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Rajakannu M, Rammohan A, Narasimhan G, Murugesan S, Rajalingam R, Palaniappan K, Rajasekar SJ, Jothimani D, Rajakumar A, Kaliamoorthy I, Rela M. Deceased Donor Liver Transplantation in India: First Report of 5-y Outcomes. Transplantation 2024; 108:2109-2116. [PMID: 38637925 DOI: 10.1097/tp.0000000000004991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND Paucity of deceased donor livers has resulted in a 10-fold rise in living donor liver transplantations (LDLTs) performed in India over the past decade. Nonetheless, number of deceased donor liver transplantation (DDLT) performed has improved with the establishment of simplified legal framework for certification of brain death and organ donation. In this study, we present our outcomes of DDLT performed at various centers, comparing their outcomes and provide a snapshot of the increasing number of DDLT across the state over the years. METHODS All consecutive patients who underwent liver transplants from January 2010 till December 2019 by our transplant team in the state of Tamil Nadu, India, were included in the study. The program was established initially at the primary hospital in the year 2010 and with the evolution of the initial experience, transplant programs were expanded to the others hospital from the year 2015. Preoperative clinical data, intraoperative characteristics, and posttransplant outcomes of DDLT were analyzed from our prospective database. RESULTS A total of 362 DDLTs (331 adults, 31 children) were performed at 11 centers. Median (range) model for end-stage liver disease score was 16 (6-39). Forty-eight split, 11 combined liver kidney, and 4 auxiliary DDLTs were performed. One-, 3-, and 5-y survival was 87.2%, 80.4%, and 76.6% in adults and 80.6%, 80.6%, and 80.6% in children, respectively. CONCLUSIONS In a country where over 80% of the LTs are performed as LDLT, we provide the first report of a heartening trend of increasing number of DDLT programs being established with excellent 5-y outcomes.
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Affiliation(s)
- Muthukumarassamy Rajakannu
- Institute of Liver Disease and Transplantation, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chromepet, Tamil Nadu, India
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2
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Gurav YK, Bagepally BS, Chitpim N, Sobhonslidsuk A, Gupte MD, Chaikledkaew U, Thakkinstian A, Thavorncharoensap M. Cost-effective analysis of hepatitis A vaccination in Kerala state, India. PLoS One 2024; 19:e0306293. [PMID: 38935781 PMCID: PMC11210869 DOI: 10.1371/journal.pone.0306293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
Several hepatitis A outbreaks have recently been reported in Kerala state, India. To inform coverage decision of hepatitis A vaccine in Kerala, this study aimed to examine the cost-effectiveness of 1) hepatitis A vaccination among children aged 1 year and individuals aged 15 years, and 2) serological screening of individuals aged 15 years and vaccination of susceptible as compared to no vaccination or vaccination without serological screening. Both live attenuated hepatitis A vaccine and inactivated hepatitis A vaccine were considered in the analysis. A combination of decision tree and Markov models with a cycle length of one year was employed to estimate costs and benefits of different vaccination strategies. Analysis were based on both societal and payer perspectives. The lifetime costs and outcomes were discounted by 3%. Our findings indicated that all strategies were cost-saving for both societal and payer perspectives. Moreover, budget impact analysis revealed that vaccination without screening among individuals aged 15 years could save the government's budget by reducing treatment cost of hepatitis A. Our cost-effectiveness evidence supports the inclusion of hepatitis A vaccination into the vaccination program for children aged 1 year and individuals aged 15 years in Kerala state, India.
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Affiliation(s)
- Yogesh Krishnarao Gurav
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Health Technology Assessment Group, ICMR-National Institute of Virology, Pune, Maharashtra, India
| | - Bhavani Shankara Bagepally
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Division of Non-Communicable Diseases, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
| | - Natthakan Chitpim
- Social, Economic and Administrative Pharmacy Graduate Program, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Abhasnee Sobhonslidsuk
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Montarat Thavorncharoensap
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
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3
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Poudel S, Gupta S, Saigal S. Basics and Art of Immunosuppression in Liver Transplantation. J Clin Exp Hepatol 2024; 14:101345. [PMID: 38450290 PMCID: PMC10912712 DOI: 10.1016/j.jceh.2024.101345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.
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Affiliation(s)
- Shekhar Poudel
- Fellow Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Principal Director and Head, Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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4
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Vaishya R, Gupta BM, Kappi MM, Sibal A, Goyal N. Liver Transplantation Research from India During the Last 25 Years: 1998-2022. J Clin Exp Hepatol 2024; 14:101313. [PMID: 38221946 PMCID: PMC10784695 DOI: 10.1016/j.jceh.2023.101313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/30/2023] [Indexed: 01/16/2024] Open
Abstract
Background and aims Liver transplant surgery has been performed in India for the last 25 years. We aimed to analyse the trends, characteristics, and key elements in the field of liver transplantation research from India. Methods On April 23, 2023, we conducted a search of the Scopus database for the literature on liver transplantation research, using a well-defined search strategy. MS Excel and VOS viewer software programs were used to examine the articles for organisation, author, journal, keywords, and high-cited literature. Results This analysis examined a total of 556 papers, which constituted only a 1.55% share of the global output. These papers involved 442 organizations, 1575 authors, and 147 journals. External funding was received in 4.13% and 23.56% were involved in international collaboration. Three Delhi-NCR organizations, namely the Medanta-The Medicity (n = 63), Institute of Liver & Biliary Sciences (n = 60), and Indraprastha Apollo Hospital (n = 48) led in publication productivity. M. Rela (n = 90) and A.S. Soin (n = 63) were the leading authors in publication productivity, while S. Sudhindran and P. Bhangui were the most impactful authors. Liver Transplantation (n = 96) and Journal of Clinical & Experimental Hepatology (n = 65) published the maximum number of these papers, whereas, Annals of Surgery and Journal of Hepatology led in the citation impact per paper. The most significant keywords were "Liver Transplantation" (n = 484), and "Living Donor" (n = 254). Only 1.80% (n = 10) of the papers were highly cited papers that received 50 to 142 citations and they together registered 69.9 citations per paper. Conclusion Although the number of publications on liver transplantation from India started growing recently, it forms only 1.55% of the global report. There is an unmet need to increase government-supported research and multicenter collaborative studies at national and international levels for high-quality patient care.
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Affiliation(s)
- Raju Vaishya
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India
| | - Brij M. Gupta
- Formerly with CSIR-NISTADS, New Delhi 110 012, India
| | | | - Anupam Sibal
- Department of Paediatric Hepatology and Gastroenterology, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Neerav Goyal
- Department of Liver Transplant and HPB Unit, Indraprastha Apollo Hospitals, New Delhi 110076, India
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5
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Wagh RS, Chauhan S, Shah M, Bairwa Y, Dalai M, Ingle M. Assessing the predictive value of serum phosphate for short-term mortality in acute-on-chronic liver failure patients: An observational study at a non-transplant tertiary care centre. Clin Exp Hepatol 2024; 10:20-29. [PMID: 38765912 PMCID: PMC11100335 DOI: 10.5114/ceh.2024.136290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/26/2023] [Indexed: 05/22/2024] Open
Abstract
Aim of the study The gradual clinical worsening of acute-on-chronic liver failure (ACLF) leads to a high 28-day mortality rate. There are several prognostication scores for predicting early mortality in ACLF. Serum phosphate, which is the main component of adenosine tri-phosphate (ATP) synthesis, is utilized for liver synthetic functions, leading to subnormal or decreased serum phosphate levels. Hence more than normal levels of serum phosphate can be used as a marker of decreased liver cell reserve. Hence, we aimed to compare serum phosphate levels with available prognostic scores to assess mortality among ACLF patients. Material and methods 100 consecutive ACLF patients according to the Asia Pacific Association for Study of the Liver (APASL) definition were studied. The baseline blood workups and determination of viral bio-markers, serum phosphate, and lactate levels on days 1, 3, and 7 were carried out and prospectively followed up, and the baseline serum phosphate levels were compared with the usual scores to predict the 28-day mortality. Results CLIF-SOFA (accuracy 76-91%) followed by CLIF-C score (accuracy 73-84%) and AARC score (accuracy 70-85%) had the statistically significantly highest accuracy as compared with CTP, MELD, and MELD-Na on all three days. Serum phosphate values (accuracy 69-86%) on all three days were not better than the CLIF-SOFA score but better than all other prognostic scores on days 3 and 7. Conclusions The high serum phosphate levels on day 3 with a value of more than 6.4 mg/dl showed almost comparable accuracy with CLIF-SOFA for screening short-term mortality. Hence serum phosphate measurement can be used as a simple bedside laboratory investigation to predict mortality in ACLF patients and early interventions in low-resource settings.
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Affiliation(s)
- Rohit S Wagh
- Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | | | - Mit Shah
- Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Yogesh Bairwa
- Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Motij Dalai
- Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Meghraj Ingle
- Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
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Fernando M, Tillakaratne S, Gunetilleke B, Liyanage C, Appuhamy C, Weerasuriya A, Uragoda B, Welikala N, Ranaweera L, Ganewatte E, Dissanayake J, Mudalige A, Siriwardana R. Challenges faced in establishing a pediatric liver transplant program in a lower-middle-income country with free healthcare service. Pediatr Transplant 2024; 28:e14681. [PMID: 38317346 DOI: 10.1111/petr.14681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/06/2023] [Accepted: 12/08/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Liver transplant is the cure for children with liver failure. Sri Lanka is a lower-middle-income country with a predominant free, state health system. Pediatric liver transplant program in Sri Lanka is still in the budding state where the initial experience of the program is yet to be documented. METHODS A retrospective review was performed including the clinical characteristics of all pediatric liver transplant recipients of Colombo North Centre for Liver Diseases since the inception of the program from June 2020 to May 2023. RESULTS There were 14 PLT performed in 3 years. The median recipient age and weight were 8 years (6 months-15 years) and 23.3 kg (6.4-49.2), respectively. The majority were boys (64%). All were from low-income backgrounds. Indications for LT were acute liver failure (5/14), decompensated chronic liver disease (5/14), and acute on chronic liver failure (4/14). Underlying liver diseases were Wilson disease (6/14), autoimmune liver disease (3/14), biliary atresia (2/14) and progressive familial intrahepatic cholestasis type 3 (1/14), and unknown etiology (2/14). The majority were living donor liver transplants (86%). Of the living donors, 42% (5/12) were Buddhist priests. There were three immediate deaths and two late deaths. The 3-month survival was 78%, and overall survival was 64%. Living donor transplants carried a higher success rate (92%) compared to diseased donor transplants (0%; 2/2). CONCLUSIONS Initial experience of pediatric liver transplant program of Sri Lanka is promising despite being established in a free healthcare system amidst the crisis circumstances.
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Affiliation(s)
- Meranthi Fernando
- Colombo North Centre For Liver Diseases, Ragama, Sri Lanka
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
| | - Suchintha Tillakaratne
- Colombo North Centre For Liver Diseases, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Bhagya Gunetilleke
- Colombo North Centre For Liver Diseases, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Division of Anaesthesia, Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | | | - Chinthaka Appuhamy
- Colombo North Centre For Liver Diseases, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Aruna Weerasuriya
- Colombo North Centre For Liver Diseases, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | | | - Nadeeshya Welikala
- Colombo North Centre For Liver Diseases, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Division of Anaesthesia, Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | | | | | | | | | - Rohan Siriwardana
- Colombo North Centre For Liver Diseases, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Department of Surgery, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
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7
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Hill AL, Khan M, Kiani AZ, Lindemann JD, Vachharajani N, Doyle MB, Chapman WC, Khan AS. Global liver transplantation: emerging trends and ethical challenges. Langenbecks Arch Surg 2023; 408:418. [PMID: 37875764 DOI: 10.1007/s00423-023-03144-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/06/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Liver transplant (LT) is the only definitive treatment for end-stage liver disease (ESLD). This review aims to explore current global LT practices, with an emphasis on challenges and disparities that limit access to LT in different regions of the world. METHODS A detailed analysis was performed of present-day liver transplant practices throughout the world, including the etiology of liver disease, patient access to transplantation, surgical costs, and ongoing ethical concerns. RESULTS Annually, only 10% of the patients needing a liver transplant receive an organ. Currently, the USA performs the highest volume of liver transplants worldwide, followed by China and Brazil. In both North America and Europe, nonalcoholic fatty liver disease is becoming the most common indication for LT, compared to hepatitis B and C in most Asian, South American, and African countries. While deceased donor liver transplant remains the most performed type of LT, living donor liver transplant is becoming increasingly popular in some parts of the world where it is often the only option due to a lack of well-developed infrastructure for deceased organ donation. Ethical concerns in liver transplantation fundamentally revolve around the definition of a deceased donor and the exploitation of living donor liver donation systems. CONCLUSION Globally, liver transplant practices and outcomes are varied, with differences driven by healthcare policies, inequities in healthcare access, and ethical concerns.
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Affiliation(s)
- Angela L Hill
- Washington University in St. Louis, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA
| | - Maryam Khan
- CMH Lahore Medical and Dental College, Lahore, Pakistan
| | - Amen Z Kiani
- Washington University in St. Louis, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA
| | - Jessica D Lindemann
- Washington University in St. Louis, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA
| | - Neeta Vachharajani
- Washington University in St. Louis, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA
| | - Majella B Doyle
- Washington University in St. Louis, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA
| | - William C Chapman
- Washington University in St. Louis, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA
| | - Adeel S Khan
- Washington University in St. Louis, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA.
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8
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Fatima I, Jahagirdar V, Kulkarni AV, Reddy R, Sharma M, Menon B, Reddy DN, Rao PN. Liver Transplantation: Protocol for Recipient Selection, Evaluation, and Assessment. J Clin Exp Hepatol 2023; 13:841-853. [PMID: 37693258 PMCID: PMC10483012 DOI: 10.1016/j.jceh.2023.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/13/2023] [Indexed: 09/12/2023] Open
Abstract
Liver transplantation (LT) is the definitive therapy for patients with end-stage liver disease, acute liver failure, acute-on-chronic liver failure, hepatocellular carcinoma, and metabolic liver diseases. The acceptance of LT in Asia has been gradually increasing and so is the expertise to perform LT. Preparing a patient with cirrhosis for LT is the most important aspect of a successful LT. The preparation for LT begins with the first index decompensation for a patient with cirrhosis. Patients planned for LT should undergo a thorough screening for infections, and a complete cardiac, pulmonology, and psychosocial evaluation pre-LT. In this review, we discuss the indications and contraindications of LT and the evaluation and assessment of patients with liver disease planned for LT.
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Affiliation(s)
- Ifrah Fatima
- University of Missouri-Kansas City School of Medicine, MO, USA
| | | | | | - Raghuram Reddy
- Department of Liver Transplantation Surgery, AIG Hospitals, Hyderabad, India
| | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Balchandran Menon
- Department of Liver Transplantation Surgery, AIG Hospitals, Hyderabad, India
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9
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Abstract
In recent years there has been a significant increase in the incidence of acute-on-chronic liver failure (ACLF). This syndrome is characterized by infections, organ failures, and high short-term mortality. Although progress in the management of these sick patients has been evident, liver transplantation (LT) remains the best treatment modality to date. Several studies have reported LT as a feasible option, despite organ failures. The outcomes following LT are inversely related to the grade of ACLF. This review discusses the current literature on the feasibility, futility, timing, and outcomes of LT in patients with ACLF.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad-500032, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, Liver Transplant Office 3400 Spruce Street, Philadelphia, PA 19104, USA.
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10
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Ramakrishnan S, Hans R, Duseja A, Sharma RR. Therapeutic plasma exchange is a safe and effective bridge therapy in patients with alcohol-associated ACLF not having immediate prospects for liver transplantation-A case-control, pilot study. J Clin Apher 2022; 37:553-562. [PMID: 36065827 DOI: 10.1002/jca.22010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/08/2022] [Accepted: 08/19/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is a well-established treatment modality in acute liver failure patients, but its efficacy in treating acute on chronic liver failure (ACLF) patients is yet to be established. AIM To assess the efficacy and safety of TPE in patients with alcohol-associated ACLF who were nonresponders to standard medical treatment (SMT) and without immediate prospects for liver transplantation. METHODS Twenty-eight alcohol-related ACLF (grade II) patients (14 cases and 14 controls) were enrolled in the study. Cases underwent standard volume TPE along with SMT while the controls were on SMT alone. The change (baseline to day 10) in laboratory parameters, cytokine concentrations, clinical severity scores along with 30 and 90 day mortality rates were noted and compared between the two groups. The adverse events (AEs) were noted in the groups and analyzed. RESULTS A total of 51 TPE procedures were performed in 14 patients (average of 3.62 procedures/patient). TPE was effective in reduction of serum bilirubin, ammonia, activated partial thromboplastin time, prothrombin time, international normalized ratio, and severity scores (ACLF Research Consortium, Maddrey's discriminant function, and model for end-stage liver disease) (P < .05). There was no significant difference in the reduction of serum interleukin-6 (IL-6), IL-10, and tumor necrosis factor-α concentrations among cases. Among the cases who received the complete TPE interventions, 30- and 90-day mortality rates were lower in the cases as compared to controls albeit only the 90-day mortality was significantly different. Procedure-related AEs was observed in 2% of procedures. CONCLUSION TPE is an effective and well-tolerated bridge therapy in patients with alcohol-associated ACLF of moderate severity not improving on SMT and without immediate prospects for liver transplantation.
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Affiliation(s)
- Sharanya Ramakrishnan
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rekha Hans
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ratti Ram Sharma
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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11
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Kulkarni AV, Premkumar M, Reddy DN, Rao PN. The challenges of ascites management: An Indian perspective. Clin Liver Dis (Hoboken) 2022; 19:234-238. [PMID: 35795622 PMCID: PMC9248925 DOI: 10.1002/cld.1209] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Anand V. Kulkarni
- Department of HepatologyAsian Institute of GastroenterologyHyderabadIndia
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12
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Shroff S, Gill JS. Bold policy changes are needed to meet the need for organ transplantation in India. Am J Transplant 2021; 21:2933-2936. [PMID: 33583127 DOI: 10.1111/ajt.16537] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/01/2021] [Accepted: 02/10/2021] [Indexed: 01/25/2023]
Abstract
Twenty-five years after India passed legislation to legalize brain death, deceased donor transplantation remains underdeveloped while the country has established formidable capacity for living donor transplantation. Because of a large number of potential deceased donors, there is hope that deceased donation could help meet India's enormous need for organ transplantation. However, significant policy and practical barriers limit progress. The vast majority of potential deceased donors are poor motor vehicle accident victims who present for care in hospitals without the necessary infrastructure or expertise to support deceased donation. In contrast, transplant infrastructure and expertise are concentrated in private hospitals and are only accessible to those with the ability to pay. Given these realities, the potential of deceased donor transplantation can only be recognized if Indians who are likely to donate organs are also provided access to transplantation. In this viewpoint, we review the current status of organ transplantation in India and propose new policies to establish a national organization to oversee deceased donor services in all states, to fund resources needed to support deceased donation, to leverage the existing living donor infrastructure to advance deceased donor transplantation, and call for establishment of government policy on funding for posttransplant care and immunosuppression.
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Affiliation(s)
- Sunil Shroff
- Urology and Transplantation, Madras Medical Mission Hospital, Chennai, India
| | - John S Gill
- University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
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13
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Balakrishnan K. Heart transplantation in India-are we there yet? Indian J Thorac Cardiovasc Surg 2020; 36:159-165. [PMID: 33061200 DOI: 10.1007/s12055-020-00987-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Komarakshi Balakrishnan
- Department of Cardio Thoracic Surgery, MGM Health Care, Nelson Manickam Road, Chennai, India
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14
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Rammohan A, Rela M, Kumar GV, Scott JX, Shanmugam N, Reddy MS, Ramachandran P. Outcomes for high-risk hepatoblastoma in a resource-challenged setting. BJS Open 2020; 4:630-636. [PMID: 32379933 PMCID: PMC7397353 DOI: 10.1002/bjs5.50297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/09/2020] [Indexed: 11/30/2022] Open
Abstract
Background Outcomes of high‐risk hepatoblastoma have been dismal, especially in resource‐challenged countries where access to chemotherapy and paediatric liver transplantation is limited for the underprivileged. This study aimed to assess the results of treatment of high‐risk hepatoblastoma in a tertiary centre, including patients who had non‐transplant surgical procedures in the form of extended resection. Methods A review of patients with high‐risk hepatoblastoma treated between January 2012 and May 2018 was carried out. Perioperative data and long‐term outcomes were analysed. Results Of 52 children with hepatoblastoma, 22 were considered to have high‐risk hepatoblastoma (8 girls and 14 boys). The mean(s.d.) age at diagnosis was 35(20) months. Of these 22 children, five died without surgery. Of the remaining 17 who underwent surgery, six had a resection (4 right and 2 left trisectionectomies) and 11 underwent living‐donor liver transplantation. Median follow‐up was 48 (range 12–90) months. Thirteen of the 17 children were alive at last follow‐up and four developed disseminated disease (3 had undergone liver transplantation and 1 liver resection). The overall survival rate at 1, 3 and 5 years was 77, 64 and 62 per cent for the whole cohort with high‐risk hepatoblastoma. In children who had surgery, 1‐, 3‐ and 5‐year survival rates were 91, 82 and 73 per cent for transplantation and 100, 83 and 83 per cent for resection. There was no difference in survival between the two surgical groups. Conclusion Excellent results in the treatment of high‐risk hepatoblastoma are possible, even in resource‐challenged countries.
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Affiliation(s)
- A Rammohan
- Institute of Liver Disease and Transplantation, Sree Balaji Medical College Hospital, Bharat Institute of Higher Education and Research, Chennai, India
| | - M Rela
- Ray of Light Foundation, Kanchi Kamakoti Children's Health Institute Laboratory and Diagnostic Services (CHILDS) Trust Hospital, CHILDS Trust Medical Research Foundation, Chennai, India
| | - G V Kumar
- Institute of Liver Disease and Transplantation, Sree Balaji Medical College Hospital, Bharat Institute of Higher Education and Research, Chennai, India
| | - J X Scott
- Institute of Liver Disease and Transplantation, Sree Balaji Medical College Hospital, Bharat Institute of Higher Education and Research, Chennai, India
| | - N Shanmugam
- Institute of Liver Disease and Transplantation, Sree Balaji Medical College Hospital, Bharat Institute of Higher Education and Research, Chennai, India
| | - M S Reddy
- Institute of Liver Disease and Transplantation, Sree Balaji Medical College Hospital, Bharat Institute of Higher Education and Research, Chennai, India
| | - P Ramachandran
- Institute of Liver Disease and Transplantation, Sree Balaji Medical College Hospital, Bharat Institute of Higher Education and Research, Chennai, India.,Ray of Light Foundation, Kanchi Kamakoti Children's Health Institute Laboratory and Diagnostic Services (CHILDS) Trust Hospital, CHILDS Trust Medical Research Foundation, Chennai, India
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15
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Tschuor C, Ferrarese A, Kuemmerli C, Dutkowski P, Burra P, Clavien PA, Imventarza O, Crawford M, Andraus W, D'Albuquerque LAC, Hernandez-Alejandro R, Dokus MK, Tomiyama K, Zheng S, Echeverri GJ, Taimr P, Fronek J, de Rosner-van Rosmalen M, Vogelaar S, Lesurtel M, Mabrut JY, Nagral S, Kakaei F, Malek-Hosseini SA, Egawa H, Contreras A, Czerwinski J, Danek T, Pinto-Marques H, Gautier SV, Monakhov A, Melum E, Ericzon BG, Kang KJ, Kim MS, Sanchez-Velazquez P, Oberkofler CE, Müllhaupt B, Linecker M, Eshmuminov D, Grochola LF, Song Z, Kambakamba P, Chen CL, Haberal M, Yilmaz S, Rowe IA, Kron P. Allocation of liver grafts worldwide - Is there a best system? J Hepatol 2019; 71:707-718. [PMID: 31199941 DOI: 10.1016/j.jhep.2019.05.025] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. The most frequent principles for allocation policies in liver transplantation are therefore criteria that rely on pre-transplant survival (sickest first policy), post-transplant survival (utility), or on their combination (benefit). However, large differences exist between centers and countries for ethical and legislative reasons. The aim of this study was to report the current worldwide practice of liver graft allocation and discuss respective advantages and disadvantages. METHODS Countries around the world that perform 95 or more deceased donor liver transplantations per year were analyzed for donation and allocation policies, as well as recipient characteristics. RESULTS Most countries use the model for end-stage liver disease (MELD) score, or variations of it, for organ allocation, while some countries opt for center-based allocation systems based on their specific requirements, and some countries combine both a MELD and center-based approach. Both the MELD and center-specific allocation systems have inherent limitations. For example, most countries or allocation systems address the limitations of the MELD system by adding extra points to recipient's laboratory scores based on clinical information. It is also clear from this study that cancer, as an indication for liver transplantation, requires special attention. CONCLUSION The sickest first policy is the most reasonable basis for the allocation of liver grafts. While MELD is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors, predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs. LAY SUMMARY An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. While the model for end-stage liver disease is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.
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Affiliation(s)
- Christoph Tschuor
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Alberto Ferrarese
- Multivisceral Transplant Unit - Gastroenterology, Padua University Hospital, Padua, Italy
| | - Christoph Kuemmerli
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Patrizia Burra
- Multivisceral Transplant Unit - Gastroenterology, Padua University Hospital, Padua, Italy.
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland.
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Cost-effectiveness and budgetary impact of HCV treatment with direct-acting antivirals in India including the risk of reinfection. PLoS One 2019; 14:e0217964. [PMID: 31170246 PMCID: PMC6553784 DOI: 10.1371/journal.pone.0217964] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 05/22/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND HCV direct-acting antivirals (DAAs) are produced in India at low cost. However, concerns surrounding reinfection and budgetary impact limit treatment scale-up in India. We evaluate the cost-effectiveness and budgetary impact of HCV treatment in India, including reinfection. METHODS A closed cohort Markov model of HCV disease progression, treatment, and reinfection was parameterized. We compared treatment by fibrosis stage (F2-F4 or F0-F4) to no treatment from a health care payer perspective. Costs (2017 USD$, based on India-specific data) and health utilities (in quality-adjusted life years, QALYs) were attached to each health state. We assumed DAAs with 90% sustained viral response at $900/treatment and 1%/year reinfection, varied in the sensitivity analysis from 0.1-15%. We deemed the intervention cost-effective if the incremental cost-effectiveness ratio (ICER) fell below India's per capita GDP ($1,709). We assessed the budgetary impact of treating all diagnosed individuals. RESULTS HCV treatment for diagnosed F2-F4 individuals was cost-saving (net costs -$2,881 and net QALYs 3.18/person treated; negative ICER) compared to no treatment. HCV treatment remained cost-saving with reinfection rates of 15%/year. Treating all diagnosed individuals was likely cost-effective compared to delay until F2 (mean ICER $1,586/QALY gained, 67% of simulations falling under the $1,709 threshold) with 1%/year reinfection. For all scenarios, annual retesting for reinfection was more cost-effective than the current policy (one-time retest). Treating all diagnosed individuals and reinfections results in net costs of $445-1,334 million over 5 years (<0.25% of total health care expenditure over 5 years), and cost-savings within 14 years. CONCLUSIONS HCV treatment was highly cost-effective in India, despite reinfection. Annual retesting for reinfection was cost-effective, supporting a policy change towards more frequent retesting. A comprehensive HCV treatment scale-up plan is warranted in India.
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Mansard M, Siddachari R, Govil S, Doraiswamy S, Kumar G, Subramanian N, Arikichenin O. Is the Institute Georges Lopez-1 solution an equally effective, cheaper alternative to the University of Wisconsin solution in liver transplantation? INDIAN JOURNAL OF TRANSPLANTATION 2019. [DOI: 10.4103/ijot.ijot_61_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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18
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Patel R, Poddar P, Choksi D, Pandey V, Ingle M, Khairnar H, Sawant P. Predictors of 1-month and 3-months Hospital Readmissions in Decompensated Cirrhosis: A Prospective Study in a Large Asian Cohort. Ann Hepatol 2019; 18:30-39. [PMID: 31113606 DOI: 10.5604/01.3001.0012.7859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/13/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Considered as a healthcare quality indicator, hospital readmissions in decompensated cirrhosis predispose the patients and the society to physical, social and economic distresses. Few studies involving North American cohorts have identified different predictors. The aim of this study was to determine and validate the predictors of 1-month and 3-months readmission in an Asian cohort. MATERIAL AND METHODS We prospectively studied 281 hospitalised patients with decompensated cirrhosis at a large tertiary care public hospital in India between August 2014 and August 2016 and followed them for 3 months. Data regarding demographic, laboratory and disease related risk factors were compiled. We used multivariate logistic regression to determine predictors of readmission at 1-month and 3-months and receiver operating curves (ROC) for significant predictors to obtain the best cut-offs. RESULTS 1-month and 3-months readmission rates in our study were 27.8% and 42.3%, respectively. Model for End stage Liver Disease (MELD) score at discharge (OR:1.24, p < 0.001) and serum sodium (OR:0.94, p-0.039) independently predicted 1-month and MELD score (OR:1.11, p-0.003), serum sodium (OR:0.94, p-0.027) and male gender (OR:2.19, p-0.008) independently predicted 3-months readmissions. Neither aetiology nor complications of cirrhosis emerged as risk factors. MELD score >14 at discharge and serum sodium < 133 mEq/L best predicted readmissions; MELD score being a better predictor than serum sodium (p - 0.0001). CONCLUSIONS High rates of early and late readmissions were found in our study. Further, this study validated readmission predictors in Asian patients. Structured interventions targeting this risk factors may diminish readmissions in decompensated cirrhosis.
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Affiliation(s)
- Ruchir Patel
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India.
| | - Prateik Poddar
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Dhaval Choksi
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Vikas Pandey
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Meghraj Ingle
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Harshad Khairnar
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Prabha Sawant
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
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Chandran B, Bharathan VK, Shaji Mathew J, Amma BSPT, Gopalakrishnan U, Balakrishnan D, Menon RN, Dhar P, Vayoth SO, Surendran S. Quality of life of liver donors following donor hepatectomy. Indian J Gastroenterol 2017; 36:92-98. [PMID: 28393329 DOI: 10.1007/s12664-017-0743-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 03/11/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although morbidity following living liver donation is well characterized, there is sparse data regarding health-related quality of life (HRQOL) of donors. METHODS HRQOL of 200 consecutive live liver donors from 2011-2014 performed at an Indian center were prospectively collected using the SF-36 version 2, 1 year after surgery. The effect of donor demographics, operative details, post-operative complications (Clavien-Dindo and 50-50 criteria), and recipient mortality on the quality-of-life (QOL) scoring was analyzed. RESULTS Among 200 donors (female/male=141:59), 77 (38.5%) had complications (14.5%, 16.5%, 4.5%, and 3.5%, Clavien-Dindo grades I-IV, respectively). The physical composite score (PCS) of donors 1 year after surgery was less than ideal (48.75±9.5) while the mental composite score (MCS) was good (53.37±6.16). Recipient death was the only factor that showed a statistically significant correlation with both PCS (p<0.001) and MCS (p=0.05). Age above 50 years (p<0.001), increasing body mass index (BMI) (p=0.026), and hospital stay more than 14 days ( p= 0.042) negatively affected the physical scores while emergency surgery (p<0.001) resulted in lower mental scores. Gender, postoperative complications, type of graft, or fulfillment of 50-50 criteria did not influence HRQOL. On asking the hypothetical question whether the donors would be willing to donate again, 99% reiterated there will be no change in their decision. CONCLUSION Recipient death, donation in emergency setting, age above 50, higher BMI, and prolonged hospital stay are factors that lead to impaired HRQOL following live liver donation. Despite this, 99% donors did not repent the decision to donate.
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Affiliation(s)
- Biju Chandran
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Viju Kumar Bharathan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Johns Shaji Mathew
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India.
| | - Binoj Sivasankara Pillai Thankamony Amma
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Unnikrishnan Gopalakrishnan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Dinesh Balakrishnan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Ramachandran Narayana Menon
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Puneet Dhar
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Sudheer Othiyil Vayoth
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
| | - Sudhindran Surendran
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, 682 041, India
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Singal AK, Kamath PS. Live donor liver transplantation for alcoholic hepatitis. Hepatol Int 2016; 11:34-37. [PMID: 27714680 DOI: 10.1007/s12072-016-9770-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/16/2016] [Indexed: 12/20/2022]
Abstract
Liver transplantation is a definitive therapy for patients with end-stage liver disease and cirrhosis, with improvement in survival and quality of life. Patients are carefully screened and selected for this modality of treatment to achieve maximum survival benefit. For example, a patient with hepatocellular carcinoma is a candidate if he or she is within Milan criteria and has no significant comorbidity. Similarly, patients with alcoholic cirrhosis are transplant candidates if they are deemed to have been rehabilitated from abusive alcohol consumption and are at low risk for recidivism. More recently, carefully selected patients with alcoholic hepatitis have been successfully transplanted. The preferred transplantation modality is cadaveric liver transplantation. However, living donor liver transplantation is carried out if there is no cadaveric liver organ allocation system, or if the patient is deemed to be at low priority for cadaveric organ transplantation based on the allocation system. Living donor liver transplantation for alcoholic hepatitis needs to be addressed with this background in mind.
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Affiliation(s)
- Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35294-0012, USA.
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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