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EDITORIAL
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 166-167

Pediatric liver transplantation in India- an integral role of intensive care


Department of Pediatric Critical Care, Medanta the Medicity, Gurgaon, Haryana, India

Date of Submission21-May-2020
Date of Acceptance26-May-2020
Date of Web Publication13-Jul-2020

Correspondence Address:
Dr. Maninder Singh Dhaliwal
Department of Pediatric Critical Care, Medanta the Medicity, Gurgaon - 122 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_86_20

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How to cite this article:
Dhaliwal MS, Raghunathan V. Pediatric liver transplantation in India- an integral role of intensive care. J Pediatr Crit Care 2020;7:166-7

How to cite this URL:
Dhaliwal MS, Raghunathan V. Pediatric liver transplantation in India- an integral role of intensive care. J Pediatr Crit Care [serial online] 2020 [cited 2020 Aug 13];7:166-7. Available from: http://www.jpcc.org.in/text.asp?2020/7/4/166/289529



The first successful liver transplant in a child was performed by Dr. T. Starzl in 1967. Over 30 years later, in 1998, the first pediatric liver transplant was performed in India.[1] In the past two decades, India has witnessed a slow but steady increase in the number of centers doing pediatric liver transplants. It is estimated that the requirement for pediatric liver transplantation in India is around 2500–3000 procedures annually. However, the number of transplants being carried out is < 200 per year. There is still a wide gap between demand and supply which exists due to a multitude of reasons. Lack of availability of surgical expertise, donors and financial constraints are the predominant factors. A pediatric liver transplant in India costs around Rs. 12–15 lakh. It is up to twenty times less costly than in the West. Yet, it does pose a financial burden to the Indian family. Medical insurance, charitable organizations, and crowdfunding are required to improve the availability of liver transplants in children. Often, patients are referred late for transplant, and their clinical condition is suboptimal and does not permit transplantation.[2] Finding a suitable donor on time is also a challenge in India. Family beliefs, lack of education, and bias against girl child influence the decision-making for transplant. The paucity of cadaveric organ supply in India is due to lack of public awareness about organ donation. Although deceased donor donations are improving in the South, the main modality in India, at present, is living-related liver transplantation.

Indications for liver transplantation in children are more varied than in adults. The different types of underlying liver diseases enhance the complexity of care required in the management of these children. Based on the Indian data, biliary atresia is one of the most common indications of liver transplant in the pediatric age group.[3] Typically, children with chronic liver disease including biliary atresia are malnourished and tend to have recurrent pulmonary infections and cholangitis. They may have multiple intensive care unit (ICU) admissions with antibiotic courses before transplant consideration. The clinical condition of such patients would need to be optimized pretransplant which can be challenging at times. A patient with acute liver failure is first admitted to the ICU, and thereafter, when necessary criteria are met, discussion for transplant is initiated with the family. The intensivist is often the first contact for the family and is closely involved in this process along with the hepatologist and surgical team.

After liver transplant, the care of a child requires a dedicated team and meticulous protocolized care. Immediate postoperative care mainly includes maintenance of hemodynamics, oxygenation, close monitoring of fluid balance, and graft functioning (liver function tests, PT/PTT [prothrombin time/partial thromboplastin time], and liver Doppler). Neuroprotective measures will need to be continued in patients with hepatic encephalopathy before transplant till its resolution. Primary nonfunction, vascular issues (portal vein thrombosis and hepatic artery thrombosis), bile leak, postoperative bleeding, and acute rejection are some of the unique complications that arise in the immediate postoperative period. Strict reverse barrier nursing is essential to minimize infections in the immunosuppressed patients postoperatively. Both detection of bacterial or viral infections and their management in these patients can be challenging. As mechanical ventilation after liver transplantation is associated with significant complications, short duration or no postoperative ventilation is advocated as feasible.[4] However, small weight babies and those with acute liver failure and hepatopulmonary syndrome may need ventilatory support for longer duration. A recent study highlighted that larger intraoperative fluid volume administration (>260 ml/kg, including blood products) was associated with longer duration of ventilation and longer ICU and hospital stay.[5]

In this issue of the Journal of Pediatric Critical Care, Sachdev et al. have described the critical care issues in children undergoing liver transplantation.[6] The 1-year survival rate reported in the study is 92.7% which is at par with most centers across the world.[3],[7] This study reinforces that close monitoring, early detection and treatment of complications are essential for successful postoperative management.

Currently, India is one of the leading countries in the world in the field of living donor liver transplantation. Various advanced options for children, including ABO-incompatible transplants and combined liver–kidney transplants, are now available in few of the premier Indian centers. With more complex candidates being taken up for pediatric liver transplantation, critical care challenges in the postoperative management are also bound to increase.

Good outcomes in pediatric liver transplantation are the result of multidisciplinary team approach. Surgical expertise is pivotal, and good postoperative intensive care support is integral for optimal survival in the immediate postoperative period. Larger studies to identify risk factors, both surgical and nonsurgical, and their impact on the postoperative critical care course in children are required to optimize outcomes in complex patients.



 
  References Top

1.
Poonacha V, Sibal A, Rajakumari DV, Soin AS, Rajasekar MR. India's first successful pediatric liver transplant. Indian Pediatr 2001:38:287-91.  Back to cited text no. 1
    
2.
Kelly DA, Sibal A. Current status of liver transplantation. Indian J Pediatr 2003;70:731-6.  Back to cited text no. 2
    
3.
Mohan N, Karkra S, Rastogi A, Dhaliwal MS, Raghunathan V, Goyal D, et al. Outcome of 200 pediatric living donor liver transplantations in India. Indian Pediatr 2017;54:913-9.  Back to cited text no. 3
    
4.
Kukreti V, Daoud H, Bola SS, Singh RN, Atkison P, Kornecki A. Early critical care course in children after liver transplant. Crit Care Res Pract 2014;2014:725748.  Back to cited text no. 4
    
5.
Chang J, Munoz AC, Garcia J, Pfeiffer B, Nares M, Monde A, et al. Research snapshot: Fluid management during pediatric liver transplantation and effects on the postoperative period. Critical Care Med 2019;47:209.  Back to cited text no. 5
    
6.
Sachdev A, Wadhva N, Mehta N, Gupta D, Guptan N, Kaur J. A study of critical care issues in pediatric liver transplantation. J Peditr Crit Care 2020;7:186-192.  Back to cited text no. 6
    
7.
Elisofon SA, Magee JC, Ng VL, Horslen SP, Fioravanti V, Economides J, et al. Society of pediatric liver transplantation: Current registry status 2011-2018. Pediatr Transplant 2020;24:e13605.  Back to cited text no. 7
    




 

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