Upgradation of Any Financial Remarks

Equipments upgradation of implications

services/or
need for
advanced
centers
Inpatient care
1. Creation of a separate area 6 beds with Space for six Approx 1 crore Details
for patients requiring multichannel beds, Nursing attached
readmission for infectious monitors, two officers – 15
diseases ventilators and (already
10 infusion sanctioned)
pumps
2 Provision of central air In process
conditioning of operation
theatre and ICU complex
3. Creation of multi organ As per appendix Advanced 46 crore
transplant Centre I centre required
Academic
4. Starting fellowship None None None
program in Vascular access
surgery
5. Development of other solid None None None
organ transplantation like
small bowel and
multivisceral
transplantation
6. Improvement in deceased None None None
donor programme
(DCD/DBD)

Research
7. Establishment of dedicated As per appendix Space for lab 12 crore
II required
Transplant immunology lab
VISION FOR NEXT 5 YEARS – Dept of Renal Transplant Surgery, PGIMER, Chandigarh

Infrastructure creation

1. Creation of a separate area for patients requiring readmission for infectious

diseases - PGIMER has been at the forefront of kidney transplantation across the
country since 1973. It was amongst the first few centers in the country to start renal
transplantation and it remains one of the very few centers and the only government
Centre in the country to offer kidney pancreas transplantation. Over the years, the
growth in numbers of transplants being performed has been huge. The numbers of
deceased organ donations have also increased. This has been acknowledged by the
central government and PGI has been awarded for this feat on multiple occasions.
The number of transplants is being perfomed currently is being restricted by the
availability of critical care beds. As the numbers of patients living with a functional
renal transplant continue to increase, many of them keep requiring readmission.
They occupy the same area as that for patients awaiting renal transplants thereby
delaying transplants for the waitlisted patients. Some of these patients requiring
readmission also have viral pneumonias or other contagious diseases and ideally
need to be kept in separate areas. To sustain the current level of numbers of renal
transplantation, a separate area for patients requiring readmission for infectious
diseases should be created with the utmost priority.

2. Provision of central air conditioning of operation theatre and ICU complex - Air
conditioning of operation theatre and ICU complex of the Department of renal
transplant surgery is non-functional for quite some time. The surgeries are being
done with window ACs which is against recommendations for operating on an
immunocompromised patient. Renovation of the department is due for the last many
years but has been put on hold on some excuse or another, and a sincere effort
should be done to complete at the earliest and definitely within the next five years to
provide a safe environment for an immunocompromised patient undergoing a
critical surgery. The proposal for renovation including budget has been already
approved but awaiting execution.

3. Creation of multi organ transplant Centre - On the long-term basis, PGI should be
working on creation of multi organ transplant Centre for transplant surgery which
 should include liver, small bowl, pancreas islet-cell transplant in addition to kidney
and whole organ pancreas transplant. This will also increase the annual number of
kidney transplants from 240 to 500 per year. Creation of such transplant program
would require space, additional beds, manpower and allocation of finances. The
department proposes to get this approval in the next five years. Some of the states
like Gujarat, Rajasthan have already worked with such a vision and have created
such centers. The proposal for this Centre is enclosed in Appendix I.

Academic

4. Starting fellowship program in Vascular access surgery

There has been an exponential increase in number of chronic kidney disease patients
requiring dialysis or transplant as each year more than a lakh patient with new end stage
renal disease are being added to the existing pool of patients. As only less than 10%
patients are able to get a transplant, remaining patients have to be managed on dialysis. The
department runs a comprehensive dialysis vascular access program undertaking about 1000
vascular access procedures each year which range from simple radio cephalic fistulas to
complex vascular reconstructions including use of transposed veins, native/synthetic grafts
both in upper and lower limb, endoscopic fistula procedures and salvage procedures for
haemodialysis access including thrombectomies, catheter directed thrombolysis and
angioplasties which are not being done at any centre in the whole of North India.  The use of
AV fistulas for dialysis is complicated by development of stenosis or narrowing in many
patients who then suffer difficulties in dialysis access and low flow which puts the life of such
individuals at risk. The department also has an active programme for surveillance of vascular
access by ultrasonography to identify and treat problems with AV fistulae performing about
300 angioplasty procedures every year. The department has pioneered the use of
ultrasound to guide angioplasties for dysfunctional AV fistulae. This minimizes the radiation
dose to the patient and physicians and allows repeated procedures to be done safely on the
patients. The department has also an advanced C arm unit to manage cases not amenable
to ultrasound guided angioplasty alone.

Clinical

5. Development of other solid organ transplantation like small bowel and

multivisceral transplantation

Small bowel transplantation (SBT) is a life-saving procedure for patients with intestinal failure
who develop complications related to parenteral nutrition. The annual number of SBTs is
less than that of all other types of solid organ transplantation but the outcomes after small
bowel transplant have improved significantly in recent years. Despite mild incongruities in
survival rate percentages between centres in North America, Europe, Australia, and
elsewhere, intestinal transplantations mostly approach survivorship rates of lung
transplantation. At one-year, graft survival rates for isolated intestine currently waver around
80%, and 70% for intestine-liver and multivisceral transplants respectively. The patient
survival for isolated intestine patients now exceeds 90% and the five-year survival rate for
patients and transplants ranges from 50 to 80% (overall mean 60%). Organ procurement
and transplantation network from USA have reported a total of 2379 intestinal transplants
between 1990 and 2013. Additionally, multivisceral transplant activities have increased
simultaneously in all continents.

6. Improvement in deceased donor programme (DCD/DBD)

As transplant is a better form of renal replacement therapy as compared to dialysis, there is

a need and scope of increasing deceased organ donation of human organs. The patients
whose organs cannot be replaced have to be maintained on other support system like
Dialysis therapy for kidney failure which is much more expensive and labour intensive and
results in overburdening of existing precious resources. Improved deceased donor donation
programme can give new lease of life to patients with end stage kidney disease. The
department also proposes to initiate deceased organ donation in hospitals across the region
so as to increase the number of donations from 30-40 per year to at least 100 per year.

Research
7. Establishment of dedicated Transplant immunology lab: The success of organ
transplant relies on an advanced immunology laboratory to run various matching
tests between donor and recipients. At present, this is being done under the
Department of Immunopathology but the facility falls short of the desired
infrastructure required to maintain a sustained living and deceased donor programme
(DCD/DBD). Equipments and manpower required for Transplant immunology lab are
mentioned in Appendix II

8. Clinical - The department has already developed a registry of patients who have
undergone transplant and plans to study the long-term outcomes and impact of
transplant on various health parameters these patients. The registry also includes
data of the donors who have donated their kidneys.
 9. Experimental - Animal models for development of surgical techniques including
laparoscopic transplantation and for development of newer drugs for tolerance &
immunosuppression. While the last few decades saw evolution of
immunosuppression, the present emphasis is on development of tolerance i.e.,
transplantation without lifelong immunosuppression. For this, advanced animal
laboratory is necessary where these ideas may be experimented. While this may not
be possible within the next five years, it can be aimed from the long term perspective.

10. Basic Sciences- This includes research into prolonged preservation of organs,
ischemia reperfusion injury and genetic analysis resulting in differential outcomes
after transplantation. Pharmacogenomics studies are lacking in patients from our
country and the department has already initiated these in collaboration with
Department of Pharmacology. A clinically actionable genetic variant exists in the
CYP3A5 gene, with the initial tacrolimus dose selection optimized based on CYP3A5
genotype. This should be able to be put in clinical practice within the next few years.
 PROPOSAL FOR MULTI ORGAN TRANSPLANT CENTRE
Appendix I
Unit description Unit cost Number of units Costs
approximation required
Each OT (OT Table 2 crores 6 12 crores
with
lights, anaesthesia
workstation, cautery/
harmonic unit, self-
retaining retractor,
Laparoscopy station 80 lakhs 2 1.6 crores
Instrument sets 10 lakhs 36 3.6 crores
C arm (CATH LAB) 7 crores 1 7 crores
Scrub station 5 lakhs 3 15 lakhs
Sterilization unit 50 lakhs 3 1.5 crores
Ultrasound for OT 25 lakhs 2 50 lakhs
ROBOT (Da Vinci) 20 crores 1 20 crores
TEG/SONOCLOT 5 lakhs 1 5 lakhs
Auto pulse CPR 25 Lakhs 1 25 lakhs

TOTAL
46.65CRORES
 Appendix II

Unit cost Number of units Costs

approximation required

Unit description
Pre-processing 1 crore 1 1 crore
equipment: centrifuge,
microscopes,
automated DNA/ RNA
isolators,
electrophoresis
Pathology laboratory: 50 lacs 3 1.5 crores
Microwave processing,
microscopy stations
Luminex platform 75 lacs 2 1.5 crores
Flow cytometer 1.5 crores 1 1.5 crores
HLA laboratory 1 crore 1 1 crore
RT-PCR 50 lacs 2 1 crore
LC-MS for therapeutic 1.5 crores 2 3 crores
drug monitoring
High throughput DNA 1.5 crores 1 1.5 crores
sequencer
TOTAL 12 CRORES
Unit description Unit cost Total required Costs
approximation
Beds with monitors 5 lakhs ICU: 12 2.2 crores
and furniture: HDU: 20
Cardiac table, side Isolation: 6
table, stools, IV Treatment rooms
stands, infusion and minor OTs: 6
pumps and fluid
warmer
General ward beds 2 lakhs General ward: 20 66 lakhs
Pvt room: 10
Recovery non
monitored beds: 3

Data management and computer systems

Unit description Unit cost Number of units Costs

approximation required
Computers 25,000 40 10 lacs
Storage: NAS 2 lacs 2 4 lacs
MANPOWER
Faculty
For 6 OT days and 3 OPD days and doubling of workload:
14 faculty members
10 fellows/ senior residents
8 junior residents

Faculty for essential services

Anaesthesiologists: 3
Pathologists: 2
Immunopathologists: 2
Radiologists: 2
Clinical pharmacologist:1
FACULTY

Post Annual costs Number of personnel Total costs

Professors 22 lacs 2 44 lacs
Associate Professors 16 lacs 4 64 lacs
Assistant Professor 10 lacs 8 80 lacs
Demonstrator 3 lacs 2 60 lacs
Lecturer 8 lacs 2 16 lacs
RESIDENTS

Post Annual costs Number of Total costs

personnel
Senior 18 lacs 18 3.24 crores
Residents(academic/nonacademic)
Fellow

Nursing staff
Post Annual costs Number of personnel Total costs
Staff nurse 4 lacs 170 6.8 crores

Technical staff

Post Annual costs Number of personnel Total costs

Technician 3.5 lacs 14 49 lacs

Clerical staff

Post Annual costs Number of personnel Total costs

Social worker/ Store 4 lacs 10 40 lacs
officer/ Computer
operator
Clerical 3 lacs 4 12 lacs

Other staff

Hospital attendants 1.8 lacs 32 57.6 lacs

Safaiwala 1.5 lacs 34 51 lacs
Pathology services – Creating a dedicated centre would also require upgrading of
pathology services to run a successful transplant program. Graft Rejection is a common
problem in post-transplant patients which needs early diagnosis and specific treatment for
improving graft survival. Presently around 300 biopsies are being done annually. As we are
targeting around 500 transplants in a year, number of allograft biopsies may also increase
exponentially, which requires additional renal pathologists to make this transplant program
successful.

Drug monitoring: Kidney transplantation is considered the best treatment modality for
patients with kidney failure. Transplant recipients require lifelong immunosuppression.
Nowadays, most centres use triple immunosuppression, consisting of calcineurin inhibitor
(tacrolimus or cyclosporine), an antimetabolite (mycophenolate mofetil or azathioprine), and
corticosteroids. The calcineurin inhibitors form the backbone of present-day
immunosuppressive regimens and most centres worldwide have now shifted to tacrolimus-
based immunosuppression. For better graft and patient survival, it is essential to optimize
the degree of immunosuppression, as over-immunosuppression might lead to increase
adverse effects and under-immunosuppression predisposes to rejection. To achieve this
balance and to individualize drug dosing, therapeutic drug monitoring (TDM) of various
immunosuppressive drugs is required.

Radiology services: Comprehensive diagnostic and interventional radiology services are

required to support a robust solid organ transplantation service by providing imaging
diagnosis and interventional management of vascular and nonvascular conditions both
prior to and following transplantation. Diagnostic radiology services include continuous
availability of radiography, fluoroscopy, ultrasonography (including intraoperative
ultrasonography), computed tomography, magnetic resonance imaging, and nuclear
medicine imaging. Interventional radiology services must be available continuously for
elective and urgent minimally invasive procedures for bridging patients to transplantation
or managing postoperative complications.