UNOS News

By Flora Simmons, MD

Record-breaking 10,000 Liver Transplants Performed in 2023

In 2023, more than 10,000 liver transplants were recorded, more than any single year in history. This continues the eleven-year streak of record-breaking numbers of liver transplants. More changes to liver allocation are coming soon and should continue to increase annual liver transplant numbers. Link Here

Changes to Minimum Donor Criteria for Kidney Biopsies Leads to increased Kidney Donors

A policy change aiming to standardize biopsy practices was implemented on September 22, 2023 to help improve kidney allocation efficiency. The policy establishes minimum donor criteria for kidney biopsies. The most recent monitoring report shows a six percent (6,930) increase in deceased kidney donors recovered. Link Here

New pre-transplant performance metric

A new risk-adjusted performance monitoring metric will take effect in July 2024 called the “pre-transplant mortality rate ratio”. The pre-transplant mortality rate ratio indicates whether patients listed at a program are more or less likely to die prior to receiving a transplant than expected. Link Here

Change to the Organ Offer Acceptance Limit

On May 29, 2024 the number of offers a transplant hospital may accept per transplant candidate will be reduced. Link Here

Research Updates and Interesting Articles

By Michael Trostler, MD and Alex Stoker MD

Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review

The aging population has led to an increase in the ages of our transplant population. This narrative review details the individual factors that aging patients deal with and should be recognized as we proceed with transplanting this patients. Frailty, sarcopenia, cognitive dysfunction, likelihood of malignancy, coronary artery disease and associated disorders are some of the preoperative factors that we need to be considering. Link Here

Understanding Alcohol Relapse in Liver Transplant Patients With Alcohol- Related Liver Disease: A Comprehensive Review

Alcoholic relapse is a formidable challenge in alcohol related liver disease and liver transplant. This review explores the nature of relapse and strategies to prevent it. This is written with alcoholic cirrhosis in mind, but the strategies are equally relevant in acute alcoholic hepatitis as these patients have not had a period of abstinence prior to transplant. A holistic approach, recognizing the interconnections between the social, psychological, medical, and physiological factors are key to preventing relapse. Link Here

Liver Machine Perfusion Technology: Expanding the Donor Pool to Improve Access to Liver Transplantation

The effect of machine perfusion on liver transplant center donor utilization. Significantly more DCD donors were used, increased DCD >50 years old, increased steatosis fraction utilization, and increased warm ischemia time. Link Here

Universal Antifungal Prophylaxis Effectively Prevents Fungal Bloodstream Infection in Pediatric Liver Transplant Recipients: A retrospective real-world study

Empiric treatment of pediatric liver transplant recipients with anti-fungals helped prevent fungal bloodstream infections in a retrospective study of 604 pediatric liver transplant recipients in China. Link Here

Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions

Liver transplant is the second most common solid organ transplant procedure worldwide, as increasing numbers of transplants are performed each year and as the age of transplant recipients increases screening for CAD is especially important. This literature review covers risk stratification techniques/tests, transplantation. Link Here

Outcomes following concomitant multiorgan heart transplantation from circulatory death donors: The United States experience

The recent emergence of ex-vivo machine perfusion and normothermic regional perfusion has allowed for expansion of the donor heart pool by utilization of Donation after circulatory death (DCD) organs. Multi-organ heart transplant candidates face a high waitlist mortality. Outcomes following multi-organ heart transplantation from DCD donors is not well established, as these patients had been excluded in recent RCTs of DCD heart transplantation.

In this retrospective study of multiorgan heart transplant candidates and recipients, the authors found willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates. Heart- kidney recipients of DCD organs had similar post-transplant outcomes compared to recipients of brain-dead donor transplants. While heart-liver and heart-lung recipients represented a group too small for analysis, all patients were alive at last follow up. Link Here

Update from the SATA Council Meeting and National Meeting in Seattle

By Jiapeng Huang, MD, PhD and David Rosenfeld, MD, FASA

SATA Executive Council met in person in Seattle on May 19-20, 2024. The Council discussed plans to develop strategic plans for the coming years.

Discussion points included streamlining SATA committees to avoid overlap and redundancies. In addition, SATA is working closely with ILTS on the upcoming SATA/ILTS perioperative meeting in Philadelphia in Oct 2024. Agenda and speakers are being finalized. SATA has initiated the official application process to become an ASA subspecialty society, which will create significant alignment, collaboration and synergy between SATA and ASA. SATA is also working very closely with our industrial sponsors to promote transplant anesthesiologists recruitment and education.

The SATA National Symposium in Seattle was a resounding success and attended by over 50 physicians . We had great presentations including a section from colleagues from the Korean Society of Transplant Anesthesiologists (KSTA). Pictured below is Dr. Gebhard Wagener with Dr. Sang-Hyun Kim from Soon Chun Hyang University Medical Center during the speakers dinner. We also had a great experience with the first POCUS/TEE Interactive Training Workshop.

Special Topics

By Alex Stoker, MD

Lipomatous Hypertrophy of the Interatrial Septum

Lipomatous hypertrophy of the interatrial septum (LHIS) is a benign cardiac lesion characterized by fat accumulation in the interatrial septum with a prevalence between 2.2% and 8% and can be diagnosed by computed tomography, cardiac MRI as well as transesophageal echocardiography (TEE). Using TEE, LHIS is best seen in the midesophageal bicaval view and typically involves hypertrophy of both the cephalad and caudal portions of the interatrial septum, projecting into the right atrium and sparing of the fossa ovalis, creating the classic “dumbbell” shape (see Fig 1 below). Criteria for LHIS includes an atrial septum thickness greater than 2 cm. LHIS can predispose patients to atrial arrhythmias due to conduction disturbances from fat infiltration as well as inflammation. LHIS is associated with advanced age, obesity and pulmonary emphysema. It is important to recognize LHIS as this can be mistaken for other pathology such as malignant cardiac tumors or even intracardiac thrombus.

Link Here

In the Spotlight: University of California – Los Angeles – Abdominal Organ Transplant Program

By David Rosenfeld, MD, FASA

For the spring newsletter we are highlighting UCLAs Abdominal Organ Transplant Program. The program is based out of the Ronald Reagan UCLA Medical Center which was opened in 2008 and is a 520-bed center of over a million square feet. This historic liver transplant program was launched and grown under the leadership of renowned surgeon Ronald Busittil in 1984. The abdominal transplant program currently includes both adult and pediatric liver, small bowel and multivisceral transplants. The pediatric arm is staffed by pediatric anesthesia physicians under the UCLA Mattel Children’s Hospital umbrella within the Reagan UCLA footprint. Renal transplantation is managed under the Department of Urology. Volume data from 2023: 195 Liver Transplants, 8 Pediatric LT, 1 Small Bowel.

The adult team includes eleven attending anesthesiologists, as well as a separate pediatric team for that arm. At all times two attendings are on call for the liver team. This team also covers hepatocellular carcinoma resections, hepatic metastatic cancers, complex Whipple procedures and invasive renal cell carcinoma surgeries. UCLA’s patient population is high acuity with an average MELD-Na of 34, with a high percentage of ICU patients listed. Cases are mixed between total cava exclusion (60%), piggyback (25%), and veno- veno bypass (5%) depending on the surgeon and anatomy, with ROTEM and TEE frequently used, and CRRT common. Anesthesiologists are a consistent member of the selection committee, with surgeons, cardiologists, pulmonology

rounds with the entire team. The anesthesiology division meets monthly with case discussions, QI reviews, preoperative evaluations, research presentations, with minutes distributed.

UCLA has a large anesthesiology residency of 27 per class. An intense two- week experience in liver transplant is combined with a two weeks of vascular in a one month rotation. Extensive LT anesthesia website educational resources, simulation-based LT resident training model, and an extensive reading list and Powerpoint lectures are offered. UCLA has a one year non-ACGME Liver Transplant Anesthesia Fellowship for up to two candidates with the goal of training the fellow to be a perioperative consultant in liver transplant anesthesia. Fellows spend 50% of time in clinical liver transplant anesthesia and 50% time working as a staff anesthesiologist. Salary reflects this blended role with additional ability to moonlight. Fellows receive training in transesophageal echocardiography with experience geared towards the Basic PTEXAM Examination of Special Competence. Research experience is encouraged. The division’s research arm is robust with ongoing prospective and retrospective investigations and an institutional outcome database collected for over 20 years. Collaborations exist with cardiology, liver transplant surgery and critical care, and other institutions. Special thanks to Fellowship Director Dr. Christine Ngyen-Buckley, and Service Chief Dr. Christopher Wray for their contributions to this section. If you have interest in having your program highlighted in the future, please contact me at Rosenfeld.david@mayo.edu

SATA Member Corner: 5 minutes with Dr. Christine Nguyen-Buckley from UCLA

By Alex Ruan, MD

Can you share a little bit about your background and your journey to a career in medicine?

My first job out of college was as a study coordinator in pediatric infectious diseases. I realized during that job that I really wanted to work with patients and take care of them as a physician. So that’s what drove me to going into medicine. For anesthesiology, I didn’t really have a good idea of what it was about, even though my husband is an anesthesiologist. During my surgery rotation, the anesthesiologist asked me to come to the head of the bed and let me participate in the patient’s care. He let me do minor things like holding the

thought, “Oh, wow! Look at all these things the anesthesiologist gets to do.” Why transplant anesthesiology?

Transplant anesthesia can be exciting and gratifying. It feels so good when you see patients you care for go from the extremes of being sick in the ICU to recovering after transplant. It’s gratifying when patients come back for routine outpatient procedures like colonoscopies and they look so well. I also have a nice mix of cases in my practice – some days I’ll do general routine cases, then other days, I’m dealing with the intensity of getting someone safely through a transplant.

Why did you join SATA? How long have you been a member of SATA and what is your current involvement with the organization?

I’ve been a member of SATA since around the time that I was a fellow. I’m trying to remember the details, but at the ASA, I think Ryan Chadha said to me “Hey, there’s this SATA meeting. Do you want to check this out?” And so I went to it. There were all these big-time transplant anesthesiologists that were there. It was very intimate and a small group at that point. And now it’s grown so much. It has been really great to be part of an organization where it has been so easy to get involved, even as a fellow.

I’m currently the chair of the SATA membership committee. I would like to help people be satisfied with their experience as SATA members, and then also to recruit members and get them involved. SATA needs the help of its members! Members can email me and I can help connect them to people in areas they may be interested in.

What are your research interests, and do you currently have any research/ clinical projects going on?

My research interests involve perioperative care of liver transplant patients. We’ve been looking at complications like intracardiac thrombosis, how to prevent and treat it, but also why it happens. I’m also interested in education in liver transplant, particularly liver transplant fellowship.

What is your favorite piece of anesthesia equipment?

How do I even choose – it’s so hard to pick a favorite! But one piece of anesthesia equipment that I used today that I was so grateful for, and just love, is having point of care testing in the OR. You can get a blood sample and then almost immediately get the patient’s glucose, hemoglobin, a blood gas, electrolytes and then repeat that as often as you need to. This allows you to do this independently and not be reliant on someone to take it to the lab, then for the lab to run it, so that you can really manage your patient very closely. I find it really crucial, not only for liver transplant anesthesia where we are getting labs every hour or even more often, but general cases as well.

What do you enjoy doing outside of work?

I have 3 sons, they’re 11, 8 and 2. So that keeps me pretty busy. But I also like traveling, I like the outdoors, I like reading a lot – anything from like psychological thrillers and true crime novels to the New York Times.

What advice would you give to a medical student or resident who is interested in liver transplants?

I would say they should definitely join SATA. We have a discounted rate for trainees, and it’s a fantastic opportunity to learn about liver transplant anesthesia and to meet and work with experts in the field. SATA has been very helpful for me in my career by helping me make connections for research projects. Medical students and residents should join the Vanguard Committee so they can get involved and further their career.

Dr. Nguyen-Buckley can be reached at cnguyenbuckley@mednet.ucla.edu.

If you or someone you know is interested in being featured in the SATA newsletter, please reach out to Dr. Alexandra Ruan aruan@stanford.edu

Newsletter Committee Update

Future ideas – we are exploring the concept of having a printed newsletter to serve our membership. The SATA newsletter committee is actively seeking

new members. Those interested in all topics related to transplant anesthesia are welcome. We are always looking to expand ideas and content for the newsletter. If interested, please contact David Rosenfeld, MD at Rosenfeld.David@mayo.edu

SATA Survey

Adult Liver Transplant Anesthesiology Practice in the Post-COVID-19 Era: Survey from the Society for the Advancement of Transplant Anesthesia

We previously sent out an email about participating in the first survey from the SATA Practice Management Committee focusing on adult liver transplant institutions in the United States. This is a reminder email to please complete the survey if you have not previously. The link is below, we greatly appreciate your time and effort to share your experience. If you

Ted Sakai (sakait@upmc.edu).

Follow this link to the Survey:

Take the Survey

Or copy and paste the URL below into your internet browser:

https://ucdenver.co1.qualtrics.com/jfe/form/SV_9piQkrlQ5YnJ3iC? Q_DL=8SwUYTYkHyJIGtG_9piQkrlQ5YnJ3iC_CGC_Wc4OqWtC9OalYgm&Q_ CHL=email

Future SATA Events and Meetings

SATA Mid State Meeting – September 27th, Virtual

SATA/ILTS Perioperative Meeting – With the ASA National Meeting, October 18, Philadelphia, PA

SATA Winter West Coast Meeting – December 14, 2024, UCSF

Transplantation Upcoming Meetings

American Transplant Congress, June 1-5, Philadelphia, PA Link Here

30th International Congress of The Transplantation Society (TTS 2024) – TTS Official Meeting, September 22-25, Istanbul, Turkey. Home (tts2024.org)

13th Congress of the International Pediatric Transplant Association (IPTA 2025)

– TTS Official Section Meeting, September 18 – 21, Berlin, Germany

18th Congress of the International Xenotransplantation Association (IXA 2025) – TTS Official Section Meeting, Sept 30-October 3, Geneva Switzerland. Link Here

BOARD OF DIRECTORS: TERM 2023 – 2024

President

Gebhard Wagener, MD

Immediate Past President

Tetsuro Sakai, MD, PhD, MHA, FASA

Founding President

Ernesto A. Pretto Jr., MD, MPH

President-elect

Lorenzo De Marchi, MD

Secretary

Jiapeng Huang, MD, PhD, FASA, FASE

Treasurer

Ranjit Deshpande, MBBS Executive Council Michael Ander, MD, FASA

Adrian Hendrickse, BM, MMEd, MAcadMEd, FRCA Sathish S. Kumar, MD

Raymond M. Planinsic, MD, FASA

Newsletter Editor-in-Chief

David Rosenfeld, MD

Newsletter Editorial Board

Sennaraj Balasubramanian, MD Amit Bardia, MD

Jiapeng Huang, MD, PhD, FASA, FASE

1. Susan Mandell, MD, PhD Sergio Navarrete, DO Yong G Peng MD, PhD Alexandra Ruan, MD

Flora Simmons, MD Natalie Smith, MD Alex Stoker, MD

Michael Trostler MS, MD

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

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

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

In the Transplant News:

Flora Simmons, MD

UNOS Updates

• ASTS Position Statement On The Role Of COVID-19 Vaccination For Transplant Candidates And Recipients: The American Society of Transplant Surgeons continues to recommend routine vaccination for all organ recipients (along with timely boosters). It also recommends vaccines for those on the waiting list, if possible. Read more at the ASTS Position Statement. 
• Kidney Transplants Increase Across All Populations Following Policy Changes: Changes to kidney allocation were made in March of this year with the goal of improving access to organs and equality. Recent data shows that kidney transplants for all age groups, blood types, CPRA, and diagnoses have increased following the implementation of these new policies.  Read more at the UNOS News Section. 
• Second Phase Of National DCD Procurement Collaborative Project Ready To Launch: UNOS has launched the second phase of a national collaborative improvement project to help organ procurement organizations (OPOs) identify and share effective practices related to recovery of donation after circulatory death (DCD) organs. Read more at the UNOS News Section.

In the Spotlight: The Miami Transplant Institute (MTI)

David Rosenfeld, MD

An affiliation between Jackson Health System and UHealth-the University of Miami Health System.

In this month’s feature we learn from Drs. Ramona Nicolau-Raducu and Yehuda Raveh some of the characteristics that are unique about MTI.  

The program is housed within the massive Jackson Memorial Hospital, one of the ten largest hospitals in the world with 2000 beds.   Year in and out they are amongst the busiest abdominal programs with a US leading 472 kidneys transplanted in 2020, including a paired exchange program.  MTI is also a front-runner in liver for the last 50 years, with over 4500 cases performed and 131 adult and 22 pediatric in 2020.  Pancreas transplant is equally robust.  For more than 20 years, and greater than 500 cases, a multidisciplinary team of experts at MTI has been treating thousands of children and adults with intestinal failure via Intestinal Rehabilitation or the Intestinal/Multivisceral Transplant Program, with outcomes well above national averages.  Along with deceased donor intestinal (~5 cases/year) and multivisceral transplants (~10-15 cases/year), autologous transplant procedures are offered.  

MTI became in recent years a bloodless center for Jehovah Witness transplants with a meticulous selection process for Jehovah’s Witness liver candidates.  A bloodless protocol has been established of using factor concentrates, hemopure (bovine hemoglobin-based oxygen carrying solution) autotransfusion and cell saver.

In February 2020 the national organ allocation system transformed from donor service area-based to an acuity circles-based model. Due to its unique geography near the tip of the Florida peninsula, the new system limits organ allocation.  As a result, use of DCD and other extended criteria grafts for liver or liver-kidney have increased, currently approximately 25% of liver grafts. In addition, patients listed for multivisceral transplantation are especially impacted by this change.  Due to specific quality requirements for suitable donors, which are typically younger and non-obese, the available donor pool is considerably smaller. Previously these patients were assigned amongst the highest status levels on the liver match run, but the current allocation model routinely prioritizes a suitable donor to a liver alone candidate that does not have the same size and quality limitations but has a high “competitive” MELD score.

The Abdominal Transplant Anesthesia Fellowship at Jackson Memorial Hospital was created in 2006 by Dr. Ernesto Pretto, Chief, Division of Transplant Anesthesia and is one of the largest in the nation with 4 fellows/year.  Transplant anesthesiology fellowships are non-ACGME accredited and are generally less popular for board eligible/certified US anesthesiology graduates, however this program has thrived through selecting highly qualified foreign graduates to consistently fill its positions.   They have graduated a remarkable 50 transplant fellows in the last 15 years (10% US graduates and 90% International).

Many thanks to Drs. Nicolau-Raducu and Yahuda for sharing details of their program. 

If interested in having your program highlighted, please contact David Rosenfeld, Mayo Clinic Arizona at Rosenfeld.david@mayo.edu

 Featured Publications in the Transplant Literature: 

Michael Trostler, MD

Living donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria: outcome of expanded criteria in tumor size (Liang et al. BMC Surg. 2021) 

Since 1996 Milan criteria for hepatocellular carcinoma has been used to guide liver transplantation to those who would benefit most and restrict deceased donor organs to those with the highest likelihood of survival. Living donor transplants tend to be directed to individuals who do not meet this criteria if the donor and recipient understand the potential risk. Liang et al. out of Taiwan report on 155 patients, 78 of which were beyond Milan criteria for tumor size or number found similar outcomes and recurrence rates. They propose a new criteria: maximum tumor size <= 6cm and total tumor size < 10cm.

Challenges and opportunities for treating intrahepatic cholangiocarcinoma (Serifis et al. Hepat Med. 2021)

There is potential to expand transplant criteria for living donor liver transplantation with less stringent criteria for directed donors. In addition to the potential for an expanded hepatocellular carcinoma guideline, cholangiocarcinoma is another disease process with historically poor outcomes which may be treated by transplantation with strict selection criteria, operative staging, and neoadjuvant therapy. 

Liver transplant outcomes after ex vivo machine perfusion: A meta-analysis (Liew et al. Br J Surg. 2021)

Ex-vivo machine perfusion – Meta-analysis included 34 articles with odds ratios favoring hypothermic machine perfusion over static cold storage. Findings include: decreased early graft dysfunction, ischemic cholangiopathy, non-anastamotic strictures and graft loss. Machine perfusion was associated with shorter length of stay. Normothermic perfusion is associated with reduced graft injury. 

Machine perfusion organ preservation: Highlights from the American Transplant Congress 2021 (Pavan-Guimaraes et al. Artif Organs. 2021)

At the American Transplant Congress (June 2021) 33 abstracts on machine perfusion were presented including heart, lung, liver and kidney. Machine perfusion may become gold standard in the future as innovation and advancement bring down costs and improve outcomes. 

SATA Committee’s Update

Yong G Peng, MD, PhD

We caught up with the Quality and Standards Committee Chair, Dr. Adrian Hendrickse (Associate Professor, University of Colorado). The members of the committee have been working hard on several surveys. The first survey, led by Dr. Cara Crouch (Assistant Professor, University of Colorado), looked at Adult Liver Transplant Anesthesiology practice patterns across the US. Their research was published in the Journal of Clinical Transplantation. (Crouch et al. Clin Transplant. 2021)

Additionally, a smaller sub-committee of members are interested in living donor liver transplantation (LDLT) status. The group, headed by Dr. Tetsuro Sakai (SATA president), has investigated LDLT programs across the US. They have submitted their findings in an abstract to the 2022 IARS/AUA and ILTS meetings. They plan to prepare a manuscript of their findings. The committee has worked closely with the Korean Society of Anesthesiologists in an effort to write a collaborative review of LDLT practice, which they are planning to submit to Clinical Transplantation. 

The Q&S committee members have worked on several other research projects, including similar survey-based methods, investigating different organ transplantation services, and pursuing the development of SATA endorsed guidelines for our subspecialty.

News clips from the Executive Board of SATA

Lorenzo De Marchi, MD, Secretary, SATA

The SATA council wishes its members a happy holiday and new year.  We are always looking for ways to ensure SATA meets your needs.  Send us your suggestions.  We are listening.  Let us update you on the most recent and exciting projects in the works.  

Membership renewal:  We look forward to working with you in the upcoming year so don’t forget to renew for 2022.  There is easy access on the website. New members will receive six months free SATA membership.  Let your colleagues know. 

The SATA-Data Collection Project; a collaborative data collection project that extends the American College of Surgeons NSQIP to  anesthesia outcome measures of abdominal transplantation.  Headed by Dieter Adelman an anesthesiologist from UCSF and Stuart Greenstein, a surgeon from Montefiore.  If your center wants to participate, please reach out to Dr. Dieter Adelman (dieter.adelmann@ucsf.edu) and Dr. Sher-Lu Pai (pai.sherlu@mayo.edu) for information.

New Professional Associations: SATA and the Society for Cardiovascular Anesthesia have agreed to work together on shared interests in both heart and lung transplantation.  We thank SATA President Dr. Ted Sakai and SATA Treasurer Dr. Jiapeng Huang, in addition to  Dr. Archer Martin from SCA for their hard work on this project.

New Committee:  SATA approves new Critical Care Medicine Committee.  Please contact Dr. Ranjiit Deshpande through the SATA home link to apply and find out more.

Expanding SATA research:  Go to the web to apply for the Society’s endorsement for your research project. Submit your application to the SATA Secretary (demarchilorenzo@yahoo.com) for Council review and feedback.

Mark the calendar and pack your flipflop and sunscreen!!

The SATA annual meeting at the IARS is in Hawaii on Monday, March 21th, 2022 as an in-person meeting.  If you can’t be there don’t forget about upcoming SATA regional meetings with CME credits.  Check on the Society’s website for a complete list and dates.

Explore Educational Content

Webinars

August 2021: Rise of the Machines in Solid Organ Transplant

February 2021: Pro/Con Debate: Routine Anticoagulation in Liver Transplantation 

October 2020: Pro/Con Debate: ECMO vs Cardiopulmonary Bypass in Lung Transplantation 

June 2020: Transplant Anesthesiology during the COVID-19 Pandemic 

Vanguard Expert Lecture Series

June 2021: Evaluation for Lung Transplantation: Pulmonologist Perspective 

March 2021: Living Donor Liver Transplantation: Donor Management 

Fellowship Lecture Series

August 2021: Cardiovascular Assessment of Liver Transplantation Candidates 

June 2021: Multivisceral Transplantation 

May 2021: Acute Liver Failure 

Transplant Anesthesia Upcoming Meetings

SATA Meetings 

SATA West Coast Liver Transplant Anesthesia Meeting, December 11, 2021 9am – 12:30pm PST – Register for the Virtual Meeting

SATA Midwest Meeting, January 22nd, 2022; 8:55 am – 12:30 PM CST – Register for the Virtual Meeting

SATA National Meeting at IARS, March 21, 2022, Honolulu, HI

SATA Tristate Meeting, April 9th, 2022

Other Transplant Anesthesia Meetings

ILTS Virtual Consensus Conference January 28-29, 2022

IARS Annual Meeting March 18 – 21, 2022, Honolulu, HI

ILTS Annual Meeting May 4 – 7, 2022, Istanbul, Turkey
 
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BOARD OF DIRECTORS: TERM  2021 – 2022

President
Tetsuro Sakai, MD, PhD, MHA, FASA

Immediate Past President
M. Susan Mandell, MD, PhD

Founding President
Ernesto A. Pretto Jr., MD, MPH 

President-elect
Gebhard Wagener, MD

Secretary
Lorenzo De Marchi, MD

Treasurer
Jiapeng Huang, MD, PhD, FASA, FASE

Executive Council
Ranjit Deshpande MBBS
Adrian Hendrickse, BM, PgDipMEd, MAcadMEd, FRCA
Christine Nguyen-Buckley, MD
Ramona Nicolau-Raducu, MD, PhD

Newsletter Editor-in-Chief

Yong G Peng MD, PhD

Newsletter Editorial Board

Sennaraj Balasubramanian, MD
Amit Bardia, MD
Jiapeng Huang, MD, PhD, FASA, FASE
M. Susan Mandell, MD, PhD
Sergio Navarrete, DO
David Rosenfeld, MD
Flora Simmons, MD
Natalie Smith, MD
Michael Trostler MS, MD