Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper.

Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries. In India, majority of deceased donations happen following brain death (BD). While existing legislation allows for DCDD, there have been only few reports of kidney transplantation following DCDD from India. This document, prepared by a multidisciplinary group of experts, reviews international best practices in DCDD and outlines the path for DCDD in India. Ethical, medical, legal, economic, procedural, and logistic challenges unique to India have been addressed. The practice of withdrawal of life-sustaining treatment (WLST) in India, laid down by the Supreme Court of India, is time-consuming, possible only in patients in a permanent vegetative state, and too cumbersome for day-to-day practice. In patients where continued medical care is futile, the procedure for WLST is described. In controlled DCDD (category-III), decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Families that are inclined toward organ donation are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. In donation following neurologic determination of death (DNDD), if cardiac arrest occurs during the process of BD declaration, the protocol for DCDD category-IV has been described in detail. In DCDD category-V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the ICU. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and techniques, such as normothermic regional perfusion (nRP) and ex vivo machine perfusion, has been provided. The outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for successful execution of DCDD in India are described. How to cite this article: Seth AK, Mohanka R, Navin S, Gokhale AGK, Sharma A, Kumar A, et al. Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper. Indian J Crit Care Med 2022;26(4):421-438.

Relative contribution of susceptibility weighted imaging, compared to conventional MRI, in the detection of common bile-duct calculi.

PURPOSE We aimed to evaluate the relative contribution of susceptibility weighted imaging (SWI) in the detection of common bile-duct (CBD) stones in comparison to the conventional MRI protocol containing magnetic resonance cholangiopancreatography (MRCP), balanced turbo field echo (BTFE), and T2-weighted spin-echo imaging techniques. METHODS MRI data containing MRCP, BTFE, T2-weighted imaging, and abdominal SWI were independently evaluated by 2 sets of experienced radiologists in 44 patients with confirmed CBD stones. Endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound where available, was used as the reference gold standard. Evaluation was performed for the visualization of CBD stones in each of the MRI techniques. Relative contribution of SWI was classified into one of four categories for each case: (1) no contribution to CBD stone visualization; (2) same as conventional techniques; (3) improved diagnostic confidence; and (4) critical for diagnosis. Stone size was also assessed. RESULTS Inter-rater agreement coefficient for CBD stone visualization was found to be "good" in MRCP (0.77), "very good" in SWI (0.94) and BTFE (0.84), and moderate in T2-weighted imaging (0.54). CBD stones were visualized with SWI in 86.4% and 82%, with MRCP in 70.5% and 70.5% cases, with BTFE in 73% and 61.4% cases, with T2-weighted imaging in 45.5% and 52.3% cases by reviewers 1 and 2, respectively. SWI did not contribute to CBD stone visualization in 2.3% (1/44); was the same as conventional techniques in 31.8% (14/44) cases; improved diagnostic confidence in 34.1%; and was critical for diagnosis in 20.5% cases. CONCLUSION SWI has the potential to serve as a strong adjunct to conventional MRI protocols used for CBD stone evaluation with very small scan-time penalty.

Minimal hepatic encephalopathy: consensus statement of a working party of the Indian National Association for Study of the Liver.

Hepatic encephalopathy (HE) is a major complication that develops in some form and at some stage in a majority of patients with liver cirrhosis. Overt HE occurs in approximately 30-45% of cirrhotic patients. Minimal HE (MHE), the mildest form of HE, is characterized by subtle motor and cognitive deficits and impairs health-related quality of life. The Indian National Association for Study of the Liver (INASL) set up a Working Party on MHE in 2008 with a mandate to develop consensus guidelines on various aspects of MHE relevant to clinical practice. Questions related to the definition of MHE, its prevalence, diagnosis, clinical characteristics, pathogenesis, natural history and treatment were addressed by the members of the Working Party.

Hereditary angioedema with recurrent abdominal pain.

Hereditary angioedema is a rare disorder characterized by quantitative or qualitative deficiency of complement C1 esterase inhibitor. We report a family whose members presented with recurrent angioedema and abdominal pain; the diagnosis was confirmed by quantitative assay of C1 inhibitor. The index patient was treated with danazol and was relieved.

HBsAg Quantification in Clinical Practice.

Several standardized commercial assays for quantification of hepatitis B surface antigen (qHBsAg) are now available. Studies on HBsAg kinetics from Asia and Europe have demonstrated that HBsAg levels are highest during the immune-tolerant phase, become lower during immune-clearance phase and are the lowest in hepatitis B 'e' antigen (HBeAg)-negative inactive low-replicative phase with a rise during HBeAg-negative chronic hepatitis B (CHB). Combined use of hepatitis B virus-deoxyribonucleic acid (HBV-DNA) and HBsAg levels may help in differentiating true inactive carrier state from HBeAg-negative CHB. Several retrospective studies have demonstrated a role for decline in HBsAg level for predicting response and nonresponse to therapy. In HBeAg-positive patients treated with pegylated-interferon (PEG-IFN), a lack of decline of qHBsAg at week 12 predicts nonresponders while a decline of qHBsAg at week 24 predicts responders to PEG-IFN. In HBeAg-negative patients, if at week 12, there is no decline in qHBsAg and the HBV-DNA decline is < 2 log, the patient is unlikely to respond, then stopping of PEG-IFN should be considered. With nucleos(t)ide analogs, the decline in HBsAg is lower than that with PEG-IFN and more marked in patients with HBeAg-positive chronic hepatitis, with elevated alanine aminotransaminase (ALT), thus suggesting that active immune response against HBV is required to lower HBsAg. In patients with HBeAg-negative chronic hepatitis, fall in HBsAg may help in developing stopping rules to reduce the need for lifelong therapy. Information provided by HBsAg is complementary to HBV-DNA and cannot replace the same. Prospective studies on HBsAg kinetics from all regions of the world are required to define optimum time of testing and cutoff levels before stopping rules can be recommended.

Thrombocytosis in liver transplant recipients: prevalence, natural history, and impact.

The prevalence, natural history, and implications of reactive thrombocytosis after liver transplantation (LT) are unknown. Prospectively collected data from July 2000 to February 2006 were analyzed. Post-LT thrombocytosis was defined as a platelet count of > 450 x 10(3)/microL lasting for >7 days and starting within 8 weeks of transplantation. In patients who survived >8 weeks, graft and patient outcomes were compared with liver transplant recipients who survived >8 weeks and did not develop any thrombocytosis. Post-LT thrombocytosis was seen in 92 (14.7%) of 627 patients. The median onset was on day 13 (range, days 1-44) and the peak platelet count was seen on day 17 (range, days 3-110). The median duration of thrombocytosis was 25 days (range, 7-1,253 days), with a median peak platelet count of 625 x 10/microL (range, 472-1,381 x 10/microL). Seronegative fulminant hepatic failure was the indication for transplantation in 18% of patients with post-LT thrombocytosis compared with 3% of controls (P < 0.001). There was a lower proportion of patients transplanted for hepatitis C-related cirrhosis in the thrombocytosis group (10% vs. 18%, P = 0.04). The occurrence of hepatic arterial thrombosis was similar in the 2 groups (5% vs. 4%, P = NS). None of the 4 patients with platelet count higher than 1,000 x 10/microL developed thrombotic complications. Post-LT thrombocytosis is more often associated with seronegative fulminant hepatic failure, and there is a negative association with hepatitis C-related cirrhosis. Post-LT thrombocytosis does not increase the risk of hepatic artery thrombosis, and patients without thrombotic complications should not be treated.

Symptomatic portal system thrombosis in soldiers due to extended stay at extreme altitude.

BACKGROUND: With induction of Indian Army to heights over 5000 m above mean sealevel (MSL), several new complications of long-term stay at extreme altitude have come to light. The authors' experience with soldiers who developed symptomatic portal system thrombosis (SPST) is described here. METHODS: Clinical data were prospectively collected between April 1998 and April 2003, on all patients hospitalized for SPST from high-altitude areas (HAA, >3000 m above MSL) and those from non-high-altitude areas (NHAA). Site of thrombosis was confirmed by imaging and included splenic, portal, superior mesenteric, or inferior mesenteric vein thrombosis. Patients were investigated to rule out known predisposing factors and prothrombotic conditions. RESULTS: A total of 37 cases of SPST were seen during the study period, of which 26 were from HAA. Mean age of cases from HAA was 27 +/- 4.6 years and all were male. Mean stay at high altitude was 11.7 +/- 6.2 months. First symptom was pain in abdomen in almost all the cases, later followed by gastrointestinal bleeding and fever in 14 each, and vomiting in 19. Clinical examination showed ascites (81%), splenomegaly (76.9%), and hepatomegaly (69.2%). Diagnosis was made by imaging scans (23 cases) and on surgery in three cases. A known prothrombotic state was detected in five cases from HAA and in eight cases from NHAA (P < or = 0.01). Ultrasound Doppler scan picked up collaterals as early as 12-45 days after onset of symptoms. CONCLUSIONS: Extended stay at HAA may be a risk factor for development of symptomatic portal system thrombosis.