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Winter 2023 SATA Newsletter

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UNOS News

By Flora Simmons, MD

UNOS Launches National Liver Pairing Program

In an effort to increase access to living donations, UNOS has initiated a national pairing program for swapping livers.  While some transplant centers have swapped livers within their own hospitals, this program now allows swapping across the nation.  

Waiting Time Adjustment Approved For Kidney Transplant Candidates Affected By Race-based Calculation

After discontinuing race-based calculations for estimated glomerular filtration rate (eGFR), the new policy will now allow African-American kidney transplant candidates to receive waiting time modifications that will increase their waiting times and associated prioritization for transplant. 

National Collaboration To Increase DCD Lung Transplantation Underway

UNOS recently launched a national initiative to identify and share effective practices that can increase transplantation of DCD lungs. Twenty-nine lung transplant programs are participating in this project. 

 

Research Updates and Interesting Articles

By Michael Trostler, MD

  • Validation of the Liver Transplant Risk Score in Europe

LTRS is a useful predictor of Mortality that has been validated in the United States, but not in Europe.  Based on the data the European registry collects, the score has been modified to exclude Diabetes.  Age, BMI, MELD score, and Dialysis status were used with linear correlation for 90-day and 1-year mortality for each point.  Included 2nd article external validation of LTRS in US (2020).

Validation of the Liver Transplant Risk Score in Europe.pdf

Preoperative Stratification of Liver Transplant Recipients- Validation of LTRS.pdf

  • Anesthesia Management of a Liver Transplant Recipient with Remimazolam

Case report of a 54 year old Female who had a prolonged living donor liver transplant (1037 min) and massive blood loss (22.5L) who was successfully managed with Remimazolam without recall or adverse events with EEG monitoring.

Anesthesia Management of a Liver Transplant Recipient with Remimazolam.pdf

  • Survival Benefit of Living-Donor Liver Transplant

Large epidemiological study on 119,275 Liver transplant patients, with 2,820 living donor transplants which found a 13-17 year life gain for those who received a liver donor transplant for MELD>11, compared to those who stayed on the waiting list.  This article generated significant interest with several comments/letters and the original authors reply which are well worth your time to read.

Survival Benefit of Living Donor Liver Transplant.pdf

Reply to Survival Benefit of Living Donor Liver Transplant 1.pdf

Reply to Survival Benefit of Living Donor Liver Transplant 2.pdf

Reply to Survival Benefit of Living Donor Liver Transplant 3.pdf.

  • Mortality scoring systems for liver transplant recipients: before and after model for end-stage liver disease score

An updated review article of end stage liver disease scoring systems and their inherent weaknesses.  The future may be artificial intelligence, but its predictive algorithms can be individualized and may not be applicable to the wider population outside of each study cohort.

Mortality scoring systems for liver transplant recipients- before and after model for end stage liver disease score.pdf

  • Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant

A concerted push via QA/QI project achieves safety and success for immediate extubation of liver transplant recipients in both low risk and high risk patients.  There was no change in mortality and only four(1.26%) patients were reintubated within 24 hours (Total 317 patients).  Quality initiative pushes immediate extubations from 13.4% to 86.7% over a five year period. 

Comprehensive Quality initiative leads to immediate postoperative extubation following liver transplant.pdf

 

Special Topics

By Alex Stoker, MD

IVC stenosis during liver transplant detected with TEE

Acute inferior vena cava (IVC) stenosis after liver transplantation is a rare but significant complication that can result in liver allograft congestion and dysfunction as well as hemodynamic instability. Transesophageal echocardiography (TEE) may be used to diagnose IVC stenosis, which may reveal a high velocity or turbulent jet entering the right atrium from the IVC as detected with color flow Doppler (CFD) (see figure below). By interrogating the IVC, it may be possible to visualize the area of narrowing within the IVC, with CFD revealing flow acceleration and turbulent flow originating at the level of stenosis. Obstruction may occur in the suprahepatic IVC, infrahepatic IVC or hepatic veins and can be due to surgical complication or due to thrombosis. There is increasing use of TEE to evaluate hepatic and IVC vasculature during liver transplantation (Khurmi et al, 2019). Reference

Midesophageal bicaval view with color compare showing the image both with and without color flow Doppler. A turbulent and high velocity jet is seen entering the right atrium from the IVC due to IVC stenosis. LA, left atrium; RA, right atrium; IVC, inferior vena cava; SVC, superior vena cava.

2022 UNOS Organ Transplant Summary

By Alexandra Ruan, MD

https://unos.org/news/2022-organ-transplants-again-set-annual-records/

 

  • More than 42,800 organ transplants performed in 2022, a 3.7% increase from 2021
  • Total kidney transplants exceeded 25,000 for the first year ever
  • Annual records also set for liver (9,528), heart (4,111) and lung (2,692) transplants
  • Over 6,400 living donor transplants
  • Deceased donation increased for 12th consecutive year
  • The U.S. has now performed over 1 million transplants

 

In the Spotlight:  Virginia Commonwealth University (VCU) Health System – Hume/Lee Transplant Center

By David Rosenfeld, MD, FASA

 

For this winter’s section we reached out to Spencer Liebman, MD, who is Chief, Division of Transplant Anesthesiology at VCU. Formerly known as Medical College of Virginia, VCU is an 820 bed health system and one of the nation’s first transplant programs.  This historic program is named for David M. Hume, MD and Hyung Mo Lee, MD, and is where one of the earliest identical twin kidney transplants was performed in 1957, with the overall program starting in 1962.  Soon after livers began in 1964, with the world’s 16th heart transplant in 1968.  The scope of organs includes livers, kidneys, pancreas, and hearts, with experience in combined heart-liver transplant.  A total of 502 organs were transplanted in 2022. 

VCU offers 112 ICU beds, 16 of which are cardiac, and a dedicated transplant ICU growing to 10 beds under the direction of Megan Rashid, MD.  The liver practice is large with 168 total adult organs, 21 of which were from living donors.  Staffing is in a team care model with five dedicated attendings, six specially trained CRNAs, and residents rotating in their CA2/CA3 years.  TEG is universal, and TEE is utilized for greater than 80% of cases.  As is becoming more common, intraoperative hemodialysis (not CRRT) was used in 40% of cases in 2022.  They offer a unique Active Severe Alcoholic Hepatitis Transplant Program with support services and strategies in place.  VCU has a non-ACGME liver fellowship with a hybrid model of combined fellow and faculty time and two positions per year.  In 2016 the Total Pancreatectomy with Islet Cell Autotransplant (TPIAT) program was started with the addition of Transplant Surgeon Marlon Levy, MD to the faculty.  A total of 18 TPIATs were performed in 2022 for chronic pancreatitis, and they are one of the few centers offering this experimental therapy.  Their cardiac program is the longest running on the east coast and the second oldest in the US.  Over 680 heart transplants have been performed, and they offer an ACGME accredited Adult Cardiothoracic Anesthesiology fellowship with two fellows per year.  There are no lung transplants being performed at present.

Many thanks to Dr. Liebman for sharing details of the transplantation program at VCU.  If interested in having your program highlighted in the future, please contact David Rosenfeld, Mayo Clinic Arizona at Rosenfeld.david@mayo.edu

*The original newsletter identified VCU as performing the first identical twin kidney transplant in 1957.  This was in error, the first kidney transplant was performed in an identical twin by Dr Joseph E.Murray in Boston in 1954.  Correction made above.   

Report from the Executive Council

By Susan Mandell, MD

We look forward to seeing SATA members at the in person SATA National Meeting, held at the IARS on April 17th, 2023, in Denver Colorado.  Please remember to renew your membership for free entry to the meeting.  SATA is pleased to announce it will hold the first combined meeting with the International Liver Transplant Society-SATA meeting  just prior to the ASA in San Francisco. This has been a very popular meeting and well attended. 

The Council is pleased to announce that there are now seven regional SATA meetings.  Please check for the meeting closest to you.  Service on the SATA Accessibility and Diversity Committee is now open to all members.  The Vanguard committee has been revitalized and membership is open to all faculty who are within 5 years of residency completion or are younger than 42, please reach out to the SATA Office for more information.   

Announcements

We are pleased to announce that SATA will be represented at the 10th Annual Korean Society of Transplant Anesthesiologists (KSTA) meeting in Seoul, Korea. During the Joint KSTA-SATA session (March 18, 2023 11:20-12:50 KST), moderated by Dr. Tetsuro Sakai and Justin Sangwook Ko, Dr. Satish Kumar will present on emerging evidence for coronary artery disease screening in liver transplant candidates and Dr. Ramona Nicolau-Raducu will present on post-reperfusion hyperfibrinolysis.  

SATA is delighted to endorse the first International Symposium for Abdominal Organ Transplant (ISAOT) in Santiago, Chile, June 8-9, 2023. 

This opportunity is presented by Dr. Klaus Torp at Mayo Clinic-Jacksonville (Founding member of SATA) who has supported the physician exchange program with the Clinica Alemanha in Santiago de Chile. Dr. Lucile Gignon (Faculty Anesthesiologist at the Clinica Alemanha in Santiago de Chile) is the local organizer of the meeting.

Attention liver transplant anesthesiologists and program directors!  SATA is offering free 6 month membership to fellows!  Please sign up by emailing sata@pacainc.com. We look forward to welcoming new fellow members!

Join the Vanguard Committee ***

Transplant Anesthesia Upcoming Meetings

 

SATA Meetings

 

SATA Tristate Regional Meeting – in person and virtual

March 25th, 2023, New York, NY

 

SATA Annual Meeting, 

April 17th, 2023, Denver, CO

 

Other Meetings: 

The 10th annual scientific meeting of the Korean Society of Transplantation Anesthesiologists (KSTA), March 18th, Seoul, Korea – in person and hybrid

Joint KSTA-SATA Session: 11:20 – 12:50 KST

 

IARS/AUA/SOCCA Annual Meeting – in person and hybrid

April 13-16th, 2023, Denver, CO

 

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

 

International Symposium for Abdominal Organ Transplant (ISAOT)

June 8-9, 2023, Santiago, Chile

 

Tristate Regional Transplant Anesthesiology Conference 2023

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Learning objectives – On completion of this activity the participants will be able to

  1. Learn about the concept of frailty and its importance in evaluation/management and outcomes for abdominal transplant recipients
  2. Discuss indications and practical considerations for use of veno-venous bypass in liver transplantation and advanced hepatobiliary surgery
  3. Review strategies for prevention and treatment of acute kidney injury in liver transplantation
  4. Learn about strategies to improve graft quality in donation after circulatory determination of death in organ transplantation, including machine perfusion
  5. Review ethical and practical considerations in organ donation after circulatory determination of death
  6. Discuss administrative considerations in managing a transplant anesthesiology service line and fellowship

Target audience

Transplant anesthesiologists, intensivists, transplant surgeons, residents, and fellows.

Time and Location:

SATURDAY, MARCH 25TH, 2023: 9 AM – 2 PM, WEILL CORNELL MEDICINE

1300 YORK AVENUE, NEW YORK, NY 10065 WEILL AUDITORIUM (C-200)

 

Virtual Venue:

https://weillcornell.zoom.us/j/97750761082?from=addon

Meeting ID: 977 5076 1082

 

Schedule:

9:00 – 9:30: Breakfast and Welcome: Christine Lennon M.D., Weill Cornell Medicine

9:30 – 10:30: Perioperative considerations

Frailty in abdominal transplant – Joseph Scarpa, M.D. and Rohan Panchamia M.D., Weill Cornell Medicine

Veno-venous bypass in liver transplantation – Juan Rocca M.D., Weill Cornell Medicine

ICU Management: postoperative acute kidney injury in liver transplantation – Christopher Tam M.D., Montefiore Medical Center

10:30 – 10:45: Break

10:45 – 11:30: Donor considerations

DCD donation and NRP – Zeeshan Akhtar M.D., The Mount Sinai Hospital

DCD practical and ethical considerations –  Christine Lennon M.D., Weill Cornell Medicine

11:30 – 12:15: Lunch

12:15 – 1:15: Administrative considerations

Anesthesiologist as the perioperative physician: the transplant anesthesiology model –  Nikhil Chawla M.D., Yale New Haven Hospital

Transplant anesthesiology service considerations – Joseph Yeh M.D., NYU Langone Health

Transplant anesthesiology fellowship considerations – Natalie Smith M.D., The Mount Sinai Hospital

1:15 – 1:45: Keynote address: Tetsuro Sakai M.D., University of Pittsburgh Medical Center

1:45 – 2:00 Closing Remarks: Gebhard Wagener M.D., Columbia University Irving Medical Center

Registration Fees and Link:
Complimentary Registration if no CME credits are required
$30.00 for SATA and SCA Members – CME Credits Needed
$60.00 for Non-SATA and SCA Members – CME Credits Needed
 
https://sata2022.wufoo.com/forms/zid5tgc0d8hdb3/ 
 

Organizing committee members (alphabetical):

  • Ranjit Deshpande, MD, FCCM (Yale New Haven Hospital, New Haven, CT)
  • Christine Lennon, MD (Weill Cornell Medicine, New York, NY)
  • Marina Moguilevitch, MD (Montefiore Medical Center, Bronx, NY)
  • Natalie Smith, MD (The Mount Sinai Hospital, New York, NY)
  • Gebhard Wagener, MD (Columbia University Irving Medical Center, New York, NY)
  • Joseph Yeh, (NYU Langone Health, New York, NY)

 

Directions to Weill Auditorium (C-200)

Enter the medical school at 1300 York Avenue.

After you go through security, proceed to the second floor via the stairs or elevator.

As you exit the staircase, make a left and walk down the hall. C-200 will be on the right.

2023 DMV Regional SATA Meeting

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Program overview:

This SATA regional meeting will provide discussion of novel areas of interest in liver, heart, and lung
transplantation.

Learning objectives:

At the end of this session participants will be able to:
1. Determine the potential benefits and challenges of ECMO in liver, heart and lung transplantation
2. Understand risk and benefit of postponing abdominal closure after liver transplantation
3. Learn the different antimicrobial strategies adopted in abdominal and cardio-thoracic transplant
patients to protect them from infection in the perioperative period
4. Understand the potential complication of vascular cannulation for V-V bypass
5. Understand the challenges of managing blood products reserve for a patient with antibody
6. Determine the best approach to liver transplant for a patient with Severe AS

Target audience:

Anesthesiologists, Intensivists, Surgeons, Hepatologists, Cardiologists, Fellows,
Resident, Medical Students, Nurse anesthetists, Advanced Practice Nurses, Anesthesiologist Assistants,
Physician Assistants, and Nursing staff who are involved in the perioperative care of transplant patients.

Core Faculty

Lorenzo De Marchi, MD, FASE (Chair)
Professor of Clinical Anesthesia
MedStar-Georgetown University Hospital
Aliaksei Pustavoitau, MD, MHS, FCCM
Associate Professor of Anesthesiology and Critical Care Medicine
Johns Hopkins University
Katie Forkin, MD
Associate Professor of Anesthesiology
Division Chief, Liver Transplant Anesthesia
University of Virginia Health
Sergio Navarrete, DO
Assistant Professor
Virginia Commonwealth University

Additional Faculty listing:

Promise Ariyo, MD MPH
Assistant Professor
Divisions of Cardiac Anesthesia & Critical Care
Department of Anesthesiology & Critical Care Medicine
Johns Hopkins University

Zachary Janik, MD
Anesthesia Resident
Johns Hopkins University School of Medicine

Olivia S. Kates, MD
Assistant Professor of Medicine
Johns Hopkins University

Shane Ottman, MD
Assistant Professor of Surgery
Johns Hopkins University

Pedjman Radkani, MD
Assistant Professor of Surgery
MedStar-Georgetown University Hospital

Gregory Serrao, MD, MSE, FACC, FSCAI
Director, Mechanical Circulatory Support
Cardiac Catheterization Laboratory
Icahn School of Medicine at Mount Sinai

Benjamin Wilson, MD
Anesthesia Resident
MedStar-Georgetown University Hospital

Hamy Kassahun, MD
Anesthesia Resident
University of Virginia Health

 

SATA-DMV 2023 10:25 am – 3:30 pm

10:25 am – 10:30 am Welcome and Introduction – Lorenzo De Marchi, MD (MGUH)

10:30 am -11:20 am ECMO in Transplant – Moderator: Aliaksei Pustavoitau, MD (JHH)

10:30 am – 10:50 am ECMO in liver transplant – Gregory Serrao, MD (Mount Sinai)

10:50 am – 11:10 am ECMO in CT transplant – Promise Ariyo, MD (JHH)

11:10 am – 11:20 am Q&A

11:20 am – 11:30 am Presidential address

11:30 am – 11:35 am Break

11:35 am – 12:30 pm Management of open abdomen in Liver Transplant (Pro/ Con) – Moderator: Sergio Navarrete, DO (VCU)

11:35 am – 11:55 am Con – Pejman Radkani, MD (MGUH)

11:55 am – 12:15 pm Pro – Shane Ottmann, MD (JHH)

12:15 am – 12:35 pm The CCM Perspective – Aliaksei Pustavoitau (JHH)

12:35 pm – 12:50 pm Q&A

12:50 pm – 1:30 pm Lunch break

1:30 pm – 2:20 pm Third Session – Moderator: Lorenzo De Marchi, MD (MGUH)

1:50 pm – 2:10 pm Perioperative Antimicrobial Therapy in Abdominal Transplant – Olivia Kates, MD (JHH)

2:10 pm – 2:20 pm Q&A

 

2:20 pm – 2:30 pm Break

2:30 pm – 3:25 pm Challenging Cases – Moderator: Katherine Forkin, MD (UVA)

2:30 pm – 2:45 pm LDLT in a patient with Severe AS – Hamy Kassahun , MD (UVA)

2:45 pm – 3:00 pm Blood management for patients with antibodies-Zachary Janik,MD (JHH)

3:00 pm – 3:15 pm Complication V-V bypass cannulation – Ben Wilson, MD (MGUH)

3:15 pm – 3:25pm Q&A

 

3:25 pm – 3:30 pm Closing Remarks

The 2023 Symposium of the Society for the Advancement of Transplant Anesthesia

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In conjunction with the annual meeting of the International Anesthesia Research Society (IARS)

Note: SATA Council meeting on April 16

 

Monday April 17, 2023 (8 AM – 3:00 PM)

Location: Mineral A-C room on Level 3, Hyatt Regency Denver at Colorado Convention Center, 650 15th Street, Denver, CO 80202

 

Registration (with CME credit):

 https://sata2022.wufoo.com/forms/z1e9i2pz1p5x4o8/    or       https://tinyurl.com/mr2rn9ks

$50 for SATA, SOCCA and SCA members, $150 for non-members, free for trainees

 

7:30 am – 8:00 am Registration

 

8:00 am – 8:15 am Welcome and Introduction

  • Gebhard Wagener, President-elect – Columbia University, New York, NY

 

8:15 am – 9:15 am: Session 1: The Yin and Yang of coagulation (60 min)

Moderator: Alexandra Ruan – Stanford University, Stanford, CA

  • New models and new drugs in coagulation (20-25 min)
    • Art Bracey – Baylor College of Medicine
  • Anticoagulants and surgery: Stop, continue, reverse?
    • Abdominal transplant (10 min)
      • Manoj Iyer – The Ohio State University Wexner Medical Center
    • Thoracic transplant (SCA) (10 min)
      •  Kenichi Tanaka – The University of Oklahoma College of Medicine

 

9:15 am – 9:45 am: Coagulation debate (30 min)

  • Are ROTEM and Cryoprecipitate dangerous for liver transplants? (10 min)
    • Christine Nguyen-Buckley – University of California Los Angeles
  • Are PCC and Vit K dangerous for heart transplants? (10 min)
    • Jiapeng Huang – University of Louisville, Kentucky

 

9:45 am – 10:30 am: Session 2: Pain and analgesia for transplant surgeries (45 min)

  • Regional techniques for thoracic transplants and VADs (10 min)
    • Anis Dizdarevic – Columbia University, New York, NY
  • Indications and challenges to early extubation in the operating room (10 min)
    • Courtney Scott – Mayo Clinic Jacksonville, FL
  • Analgesia for living liver donors (KSA) (15 min)
    • Justin Ko – Sungkyunkwan University School of Medicine, Samsung Medical Center; Director of Scientific Affairs, Korean Society of Anesthesiologists – Seoul, Korea

 

10:30 am – 11:00 am: Break

 

11:00 am – 11:20 am State of the Society

  • Ted Sakai, President of SATA – University of Pittsburgh Medical Center, PA
    • (Introduction: Susan Mandell – McGovern Medical Center, Houston TX

 

11:20 am – 12:00 pm Case presentations

Moderator: Adrian Hendrickse – University of Colorado Denver, CO

  • Thoracic Transplant
    • Michelle Chen- Columbia University, New York, NY
    • Mentor: Andrea Miltiades – Columbia University, New York, NY
  • Abdominal transplant
    • Zach Fleissner – Mayo Clinic Jacksonville, FL
    • Mentor: Ryan Chadha – Mayo Clinic Jacksonville, FL

 

12:00 pm – 1:00 pm Session: What’s new in organ donation and allocation (60 min)

  • How is transplantation organized: past and future of UNOS and organ transplantation in the US (15-20 min)
    • Jennifer Prinz – CEO of Donor Alliance and Vice Chair of the OPTN Policy Committee
  • The impact of the new regulation of organ allocation on transplant practices (15-20 min)
    • Jim Pompeselli – University of Colorado Denver, CO
  • Deceased donor management and machine perfusion modalities (15 min)
    • Emily Vail – University of Pennsylvania, Philadelphia, PA

 

1:00 pm – 1:30 pm Break

 

1:30 pm – 2:30 Session: How and why do we maintain blood pressure and perfusion (45 min)

Moderator: Ana Fernandez-Bustamante – University of Colorado Denver, CO

  • Just a bystander organ? How do we protect the kidney? (15 min)
    • HT Lee – Columbia University, New York, NY
  • New kids on the block
    • Angiotensin (10 min)
      • Michael Bokoch – University of California San Francisco, CA
    • Terlipressin (in collaboration with the Society of Critical Care Anesthesiologist, SOCCA) (10 min)
      • Sathish Kumar, University of Michigan, Ann Arbor, MI

 

2:30 pm – 2:45 pm First SATA Research Award

  • SATA Research Committee
    • She- Lu Pai – Mayo Clinic Jacksonville, FL
    • Dieter Adelmann – University of California San Francisco, CA

 

2:45 pm – 3:00 pm Closing Remarks

  • Lorenzo De Marchi, SATA Secretary – MedStar Georgetown University Hospital

 

December 2022 Article of the Month

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Alcohol-associated liver disease predicts increased post-liver transplant opioid use.

Abstract:

BACKGROUND: Alcohol-associated liver disease (ALD) is a rising indication for liver transplantation (LT). Prolonged opioid use after LT leads to increased graft loss and mortality. The aim is to determine if patients transplanted with a primary diagnosis of ALD had higher risk of post-LT opioid use (p-LTOU) compared to non-ALD patients.

METHODS: This is a retrospective study of patients who underwent LT between 2015 and 2018 at Medstar Georgetown Transplant Institute. Patients with prolonged hospitalization post-LT (>90 days), death within 90 days post-LT, and re-transplants were excluded.

RESULTS: Two hundred and ninety-seven patients were transplanted, among 29% for indications of ALD. ALD patients were younger (52 vs. 56 years), more likely to be male (76% vs. 61%), Caucasian (71% vs. 44%), have higher MELD (28.8+/-8.8 vs. 25+/-8.8), and psychiatric disease than non-ALD patients (P < .05). There was no difference in pre-LT use of opioids, tobacco, marijuana, or illicit drugs between ALD and non-ALD patients. Pre-LT opioid use (OR = 11.7, P < .001), ALD (OR = 2.5, P = .01), and MELD score (OR = .95, P = .02) independently predicted 90-day p-LTOU.

CONCLUSIONS: ALD, pre-LT opioid use, and MELD score independently predict p-LTOU. Special attention should be paid to identify post-LT prolonged opioid use in ALD patients.

Comments made by Cale Kassel M.D., FASA

 

Summary:

In this retrospective study, the Johnson-Laghi et al reviewed patients undergoing liver transplantation focusing on patients with known alcoholic liver disease and previous opioid use prior to transplantation. As has been described, the use of pre-operative opioids is associated with worse outcomes in other surgical procedures. The authors sought to identify if post-LT opioid use (p-LTOU) was greater in patients with alcoholic liver disease (ALD) compared to those without alcoholic liver disease.

Patient demographic data included diagnosis of psychiatric disease, use of psychiatric medications, use of illicit drugs, use of benzodiazepines, use of marijuana, prior alcoholic rehabilitation, and legal encounters related to alcohol (DUI). Use of pre-operative opioids included use both scheduled and as needed within the three months prior to transplantation. The total dose was converted to morphine equivalents for comparison.

Overall, opioid use post-LT was more common with patients with ALD compared to those without at 30, 60, and 90 days. At 90 days, 44% of ALD patients were taking opioids compared to 27% of non-ALD patients (p = 0.004). Multi-variate logistic regression demonstrated pre-LT opioid use, primary diagnosis of ALD, and lower MELD predicted 90-day post-LT opioid use.

Further analysis showed specific risk factors for p-LTOU at 60 days to include living alone. As the authors noted, this shows the importance of good social support for patients evaluated for LT. This was not a significant variable at 90 days however.

As the authors noted, more research is needed on this topic to further identify risk factors for opioid use following LT. Additionally, this is an area for anesthesiologist involved in the listing process to add value. Opioid tapering prior to LT may provide benefit for patients. Identifying patients with any patient who take opioids, can allow for early intervention including opioid tapering.

Fall 2022 Newsletter

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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

Michael Trostler, MD

1. Influence of anesthesia type on post-reperfusion syndrome during liver transplantation: a single center retrospective study   

Highlights:  South Korean study of 398 patients evaluating incidence of post-reperfusion syndrome in a propofol vs sevoflurane anesthetic, found a statistically significant decrease in the sevoflurane group.

2. Outcomes of Bariatric Surgery Before, During, and After Solid Organ Transplantation  

Highlights: Bariatric surgery was able to be performed safely, pre-transplant, simultaneously with transplant, or post-transplant with no increase in adverse events related to the bariatric procedure.  Bariatric surgery leads to weight loss and decreased comorbidities in this patient population.

3. Orthotopic Transplantation of the Full-length Porcine Intestine After Normothermic Machine Perfusion  

Highlights: The new trend of machine perfusion in organ transplantation is at the forefront of transplantation and extended criteria organs.  Porcine model of intestinal transplant has been shown to be viable and successful.

4. Safety of Intraoperative Blood Salvage During Liver Transplantation in Patients With Hepatocellular Carcinoma A Systematic Review and Meta-analysis  

Highlights: A review article of 9 studies including 2000 patients shows no increase in disease free survival, HCC recurrence or impaired overall survival.  If cell salvage is desired, it should not be immediately disregarded as an option just because of a hepatocellular carcinoma diagnosis.

5. Regional and National Trends of Adult Living Donor Liver Transplantation in the United States Over the Last Two Decades   

Highlights:  After a peak in living donor liver transplants in 2001 there was a fall, but there has been a steady rise from 2011 to 2019.  There have been improvements in transplant survival over the years with a significantly decreased mortality over the past few years compared to the first few years.

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

David Rosenfeld, MD

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

October 2022 Article of the Month

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Utilization and outcomes of deceased donor SARS-CoV-2–positive organs for solid organ transplantation in the United States.

Abstract:

Coronavirus disease-19 has had a marked impact on the transplant population and processes of care for transplant centers and organ allocation. Several single-center studies have reported successful utilization of deceased donors with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests. Our aims were to characterize testing, organ utilization, and transplant outcomes with donor SARS-CoV-2 status in the United States. We used Scientific Registry of Transplant Recipients data from March 12, 2020 to August 31, 2021 including a custom file with SARS-CoV-2 testing data. There were 35 347 donor specimen SARS-CoV-2 tests, 77.5% upper respiratory samples, 94.6% polymerase chain reaction tests, and 1.2% SARS-CoV-2-positive tests. Donor age, gender, history of hypertension, and diabetes were similar by SARS-CoV-2 status, while positive SARS-CoV-2 donors were more likely African-American, Hispanic, and donors after cardiac death (p-values <.01). Recipient demographic characteristics were similar by donor SARS CoV-2 status. Adjusted donor kidney discard (odds ratio = 2.08, 95% confidence interval [CI] 1.66-2.61) was higher for SARS-CoV-2-positive donors while donor liver (odds ratio = 0.44, 95% CI 0.33-0.60) and heart recovery (odds ratio = 0.44, 95% CI 0.31-0.63) were significantly reduced. Overall post-transplant graft survival for kidney, liver, and heart recipients was comparable by donor SARS-CoV-2 status. Cumulatively, there has been significantly lower utilization of SARS-CoV-2 donors with no evidence of reduced recipient graft survival with variations in practice over time.

 

Comments made by Cale Kassel M.D., FASA  

Summary:

When the COVID-19 pandemic began, there were obvious concerns among the transplant community. First and foremost, how could we protect patients following transplant and while waiting from transplant. As our understanding of COVID-19 evolved, so to did our ability to manage the disease in organ transplantation. The question of utilizing COVID-positive organs for transplantation emerged. Schold, et al reviewed SRTR data to look at utilization of COVID-positive organs (kidney, liver, and heart) from early in the pandemic to present. Several key findings emerged as they evaluated the data. 

First, they found utilizing COVID-positive grafts did not demonstrate worse outcomes for patients. Graft survival was similar between COVID-positive and COVID-negative grafts for kidney (95.5% vs. 95.3%), liver (93.9% vs. 97.0%), and heart (92.8% vs. 96.7%). 

Second, utilization of COVID-positive donors remained low. Recovery of COVID-positive organs was lower for kidneys, livers, and hearts. Additionally, discard of recovered grafts were lower in COVID-positive grafts. However, kidney graft discard rate of COVID-positive grafts was lower in the later study period (Dec 2020-April 2021) compared to the early study period (March 2020-November 2020). The overall rate of discard for COVID-positive kidneys was still lower than COVID-negative. Heart and liver discard rates were lower in COVID-positive donors as well. 

As we continue to learn more about the effect of transplantation of COVID-positive organs, we can continue to optimize patients and grafts to improve outcomes. Early data from this study and others suggests COVID-positive grafts can provide a safe option for patients awaiting transplantation.

References:

Schold JD, Koval CE, Wee A, Eltemamy M, Poggio ED. Utilization and outcomes of deceased donor SARS-CoV-2–positive organs for solid organ transplantation in the United States. American Journal of Transplantation 2022;22(9):2217-2227. DOI: https://doi.org/10.1111/ajt.17126.

SATA Council Members Elected

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New SATA Council Members Elected!

Dear SATA Members, 

The SATA election of the two new executive councilors for our Society’s Council has concluded.

Many thanks to everyone that participated in casting a ballot. Special thanks to all the five excellent candidates who put their names on the list. Thank you for being willing to participate in helping shape the future of our Society. 

The SATA Council is happy to announce the newly elected Council members: Dr. Sathish Kumar from the University of Michigan and Dr. Adrian Hendrickse from the University of Colorado (re-elected) for the two-year term (2022 – 2024). We are thrilled to work with you and looking forward to getting the new insights to make SATA a more robust transplant society!

 

Adrian Hendrickse, BM, MMEd, MAcadMEd, FRCA 

(2020 – 2022; reelected – 2024)

Associate Professor of Anesthesiology

Fellowship Program Director, Liver Transplant Anesthesiology

University of Colorado Anschutz Medical Campus

 

 

 

 

Sathish S. Kumar, MD

(2022 – 2024)

Clinical Associate Professor, 

Department of Anesthesiology

University of Michigan

 

 

Special thanks and kudos to Dr. Ranjit Deshpande from Yale University (2020 – 2022) for his outstanding job in the past two years as a SATA Council member. Dr. Deshpande helped create our Society’s Finance and Critical Care Committees during his tenure. Dr. Deshpande will continue his work for SATA with his involvement in the committees above. He will also serve as a non-voting Council member. 

 

Sincerely, 

Lorenzo De Marchi, MD.

Secretary, SATA

 

Tetsuro Sakai, MD, PhD, MHA

President, SATA

Summer 2022 Newsletter

By

UNOS News

By Flora Simmons, MD

 

OPTN Board Eliminates Race-based Calculation For Transplant Listing

In a momentous measure to provide equitable access to all transplant candidates, the board of directors of the Organ Procurement and Transplantation Network recently approved a precedent requiring transplant hospitals to use race neutral calculations when estimating a candidate’s glomerular filtration rate (GFR).  Read more here.

 

Kidney Transplants have Increased in Minorities since Policy Changes 

Following implementation of the updated allocation system, one year monitoring reports show that transplant rates increased significantly for several key populations including Black, Hispanic, Asian, and pediatric candidates. The updated allocation system replaced the donation service area and administrative regions with a 250 nautical mile circle around the donor hospital. Read more here. 

 

Research Updates and Interesting Articles

By Michael Trostler, MD

 

“Abdominal Organ Transplantation: Noteworthy Literature in 2021”– Seminars in Cardiothoracic and Vascular Anesthesia

Highlights:  Yearly article by corresponding author, SATA president Dr. Tetsuro Sakai, selecting 20 articles from over 10,000 articles published over the year.  Read the article here

 

“Analysis of outcomes and renal recovery after adult living-donor liver transplantation among recipients with hepatorenal syndrome” – American Journal of Transplantation

Highlights:  Retrospective analysis of 2185 living donor liver transplants over a 7 year period found that time from HRS to transplant was significantly associated with recovery, and recovery was significantly associated with survival. Read the article here

 

“Hypothermic oxygenated perfusion in extended criteria donor liver transplantation—A randomized clinical trial” – American Journal of Transplantation

Highlights: Machine perfusion is at the forefront of new technological innovation in the transplant community.  A randomized control trial of HOPE in 110 extended criteria donors found improved outcomes with lower graft dysfunction and better graft survival. Read the article here

 

“Transplantation of a human liver following 3 days of ex situ normothermic preservation” – Nature Biotechnology

Highlights: 3 days of Ex-Vivo machine perfusion prior to transplant was successful and at one year follow-up the recipient was alive and the biliary tree intact.  Read the article for the amazing details here 

 

“Final Safety and Efficacy Results from a 106 Real-World Patients Registry with an Ascites-Mobilizing Pump” – Liver International

Highlights: 12 European centers have followed 106 patients over 24 months with a “Alfapump”, an intraperitoneal fluid management system that pumps ascites from the peritoneal cavity into the bladder for excretion.  Designed for those ineligible for a TIPS procedure. Read the article here

 

“Sequential liver and kidney living donors: Making the ultimate gift twice” – Clinical Transplantation

Highlights: 150 living donors in the United States have donated more than one organ.  20 of these donors donated at UPMC- Pittsburgh, with 70% non-directed/altruistic with first donation and 80% non-directed/altruistic at the second donation. Read the article here

Special Topics

By Alex Stoker, MD

 

Imminent Death Donation

Imminent death donation (IDD) is a proposed organ donation practice described as the recovery of a living donor organ immediately prior to an impending and planned withdrawal of ventilator support expected to result in the patient’s death [OPTN white paper, 2016]. This practice is aimed at increasing the availability of donated organs through increased utilization of organs from donors who may have had non-progression during attempted DCD donation and by reducing organ ischemia.  In 2016 the ethics committee of the Organ Procurement & Transplantation Network (OPTN) outlined several ethical concerns, potential risks, as well as challenges of IDD; however, acknowledged the possibility of overcoming those challenges in the future [OPTN white paper, 2016]. A recent survey by Washburn et al explored the public attitudes towards IDD in the United States and describe a scenario in which one kidney, a portion of liver and portion of lung are donated prior to withdrawal of life support [Washburn et al, 2020]. 

Read more from reference here

 

Rise of the Machines – Normothermic Ex Vivo Perfusion in Liver Transplantation 

Since the first use of normothermic machine perfusion (NMP) in human orthotopic liver transplantation in 2013 there has been considerable and growing interest in using NMP to improve organ quality prior to transplantation by maintaining the allograft in a physiologic state during transportation. While ongoing investigations have yet to confirm all the potential benefits, NMP may reduce allograft ischemic damage, lessen the metabolic and hemodynamic derangements following liver reperfusion, increase the utilization of marginal organs, improve transplant logistics and expand the donor pool.

Read more from reference here

 

In the Spotlight: Duke University Medical Center –Cardiothoracic Transplant Program  

By David Rosenfeld, MD;  Alex Stoker, MD

For this summer’s piece we choose to focus exclusively on the adult cardiac and lung transplant program at Duke. A large medical center with 1048 patient care beds, Duke University Hospital is one of the premier centers in the world for cardiac and lung transplantation.  According to 2021 SRTR data they were third in the US in adult cardiac ​transplant volume with 104, second in lung with 108, and also performing three combined cardiac-lung ​transplants, and ​one lung-liver transplant. 

Led by ​Dr. Mihai Podgoreanu, the Duke Cardiothoracic Anesthesiology Division has been a leader in comprehensive perioperative management of thoracic organ and combined organ transplant recipients as members of the Duke Transplant Center, which recently celebrated its 10,000th transplant milestone. Perioperative transplant care is provided by a highly integrated group of cardiothoracic anesthesiologists and intensivists, 4 or 5 ​anesthesia residents, and up to 10 fellows covering a total of 9 adult cardiothoracic operating rooms and 32 CTICU beds.  Duke has one of the largest and busiest Adult Cardiothoracic Anesthesia (ACTA) fellowship programs in the US (14 fellows/year), led by Dr. ​Brandi Bottiger who also directs Quality Improvement across the Duke Transplant Center. Concomitantly, the Anesthesiology Critical Care Medicine (CCM) fellowship program​, led by Dr. Nazish Hashmi, is rapidly growing ​(8 fellows​/year), with a strong emphasis placed on acute care of critically ill transplant patients. Thoracic transplant recipients recover in the cardiothoracic intensive care unit (ICU), which offers 24/7 coverage by anesthesiologists with cardiothoracic and critical care training. The ACTA and CCM fellows participate in multidisciplinary care of these patients along the continuum from the operating room​ and through the cardiothoracic ICU, while gaining an unparalleled experience in perioperative echocardiography, complex cardiopulmonary and mechanical circulatory support physiology.

 

The Duke Heart Transplant program, under the medical directorship of Dr. Adam Devore, has a comprehensive patient selection process where many disciplines are represented, including anesthesiologists and intensivists.   Performing the first donation after circulatory death (DCD) case in 2019, the cardiac transplantation program has completed more than 80 heart transplant procedures with DCD donors.  To facilitate this innovative practice which significantly expands the donation pool, Duke has been early in its use of the Transmedics Organ Care System (OCS) and is one of five centers included in a prospective non-inferiority trial comparing transplantation of DCD organs resuscitated with the device compared to donation after brain death hearts preserved with traditional cold storage methods.  Dr. Jacob Schroder is the surgical director of heart transplantation and the principal investigator for the OCS DCD heart trial, which helped support the FDA’s approval of the device for DCD donor hearts in April 2022.  

Similarly, the Duke Lung Transplant program, under the medical directorship of Dr. John Reynolds, has a comprehensive, multidisciplinary patient selection process. Anesthesiologists are involved in developing quality metrics and improvements in clinical care. The Duke Lung Transplant​ program, with surgical director Dr. John Haney, has adopted elective intraoperative VA ECMO during lung transplantation to reduce allograft reperfusion injury, increase cardiopulmonary stability, and reduce comorbidity associated with cardiopulmonary bypass use. They utilize a hybrid ECMO circuit that can be quickly converted to a full CPB circuit if needed emergently. 

Transplantation is truly a team sport at Duke, with a dedicated multidisciplinary team in place to care for these complex patients.     

Many thanks to Dr. Bottiger for sharing details of  the transplantation program at Duke University Medical Center.  If interested in having your program highlighted in the future, please contact David Rosenfeld, Mayo Clinic Arizona at Rosenfeld.david@mayo.edu

Announcements

Attention liver transplant anesthesiologists and program directors!  SATA will be offering free 6 month membership to fellows!  Please sign up by emailing sata@pacainc.com. We look forward to welcoming new fellow members!

Transplant Anesthesia Upcoming Meetings

SATA Meetings:

Midstate SATA Regional Meeting: September 24, 2022

Southern SATA regional Meeting: November 5, 2022 

Mid-Western SATA Regional Meeting: January 21, 2023

 

Other Meetings: 

ILTS Perioperative Care in Liver Transplantation Meeting 2022

October 21, 2022; Ochsner Health, LA; in-person and virtual

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