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Organ Transplant Transplants E.G New Layout-Dt 14-2-2009 - final.pmd 1 2/14/2009, 5:16 PM FROM THE EDITOR’S DESK / CONTENTS 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 From the 24 Live Related Renal Transplant Dr. Alan Almeida Editor’s Desk 30 Stem Cell Transplant (SCT) Dr. Asha Kapadia Worldwide tens of 32 Lung Transplant - thousands of lives are Where does it stand today? transformed by the miracle Dr. Manoj Agni of organ donation. Tissue 36 Short History of Organ Transplant transplants e.g. skin, Dr. R. A. Bhalerao cornea, bone-marrow, 38 Hinduja News vessels are invaluable. In 40 Welcome the last half century transplant surgery has transformed from research to life-saving surgery. For every successful transplant there are Editorial Board thousands who are on the waiting list and Dr. Philip Abraham Dr. Tester Ashavaid probably die waiting to receive the graft. Organ Dr. C. Balakrishnan transplants are complicated by scarcity of organ Dr. Sudeep Shah Dr. Gauri Mankekar donors, various ethical and social issues. Editor In this issue Dr. Sudeep Shah, Liver Transplant Dr. Reeta J. Dalal Surgeon at Hinduja Hospital has put together Editor Emeritus articles from various specialities to give you an Dr. V. R. Joshi ‘Update on organ transplants’. Guest Editor Dr. Sudeep Shah Photography Pramod Tandel Dr. Reeta J. Dalal Consultant Physician 2 2008 Vol 23 No. 1 New Layout-Dt 14-2-2009 - final.pmd 2 2/14/2009, 5:16 PM GUEST EDITORIAL Dr. Sudeep Shah Introduction to Organ Transplantation 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 2008 Vol 23 Vol No. 1 3 New Layout-Dt 14-2-2009 - final.pmd 3 2/14/2009, 5:16 PM Cadaver Transplantation Despite the immense benefits of successful organ transplant, the full development of the transplant program is hindered by organ shortage. By Dr. Rasika Sirsat TRANSPLANTATION IS CURRENTLY considered skin and cornea can be transplanted. This is due to an accepted treatment modality for patients with end important break throughs in immunosuppressant drugs stage organ failure where therapy with drugs or and tissue typing. More than 1 million people world wide restorative surgery is not feasible. Approximately, 25 have benefitted from successful organ transplantation. different organs and tissues including kidney, heart, Of these, kidney transplant results have been the most lung, liver, pancreas, bone, cartilage, bone marrow, gratifying. With improvement in results, the demand for 4 2008 Vol 23 No. 1 New Layout-Dt 14-2-2009 - final.pmd 4 2/14/2009, 5:16 PM COVER STORY CHECK LIST NEUROLOGICAL EXAMINATION TO human organs for transplantation has following the second set of test to confirm DEMONSTRATE increased. The source of donor organs are Brain Death. BRAIN DEATH living related donors (LRD), living un- The Zonal Transplant Co- ARE related donors (LURD), cadaver – non ordinating Center (ZTCC) is informed heart beating donors (NHBD) and about a potential Cadaver donor. The Absence of oculomotor/ cadaver – heart beating donors ZTCC is a city based organisation who co- photomotor “ reflex Absence of MORE THAN 1 MILLION PEOPLE WORLD corneal reflex WIDE HAVE BENEFITTED FROM Absence of facial SUCCESSFUL ORGANTRANSPLANTATION. movements “ Absence of spontaneous muscle (HBD). Most of cadaver transplanted ordinate all activities for organ procurement, movements kidneys are obtained from brain dead donors maintainenance of a computerized central with functional circulation. Brain death can registry of potential recipients and allocates Absence of oculo-vesitibular occur due to spontaneous intracranial organs as per the criteria laid down. The reflex hemorrhage, head trauma, cerebral aim of ZTCC is to provide impartial and ischemia or primary cerebral tumours. effective organ distribution. The prospective Absence of gag reflex Brain death can be diagnosed at the 2 recipients for kidney transplant are called bedside by performing various tests in as per criteria laid down by ZTCC. It is Absence of patients in whom the cause of coma is known essential that a person who registers for a cough reflex and those who do not have severe cadaver transplant keeps some funds aside Absence of hypothermia (< 35oC) and have not in the eventuality of being called for a spontaneous received neurodepressor drugs, transplant surgery. The recipient should also breathing neuromuscular blockers and anti-cholinergic follow up regularly, at the center where he is determined by Apnea test. drugs. registered so that the nephrologist is aware The transplant co-ordinator can then of his/her medical fitness for surgery. counsel the close relatives regarding organ The suitability of donor organ is checked donation. Once close relatives give written by performing a Lymphocyte cross match. If consent for organ donation, organs can be negative the recipient can proceed for retrieved after declaration of brain death Transplant. If the lymphocyte cross match is BRAIN STEM DEATH IS IRREVERSIBLE AND “ “HAS BEEN RECOGNISED BY LAW SINCE 1995. 2008 Vol 23 Vol No. 1 5 New Layout-Dt 14-2-2009 - final.pmd 5 2/14/2009, 5:16 PM COVER STORY positive the recipient next on professionals and lack of the list is considered for the Apnea test organ sharing agencies. transplant, provided Patient is put on FiO2 of 100% for 20 India spends 1.5% of GNP lymphocyte cross match is minutes while still on the ventilator. on health care. End stage negative. The shortage of Thereafter ventilator is disconnected and kidney disease (ESKD) organs can be expanded by patient is put on 6L/minute of O2. Serial treatment has extremely low including non-heart beating arterial blood gas are checked until priority as compared to donors (NHBD) i.e. organs PCO2 > 60mm Hg with PO2 around population control, are retrieved only after heart 100 mm/Hg. Watch for movements of eradication of stops functioning. The main diaphragm if there is no spontaneous communicable disease, issue with NHBD is higher nutritional program, etc. respiration that indicates an absence of rate of delayed graft function hence government funding brain stem respiratory centre function. compared with that for renal replacement These tests are repeated and confirmed associated with heart beating treatment is a miniscule after 6 hours. Only then the patient can brain dead donors. However amount. Very few ESKD at 3 months graft function is be declared as Brain dead. These tests patients are reimbursed by not significantly different are to be performed by 4 medical their employers, while others between the two. practitioners (Neurosurgeon, Physician, rely on their family and Most of the kidney Neurologist, Intensivist) as per charitable organizations for transplants performed in Transplantation of Human Organs Act funds. Public unawareness, India are from live donors. (TOHA) 1994. Brain death is explained religious sentiments, family For those patients who do to relatives by the treating physician after pressures all contribute to not have an option of related the first set of tests are performed. bringing down the number of kidney transplantation, the actual organ retrieval from only option is to wait for a potential cadaver donors. cadaver kidney. The Human Organ Transplantation Act In Spain organ procurement system has been was passed in 1994 following which cadaver transplants professionalized. The organ procurement team is have been carried out all over India. In Maharashtra, the responsible for the whole organ donation process from first cadaver transplantation after the act was performed donor identification to organ retrieval and they are LACK OF PUBLIC AWARENESS, MISPLACED RELIGIOUS “ SENTIMENTS, FAMILY PRESSURES ALL CONTRIBUTE TO BRINGING “DOWN THE NUMBER OF POTENTIAL CADAVER DONORS. on the 27th of March 1997, thereafter about a hundred accountable for their performance, there are 127 such and fifty more have been performed up to date. So far, teams. Their organ donation rate has more than doubled about 1200 cadaver transplants have been carried out in over the last one decade and the percentage of multi- India, far short of what is required. This is in spite of 8500 organ retrieval has soared from 35 to 83% enabling a 3- fatal road traffic accidents per year. Per city about 8 to 10 fold rise of possible solid organ transplant. brain dead patients would be there at a time, however, Currently, organ shortage is the main obstacle to the the conversion rate is less than 19%. This is due to multiple full development of the transplant programme. It is possible factors like poor infrastructure for quick and safe to increase the cadaveric organ donation rate and also transportation of accident victims, lack of ventilatory promote living donation.
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