1. Perfusion fluids Cost and Economics Dr.R.V.Raghavendra Rao M.S,M.Ch(SGPGI),FHPB,FLT(SNUH) Consultant Surgical Gastroenterologist and Liver Transplantation Surgeon Hyderabad Mob:9866458511 Email: drrvrrao@gmail.com

2. Perfusion fluids Cost and Economics The issue which has swept down the centuries and which will have to be fought sooner or later is the people versus the banks -Lord Acton

3. Perfusion fluids Cost and Economics perfusion /per·fu·sion/ (-zhun) The act of pouring over or through, especially the passage of a fluid through the vessels of a specific organ. Dorland's Medical Dictionary for Health Consumers per·fu·sion (p r-fy zh n) The injection of fluid into a blood vessel in order to reach an organ or tissues, usually to supply nutrients and oxygen The American Heritage® Medical Dictionary

4. Perfusion fluids Cost and Economics

5. Commonly used fluids  University of Wisconsin (UW) solution  HTK Solution  Renograph / Marshal  Celsior - mainly cardiac  Perfadex – mainly pulmonary

6. Perfusion fluids Cost and Economics Cost factors  Varies from INR 3500 to 26000/- per litre  Depends on -Type of Fluid -Import regulations -Quantity (1lit vs 5 lit bags) -Availability

7. Perfusion fluids Cost and Economics Factors to be considered in cost analysis  Logical efficiency  Immediate graft function  Delayed Graft function  Spectrum of usage

8. Perfusion fluids Cost and Economics Cost comparision between two commonly used solutions (UW vs HTK) University of Pittsburg research report 2003 Alonso D, etal. Am J Transplant. 2008;8:1942-1945 StewartZA, et al. Am J Transplant. 2009;9:217-221 Robert J Stratta 2009 -UW 0n average USD 137.6 costlier than HTK/ Pt

9. Perfusion fluids Cost and Economics A typical case (Involving Kidney and Liver)  Aorta perfusion - Marshal - 10000/- (3lit)  Portal perfusion - UW solution - 52000/- HTK - 48000/- (1lit+1lit) (6lit)  Cold preservation-UW solution - 26000/- -8000/- (1lit)

10. Perfusion fluids Cost and Economics Considerations for selection of perfusant to reduce costs  Single organ or multiorgan harvesting  DDLT vs LDLT  Brain Dead Vs NHBD  Standard or Extended criteria donors  Expected cold ishaemia time  Availability of solution

11. Perfusion fluids Cost and Economics Factors which increase the cost of a preservative solution  Maintance of cold chain  Need for additional products before usage  Wastage during solution packaging

12. Perfusion fluids Cost and Economics Recent Developments  Machine perfusion Costs on average USD 3000 more Moers, c. et al N. Engl. J. Med. 360, 7-29 (2009) Buchanan, P. M. et al. Am. J. Transplant. 8, 2391-2401 (2008). Gerrfield ss, et al. Tranplant proc.2009 Nov;41(9) : 3531-6

13. Perfusion fluids Cost and Economics Reducing the costs S selection of Donor E L Low volume flush (?) E Efficiency C Coordination between teams T Transportation

14. You don't make the poor richer by making the rich poorer - Sir Winston Churchill