organ donors
require careful maintainance in ICU.
Cadaver livers may be divided along
anatomical planes to reduce size for
children or alternately split to provide
two grafts- a smaller left lobe for children
and right lobe for small adults, either in
situ or on the bench after retrieval.
The liver is perfused with University of
Wisconsin (UW) solution or Histidine-
tryptophan-ketoglutarate (HTK)
solution. The liver may preserve for upto
24 hours in UW and 15 hours in HTK
solution.
LIVER TRANPLANT
PARALLELING ADVANCES IN IMMUNOSUPPRESSION, ANESTHESIA,INTENSIVE CARE AND REFINING OF SURGICAL TECHNIQUES,
SURVIVAL OF MORE THAN 80% HAVE BEEN ACHIEVED.“
“
22 2008 Vol 23 No. 1
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The Recipient ProcedureThe native liver is removed, a step that is difficult because of portal hypertension collaterals
and coagulopathy, and replaced by the donor liver, joining the vena cava, portal vein,
hepatic artery and bile duct. T-tubes or stents are occasionally employed across the biliary
anastomosis. In case of bile duct disease such as biliary atresia, a Roux loop of jejunum
is used. longer considered essential. The native vena cava is left in place in all living
related transplants and also in select cadaveric transplants.
Hepatitis C, where accelerated cirrhosis may occur in
up to 25% cases. Autoimmune hepatitis, primary
sclerosing cholangiitis and tumours may recur.
Recidivism causes graft loss in alcoholics.
PROGNOSIS
Modern transplant techniques offer a one year survival
of 80-90% and 5 year survival of 70-80% for
appropriately selected patients with chronic liver disease
undergoing timely transplants. The survival for fulminant
liver failure is marginally lesser. Living related and
cadaver transplant have similar survival rates.
INDIAN SCENARIO
Cadaver liver transplantation has been legally possible
since the Human Organ Transplant Act of 1994.
However, numbers have been limited. Various agencies
such as the Mohan Foundation (Chennai, Hyderabad),
Organ retrival banking organization (ORBO) (Delhi)
and Zonal Transplant Co-ordinating Center (ZTCC)
(Maharashtra) are involved in increasing awareness
for cadaver organ donation amongst physicians and
lay people. Living related liver transplant is offered in
some centers for those patients with suitable related
donors, with good results.
LIVER TRANPLANT
2008 Vol 23 Vol No. 1 23
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Live Related RenalTransplantRenal transplantation is the best form of renal replacement therapy with live
related donor transplant being the solution of choice in End Stage Renal Disease
patients. By Dr. Alan Almeida & Dr. Ashwinikumar Khandekar
RENAL TRANSPLANTATION REMAINS the
best form of renal replacement therapy providing
better quality of life and survival compared to
dialys is. Contrary to common percept ion,
transplantation, in the long run, is a less expensive
option than dialysis, giving better rehabilitation. Live
24 2008 Vol 23 No. 1
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WHO CANNOT
DONATE A
KIDNEY?
Following is a list of
conditions which
preclude renal
donation.
ABSOLUTEPsychiatric diseaseinterfering withability to consentActive drug oralcohol abuseEvidence of renaldisease (low GFR,urinaryabnormalities)Recurrent orbilateralkidney stonesCollagen vasculardiseaseDiabetes withkidneyinvolvementSevereHypertensionMalignancyActive infectionChronic activeviral infection(hepatitis B or C,HIV)Significant chronicliver diseaseCurrent pregnancy
RELATIVE
Age <18 or >65
years
Obesity (especially
BMI >35)
Mild or easily treated
hypertension
Single prior episode
of nephrolithiasis
Borderline urinary
abnormalities
CHECK LIST
CONTRARY TO COMMON PERCEPTION,RENAL TRANSPLANTATION, IN THE LONGRUN, IS A LESS EXPENSIVE OPTION THAN
DIALYSIS, GIVING BETTER REHABILITATION.“ “
LIVE RELATED RENAL TRANPLANT
THE FIRST SUCCESSFUL RENALTRANSPLANTATION WAS PERFORMED BETWEEN
IDENTICAL TWINS BY JOSEPH MURRAY IN 1954.“
“
Percent survival after living-related/cadaveric donor transplant and dialysis
Treatment 1 yr 2 yr 5 yr 10 yr
Type surv ival surv ival surv ival surv ival
Living-related donor
renal transplant 97.79 95.82 90.21 74.84
Cadaveric donor transplant 94.68 91.96 78.93 55.07
Dialysis 77.96 62.39 27.96 8.49
related donor transplant still remains the
solution of choice in End Stage Renal
Disease patients with the promise of
deceased donor (cadaver donor)
transplantation still not fulfil l ing its
promised growth.
HISTORY
The first successful renal transplantation
was performed between identical twins
by Joseph Murray in 1954. No
immunosuppression was used because
the donor was genetically identical to the
recipient. Transplantation grew with the
advent of newer immunosuppressive
agents such as azathioprine (1960). A
combination of steroids and azathioprine
soon became the s tandard
immunosuppressant reg imen for
t ransplants . Cyclospor ine became
available in the mid-80s, dramatically
reducing the incidence of acute rejection
and improving overall graft survival.
Mycophenola te mofe t i l (and
mycophenol ic ac id ) , tacro l imus,
sirolimus / everolimus and other agents
were added over the ensuing years. Not
only were newer drugs added but
biological agents to prevent or treat
rejection have evolved. The current day
s tandard t r ip le reg ime inc ludes
Mycophenola te , Tacro l imus or
Cyclosporine and steroids.
2008 Vol 23 Vol No. 1 25
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AS PER THE EXISTING HUMAN ORGAN TRANSPLANT ACT 1994,ANY FIRST DEGREE RELATIVES OF THE RECIPIENT ( PARENTS,
SIBLINGS, CHILDREN) OR THE SPOUSE CAN BE AN ORGANDONOR PROVIDED THEY ARE BLOOD GROUP COMPATIBLE.
“ “LIVE RELATED RENAL TRANPLANT
26 2008 Vol 23 No. 1
OPTIONS FOR PATIENTS WITH END STAGE
RENAL DISEASE (ESRD)
Uremic symptoms arise in renal failure patients with a
creatinine clearance ≤ 10 mL/min with symptoms of
anorexia, nausea, weight loss, breathlessness, anemia
and somet imes reduced ur ine output being
predominant. Toxins, otherwise thrown out in the urine
by better functioning kidneys, accumulate in the
circulation in uremic patients,. This is the time that
the excretory function of the kidney need to be replaced
by the process of dialysis, either hemodialysis or
peritoneal dialysis. The synthetic functions viz.
production of vitamin D and the hormone erythropoietin
still need an external supplement in the form of
injections or tablets. Renal Transplant is a more
complete solution since a normal functioning kidney
is placed inside the recipient which carries out both
the excretory as well as the synthetic functions.
Sometimes, it may be prudent to do a transplant even
before the patient requires institution of dialysis and
is called a pre-emptive transplant (pre-empt the need
for dialysis).
WHO CANNOT HAVE A KIDNEY
TRANSPLANT?
Treatment options for patients with ESRD include
palliative care, hemodialysis, peritoneal dialysis, and
kidney transplantation. During the pretransplant
evaluation, patients are categorized as low, moderate,
or high risk based on surgical risk factors and comorbid
medical condit ions. Absolute and relat ive
contraindications to kidney transplantation are listed in
the table. Absolute contraindications include some types
of neoplastic disease, HIV infection, AIDS, some
infectious processes, some systemic diseases, and
irreversible vital organ failure. However, due to special
expertise and/or research protocols at individual centers,
pat ients with these contraindicat ions may be
transplanted, but this is not reflective of current practice
standards.
Contraindications to Renal Transplantation
Contraindication Absolute Relative
Cancer X
HIV positive/AIDS X
HCV infection X
HBV infection X
Morbid obesity X
Atherosclerosis X
Cardiac Disease X
Uncontrolled hypertension X
Smoking X
Unresolved psychosocial issues X
Active UTI X
Active tuberculosis X
Irreversible heart failure, XIrreversible lung failure XIrreversible liver failure X
Active systemic disease(ie, lupus, sickle cell
disease, Wegener’s disease) X
WHO CAN DONATE A KIDNEY?
As per the existing Human Organ Transplant Act 1994,
any first degree relatives of the recipient ( parents,
siblings, children) or the spouse can be an organ donor
provided they are blood group compatible. Blood group
[ABO] compatibility is the same as that in relation to
blood transfusion except that the Rh compatibility is not
required for renal transplant. Blood group ‘AB’ is a
universal recipient while ‘O’ is a universal donor. A
donor between 18 and 55 years of age would be
preferred, though at times, donors of older age may
also be accepted (biological age vs chronological age).
It is understandable that a kidney from an elderly donor
would have lower GFR (commensurate with the age-
related decline) and other associated co-morbidities.
WORK UP OF A DONOR
A donor is identified at a family conference and
undergoes detailed evaluation starting off with a detailed
history to rule out medical disorders that would preclude
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Common side effects ofImmunosuppressives:• Cyclosporine can cause excessive
facial hair growth, gum hypertrophy,
hypertension, lipid abnormalities and
the drug itself is toxic to the kidneys
if the blood levels are high. It can
also affect the endocrine functions
of pancreas and lead to diabetes
mellitus.
• Azathioprine can cause bone
marrow suppression
• Mycophenolate causes selective
suppression of WBC production.
Loose motions are a common side
effect.
• Steroids side effects include truncal
obesi ty, hypertension, l ipid
abnormalities, cataracts, avascular
necrosis of femur head, muscle
weakness, osteoporosis and glucose
intolerance.
• Sirolimus and Everolimus can affect
wound healing, cause proteinuria
and in combination with
Cyclosporine or Tacrolimus affect
the kidney function.
LIVE RELATED RENAL TRANPLANT
2008 Vol 23 Vol No. 1 27
organ donation. After
an in-depth cl inical
examination, the donor is
subjected to laboratory
workup.
The first step is the
demonstration of blood
group compatibility (ABO).
I f the blood group is
compatible, the donor is
tested for renal functions
and any systemic condition
which might interfere with
organ donation or surgical
fitness. If the renal functions
are good and there is no
risk other than that
associated with an elective
surgery, only then the
prospect ive donor is
considered fit to donate.
The possibi l i ty of
transmitting an infection
should be ruled out by
performance of serological
tests. HIV seropositivity is a
contra-indication to renal
donation. Similar ly,
Hepatitis B or Hepatitis C
seropositive individuals
cannot donate to respective seronegative recipients. Any
active infection, especially urinary tract infection should
be completely treated prior to kidney donation. Specific
viral illnesses which are quiescent in a normal individual,
can become life threatening in an immunosuppressed
individual and need to be ruled out prior to donation.
These includes Cytomegalovirus (CMV) and Epstein -
Barr virus (EBV). An active infection can be ruled out
serologically by measuring IgM antibodies against these
viruses.
To quantify the donor’s renal functions, a 24 hr urinary
creatinine clearance is done or similar information may
be obtained by measuring the level of kidney function
on a nuclear medicine study (DTPA GFR). Surgical fitness
is largely decided by cardiovascular fitness followed by
the hepatic functions and respiratory i l lnesses
compromising lung functions. Finally the surgical
anatomy of blood supply to the kidneys needs to be clearly
delineated prior to surgery. This is done by either a
conventional renal
angiogram or Digital
Subtraction Angiogram
(DSA) or Computerized
Tomography (CT)
Angiogram depending on
availability.
HLA TEST AND
LYMPHOCYTE
CROSSMATCH
Human Leukocyte Antigen
(HLA) is a set of antigens
encoded by Major
Histocompatibility Complex
on chromosome 6. There
are two classes, class I and
class II. Class I includes
subgroups A, B and C and
class II includes subgroups
DR, DQ and others. Each
subgroup expresses two
alleles. Hundreds of such
alleles have been identified
and more are added every
few months. For Renal
Transplantat ion, the
subgroups A, B and DR are
considered important.
Identical twins will have
100% matching in these alleles. The other siblings can
have a 100% match (HLA identical), a 50% match
(haplo-identical) or a zero match between them. Parents
have a 50% match with their offsprings. Better the HLA
match, lesser is the immunosuppression required and
longer is the graft survival. Even though the HLA match
may be 100%, there are several other antigenic stimuli
which can incite an immunological response by the
recipient precipitating a graft rejection. This can be
tested by doing a lymphocyte crossmatch test where
donor lymphocytes are incubated with recipient serum
and if more than 10% of donor lymphocytes are destroyed
by recipient serum, it is designated as positive and a
transplant precluded at that stage and a search for
alternative donor initiated. This situation arises after
multiple pregnancies or donor specific transfusions.
WORKUP OF THE RECIPIENT
The workup is largely directed towards surgical fitness
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THE OLD KIDNEYS ARE USUALLY PRESERVED SINCETHEY ARE HARMLESS AND CAN ACTUALLY CONTRIBUTE
SOME FUNCTION EVEN AFTER TRANSPLANT.“
“
LIVE RELATED RENAL TRANPLANT
and the viral illnesses mentioned above and have similar
implications as in the donor. Active infections including
UTI, dental abscesses, dental caries need to be ruled
out. In children, a common cause of renal failure is
abnormal bladder function. Bladder function needs to
be tested for its ability to accommodate and hold the
increased urine after transplant. If abnormal, a corrective
bladder surgery may be required.
TRANSPLANT SURGERY
Two surgical teams operate simultaneously on the donor
and the recipient. The donor kidney is placed in the
recipient’s iliac fossa outside the peritoneal sac. The
renal blood vessels are joined to the iliac blood vessels
and the ureter is joined to the bladder with a technique
designed to prevent reflux from the bladder into the renal
graft. The old kidneys are usually preserved since they
are harmless and can actually contribute some function
even after transplant. The additional surgery of removing
old kidneys can be avoided unless they are severely
infected or are too large and occupying the whole of
abdomen.
IMMUNOSUPPRESSION
Except in an identical twin, immunosuppression is
required to prevent rejection. This includes the
medicat ions l ike cyclosporine or Tacrol imus,
Mycophenolate (MMF) or Azathioprine along with
glucocorticoids. Newer, more potent drugs include
Sirolimus and Everolimus. If the HLA match is poor, an
‘induction’ agent is used in the form of monoclonal or
polyclonal antibodies against lymphocytes. These
medications are started a day or two prior to the surgery
and the antibodies are usually given just prior to the
surgery and after a fixed interval thereafter depending
on the drug used. The immunosuppression needs to
be continued life-long. These drugs need to be
monitored since the ‘therapeutic index’ is quite narrow.
Blood levels of cyclosporine and Tacrolimus are checked
routinely till the desirable level is achieved and thereafter
whenever the need is felt. Levels are also monitored for
Sirolimus and Everolimus. With the current day potent
immunosuppressants, graft life has increased at the cost
of increased risk of infections. Urinary Tract Infection
still remains the commonest infection followed by
bacterial pneumonia, viral illnesses like CMV and fungal
infections. Tuberculosis still remains a potent threat in
transplant recipients . A polyoma virus called BK virus
is becoming increasingly more recognized as a cause
for steady decline in graft function.
POST TRANSPLANT PERIOD
The transplant recipient requires close follow-up in the
post transplant period. The initial year is the most
important but the surveillance should continue lifelong
to ensure a long survival.
OUTCOMES OF RENAL TRANSPLANT
With potent immunosuppressive options available
today, graft survival has significantly improved. The
graft ‘half-life’ has increased to 12 to 15 years from a
previous 5 to 10 years. The outcomes are better with
complete HLA match (100%) compared to haplo-
identical (50% match) which in turn has better survival
than zero match. However, the outcomes are affected
by acute rejection episodes, severe infections,
recurrence of the native kidney disease in the graft
and cardiovascular diseases.
THE GRAFT ‘HALF-LIFE’ HAS INCREASED TO 12 TO 15YEARS FROM A PREVIOUS 5 TO 10 YEARS.“
“
28 2008 Vol 23 No. 1
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UPDATE
To commemorate the 75th Birth Anniversary of Smt. Lalita Girdhar Hinduja on 1st November
2007, Hinduja Hospital took another step forward in the hi-tech world of modern medicate
to uphold the strong organization values of to improve patient safety and comfort,
inaugurated 8 new state-of-the-art operation theatres.
The new digitalized Operation Theatre complex is the first in many aspects in the country
and can match the best in the world. These theatres have been designed , keeping in mind
the surgeon, anesthetist, nurses and other OT personnel working requirements.
Highlights of this new OT complex:
• Guided Airflow Ventilation System (GAF): a patent technology for keeping
surgical site free of contamination.
• The Heat Ventilation and Air Conditioning Systems (HVAC): Each OT has it’s
individual Air Handling Unit (AHU) with independent temperature and humidity
controls. The first hospital to install the Digital Direct Control (DDC) for
management of pressurization of the complex, cleanliness of the various filtration
process based on room zoning, will greatly enhance the management of the air
quality with in the complex.
• Operating Lights: Light Emitting Diodes (LED) provides shadowless operating
light, excellent visualization, minimum heat generation and proper dissipation
with high light intensity.
• Integrated camera with LED lamps to capture crystal clear live images
• Simultaneous web telecasting of procedures.
New State-of-the-Art Operation Theatres
CONFERENCE AND SEMINAR
PLEASE VISIT www.hindujahospital.com/registration to register online
OR
VIEW PAST & FUTURE EVENTS.
2008 Vol 23 Vol No. 1 29
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THE IDEA OF rebui lding a bone marrow
destroyed by radiation was born in the aftermath
of World War II and the subsequent nuclear arms.
First modern transplants started in 1957 in patients
with end stage leukemia.
Stem Cell Transplant (SCT)
INDICATIONS
The rationale for SCT differs for different diseases. Mainly,
it serves as:
• A rescue procedure after treatment with high dose
chemotherapy in certain malignancies
• As replacement therapy in patients with marrow
While Stem Cell Transplant has vast benefits, it is associated with a number of
complications, some of which may be life threatening.
By Dr. Asha Kapadia, Dr. Sachin V. Almel & Dr.Uma Dangi
30 2008 Vol 23 No. 1
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failure or autoimmune disorders
• As a vehicle for gene therapy
• Possible strategy to establish tolerance
for solid organ transplants
TRANSPLANT PROCEDURE
In preparation for SCT, it is necessary to
“condition” the patient. The conditioning
regimens vary with the type of disease and
can be high dose chemotherapy, biologic
• Thrombocytopenia
• Infections
• Mucositis
• Venoocclusive disease
• Acute GVHD
• Graft failure
Late effects:
• Chronic GVHD
• Growth failure
• Infertility
DONOR
SELECTION
The choice of the
source of stem cells
depends on many
factors, importantly
the patient’s disease.
Depending upon the
source, transplant
can be –
Autologous -
source are
patient’s own
cells
Syngeneic –
donor is an
identical twin
Allogeneic –
• HLA identical
donor (related
/ unrelated)
• HLA non
i d e n t i c a l
donor (related
/ unrelated)
Xenogeneic –
different species
The stem cells are
either collected
from the bone
marrow; or the
peripheral blood
after treating with
growth factors.
therapy and radiation. The stem cells are
infused through a large bore central
venous catheter. Post transplant, the
engraftment depends on the source of the
stem cells and the use of G-CSF, usually
occurring at day 10 – 21.
COMPLICATIONS
SCT is associated with a lot of
complications, some of which may be life
threatening.
Early Toxicities:
• Neutropenia
• Cataracts
• Second malignancies
Transplant program at Hinduja Hospital
We have been doing Autologous
peripheral blood stem cell transplants’s
here at Hinduja Hospital for last 6 years,
mostly for malignant conditions viz.
mul t ip le myeloma and re lapsed /
refractory lymphomas. We have done
around 13 transplants so far, with good
results. We also plan to start Allogeneic
transplant at our centre in a short
while.
POST TRANSPLANT, THE ENGRAFTMENT
DEPENDS ON THE SOURCE OF THE STEM
CELLS AND THE USE OF G-CSF, USUALLY
OCCURRING AT DAY 10 – 21.“ “
CHECK LIST
STEM CELL TRANSPLANT
2008 Vol 23 Vol No. 1 31
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INTRODUCTION:
TWENTY FIVE YEARS AGO the first successful
clinical lung transplant was performed and since
then lung transplantation has become the modality
of choice for a variety of end-stage lung diseases.
Lung transplant –Where does it stand today ?
This has essentially been due to the amazing advances
that have been made in the field through refinement of
surgical techniques and improved understanding of
transplant immunology and microbiology.
Approximately 1,400 transplants are performed
With refinement of surgical techniques and a greater understanding of
immunology and microbiology, the success of lung transplantation has increased
manifold. By Dr. Manoj Agni
32 2008 Vol 23 No. 1
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worldwide each year. The operative
mortality rates are less than 10% and one
year survival is greater than 80% for most
diagnoses. Functional results are excellent
and durable. Post-transplant quality-of-life
25% predicted.
• Resting Hypoxia – PaO2 < 60 mm
Hg.
• Hypercapnia – PaCO2 > 50 mm
Hg.
studies demonstrate s igni f icant
improvement in the majority of patients.
Unfortunately, donor shortages continue
to limit the more widespread application
of lung transplantation. In order to address
this issue, marginal donors, living lobar
and split lung donor techniques have been
used clinically to increase the number of
donor lungs available.
FOR WHOM AND WHEN ?
• Emphysema due to chronic
obstructive pulmonary disease
or ααααα-1-antitrypsin deficiency
• Cystic fibrosis and
• Pulmonary f ibrosis.
• In the paediatric population,
cystic fibrosis and pulmonary
vascular disease are the prime
indications.
Referral guidelines:
• Endstage lung disease with l i fe
expectancy less than 1 - 2 yrs.
• Postbrochodilator FEV1 less than
DONOR LUNGS ISSUES
Ideal donors are ones with a
nonsmoking his tory, clear chest
radiograph, negative bronchoscopy and
good gas exchange (PaO2)/ (FIO2)
>300). Unfortunately, only 5–10% of
multiorgan donors have lungs that meet
these criteria
Donors aged less than 60 yrs are
preferable.
Contra indicat ions: ABO
incompatibil i ty between donor and
recipient, human immunodeficiency virus
positivity, active malignancies (outside the
central nervous system), and active
hepatitis infections remain absolute
contra indicat ions to donor lung
procurement.
Most adult lung transplants can
be conducted without the requirement
for cardiopulmonary bypass. Patients
with severe primary or secondary pulmonary
hypertension and paediatric patients need,
cardiopulmonary bypass.
SINGLE OR
DOUBLE LUNG
TRANSPLANT ?
ON OR OFF
BYPASS ?
General guidelines for
the selection of the
procedure are based
on the nature of the
original disease and
are as follows:
Double-lung
transplantation
• Cystic fibrosis
• Generalized
bronchiectasis
• Some patients
with COPD
Single-lung
transplantation
• Restrictive
fibrotic lung
disease
• Eisenmenger
syndrome with
reparable
cardiac
anomaly
• Some patients
with COPD
• Primary
pulmonary
hypertension
Heart- lung
transplantation
• Eisenmenger
syndrome with
irreparable
cardiac defect
• Pulmonary
hypertension
with cor
pulmonale
• End-stage
lung disease
with concurrent
severe cardiac
disease
CHECK LIST
LUNG TRANSPLANT
DONOR SHORTAGES CONTINUE TO LIMIT
THE MORE WIDESPREAD APPLICATION
OF LUNG TRANSPLANTATION.“
“
2008 Vol 23 Vol No. 1 33
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AFTER ALL THIS,
HOW WELL DO THE
RECIPIENTS DO ?
Operative mortality and
long-term survival vary by
diagnosis, with emphysema
providing results somewhat
superior to more
challenging conditions
such as pulmonary fibrosis
and pulmonary
hypertension. The operative
mortality is usually around
5 - 10%.
Postoperative functional
resul ts are excel lent.
Fol lowing bi lateral
transplantat ion for
emphysema, the mean
FEV1
increases from a preoperative level of 16% of the
predicted value to 84% at 3 months. This improvement
in pulmonary function is maintained at 1 yr with a mean
FEV1 of 75% predicted. Among cystic fibrosis patients,
results are similar, with a preoperative FEV1 of 22%
predicted increasing to 68% predicted early
postoperatively and 70% predicted at 2 yrs.
Among more than 14,500 lung transplant recipients
on the ISHLT ( International Society of Heart Lung
Transplantation) Registry, overall 1-, 3- and 5-yr survival
is 76, 57 and 43% respectively. Among single lung
recipients, FEV1
at 5, 6 and 7 yrs after transplantation
was 75, 73 and 68% predicted respectively. Experience
with pulmonary hypertension has also been gratifying.
These patients have experienced immediate restoration
of normal right heart function and pulmonary
haemodynamics which persists over a 4-yr follow-up
period. Actuarial survival of paediatric recipients is
77% at 1 yr, 62% at 3 yrs and 55% at 5 yrs.
Improvement in quality of life is seen after the
transplant and usually becomes evident after 3–6
months. Mobility, energy,
sleep, activities of daily
living dependency level
and dyspnoea were reported
to be improved following
lung transplantat ion.
Pretransplant psychological
status appears to affect
post-transplant quality of life
and adjustment.
BILATERAL
LIVING-DONOR
LOBAR LUNG
TRANSPLANTATION
Bilateral living-donor lobar
lung transplantation is a
procedure for pat ients
considered too ill to await
cadaveric transplantation. In this procedure, right and
left lower lobes from two healthy donors are implanted
in the recipient in place of the whole right and left lungs,
respectively.
Because only two lobes are transplanted, it seems to
be best suited for children and small adults Furthermore,
since paediatric patients receiving living lobar
transplants experienced less BOS and better pulmonary
function than paediatric recipients receiving cadaveric
donor lungs, living lobar transplantation may be the
preferred method for children.
Dramatic improvement of
pulmonary hemodynamics is
confirmed by chest X-ray and
echocardiogram. The mean
pulmonary artery pressures can
decrease from 72 mmHg to 11
mmHg. A year postoperatively, the patient is in
excellent physical condition with a forced vital capacity
and FEV1 close to 90% of predicted.
What to watch out forpostoperatively – earlyand late ?
Reperfusion injury - Early lung
allograft dysfunction occurs in 15–20%
of cases.
Airway complicat ions
In fec t ions
Rejection - Most recipients experience
at least one episode of acute rejection
within the f i rs t year fol lowing the
transplant. Calcineurin inhibitors are
used in virtually all patients
Bronchiolitis obliterans syndrome -
BOS
LUNG TRANSPLANT
IN BILATERAL LIVING-DONOR LOBAR LUNG TRANSPLANTATION,
RIGHT AND LEFT LOWER LOBES FROM TWO HEALTHY DONORS
ARE IMPLANTED IN THE RECIPIENT IN PLACE OF THE WHOLE
RIGHT AND LEFT LUNGS, RESPECTIVELY.“ “
34 2008 Vol 23 No. 1
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LUNG TRANSPLANT
Chest X-rays before (A) and after (B) receiving
LDLLT. (A) Before operation. Marked cardiomegaly
was present. (B) Three months after receiving
LDLLT. Well-expanded lobes filled the chest cavity,
leaving no detectable dead space without
cardiomegaly.
Survival af ter l iv ing-donor lobar lung
transplantation. After receiving a living-donor
lobar lung transplantation, 31 of 33 recipients
(94%) are currently alive for as long as
77 months.
Auto graft -Transplant of tissue to the same person e.g. Skingrafts, vessel grafts for CABG
Allo graft -Transplant from a genetically non-identical memberof same species e.g. human organ/ tissuetransplants.
Iso graft -Transplant to a genetically identical recipient e.g.identical twins
Xeno graft -Transplant from one species to another e.g. porcineheart valve transplant
Split Transplants -Donor organ (e.g. liver) may be divided betweentwo recipients.
Domino Transplants -This operation is performed for cystic fibrosis as bothlungs and heart are easier to transplant enbloc,recipients healthy heart is transplanted into someoneelse.
TYPES OF TRANSPLANTS
2008 Vol 23 Vol No. 1 35
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AUTO SKIN GRAFTS have been in Mumbai since
1950 progress happened in improved knife blades,
electronic dermatome and meshing. Heterogenous
grafting did not succeed, as was expected. Skin
banking and culture are for the future.
SHORT HISTORY OF ORGANTRANSPLANT
Solid organ transplant of kidney first took place in
around 1965 – 66. It was performed by Dr. Pardanani,
under leadership of Dr. P. K. Sen in K.E.M. Hospital.
However organ performed for a few days, as powerful
immuno-suppressives were not available. Donation of
PROGRESS IN CITY OF MUMBAI - By Dr. R. A. Bhalerao
36 2008 Vol 23 No. 1
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organ from cadaver was obtained by
obtaining affidavit from “cadaver” patient’s
relative, in presence of a Magistrate or JP.
Same process was used for cadaveric
donations of two livers and two hearts. Liver
transplantation was carried out by Dr. R. A.
Bhalerao and cardiac transplant by Dr. P. K.
Sen. The retrieval team was headed by
Dr. R. A. Bhalerao. However these efforts
were mainly supplemented by first successful
cardiac transplant in South Africa by
Christian Bernard. The liver transplants were
mainly technical success, cardiac transplants
worked for few hours. Further efforts got
dwarfed by some legal technical objections
pointed out by Dr. T. H. Ridani, the then
Dean of K.E.M. Hospital. One additional
cardiac transplant was done by Dr. K. F.
Dastur in Nair Hospital. Further cadaveric
transplants, had to wait till Human Organ
Transplantation Act, 1994. The first long
term successful cadaveric kidney transplant
was performed by Dr. Vatsala Trivedi,
Urologist from Sion Hospital, and since then,
L.T.M.G., K.E.M. Hospital and corporate
hospitals Jaslok and Hinduja Hospital are
in forefront of kidney and liver transplant
operations, with both cadaveric and live
related donor programme. ‘Selling’ of
kidneys, prosecutions, and public debates
have now brought the organ donations
programme to a new crisis with shrinking
cadaver organs rising demands and
‘morality ’ block by different segments
of society including press, police,
judiciary, doctors. Government being
involved in more ‘urgent’ national problems
the future looks unclear. The same happened
in ‘blood transfusion’ programme
where now voluntary donor programme is
replacing professional donor programme.
In Asian countries cadaveric donations
share additional social and religious
inhibitions, hence this slow progress appears
inevitable.
1. Dr. Ashwini Gandhi Bhalerao was awarded
the “Dr. Suresh Nadkarni Mitramandal
Award for the year 2006-2007” by the
Indian Medical Association, Maharashtra
State for her activities in the field of health
education through mass media, books on
health related topics and conducting lectures for public health
education.
2. Dr. Shusheel Kharbanda, resident
(urology) won the first prize in paper
presentation for a paper “PROLONGED
ILEUS POST RADICAL CYSTECTOMY:
CONSIDER TOBACCO”. The paper was
presented in Mumbai Urology Society –
Annual Meeting 2008, held at Lonavala between 4th – 7th July
2008.
3. Dr. Lancelot Mark Pinto, 3rd year Dip. N.B.
in Respiratory Medicine, won the second
prize for the South Asian Cochrane
Network Essay competition for Post –
graduate students in the health sciences
on the topic “BARRIERS TO EVIDENCE
INFORMED PRACTICE IN SOUTH ASIA
AND POSSIBLE SOLUTIONS” at the 2nd South Asian Regional
Symposium on Evidence Informed Health Care at the Christian
Medical College, Vellore on April 9th 2008.
AWARDS
SHORT HISTORY OF ORGAN TRANSPLANT
2008 Vol 23 Vol No. 1 37
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PET SCAN
P.D.Hinduja Hospital and MRC recently installed the
second generation PET/CT in September 2007, an
advanced version of Discovery TM Ste from GE
Healthcare for the first time in India. The advantages
of this PET/CT scanner gives images that help doctors
to diagnose patients in early stages of cancer and
increase the prospect of preventive cure. It enables
the radiation oncologist to focalize the beam of
HINDUJA NEWS
38 2008 Vol 23 No. 1
Interactive Session by Dr. Phulrenu Chauhan
Abhijeet Sawant with his young fans
radiation to the active part of the tumor. This helps
the risk of radiation exposure to the neighboring
normal tissue. The machine has been used to perform
a whole body scan on a seven year-old patient.
CAMPS
12 Medical Camp were organised commemorating
the 75th anniversary year of L. G.H.
WORLD JUVENILE DIABETES DAY &
CHILDREN’S DAY
On 14th November, Hinduja Hospital organized a
camp for the juvenile diabetes on Children’s Day. More
than 60 diabetic children with their families joined in this
celebration. The chief guest for the day was Abhijeet
Sawant, India’s very first Indian Idol. The programme
included an electrifying tabla performance by the young
tabla artists, the Khan Brothers. Magic show performance
by Mr. Ashraf Khan and active participation from the
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HINDUJA NEWS
2008 Vol 23 Vol No. 1 39
Dr. Kirtane felicitating Mrs. Vakil at the 2nd CochlearImplant Workshop
Demonstration of Intubation
Cornell, USA. A team of outstanding faculty members from
both the institutions provided an integrated view of
Emergency Medicine.
The highlights of this conference were hands-on –
experience with mannequins which is first of its kind in
India, especially flown in from USA. These mannequin
simulators helped develop an increasingly realistic physical
and procedural components to complement an already
high level of situational realism. The objective of this
conference was to establish a residency programme in EMS
Emergency procedure – Drawing of Femoral blood
children during the brief interactive session conducted by
Dr. Phulrenu Chauhan which included a quiz on juvenile
diabetes for educating and raising awareness among the
audience.
WORKSHOP
The P D Hinduja Hospital organized the 2nd Cochlear
Implant Update from 22 – 23 December, 07. The
Workshop was aimed at ENT surgeons, audiologists and
educators for the hearing impaired, keen to start their
own Cochlear Implant Programmes.
Recognizing the need for a wider awareness on
Cochlear Implants and the need for professionals to
understand the team approach required to make
Cochlear Implants a success, P D Hinduja National
Hospital, through this workshop, aimed to provide basic
information and training to the participants.
The workshop also felicitated Mrs. Meher K Vakeel,
a pioneer in the field of education for the hearing
impaired in India. Mrs. Vakeel, who has dedicated over
forty years of her life, to the education of the hearing
impaired is credited with establishing The Education
Audiology and Research Society, the first teacher training
course for the hearing impaired in India, an infant centre
for early diagnosis and parent guidance, and the
introduct ion of neonatal hearing screening
programmes. Among other accolades she is the recipient
of the prestigious ‘International Meritorious Service
Award” by the Alexander Graham Bell Association for
the Deaf, UK.’
CONFERENCE ON EMERGENCY
MEDICINE
On 14th & 15th November, Hinduja Hospital conducted a
workshop on Emergency Medical Services, in collaboration
with the Division of Emergency Medicine – New York
Presbyterian - The University Hospital of Columbia and
by sensitizing the medical fraternity to the nuances of EMS
as a practice in the developing countries.
To take the EMS dream further, P.D. Hinduja National
Hospital & MRC has taken a step towards developing
Emergency Medicine as an independent specialty in India.
Hinduja hospital has always been at the vanguard of
pre-hospital care development. A Policy program is
being developed for recommendation to the National
Knowledge Commission a high level advisory body, during
the meeting of the Dean and Heads of major institutions
from Mumbai apart from senior faculty on Emergency
Medicine from New York Presbyterian – The University
of Columbia and Cornell was held on the 13th of
November 2007.
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WELCOME
Printed and Published by Marketing Department, P. D. Hinduja National Hospital & Medical Research Centre, Veer Savarkar Marg,
Mahim, Mumbai - 400 016 at SYNERGY CREATIONS , for free and private circulation. Editor : Dr. Reeta Dalal. Registered.
(The Publisher cannot be held responsible for errors or for any consequences arising from the use of the information
contained in this newsletter.)
Dr. (Mrs.) Chitra Madiwala has joined as the Consultant Histopathologist in the department of
Laboratory Medicine.
Dr. Madiwale completed her MD (Pathology) in 1988 from the University of Mumbai and fellowship
in Nephropathology from USA. She has over 22 years of experience having worked at G.S.Medical
College & KEM hospital - Mumbai and as an associate Professor at G.S. Medical College & KEM
Hospital.
Her areas of interest include nephropathology, gynecologic - pathology and orthopedic - pathology.
Dr. Sudhir Warrier has joined as a Consultant in Hand & Reconstructive Surgery, section of
Orthopedics.
Dr. Warrier did his MS (Orthopedics) in 1987 from Grant Medical College, University of Mumbai.
He has done fellowships from Gyeongsang National University, Korea; Okayama University, Japan
& Government Stanley Hospital, Chennai. He was awarded the Best Discourse Award at the XIIth
International Orthopedic Congress, Pakistan in the year 1997 and the Scholarship of Asia Pacific
Societies for Surgery of the Hand, Hong Kong in the year 2002.
Dr. Warrier is attached to Laud Clinic, Shushrusha Citizen Co-op Hospital & Jaslok Hospital. He is regularly involved in
training programmes across the country for the post-graduate students & practicing orthopedic surgeons through workshops
on Hand Surgery & External Fixation.
Dr. Pankaj Deshpande has joined as Consultant in Pediatric Nephrology, section of Pediatric
Medicine.
After completing his MD in pediatrics and 2 years in Pediatric Nephrology from Bai Jerbai Wadia
hospital for Children, Dr. Deshpande went to UK in 1996. He pursued his MRCP in Pediatrics in
1997 and post MRCP he specialized in Pediatric Nephrology in various centers' of excellence in UK.
He has worked as a Pediatric Nephrology Consultant at Southampton General Hospital, UK from
2001 to 2005.
He returned to Mumbai in 2005 and ever since then has been practicing as a pediatric nephrology consultant at MGM
Hospital, Lok Hospital, Kidney Speciality Group and Sai Child Care Centre.
Dr. Sharmila Ghosh has joined as the Consultant Haematologist in the Dept of Laboratory Medicine
Dr. Ghosh completed her MD in Pathology in 1995 from Kasturba Medical College. She was trained
in Hematology from St. Jude Hospital - US, in January 2008 and did advanced training in Bone
Marrow reporting, Flow Cytometry and FISH at the Royal Free Hospital - London in 2004. She has
also received training in Quality Systems e.g. ISO - 13000 from Tata Business Excellence.
Dr. Ghosh has expertise in Phase I to Phase IV Clinical Trials, entailing planning, resource utilization
and manpower management. She is skilled in planning and scheduling work, establishing systems,
setting goals and standards.
Dr.Ghosh has worked at Asian Institute of Oncology, Raheja Hospital and Tata Memorial Hospital in Mumbai and
Jamshedpur. Prior to joining us she had worked at SRL Ranbaxy Ltd. as a Consultant Hematologist.
Her area of interest is Hemato-Oncology.
Dr. Uday Limaye has joined as the Consultant in Interventional Neuroradiology, section of
Interventional Radiology (DSA) in the department of Imaging. He completed his DNB from Grant
Medical College and Sir JJ Group of Hospitals, Mumbai in 1995 and underwent specialty training
from world renowned Interventional Neuroradiology centres like Foundation Rothshield
Hospital,(France); Royal Perth Hospital, Australia and Haciteppe University, Turkey.
Dr. Limaye is the Associate Professor& Chief of Interventional Neuroradiology at Seth G.S.Medical
College & KEM Hospital; Mumbai .He has done pioneering work on Dural Venous Sinus thrombolysis,
which was adjudged as the best paper at the Eastern Neuroradiology Meeting, Toronto in 2005.
His areas of interest & expertise include intracranial stenting for Brain Aneurysms & Intracranial Artherosclerosis, Acute
Stroke Therapy & Endovascular management of Craniofacial Vascular Malformations.
WELCOME
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