Authors' reply.

Sir,

Thank you for the queries raised. Please find the clarifications below:

Financial Cost of the treatment

The cost of the transplantation procedure is packaged at INR 12 lakhs at our center. This includes both the donor, the recipient operations, and postoperative care until discharge. The major items of cost include disposables, medications, drugs used, and laboratory testing of tacrolimus levels. However, this amount varies widely across the country and is by no means the standard. Indirect costs are again very variable and depend entirely on the family's preferences and lifestyles. In the first year post transplant, the immunosuppression is higher and the tacrolimus testing frequent. The expense for the medications and tests range from INR 12000-15,000 per month in the first year. Subsequently, the costs come down and by the third year post transplant, it works out to about INR 4000 per month. Fortunately, as transplantation becomes more mainstream, the costs — both of the medication and the testing, have been steadily falling.

Survival by etiology

This data needs to be qualified by the following facts:

Children with biliary atresia are often in poor health. A combination of poor nutritional status, previous abdominal surgery, cholangitis, portal hypertension, and often spontaneous bacterial peritonitis puts these children in a very high-risk category. In this series, most of the deaths happened early in the series; most early cases performed were biliary atresia children, who had had a Kasai procedure by the same team earlier. This is reflected in the fairly high mortality in this group. Of the cases operated later in the series, survivals for biliary atresia have been on par with other indications.

There has been only one child in each of the last four4 groups. Although the only child with fulminant hepatic failure in this series survived, he has residual neurological sequelae. The published literature suggests a survival rate of >70% for acute liver transplantation in fulminant hepatic failure as compared to >90% for other indications.[1]

Indian Experience of Liver Transplantation

Unfortunately the published Indian experience is scanty and mostly restricted to case reports and short communications.[23] In the major centers, about 10% of the patients undergoing liver transplantation are children. The number of small children (<10 kg) undergoing transplants are even less (personal communication).