SATA

Society for the Advancement of Transplant Anesthesia

Sergio

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

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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

SATA Council Nominations – 2022

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Name with degree(s): Kyota Fukazawa, MD, PhD
Institution: University of Washington

Academic appointment: Professor

Departmental role:

Director of Transplant anesthesia,
Director of Transplant Anesthesia Fellowship Program

Specialty: Abdominal Transplant

Years of SATA membership: Founding member, member since 2012

Role(s) in SATA:

SATA West Coast Annual Regional Meeting: Senior Chair, 2018~
SATA Fellowship Committee 2020~
SATA Practice Management Working Group (SATA) 2022~
SATA Federation (International relation) Committee 2018~
SATA Abdominal transplant task force Committee 2018~
SATA Board of Directors 2016~
SATA Founding member 2012~

The reason for seeking the SATA Council position:

Having played a progressively more involved roll in SATA from joining in 2012 to being the senior chair of SATA west coast meeting this year, I am confident in taking the next step to expand my leadership skills. During serving multiple committees in my own institution, ILTS and SATA, I learned how important it is to listen. I want to be a listener to understand the issues of peers and work to put their ideas into action.

Name: Uzung Yoon M.D., M.P.H.

Institution: Sidney Kimmel Medical College
Thomas Jefferson University Hospital
111s 11th St G8290, Philadelphia, PA 19107
c: 215-910-0557, w: 215-955-6161
uzung.yoon@jefferson.edu

Academic appointment: Assistant Professor, Department of Anesthesiology

Departmental role: Co-Director, Liver transplantation Anesthesiology
Program Director, Liver Transplantation Anesthesiology Fellowship
Director, Anesthesia Coagulation Laboratory

SATA membership: 4 years

Role: Active member

Specialty: I am currently a liver transplantation anesthesiologist at Thomas Jefferson University
Hospital in Philadelphia.

The reason for seeking the SATA Council position:

The SATA has been invaluable in my growth and perspective as a transplant anesthesiologist. I attended numerous SATA meetings from New York down to Washington DC. I connected with colleagues, had intellectual discussions, and presented at recent meetings. I would like to become more actively involved in directly contributing to the organization. I also have seen SATA growing rapidly in the past few years and have big ambitions to promote SATA that more transplant anesthesiologist could benefit from the society.
From prior committee experience, I have learned that the most effective way to progress our field is through being active, and collaborating across institutions. Thank you for your consideration of my application. If any additional information is needed, I can be reached at the following email address: uzyoon@gmail.com or uzung.yoon@jefferson.edu.

Name with degree: Sathish S Kumar, MBBS

Institution: University of Michigan

Academic appointment: Associate Professor of Anesthesiology

Departmental role: Director of transplantation anesthesia

Specialty: Abdominal Transplant Anesthesia

Years of SATA membership: 3 years

Role(s) in SATA: committee’s on Q&S, Senor chair for Midwest regional meetings and organized past two meetings, Co-chair- TEE for abdominal transplantation, Committee on LDLT.

The reason for seeking the SATA Council position:

The reason for seeking the SATA Council position: I am passionate about clinical care of patients undergoing transplantation and my vision is to promote and enhance the care of solid organ transplantation including the care of living donor transplantation. My ongoing role with SATA in achieving this mission has been instrumental in getting younger generation of anesthesiologist involved in transplantation and work with SATA to further advance it. Given my role as a leader in my department, I strongly believe that I can contribute and help advance our society by being a member of the council. I look forward to that opportunity and working with a group of like minded individual to achieve that common goal. I feel I have a lot more to contribute to advance our society nationally and internationally to provide the best and safe clinical care of these patients. I look forward to working with SATA in advancing and promoting research in the area of transplantation.

Name: Raymond M. Planinsic, MD, FASA

Academic appointment: Professor of Anesthesiology

Departmental role: Chief of Transplantation Anesthesiology University of Pittsburgh Medical Center / Perioperative Medicine Director of Transplantation Anesthesiology Fellowship

Institution: University of Pittsburgh School of Medicine

Specialty: Abdominal Transplant Anesthesia

Years of SATA membership: Member of SATA since inception, one of it’s Founding Members

Roles in SATA:
Member Bylaws Committee, Member Fellowship Committee, Member SATA Practice
Management Working Group, Course Director of First SATA Review Course, Invited
speaker/panel member multiple SATA meetings

Reason for seating SATA Council position:

I am seeking appointment to the SATA Council at Large position to help continue to serve and improve SATA’s presence, role and influence in advancing the interests of its membership and the specialty of transplant anesthesia. SATA is in a unique position of educating the transplant field of the importance and role of transplant anesthesiologist. With continued involvement in the field, SATA can help set standards of practice, improve training of specialists, provide a forum/stage to voice the concerns of membership on how to improve patient care and increase the recognition of our field.

Name with degree: Adrian Hendrickse BM MMEd MAcadMEd FRCA

Institution: University of Colorado

Academic appointment: Associate Professor

Departmental role: Medical Director Abdominal Organ Transplant Anesthesia Team. Program Director Liver Transplant Anesthesiology Fellowship

Specialty: General Anesthesia, Regional Anesthesiology and Abdominal Organ Transplant Anesthesiology

Years of SATA membership: 5 years SATA membership

Roles in SATA: Chair of Quality and Standards Committee from 2019 to present Member of the Byelaws Committee from 2022

Reason for seating SATA Council position:

I believe that our society needs to offer a broader offering in education to its membership. I want to develop educational material that will engage new and interested learners in the field of transplant anesthesiology whilst harnessing the knowledge and experience of our existing members from across the country. Collaboration within our society should make this enterprise something worth pursuing and being a council member will enable me to leverage the support needed.

Update on Live Donor Liver Transplantation – Vanguard Lecture

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April Article of the Month 2022

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Outcome of Liver Transplants Using Donors After Cardiac Death with Normothermic Regional Perfusion.

Abstract:

Background and aims: The incorporation of normothermic regional perfusion (NRP) to donors after cardiac death (DCD) allows the recovery of liver grafts without the deleterious effects on graft survival the super-rapid technique may cause. The aim of the present report is to determine if the use of NRP in Maastricht type III DCD donors achieves short- and medium-term results comparable to donors after brain death (DBD).

Patients and methods: This is an observational cohort study including 117 liver transplants executed between November 2016 and April 2021, divided into NRP (n = 39) and DBD (n = 78).

Results: Donors were younger in the NRP group (NRP 52 vs DBD 59.4 years; P < .005). Liver recipients in each study group were of similar age and severity of liver disease, although the predominant transplant indication in the NRP group was hepatocellular carcinoma. No differences in ischemia times were found. The incidence of early allograft disfunction and primary nonfunction was balanced between NRP and DBD. Eight patients required retransplant, all of them in the DBD group. No differences were found in biliary complications (NRP 12% vs DBD 5%; P = .104). Ischemic cholangiopathy affected a single DBD patient. Graft survival’s Kaplan Meier curve shows a better outcome in the NRP group, although the difference did not reach significance (P = .075).

Conclusions: The incorporation of perfusion machines, and specifically the NPR in situ, converts suboptimal liver grafts such as DCD into organs comparable to DBDs.

Comments made by Cale Kassel M.D., FASA  

Summary:

In this observational cohort study the authors compared the use of normothermic regional perfusion (NRP) in donation after cardiac death (DCD) donors to donation after brain death donors (DBD). A total of 117 liver transplants were included, 39 in the NRP group and 78 in the DBD group.

Donors for the two groups were largely similar we a few exceptions. Donor age was lower in the NRP group (52 vs. 59.4; p = 0.005). While the number of days in the ICU was higher in the NRP group (7.21 vs. 2.62; p = 0.000), the use of vasopressor support was higher in the DBD group (86.4% compared to 35.1%). 

Recipient differences were similar for MELD scores for the NRP and DBD groups. (14.48 vs. 16.14; p = 0.392). The authors noted differences in indication for transplant between the two groups. For DBD, alcoholic cirrhosis was the most common indication followed by hepatocellular carcinoma. In the NRP group, hepatocellular carcinoma was the most common indication. 

No primary endpoint was noted but overall survival was similar between the two groups. One year survival for the NRP group as 94% compared to 84% in the DBD group and at three years, survival was 71% for the NRP group and 75% for the DBD group. While the Kaplan-Meier curve showed better survival with the NRP group, this did not reach statistical significance (p = 0.075). Biliary complications were not statistically different between the two groups (NRP at 12%, DBD at 5%). Early allograft dysfunction, primary non-function, and acute kidney injury were similar between the two groups. 

With constant need for donor organs, new ways to procure organs for transplant warrant consideration. Early evidence raised concerns on the rate of biliary complications with DCD donors that may limit their usefulness. However, NRP or machine perfusion appears to offer promise for DCD organ use while also minimizing biliary issues post-operatively. This small study adds to the body of evidence supporting the use of NRP for DCD organs. 

References:

Rodriguez RP, Perez BS, Daga JAP, et al. Outcome of Liver Transplants Using Donors After Cardiac Death with Normothermic Regional Perfusion. Transplantation proceedings 2022;54(1):37-40.

Spring 2022 Newsletter

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UNOS News

By Flora Simmons, MD

Liver transplant rates increase after implementation of new organ allocation policy

The OPTN data report is now available and describes key measures of the new liver and intestinal allocation policy for the 18-month period from February 2020 through August 2021.  Results show an overall  increase in deceased donor liver-alone and liver-kidney transplants, significantly increased transplant rate for sicker patients, and more transplants being performed between 250 and 500 nautical miles, leading to slightly longer median cold ischemic times. Read more here.  

 

Record setting year for heart, liver, and kidney transplants in 2021

For the first time, organ transplants in the United States exceeded 40,000 for a grand total of 41,354 organs transplanted in 2021. There were a total of 24,669 kidney transplants, 9,236 liver transplants, and 3,817 heart transplants. Heart transplants have set a new record for the past 10 consecutive years, while liver transplants have set annual records for the past nine years.  Read more here. 

 

DCD Procurement Collaborative Project surpassed goal and recovered DCD donors at a higher rate than the rest of the nation

Twenty-six OPOs from across the country collaborated with the aim to increase the number of DCD donor procurements. Improvement efforts were focused across multiple areas including strengthening relationships between donor hospitals and transplant programs and optimizing clinical practices. The cohort procured 34% more DCD donors in 2021 compared to 26% for the rest of the nation. Read more here.

 

New relationship with Corey & Associates (PACA) 

From Susan Mandell, MD and David Corey, MBA

SATA is excited to announce a new partnership with Corey & Associates (PACA) that will assist with the day-to-day business management of the society’s activities.  PACA has worked in the area of management and government relations since 1975, SATA looks forward to working with PACA in order to improve this membership experience.  Please find a link to PACA on our webpage here 

 

SATA and SCA Collaboration Update  

By Yong G. Peng, MD, PhD, FASE, FASA

 With the help of SATA treasurer Dr. Jiapeng Huang preliminary communication, SATA executive council members Drs. Tetsuro Sakai, Jiapeng Huang and Susan Mandell had a Zoom meeting with the Society of Cardiovascular Anesthesiologists (SCA) leadership group.  This was a productive discussion covering a wide range of potential collaborations between SCA and SATA. 

SCA’s president Dr. Andrew Shaw has fully endorsed Drs. Archer Martin of Mayo Clinic Jacksonville and Sharon McCartney of Duke to become the inaugural Co-Chairs for the Transplant Anesthesia Subcommittee of SCA.  Together they will oversee all the projects and progress of collaboration between SATA and SCA.   

The initial area of mutual interest will include the following: 

  1. SATA and SCA will exchange a formal Memorandum of Understanding (MOU) to make the collaboration official 
  2. Both organizations recognize the mutual interests including but not limited to: a) data-based research (heart and lung). b) practice guidelines  c) advocacy to UNOS 
  3. Both societies leaders also agreed on the importance of structured training and educational process for adult lung transplantation (ALT) anesthesiologists. They will work on the specific logistics to provide TEE training curriculum and competency assessment for ALT anesthesiologists 

In response to the call for SATA and SCA collaborations, both SATA’s CT Transplantation Committee and CT Educational Task Force Committee recently had a Zoom meeting to lay out the specific action plans.  The committees proposed that SATA has three cardiothoracic related entities (CT transplantation Committee, TEE Work Group and CT Educational Taskforce) working together to consolidate resources and make a collective effort to reach important goals. These include promoting cardiothoracic related missions of SATA to other societies scientific activities, distribution of cardiothoracic transplantation educational materials on the SATA website, hosting regular meetings on relevant cardiothoracic transplant topics to maintain SATA member’s interest, and keeping all three entities member engagement to advance SATA’s clinical and research interest in collaboration with other professional societies.

 

Research Updates and Interesting Articles

By Michael Trostler, MD

  1. OPTN/SRTR 2020 Annual Data Report Liver,  has been published.  This is the first official update from the start of the pandemic.  As of June 2020, 98,989 liver transplant recipients were alive.  The report is full of interesting information on total numbers, demographics, and outcomes.  Read more here
  • Does machine perfusion improve immediate and short-term outcomes by enhancing graft function and recipient recovery after liver transplantation? – A systematic review of the literature, meta-analysis and expert panel recommendations

Highlights: Hypothermic machine perfusion decreases post-reperfusion syndrome and early graft dysfunction.  Normothermic machine perfusion reduces incidence of post-reperfusion syndrome and early graft dysfunction.  Normothermic regional perfusion decreases likelihood of early graft dysfunction and risk of primary non-function.  Read more here

  • Sequential hypothermic and normothermic machine perfusion enables safe

transplantation of high-risk donor livers

Highlights:  Sequential Dual hypothermic oxygenated machine perfusion followed by Normothermic Machine Perfusion (DHOPE-NMP) was used to salvage 63% of originally discarded livers with 1 year graft survival 94%, and patient survival 100%.  Read more here

  • Liver resection versus liver transplantation for hepatocellular carcinoma within Milan criteria: a meta-analysis of 18,421 patients.

Highlights:  Mortality after liver resection is nearly 50% higher than liver transplant in hepatocellular carcinoma.  Read more here

Articles of the month from January and February, 2022

By Michael Ander, MD

  • Postreperfusion syndrome in liver transplantation: outcomes, predictors, and application for recipient selection

Highlights:  Donor age, donor BMI, moderate macrosteatosis, and CIT were identified as risk factors for the development of PRS in LT using DBD grafts. PRS risk evaluation may improve donor-to-recipient matching based on their MELD scores. Read more here

  • Is obesity associated with better liver transplant outcomes? A retrospective study of hospital length of stay and mortality following liver transplantation

Highlights:  Results provide evidence that overweight and obesity class 1 are associated with decreased length of stay and mortality following liver transplant, while underweight and obesity class 3 are associated with prolonged length of stay.  Read more here

 

In the Spotlight:  Houston Methodist Medical Center (Texas Medical Center)

By David Rosenfeld, MD, FASA

For this quarter’s segment we were able to connect with Scott Lindberg, MD, FASA, director of liver transplant anesthesiology at the 900 bed Houston Methodist Medical Center. 

Currently Methodist is one of the busiest abdominal programs in the US with 183 livers, 255 kidneys (47% live donor), and 14 pancreas cases completed in 2021. For the liver program nearly all are cadaveric, however they have launched a liver donor program with their first case in October 2021, and a second scheduled in early 2022.  Methodist is aggressive in utilizing advanced age/extended criteria grafts with over 20% DCD.  They are frequently using the Transmedic normothermic perfusion system and are working to publish their early experience.  Nearly all cases are on VV bypass, PA catheter and FloTrac are routine, TEE is placed in nearly 100% of cases with one team member advanced certified.  ABG assays are POC in-room. ROTEM is performed in the central lab; however, the tracing is visible in real time in the OR. Antifibrinolytics are given with documented hyperfibrinolysis in conjunction with on field coagulopathy, and in cases when greater than eight units of packed cells are administered.  A small percentage of patients are extubated in the operating room.    

The most unique aspect of the liver transplant anesthesiology practice is that it is covered exclusively with a dedicated six-physician team from the private practice group US Anesthesia Partners working either as the sole in-room provider or in conjunction with UT Houston anesthesia residents, who rotate late in the CA2 and throughout the CA3 years.  Team members carry faculty appointments at the Weill Cornell School of Medicine and/or Texas A&M College of Medicine.  This private staffing model is clearly uncommon, and particularly unusual given that the program was the third largest volume US center in 2021.  Several years ago, Methodist hired liver transplant anesthesiologist Randolph Steadman, MD, MS, to serve as Chair of Anesthesiology, to lead the hospital-based group, and to increase collaboration between the private and hospital practices. In that vein, in September 2021 the department was accredited for an anesthesiology residency, with Dr. Lindberg of US Anesthesia Partners in the role of program director. It is an exciting time as they recently matched their first class of six categorical residents to begin in July 2022. 

The transplant program has made it their mission to expand the donor pool by looking to technology and data to push the boundaries of extended criteria donors.  There is also a commitment to increase research activity with the establishment of the residency program.

 

Upcoming Meetings

SATA Meetings 

SATA Tristate Liver Anesthesiology  Meeting, NYU School of Medicine, April 9th, 2022; 9:00 am – 2:00  pm EST. Click here to Register Click here to review the Program Agenda

SATA Virtual Lung Transplant Anesthesia Fellowship Series, April 16, 2022 6:00 PM EST.  Dr. Jack Hanley will be interviewed by Dr. Brandi Bottiger exploring a surgeon’s perspective on lung transplantation.  Click here for advanced registration. here 

SATA East Regional Meeting, DMV Liver Transplant Anesthesia Meeting 2022.  Virtual, April 23rd, 2022 8:45am – 12:45 pm EST.  Click here for details here 

Other Meetings

ILTS Annual Meeting May 4 – 7, 2022, Istanbul, Turkey

American Transplant Congress June 4 – 8, 2022, Boston, MA

International Liver Transplant Congress June 22 – 26, 2022

ILTS Perioperative Care in Liver Transplant Meeting, October 21, 2022, New Orleans, LA

 

Opportunities

UTHealth Anesthesiology – Medical Co-Director of the Transplant Intensive Care Unit

The Department of Anesthesiology at McGovern Medical School at UTHealth is seeking applicants for the position of Medical Co-Director of the Transplant Intensive Care Unit (TSICU) at Memorial Hermann Hospital- Texas Medical Center.  

The role of the Medical Co-Director is to oversee and integrate all clinical policies and practice standards in close cooperation and collaboration with the Chief of Transplant Surgery, Pulmonary Critical Care Medicine and other collaborating services in the Transplant Service Line. The Medical Co-Director will partner with the Chair of the Department and the Division Chief of Critical Care Medicine to promote a cohesive strategy to enhance patient care, structure educational systems, standardize translational research opportunities and infrastructure where appropriate and promote a culture of clinical excellence.  Additionally, the Medical Co-Director will contribute to the transplant anesthesiology team and collaborate with hospital leadership including the Transplant Service line administrative and nursing teams.

Required qualifications:

  1.     MD/DO or equivalent with Board Certification in Anesthesiology
  2.     Title or experience commensurate with a rank of Assistant Professor or greater
  3.     Fellowship training in an ACGME Accredited Critical Care Medicine program
  4.     Additional fellowship training in transplant anesthesiology is preferred

If interested, please submit your CV and cover letter to:

George Williams, MD, FASA, FCCM, FCCP

Vice Chair for Critical Care Medicine, Department of Anesthesiology

McGovern Medical School at UTHealth

George.W.Williams@uth.tmc.edu

February 2022 – Article of the Month

By

Is Obesity Associated with Better Liver Transplant Outcomes? A Retrospective Study of Hospital Length of Stay and Mortality Following Liver Transplantation. Anesthesia and Analgesia. 2022.

Abstract:

Background: The rise in obesity in the United States, along with improvements in antiviral therapies, has led to an increase in the number of obese patients receiving liver transplants. Currently, obesity is a relative contraindication for liver transplant, although exact body mass index (BMI) limits continue to be debated. Studies conflict regarding outcomes in obese patients, while some argue that BMI should not be used as an exclusion criterion at all. Therefore, this retrospective study-utilizing a large national database-seeks to elucidate the association between recipient BMI and hospital length of stay and mortality following liver transplant.

Methods: A retrospective study was conducted using the United Network for Organ Sharing Standard Transplant Analysis and Research database. Fine-Gray competing risk regressions were used to explore the association between BMI and rate of discharge, which varies inversely with length of stay. In our model, subdistribution hazard ratio (SHR) represented the relative change in discharge rate compared to normal BMI, with in-hospital death was considered as a competing event for live discharge. Cox proportional hazard models were built to assess the association of BMI category on all-cause mortality after liver transplantation. Cluster-robust standard errors were used in all analyses to construct confidence intervals.

Results: Within the final sample (n = 47,038), overweight (≥25 and <30 kg/m2) patients comprised the largest BMI group (34.7%). The competing risk regression model showed an association for increased length of stay among underweight (SHR = 0.82, 95% confidence interval [CI], 0.77-0.89; P < .001) and class 3 obesity patients (SHR = 0.88, 95% CI, 0.83-0.94; P < .001), while overweight (SHR = 1.05, 95% CI, 1.03-1.08; P < .001) and class 1 obesity (SHR = 1.04, 95% CI, 1.01-1.07; P = .01) were associated with decreased length of stay. When the sample excluded patients with low pretransplant functional status, however, length of stay was not significantly shorter for overweight and obesity class 1 patients. Cox proportional hazard models demonstrated increased survival among overweight, class 1 and class 2 obesity patients and decreased survival among underweight patients.

Conclusions: Our results provide evidence that overweight and obesity class 1 are associated with decreased length of stay and mortality following liver transplant, while underweight and obesity class 3 are associated with prolonged length of stay. Pretransplant functional status may contribute to outcomes for overweight and class 1 obese patients, which necessitates continued investigation of the isolated impact of BMI in those who have had a liver transplant.

Comments made by Cale Kassel M.D., FASA  

Summary:

In this retrospective study1 examining obesity in liver transplant patients, the authors utilized data from the Scientific Registry of Transplant Recipients (SRTR) to compare obesity class and hospital length of stay (LOS) and mortality. With nonalcoholic steatohepatitis (NASH) set to become the leading indication for LT, providers must consider the risks of transplantation in obese patients. With conflicting data on the risk of obesity in LT, this is usually a center-specific guideline on listing patients with elevated BMI. A total of 47,038 patients were reviewed and divided into 6 groups (underweight, normal, overweight, obese I, obese II, and obese III).

Compared to normal weight patients, hospital LOS was lower in the overweight and class I obesity group while it was longer in the obese III and underweight groups. Further risk analysis that excluded patients with hospitalization prior to transplant, functional status < 50%, mechanical ventilation still demonstrated longer LOS with underweight and obese III groups.

At 90 days, survival was lowest in the underweight and class III obesity group of patients (95.5%, 94.1% respectively). Survival at 1 year and 10 years were lowest in the underweight group of all groups studied. Interestingly, the class I obesity group had the best 1-year and overall survival by the unadjusted Kaplan-Meier model.

The retrospective nature of the study and the presence of ascites are both limitations interpreting the data. Factoring in ascites in the body weight calculation can be challenging and may have led to overrepresentation of obese patients in this study.

Ultimately, the authors found shorter LOS in overweight and class I obesity. Both underweight and class III obesity had longer LOS. Further research into this topic is needed to evaluate the role of functional status in obesity and outcomes. For programs looking to identify specific cutoffs, the authors suggest, based on their findings, that many centers may benefit from a BMI cutoff of > 40 kg/m2.  It should be noted that both the AASLD and AST consider class III obesity as a contraindication for LT. The EASL suggests careful evaluation of patients with a BMI > 35 kg/m2.

References:

  1. Du AL, Danforth DJ, Waterman RS, Gabriel RA. Is Obesity Associated with Better Liver Transplant Outcomes? A Retrospective Study of Hospital Length of Stay and Mortality Following Liver Transplantation. Anesthesia and Analgesia. 2022.

January 2022 – Article of the Month

By

Postreperfusion syndrome in liver transplantation: Outcomes, predictors, and application for recipient selection. Clinical Transplantation. 2022.

“Background: This study aimed to identify risk factors for postreperfusion syndrome (PRS) and its impact on LT outcomes.

Methods: Data analysis was performed in 1021 adult patients undergoing donation after brain death (DBD) LT to identify PRS incidence, the risk factors for PRS development, and its impact on LT outcomes.

Results: The overall incidence of PRS was 16.1%. Independent risk factors for PRS included donor age (odds ratio (OR) 1.01, P = .02), donor body mass index (BMI) (OR 1.04, P = .003), moderate macrosteatosis (OR 2.48, P = .02), and cold ischemia time (CIT) (OR 1.06, P = .02). On multivariable analysis for 30-day graft failure, PRS (hazard ratio (HR) 3.49; P < .001) and Model for End-stage Liver Disease (MELD) score (HR 1.01; P = .05) were independent risk factors. Patients were categorized into four distinct groups based on PRS risk groups and MELD groups, which showed different 1-year graft survival (P < .001). There were comparable outcomes between low PRS risk – high MELD and high PRS risk – low MELD group (P = .33).

Conclusions: Donor age, donor BMI, moderate macrosteatosis, and CIT were identified as risk factors for the development of PRS in LT using DBD grafts. PRS risk evaluation may improve donor-to-recipient matching based on their MELD scores.”

Comments made by Cara Crouch, MD  

This article conducted a retrospective review of all adult DBD liver transplants from a single center over a 15-year period, excluding patients who received multi-organ transplants, DCD grafts, split grafts, LDLT, retransplant and patients who were transplanted due to acute liver failure, to identify risk factors for the development of postreperfusion syndrome (PRS). The authors also reviewed outcomes and offer suggestions for donor/recipient matching to reduce the incidence of PRS. The authors defined PRS as “a >30% decline in mean arterial pressure (MAP) from baseline within 5 minutes of graft reperfusion and lasting at least 1 minute.” A total of 1021 cases were reviewed and the overall incidence of PRS was found to be 16.1%.

The authors found no recipient factors that were statistically significant for an association with PRS. Four donor factors were found to be independently associated with PRS: donor age, donor BMI, moderate macrosteatosis (30-60%) and cold ischemia time. The authors used this data to develop a PRS risk sore used to categorize patients as either low or high PRS risk.

Patients also underwent further risk stratification, low ( 25) vs. high (>25) MELD, in combination with low vs. high PRS risk to analyze graft and patient survival. The occurrence of PRS was found to be associated with worse short-term graft and patient outcomes but not long-term outcomes. When PRS risk and MELD score were combined, it was found that patients with high MELD and high PRS risk factors had poor outcomes. The authors suggest that identifying the PRS risk factors and utilizing the risk score may allow for more optimal donor/recipient matching to improve overall outcomes.

References:

1. Bekki Y, Myers B, Wang R, Smith N, Zerillo J, Rocha C, Tabrizian P, Moon J, Arvelakis A, Facciuto M, DeMaria S, Florman S. Postreperfusion syndrome in liver transplantation: Outcomes, predictors and application for recipient selection. Clinical Transplantation. 2022.

International consensus recommendations for anesthetic and intensive care management of lung transplantation

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“International consensus recommendations for anesthetic and intensive care management of lung transplantation. An EACTAIC, SCA, ISHLT, ESOT, ESTS, and AST approved document.”

Nandor Marczin, MD, PhD, Eric E.C. de Waal, MD, PhD, Peter M.A. Hopkins, MD, Michael S. Mulligan, MD, Andre Simon, MD, PhD, Andrew D. Shaw, MB, FRCA, FRCPC, FFICM, Dirk Van Raemdonck, MD, PhD, Arne Neyrinck, MD, PhD, Cynthia J. Gries, MD, MS, Lars Algotsson, MD, PhD, Laszlo Szegedi, MD, PhD, and Vera von Dossow, MD, Task force Chairs and Writing Group (exclusive of the consensus developing and coordinating group members): Aidan Burrell, MBBS, PhD; Paula Carmona, MD, PhD; Donna Greenhalgh, MB, ChB, FRCA; Dominik Hochter, MD; Bessie Kachulis, MD; Christopher S. King, MD; Marc J. Licker, MD; David R. McIlroy, MBBS, MClinEpi, MD, FANZCA; Priya Nair, MBBS, MD, FCICM, PhD; Daniela Pasero, MD, MSc; David Pilcher, MBBS, MRCP, FCICM, FRACP; Steffen Rex, MD, PhD; David Royston, FRCA; Peter Slinger, MD, FRCPC; Franco Valenza, MD; Chris Walker, MBBS, FRCA, FFPMRCA, FFICM. Consensus members (exclusive of the consensus developing and coordinating group or co-chairs and writing group members): Antonio Arcadipane, MD; Oliver Bastien, MD, PhD; Joseph A. Bekkers, MD, PhD; Dominique Bettex, MD; Francesca Caliandro, MD; Erika Dal Checco, MD; Robert Duane Davis, MD; Goran Dellg- ren, MD, PhD; Andreas Espinoza, MD, PhD; Marie Louise Felten, MD; Paolo Feltracco, MD; Marc Fischler, MD; Linda J Fitzgerald, PharmD, BCPS; Ana Flo Forner, MD; Isabel Fragata, MD; Ana Gonzalez Roman, MD, PhD, MBA; Paul Harris, MBChB, FRCA, FFICM, RCPathME; Matthias Hommel, MD, MBA; Nicholas J. Lees, FRCA, EDIC, FFICM; Morgan Le Guen, MD, PhD; Marc Leone, MD, PhD; Thierry Lepoivre, MD; Carlo Marcucci, MD; Sabina Martelli, MD; Mir- eille Michel-Cherqui, MD; Ulrich Molitoris, MD; Philippe Montravers, MD, PhD; Roberto Mosca, MD; Barbora Parizkova, MD, FRCA; Mahesh Prabhu, MD, FRCA, FFICM; Francesco Pugliese, MD; Sanjeev M. Raman, MBBS, MD; Cristina Ramos, MD; Vito Marco Ranieri, MD; Maria I. Real, MD, PhD; Sven-Erik Ricks- ten; Ana Gonzalez Roman, MD, PhD, MBA; Bertrand Rozec, MD, PhD; Shiva M. Sale, MBBS, MD, FASE; Juan F. Sanchez, MD, FCCP; Johanna Schwarzenberger, MD; Sema Turan, MD; Kamen Valchanov, BSc, MD, FRCA, FFICM; Vincent G. Valentine MD, FCCP; Peter von Homeyer, MD, FASE; Alain Vuylsteke, BSc, MA, MD, (FRCA, FFICM); Thomas Weig, MD; Iratxe Zarragoikoetxea, MD, PhD; Sebastian Zenz, MD. Independent Reviewers: Pierre-Emmanuel Falcoz MD; Ilhan Inci, FEBTS; Andrew Roscoe, FRCA; Mert Senturk, MD.
J Heart Lung Transplant 2021 Nov;40(11):1327-1348.

This quarter’s editorial is taking a step off the beaten path. Last month the Journal of Heart and Lung Transplantation published, what I believe to be, a groundbreaking international multidisciplinary document for perioperative care of lung transplant recipients. This document acknowledges that anesthetic and intensive care management impacts long term outcomes in lung transplant recipients. It offers a combination of published data and expert opinion for guidance and is the first major consensus document to specifically address anesthetic care for lung transplantation.

Key themes include the inclusion of anesthesiologists and intensivists in the selection of lung transplant recipients, use of echocardiography intraoperatively, indications for intraoperative rescue mechanical support, timing of ECMO wean, and strategies for the prevention of primary graft dysfunction. This is a strong document. I hope you give it a read.

Barbara Wilkey, MD