Liver Transplant

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Welcome to the UCSF Liver Transplant Anesthesia website! Liver transplant anesthesia is a division of the Department of Anesthesia and Perioperative Care at UCSF. We are proud to be an integral part of the liver transplant team at UCSF, one of the largest and most successful liver transplant programs in the country. Our mission is to provide outstanding clinical care to transplant patients and all patients with end-stage liver disease. Our team is also dedicated to excellence in teaching and is at the forefront of exciting clinical and translational research within transplantation. On this website, we present our team members, highlight our research endeavors, provide information about our clinical service, and share resources for the resident rotation. For those interested in our one-year fellowship position, more information can be found here

Kate Kronish, MD
Chief, Division of Liver Transplant Anesthesia

 

 

Clinical Service

UCSF has a world class Transplant Division with a distinctly robust and high-volume Liver Transplant service that includes a team of highly specialized nurses, nurse practitioners, social workers, hepatologists, intensivists, transplant surgeons and liver transplant anesthesiologists. UCSF consistently exceeds the national average for transplant rate with 180 liver transplants completed in 2017, including 29 living donor liver transplants. We have the privilege of caring for some of the most medically complex, high acuity patients. 55% of our liver transplant recipients have MELD scores of 15 or greater and 30% of our recipients have MELD scores greater than 30. Despite the severity of illness of our transplant recipients, we have exceptional graft and patient outcomes, with a 93% recipient one-year survival with functioning graft and an 85% 3-year survival with functioning graft. In 2017, the Liver Transplant Program at UCSF earned the highest score for risk adjusted outcomes based on data from the Scientific Registry of Transplant Recipients (SRTR). For more detailed information on transplant demographics and outcomes at UCSF and other centers, visit https://www.srtr.org/

UCSF has the second largest living donor liver transplant program in the United States. We take a multidisciplinary and comprehensive approach to the care of both donors and recipients that involves close collaboration between the transplant surgeons and liver transplant anesthesiologists. 

As part of the hepatobiliary service, the liver transplant anesthesia team also provides expert anesthetic care to patients undergoing hepatic resections and biliary reconstruction, as well as to those with end-stage liver disease undergoing other complex surgical procedures.

Studies and Projects

Mild Hypothermia and Acute Kidney Injury in Liver Transplantation (MHALT):

The Liver Transplant Anesthesia Divisionis currently conducting the Mild Hypothermia and Acute Kidney Injury in Liver Transplantation (MHALT) Trial. Acute kidney injury (AKI) is a major complication that impairs recovery after liver transplantation and can lead to increased mortality, graft loss, costs, and ICU and hospital length of stay. Mild hypothermia (34-35°C) has been shown in animal models, and more recently in deceased kidney donors, to help preserve kidney function after ischemic injury or transplantation. MHALT (NCT03534141) is a single-blind, randomized controlled trial of mild hypothermia during liver transplantation (see figure) that aims to determine the optimum patient core temperature to preserve post-operative kidney function. MHALT is currently enrolling subjects. The study is funded by a Department of Anesthesia & Perioperative Care Seed Award and a UCSF REAC grant.

 

Liver Transplant Quality Improvement Database: 

The liver transplant anesthesia group maintains a comprehensive perioperative data repository that includes recipient transplant data since 2010. This database captures an extensive range of preoperative and intraoperative variables that allow us to query our practices and outcomes and subsequently refine our approach to provide the best care possible. 

Link to LQI found here

Transplant Outcomes in Anesthesia Database

Liver transplantation is a multidisciplinary collaboration between multiple teams of health care practitioners (nurses, surgeons, anesthesiologists, hepatologists, and intensivists), as well as organ procurement organizations (OPOs). The unification of data from disparate sources is a critical step toward investigating liver transplant outcomes. The Transplant Outcomes in Anesthesia Database (TOAD) consolidates and structures EMR and non-EMR data generated by UCSF surgeons and anesthesiologists, as well as OPO data regarding the organ donor and the procurement processes. This database facilitates quality improvement of surgical and anesthetic management for the UCSF Liver Transplant team and serves as a proof of concept for the integration of patient data sources.

Interesting Articles/Papers  

Claus Niemann, senior member of the liver transplant anesthesia team and co-director of the Ischemic Organ Injury Lab, and is actively involved in donor organ research. Niemann and colleagues published in NEJM their work showing that mild hypothermia in deceased organ donors significantly reduced delayed graft function in kidney transplant recipients.  Further information about this study found here.

When brain-dead organ donors were cooled, their kidneys worked better in transplant recipients

Notable Publications

Our liver transplant anesthesia team has contributed extensively to the body of literature regarding liver transplantation and donor management. Below is a sample publication list.

The Impact of Deceased Donor Liver Extraction Time on Early Allograft Function in Adult Liver Transplant Recipients.
Adelmann D, Roll GR, Kothari R, Syed S, Burdine LJ, Tavakol M, Niemann CU.
Transplantation. 2018 Nov;102(11):e466-e471

Desmopressin Reverses Overly Rapid Serum Sodium Correction in a Hyponatremic Patient Undergoing Living Donor Liver Transplantation: A Case Report.
Brinson EL, Yu JS, Liu LL, Bokoch MP.
A A Pract. 2018 Aug 1;11(3):82-84. 

Intraoperative Management of Liver Transplant Patients Without the Routine Use of Renal Replacement Therapy.
Adelmann D, Olmos A, Liu LL, Feiner JR, Roll GR, Burdine L, Tavakol M, Syed S, Orandi BJ, Niemann CU.
Transplantation. 2018 May;102(5):e229-e235. doi: 10.1097/TP.0000000000002137.

Central venous pressure monitoring in living donor kidney recipients does not affect immediate graft function: A propensity score analysis.
Adelmann D, Bicknell L, Niemann CU, Feiner J, Roll GR, Burdine L, Whitlock EL.
Clin Transplant. 2018 May;32(5):e13238. doi: 10.1111/ctr.13238. Epub 2018 Mar 30.

Anesthesia for Liver Transplantation.
Adelmann D, Kronish K, Ramsay MA.
Anesthesiol Clin. 2017 Sep;35(3):491-508. doi: 10.1016/j.anclin.2017.04.006. Epub 2017 Jul 10. Review.

Therapeutic Hypothermia in Deceased Organ Donors and Kidney-Graft Function.
Niemann CU, Feiner J, Swain S, Bunting S, Friedman M, Crutchfield M, Broglio K, Hirose R, Roberts JP, Malinoski D.
N Engl J Med. 2015 Jul 30;373(5):405-14. doi: 10.1056/NEJMoa1501969.

Impact of a quality improvement project on deceased organ donor management.
Olmos A, Feiner J, Hirose R, Swain S, Blasi A, Roberts JP, Niemann CU.
Prog Transplant. 2015 Dec;25(4):351-60. doi: 10.7182/pit2015129

Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to medium-income countries.
Rando K, Niemann CU, Taura P, Klinck J.
Liver Transpl. 2011 Nov;17(11):1247-78. doi: 10.1002/lt.22405.

Critical care of the end-stage liver disease patient awaiting liver transplantation.
Findlay JY, Fix OK, Paugam-Burtz C, Liu L, Sood P, Tomlanovich SJ, Emond J.
Liver Transpl. 2011 May;17(5):496-510. doi: 10.1002/lt.22269. Review.

Multivessel coronary artery disease predicts mortality, length of stay, and pressor requirements after liver transplantation.
Yong CM, Sharma M, Ochoa V, Abnousi F, Roberts J, Bass NM, Niemann CU, Shiboski S, Prasad M, Tavakol M, Ports TA, Gregoratos G, Yeghiazarians Y, Boyle AJ.
Liver Transpl. 2010 Nov;16(11):1242-8

Predictors associated with terminal renal function in deceased organ donors in the intensive care unit.
Blasi-Ibanez A, Hirose R, Feiner J, Freise C, Stock PG, Roberts JP, Niemann CU.
Anesthesiology. 2009 Feb;110(2):333-41.

 

Fellowship

Liver Transplant Anesthesia Fellowship

Number of positions: 1-2 per year 

Duration: 1 year 

Description: Our liver transplant anesthesia fellows work with an outstanding team of liver transplant anesthesiologists and surgeons at one of the busiest transplant centers in the country. Our anesthesia team consists of 14 faculty trained in liver transplant anesthesia and critical care. We perform close to 200 liver transplants per year, including 20-30 living donor transplants and 8-10 pediatric transplants. Patients are often acutely ill, with high MELD scores at time of transplant. 

In this unique non-ACGME fellowship, trainees split their time between working as the liver transplant anesthesia fellow and serving on faculty as an attending clinical instructor in the general OR (average 2 days/week in the main OR) and have the opportunity to work overtime hours in the general OR for additional pay. Our fellows participate in adult and pediatric cadaveric and living donor liver transplants, as well as transplant selection committee meetings, transplant morbidity and mortality conference, and journal club. Fellows are expected to participate in at least one scholarly project during the year. There are several ongoing research, education, and quality improvement projects to which fellows may wish to contribute. 

The fellowship prepares candidates for leadership positions in transplant centers and fulfills criteria required to become Director of Liver Transplant Anesthesia as put forward by the ASA. 

Clinical responsibilities: On designated fellowship days, the fellow will be on call for liver transplants occurring day or night. Fellows will only take call until 7pm on evenings preceding an attending clinical instructor day.  Fellows will take an average of two weekends per month of home call. Fellows will participate in 60-80 liver transplants during their fellowship year. Designated attending days will be spent providing anesthesia services for a wide range of cases in the general OR, either working alone or supervising residents and/or CRNAs. 

Research opportunities: During the fellowship year there is ample opportunity to participate in transplant research. Our group is currently conducting several large database projects and multiple randomized controlled trials. Our fellows are encouraged to attend and present at a liver transplant conference, such as the ILTS.

Application: Requires CV, statement of interest (limit 500 words), and 2-3 letters of recommendation.

Email CV and statement of interest to Dr. Sonali Joshi ([email protected]) and Dr. Kate Kronish ([email protected])

Letter writers should email their recommendations directly to Dr. Sonali Joshi.

Please contact Dr. Sonali Joshi, Fellowship Director, with questions.