Fall 2022 Newsletter

In the Transplant News: Flora Simmons, MD   Policy Changes Improve Access For the Highest Acuity Patients The data reports on the first two years of the new liver and intestinal allocation policy based on acuity circles. The policy was designed to increase equity consistency in transplant access for the most urgent candidates. Key improvements include significantly increased liver transplants for candidates with MELD scores of 29 or higher as well as those in Status 1A or 1B. Notably, the geographic variability in medical urgency scores at transplant has decreased at the levels of donation service area, state, and region.    UNOS Organ Tracking Service Is Now Underway 26% of all organ procurement organizations (OPOs) are now utilizing the UNOS organ tracking service to monitor organs in transit. The UNOS Organ Tracking Service is used to track organs from packaging to final delivery to the recipient team. The device pings every two minutes to provide real time updates.   U.S. Leads The World In Transplants With Its 1 Million Transplant Milestone The U.S. has reached a historic 1 million organ transplantations. This milestone was made possible due to the expansion of more equitable organ allocation policies, expanding the donor pool, and advancements of organ preservation techniques.    OPTN: The Latest Data On Organ Donation And Transplants In The U.S. Find comprehensive reports and metrics at the regional and national level. Learn how the OPTN ensures equity for waitlisted patients.

Research Updates and Interesting Articles

Special Topics Alex Stoker, MD Intrapulmonary shunting and paradoxical air embolism during liver transplantation Patients with end-stage liver disease often have evidence of intrapulmonary shunting (IPS) due to pulmonary vascular dilation with a prevalence estimated to be between 13 and 47%. IPS may be detected preoperatively with transthoracic echocardiography as air bubbles appearing in the left atrium 5 to 6 cardiac cycles after first appearing in the right atrium. Despite the frequency of intrapulmonary shunting in patients presenting for liver transplantation, cases of severe paradoxical air embolism (PAE) causing hemodynamic collapse are rarely reported in the literature ( Badenoch 2017, Smart 2021). With the increasing use of TEE during liver transplantation, there is opportunity to diagnose PAE by visualizing air passing to the left atrium from the pulmonary veins (see figure below). A PAE has the potential to travel to the coronary arteries or cerebral circulation and should be considered as a possible cause of organ dysfunction or hemodynamic perturbations during liver transplantation.

Mid esophageal view of the left atrium and left ventricle with air bubbles seen emerging from the left upper pulmonary vein.  LA, left atrium; LV, left ventricle; LUPV, left upper pulmonary vein.

In the Spotlight: Saint Louis University Medical Center Transplant Program

For this quarter’s segment, we connected with Dr. Govind Rangrass, MD, Director of Transplant Anesthesia and Director of Quality/Patient Safety at the new 400-bed SSM Health/Saint Louis University Hospital (SLUH).

Saint Louis University has a long history with abdominal transplant, at one time being one of the busiest transplant centers in the country. In recent years, their volumes have hovered between 30-40 liver transplants/year. SLUH recently merged with the SSM Health, a large hospital network, and as its only transplant center, the program is gearing up for an increase in transplant evaluations and referrals and is carefully navigating the listing process for high-risk patients.  

As part of the selection process, the transplant anesthesia director sits on the Liver Recipient Selection Committee. A unique aspect of their program is that they have a separate High Risk Cardiac Evaluation Meeting, which meets weekly to discuss candidates with complex cardiac disease who may benefit from additional pre transplant work-up optimization and ensure postoperative continuity of care with the cardiology team. One of their transplant faculty was the corresponding author of the newly released AHA Scientific Statement on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates published in Circulation. Between 2019-2021, patients undergoing liver transplantation at SSM Health/SLUH had 100% survival at one month and 94% survival at one year post transplant.

Their program is one of the few that uses alternative portal flow in transplant for patients with portal vein thrombosis using reno-portal (connecting left renal vein of recipient to donor portal vein to act as inflow) and gastro-portal (using left gastric vein as inflow) anastomoses. Another unique aspect of the program is the disproportionately high number of hepatitis C positive donor livers utilized (~20%). Their program is gaining more experience with the Transmedic normothermic perfusion pumps, which it intends to continue using in the future.

TEG 6S is routinely used and available and housed in the hospital coagulation lab, with a real time tracing available in the operating room. Venovenous bypass is used selectively for redo liver transplants, patients with portopulmonary hypertension with RV dysfunction or hepatopulmonary syndrome, and high MELD patients on preoperative CRRT. Heparin (50U/kg) is administered for hypercoagulable patients prior to caval cross-clamping, and antifibrinolytics are administered as a bolus during the anhepatic stage. Octreotide infusions (50mcg bolus followed by 100mcg/hr) are routinely run for patients with significant portal hypertension. 

The SSM Health/SLUH transplant program hosts a robust outcomes research center and has multiple grant-funded research projects. Examples include a study on biomarkers of kidney function to predict perioperative acute kidney injury; a normothermic perfusion basic science lab studying pharmacologic tools to reduce ischemia reperfusion injury in discarded human livers placed on perfusion pumps; and a $1.8 million grant in conjunction with Missouri University of Science and Technology to develop artificial intelligence driven decision-making tools for organ allocation. 

Announcements

The Accessibility and Inclusion Committee

The SATA Council is pleased to announce the introduction of The Accessibility and Inclusion Committee.  The Committee will help develop SATA policies by providing the Council with their views on how to ensure members have equal access to all service opportunities within the organization,  All SATA members are invited to nominate themselves or a colleague to serve on this new important committee as part of the society leadership.  Please send your nominations to the SATA Secretary: Lorenzo De Marchi at demarchilorenzo@yahoo.com 

Service: Appointment by SATA Council

Term:  2 years; can be renewed

Requirements:  SATA Membership in good standing

Purpose: Oversight and Advocacy Committee

Seed Grant Funding Mechanism

The SATA Seed Grant is a one-year $5,000 transplant project starter grant, open to junior faculty members and trainee physician members of the Society. The grant aims to inspire and assist aspiring faculty/trainee physicians who have yet to receive any previous funding to start a transplant-related project. The grant requires the recipient to submit a support letter from the mentoring faculty and the Department Chairperson.  

Application/Grant Cycle:

• November 1, 2022 – Announcement of the grant 

• December 1, 2022 – Opening of the submission site  

• February 28, 2023 – Closure of submission site 

• April 1, 2023 – Announcement of the awardee and send letters of feedback to the other applicants  

• April 17, 2023 – Grant presentation at SATA National Meeting in Denver, CO 

• July 1, 2023 – Grant initiation 

• December 31, 2023 – submission of the mid-term report 

• June 30, 2023 – submission of the final report 

Click here to review the SATA Seed Grant Grading

Click here to review the SATA Seed Grant Proposal

Transplant Anesthesia Upcoming Meetings

SATA Meetings

Southeastern SATA Regional Meeting: November 5, 2022 

SATA West Meeting: December 10, 2022, San Francisco – in person and hybrid. 

Submit an Abstract by email to: Dieter.Adelmann@ucsf.edu

Mid-Western SATA Regional Meeting: January 21, 2023

Other Meetings: 

The Liver Meeting – aasld.org, November 4-8, 2022, Washington, DC

The 2023 International Congress of ILTS, ELITA and LICAGE

May 3-6, 2023; Rotterdam, Netherlands

American Transplant Congress (ATC) 2023 Annual Meeting

June 3-7, 2023, San Diego, CA