Living Donor Liver Transplantation in Pakistan

Abstract

Liver disease is a significant problem in Pakistan. In a country of approximately 200 million people, 5% (10 million) are infected with hepatitis C virus, and more than 2 million are in need of liver transplantation to save their life.1,2 Pakistan's first liver transplant was performed in 2003 in an international collaborative effort at the Sind Institute of Urology and Transplantation in Karachi. Activities in liver transplantation had been on a hiatus until 2011 when a team of local doctors performed a deceased donor liver transplant in Lahore. From 2012 onward, a number of centers undertook the challenges in developing living donor liver transplant programs across the country. The provinces of Punjab and Sind have been in the forefront of liver transplant activity in Pakistan (Figure 1).FIGURE 1: Centers with liver transplant activity across Pakistan until February 28, 2017.MEDICAL AND SURGICAL CHALLENGES Certain factors have been highlighted as potential obstacles to successful liver transplant activity in Pakistan.3 In the recent past, there has been a significant progress in assessing the burden of need while improving public awareness and readiness of medical facilities. However, a significant gap remains in supply and demands and is linked to funds, technical competence, skill transfer, and sustainability through incentivization and outcome assessment. The most critical factor in developing high-volume transplant programs across the country remains a lack of skilled workforce. Other than in 2 centers run by local teams, transplant numbers in centers that work with international collaboration remain very low (Table 1). Security concerns and visa delays make frequent travel by international teams a difficult proposition. Moreover, the parachuting approach of international transplant teams at various centers for short periods leads to interruptions in the continuity of care. Thus, the presence of efficient local transplant teams is critical in developing successful and sustainable transplant programs (Table 1). Until February 28, 2017, a total of 539 liver transplants have been performed in Pakistan, and approximately 95% of these were performed in the 2 centers run by local teams.TABLE 1: Transplant activity across various centers in the country up to February 18, 2017HEALTH ECONOMICS AND INSURANCE PATTERNS With the exception of a few countries, healthcare in the developed world is the government's responsibility.4 In contrast, healthcare financing in Pakistan is predominantly out of pocket.5 Although the healthcare system in Pakistan has evolved to a well-planned, district-based network of health facilities, the present system is finding it difficult to cope with growing pressure from an ever increasing population and awareness in people regarding their civil rights.4 Living donor liver transplantation is different from deceased donor liver transplantation in that, although requiring highly skilled surgical, medical, and intensive care facilities and infrastructure, it can be successfully accomplished by focusing resources and expertise in a single hospital rather than attempting to develop an entire transplantation infrastructure.6 Insurance coverage has not gained widespread acceptance in Pakistan owing to various sociopolitical and financial reasons. It has been shown that information asymmetry, adverse selection, moral hazard, and fraud raise concerns for the sustainability of insurance programs in developing countries.7 A living donor liver transplant in Pakistan costs between US $35 000 and US $45 000. Most of our patients are self-funded; however, in recent years, there has been increased support from government and philanthropic organizations. Financial restrictions continue to be the biggest hurdle in making liver transplant accessible to patients in need. RECIPIENT AND DONOR OUTCOMES Most transplant programs are still in their infancy in Pakistan, and published outcomes have therefore been limited. Nevertheless, 1-year survival rates of 87% have been demonstrated by one of the busiest transplant centers in Pakistan.3 Grade 3 or above Clavien-Dindo complications were seen in 52% patients, with 23% patients experiencing biliary complications. With regard to donor outcomes, an overall morbidity of 17% has been reported with a biliary complication rate of 3%.8 Based on personal communication, one donor mortality has been reported from one of the institutes in the Sind province resulting in a donor mortality of 0.2% in the country (Gambat Institute of Medical Sciences, oral communication, November 30, 2016). Until February 28, 2017, we have performed 408 LDLTs in our center. Estimates of 1- and 4-year overall survival are 83% and 77%, respectively. Overall, 21.4% of patients had a biliary complication, and there was no donor mortality. With a limited availability of deceased donors, auxiliary, swap, and domino transplants have also been performed to increase the donor pool. We have also accepted donors with hepatitis B core antibody positivity and Gilbert syndrome. ETHICS The Human Organ and Transplantation Authority regulates legal and ethical aspects of liver transplantation in Pakistan. The donors have to be legally (spouse, brother/sister-in-law) or blood related to the patient to be eligible for donation. This has been mandated based on previous reports of commercialization in kidney donations in the country.9 The decentralization of Human Organ and Transplantation Authority with the 18th amendment under the constitution of Pakistan has moved various ministries including the Ministry of Health from a central to a provincial control.10 Those changes have resulted into 5 autonomous provincial bodies regulating transplant activity, allowing a more stringent legal and regulatory process at the provincial level. At the same time, the current decentralized approach challenges the implementation of a future national transplant registry that may monitor transplantation activity and outcomes countrywide. FUTURE DIRECTIONS It is expected that transplant activity will continue to rise in the near future in Pakistan based on the tremendous burden of chronic liver disease and hepatocellular carcinoma. With structured training programs in place, current limitations in surgical/medical workforce are expected to improve. The self-sufficiency in regard to transplant infrastructure will reduce the reliance on international collaborations while providing a continuity of care for the ever increasing numbers of cirrhotic patients. Financial constraints will play a major role in expanding private sector transplant centers. The government will have to consider innovative ideas including private-public sector partnerships and proper incentivization of transplant personnel to make liver transplantation available to the underprivileged in Pakistan. The implementation of a National Transplant Registry is inevitable to ensure transparency in various steps of organ donation and outcome reporting while providing transplant services of international credibility.