The First National Consensus Symposium on Liver Transplantation and Cadaveric Organ Donation was held at Sir Ganga Ram Hospital, New Delhi on 2 February 2003. This was the culmination of a keen desire on the part of most of us working towards developing liver transplantation and promoting cadaveric organ donation in India to meet and discuss our problems in order to find some solutions. This forum was especially important since the western model can be duplicated in India only to a limited extent. Thus, we have to develop our own solutions for the socio- cultural and economic circumstances peculiar to India. There was an overwhelming response to the meeting and there were more than 80 experts who participated from 10 cities across the country.

The consensus meeting comprised of five sessions. In the first session, all the centers (AIIMS, Delhi; Sir Ganga Ram Hospital, Delhi; Apollo Hospitals, Delhi and Chennai; Jaslok hospital, Mumbai; SGPGI, Lucknow; CMC, Vellore St John's Hospital, Bangalore) in the country that have conducted liver transplantation were invited to present their experience. The second session was devoted to talks on areas that constitute the major hurdles in liver transplantation in India, namely, late referrals (and poor risk recipients), lack of confidence in liver transplantation among patients and gastroenterologists, poor networking of hospitals, problems with pediatric transplantation and suitability of living donor liver transplantation in India.

For the third session, organizations working towards promoting cadaveric organ donation in India were invited. Participating organizations included MOHAN( Multi Or Harvesting Aid Network), Chennai, FORTE, Bangalore; ZTCC, ORBO and HOPE, Delhi, who highlighted their experiences, achievements, goals and the socio-cultural hurdles faced in realizing cadaver donors. They also touched on the idea of having a common platform to further organ donation and feasibility of organ sharing within and between cities. Flaws in the Transplantation of Human Organs Act 1994 were also discussed.

The next part of the proceedings was a lively and interactive panel discussion on how we could take liver transplantation forward in India.

The fifth and final session was a panel discussion on how to take cadaveric organ donation forward in India. The meeting generated a lot of healthy discussion and inspite of conflicting views on many controversial issues, some general guidelines and consensus statements were framed which are summarized below:

1. Several centers have now acquired the necessary infrastructure and expertise to perform liver transplantation in India.

2. All centers felt that, in general, recipients were referred late for transplant. This was thought to contribute significantly to the poor initial results. Data from other centers abroad also supports this view. Hence, it was recommended that patients with chronic liver disease should be sounded about a transplant and referred to the transplant team when they are relatively stable (class Child's B and stable Child's C).

3. Some centers attributed early failures to badly managed cadaveric donors. It was agreed that all hospitals with possibility of cadaver organ donation should make their ICU staff sensitive to the needs of cadaveric organ transplantation and have standard donor management protocols with which the ICU staff must be well versed.

4. The point of adequate technical expertise was hotly debated and so was the advisability of getting well- established foreign teams to perform transplants in India.  It was agreed that presence of well-trained surgeons, herpetologists and anesthetists was clearly a basic requirement. More important than getting one or two surgeons from abroad, it was the systematic establishment of a well-oiled multidisciplinary setup and strict adherence to aseptic discipline that was the key in achieving success.

5. Post-operative infection was identified as the single most important factor in determining outcome after transplant. It was agreed that sepsis after liver transplant was a complex and multi factorial issue. Poor graft function, inadequate blood supply or drainage and biliary complications were some of the technical factors responsible for sepsis. These should always be excluded and with experience, the incidences of these complications would fall. Other than that, rational antibiotic polices, and strict aseptic discipline in the OT and ICU were vital to the avoidance of significant septic complications after transplant.

6. It was agreed that like some other countries such as Japan, South Korea and Taiwan, living donor liver transplantation was a suitable option in India as long as it was done by adequately trained teams in suitably equipped centers.

7. Lack of well –Developed Cadaver Organ Donation programmes was identified as a major hurdle in the establishment of liver transplantation in India. This prevented centre’s from performing transplants in large numbers and overcoming their teething troubles. It also prevented patients and their referring doctors from developing confidence in the system since there was no guarantee as to how long a particular patient would ever get a suitable organ at all. Hence, concerted national efforts to spread awareness about the concept of brain death and to promote cadaver organ donation by both government –funded organizations and NGOs was imperative 

8. Few key points in realization of cadaver organ were:

a) Widespread dissemination of information about brain death, cadaver donation and the success of organ transplantation both among lay public (at all socio-economic levels) and healthcare staff (doctors and paramedical staff) was needed.

b) It was essential to appoint dedicated Transplant Coordinators in all hospitals where there were established ICUs and organ donation was a possibility. All over the world, they have played a vital role in identifying prospective donors, motivating their families, facilitating the entire donation and transplantation process.

c) Donor organs are a national health resource and they should never be wasted. To ensure optimal utilization of donated organs, efficient organ sharing between transplant centers must be developed. Initiative for Organ Sharing (INOS) launched under the aegis of MOHAN Foundation of Chennai was one such laudable move. It was suggested that initially regional and then national organ sharing networks should be developed.

d) It was suggested that the initial approach to the family of a prospective donor should be for eye donation. Once the family was positively inclined, they could be asked about other organs. This approach was used in Chennai with impressive results.

9. It was suggested by representative of MOHAN that in order to facilitate cadaver organ donation, the Government needed to issue certain new directives and bring about some changes in the Transplantation of Human Organs Act 1994 as follows:

a) Intimation of 'Brain Death' to relatives: The treating physician should be required to announce brain death to relatives once it is ascertained using criteria laid down by law (THOA 1994)

b) Required Request Law: In the event of brain death, it should be compulsory for the ICU staff to suggest organ donation to the relatives and request their permission for the same.

c) Inclusion of the clause of Organ Donation in the Driving License.

d) Delinking of hospitals where "organs can be retrieved" from hospitals where they can "actually be transplanted". Moving brain-dead persons from one hospital, that "is not approved" to another that "is approved" limits the scope of the number of brain-dead patients who can be available for donation.

e) In medico-legal cases, making it possible to undertake "post-mortem" at the same time as the "organ retrieval surgery". Shifting the body from one hospital to another for post-mortem is emotionally traumatic to the relatives of the donor and delays the process of handing over the body to the family.

f) Making it compulsory for all major hospitals in India with ICU facilities to employ a Transplant Coordinator in their ICUs, both to identify brain-dead patients and inform appropriate authorities for necessary action and to counsel the family for organ donation.

The above recommendations had already been forwarded to the Health and Family Welfare Ministry by MOHAN Foundation and some of the state Governments. Despite divergent views, the symposium was marked by unmistakable enthusiasm to succeed and clearly highlighted common hurdles faced by all. Guidelines and consensus statements were agreed upon and the meeting ended on an optimistic note with the decision to hold a similar forum annually to propel the development of the field. The detailed proceedings of the symposium are being published and will be released shortly in the form of a book.