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Though liver transplant has been a well-established treatment for liver diseases in developed countries for several decades, developing countries have lagged behind in this field. However, in the last decade, there has been major progress in the field of liver transplantation in India. In particular, living-related liver transplant (LRLT) has flourished over the last five years [1]. Among developing countries, India currently performs the largest number of LRLTs and drains patients from some surrounding countries as well. In the Western world, the government bears the expenditure on transplant programs. In some countries, insurance companies have recognized that it is more economical to fund liver transplantation than to pay for the management of end-stage liver disease, and now cover for this procedure. India spends much less on healthcare than the West. Communicable diseases such as tuberculosis and malaria take precedence, and few government hospitals would spare the budget to set up an LDLT program. The vast majority of liver transplants are thus performed in the private sector [1]. A certain section of the population is able to struggle and gather the money required for liver transplant. However, the expenditure does not end with surgery; rather, a successful procedure entails lifelong immunosuppression, a costly undertaking. Expectedly, the patients and their families are keen to know the magnitude of this expenditure in advance, and whether this cost burden can be somehow reduced. Fortunately for these patients, India is blessed with a strong pharmaceutical industry that manufactures generic drugs [2]. These companies sell drugs such as tacrolimus and mycophenolate mofetil (MMF) at a fraction of the price in the developed world. A paper by Sudhindran et al. [3] from Cochin in this issue of the Journal provides valuable information on the cost of immunosuppression over the first one-year period after LDLT in Indian patients. The most interesting revelation of this study perhaps was that the cost of calcineurin inhibitor (CNI) therapy in India is extremely low. Using a generic preparation, the cost of this treatment was in the range of Indian Rupees (INR) 3,000 to INR 5,000 per month (1 USD0approximately INR 50). Interestingly, the largest component of the cost of CNI therapy was the expenditure on monitoring of drug levels. Using Abbott IMx kits, which are based on microparticle enzyme immunoassay technology, each measurement of tacrolimus drug level in their institution cost INR 3,900 which was roughly similar to the cost of onemonth supply of the CNI drug. The authors therefore suggest that it may be useful to find ways of tailoring downwards the need for monitoring of these levels in an attempt to reduce the cost of immunosuppressive treatment. However, the cost of drug monitoring that the authors have mentioned appears a bit high, since in many transplant centers in India such drug assay costs between INR 2,100 and INR 3,000 (personal communication). It must be noted that, as a protocol, the authors of this current paper accepted a lower level of CNI during the first few months after LRLT. This is similar to the practice in other transplant centers. It has been observed that CNI drug levels needed to prevent rejection are lower in the LRLT setting than following deceased donor liver transplantation (DDLT) [4]. Further, the authors of the current paper were fairly liberal in the use of antimetabolites such as MMF in support. The authors note that the blood levels produced by the generic CNI preparations used in the study were predictable S. Saigal Medanta, The Medicity, Sector 38, Gurgaon, Haryana 122 001, India

Liver transplantation—Economics in the less developed world