The first successful liver transplantation (LT)
was performed by Dr T E Starzl in 1963 [1]. Since then, LT has evolved
and matured into an established therapy for liver failure that involves
a multidisciplinary and dedicated team of transplant surgeons, pediatric
hepatologists, intensivists, anesthetists, nurses and other support
staff. With excellent results, the indications for LT have expanded and
include acute liver failure, chronic liver failure, and metabolic
conditions where there is no liver failure but damage to other organs is
prevented such as Crigler Najjar Syndrome, hyperoxaluria and
hypercholes-terolemia [2]. Multi-organ transplantation is also now well
established [3].
The need for pediatric LT is estimated to be 1-2 per
million population as per data from the West. Extrapolating that data to
India, there is a need for 2500 transplants in children per year. As
many as 30% of children with liver diseases seen in a referral centre in
North India were reported to be candidates for LT [4].
In November 1998, the first successful LT in India
was performed in an 18-month-old child with biliary atresia [5]. The
child’s father became the first living related donor in India. This
child remains well 15 years post LT. The need for developing a LT
program in India has been debated for long [4,6].
While the first successful LT provided the impetus to
establish transplantation in India, the first few years posed several
challenges [7]. Many children who needed a transplant were often
referred late, as there were very few guidelines on when to refer a
patient to a specialized centre. The vast majority of children who
needed a trans-plant came from a low socioeconomic status with resource
constraints. In addition, a bias against the girl child and lack of
cadaveric donor livers also limited the number of transplants performed.
In the absence of cadaver donation, the only realistic option was
develop-ing a living related liver transplantation program (LRLT).
The last five years; however, have seen a dramatic
growth in LT in India. There are six well-established pediatric liver
transplant programs in the country. Two programs perform more than 30
transplants each year. The total number of pediatric liver transplants
performed in India has now exceeded 350. Pediatric patients constitute
about 10% of the total liver transplants being performed at the two
busiest programs. More than 95% of these transplants are living related.
About 75% of LT are for cholestatic liver diseases, mainly biliary
atresia [8].
The success of the liver transplant programs in the
country can be attributed to various factors. Our surgeons after having
been trained in various centers in the West have replicated and indeed
improved upon the surgical techniques that they learnt there. With time,
the quality of the intensive care provided to these patients has
improved tremendously. This is in parallel to the general improvement in
pediatric intensive care in the country. With increasing experience, the
quality of post-transplant care has also become standardized. The
armamentarium of drugs used for immunosuppression has improved with the
newer drugs, which are less toxic and more effective. This has led to a
better management of the immunosuppression and thus improved survival.
With increasing experience, LT is now offered for
complicated cases, for metabolic diseases and other rare disorders. In
2008, the first successful transplant in India for Crigler-Najjar
syndrome was performed [9]. Excellent results have also been reported in
younger children. Hundred percent survival for both graft and recipient
in infants with weight less than 7.5 kgs was reported in 2010 [10]. The
success of both pediatric liver and kidney transplant programs in the
country has spurred the development of programs for combined liver and
kidney transplants. Combined liver and kidney transplants are now being
performed in increasing numbers. Another achievement from India is the
world’s youngest domino liver transplant [11]. A welcome
development has been the increasing numbers of fathers willing to come
forward as donors [12]. The availability of generic immunosuppressant
drugs and consumables has greatly aided in bringing down costs. The
average cost of a transplant in India is 12-15 lakhs INR. This is only
about 1/5
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