Despite significant improvement in understanding pathophysiology and medical management in patients with end-stage liver disease (ESLD) liver transplant (LT) may be ultimately needed in some of these sick patients who fail conservative therapy. In contrast to western countries (where cadaveric LT constitute the major bulk of LT), in majority of Asian countries including India, LDLT constitute the major bulk of LT.1 With significant improvement in surgical techniques, use of potent immunosuppressive agents, improvement in infrastructure and training of LT physicians and surgeons along with of multidisciplinary approach has improved outcomes of transplantation.2 As a result of these advancements, the number of LT being performed annually in has gradually increased in last decade. Despite this, a number of barriers to LT still remain especially in centers in second tier cities where a dedicated liver transplant program has just been initiated and yet to be fully established.
Kalinga Institute of Medical Sciences and Pradyumna Bal Memorial (KIMS and PBM) is a well-known and a decade old medical college and tertiary care hospital in eastern India. The first LDLT was successfully performed in 2022 with help of a renowned team of surgeons from northern India. Despite conducting a successful LT in the first attempt, we were unable to perform the second procedure in spite of extensive screening and counselling of potential recipients for over 1 year. In the year 2023, we screened about 103 patients with ESLD and tried to find out the potential barriers/reasons for non-realization of these potential candidates to finally undergo LT.
The common etiologies of liver disease were ethanol (58.5%), non-alcoholic fatty liver disease (NAFLD) and hepatitis B virus. Three (2.8%) patients with primary sclerosing cholangitis were screened for LT in view of recurrent episodes of cholangitis. Seventy-four (71.8%) patients had decompensated cirrhosis while 26 (25.2%) patients had acute on chronic liver failure (ACLF). The mean CTP and MELD scores were 9.9 (±1.8) and 20.8 (±7.1), respectively. The major barriers to a successful LT included Financial constraints (36.8%) and lack of a suitable donor (27%). Fourteen (14.7%) patients were initially evaluated but ultimately became too sick to be transplanted. Four (4.2%) patients had no suitable donors and finances. Eight (7.5%) patients improved with medical management. The details regarding various barriers have been provided in Table 1.
Table 1.
Barriers to Liver Transplantation.
| Barriers | Frequency | Percentage |
|---|---|---|
| Financial constraints | 35 | 36.8 |
| No donor | 26 | 27 |
| Too sick to transplant | 14 | 14.7 |
| Not convinced/willing | 4 | 4.2 |
| No donor/finances | 4 | 4.2 |
| Not feasible | 12 | 12.6 |
These barriers, despite being mentioned here as discrete entities, in fact may be interlinked. Most of these patients come from poor socioeconomic background with limited access to even basic health care. For most of these patients and relatives, organ donation (especially liver) is often considered life threatening. Thus, despite extensive counseling for organ donation, most of the potential donors ultimately don't up for conducting minimal preliminary investigations. Another potential cause of lack of suitable donor is the social stigma associated with ethanol abuse. The most common cause of ESLD in our population was ethanol abuse. The relatives of most of these sick patients are often not willing for liver donation or offer any sort of financial help. More importantly, outcome of LT is often thought to be dismal (Probably based on initial results from India).3 In such a scenario, most relatives are unwilling put the life of donor and their hard earned money at stake. Some of the willing patients often don't want spend their money and simultaneously threaten the life of the donor in a new transplant center despite the procedure being performed by a well competent surgeon from an established LT center.
The barriers mentioned above may not be obvious and seem trivial for most of the first tier cities in India where LDLT is well established and are performed routinely (especially in private sector hospitals). To improve the rate of realization of the potential recipients in second tier cities, contribution of both public and private sectors is the need of the hour. Health insurance coverage of Indian is far from satisfactory. More importantly, diseases related to ethanol abuse, organ transplantation and organ donation related surgeries are not coved by most private insurance agencies.4 In such a scenario, role of crowd funding and funding by various non-government organizations may play important role in overcoming the economic barrier. The lack of donor can be compensated to some extent by improving public awareness regarding cadaveric donation. Initiating a Dead Donor Liver Transplant (DDLT) program is relatively easier (especially in tier 2 cities) as technical expertise is significantly less and donor risk is nil. The importance of availability of a well-trained LT surgeon need not be overemphasized. Lack of an in-house well trained transplant surgeon often leads to death of sick patients as timely availability of an outsourced trained transplant team is usually difficult for these patients. More importantly, starting a DDLT program without an in house surgeon is virtually impossible as most of these surgeries are performed on emergency basis and getting a trained surgeon in such a short notice is often not logical.
To conclude widespread and adequate insurance coverage, public and private funding along with improved awareness regarding organ donation should increase the number of LTs conducted in second tier cites. More importantly, these new LT centers should make the necessary infrastructure and manpower under one roof before starting the program. In the event of lack of a well-trained surgical team, DDLT may be the preferred mode of LT as it requires lesser resources, expertise and involves no donor risk.
ConflictS of interest
The authors who have taken part in this study declare that they do not have anything to disclose regarding conflict of interest with respect to this manuscript.
Funding
The authors who have taken part in this study declare that they do not have anything to disclose regarding funding with respect to this manuscript.
References
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