Meeting Report on the 2012 Annual Congress of the International Liver Transplant Society

The International Liver Transplant Society’s (ILTS) 18th Annual International Congress was held on May 16–19, 2012 in San Francisco, California. Over 1300 registrants, representing 53 countries, attended the meeting. Approximately one third of attendees were from North America, with significant representation from Europe (24%), Asia (21%), and South America (5%). The predominant specialties represented were surgery, hepatology, and anesthesiology. The meeting advances the society’s mission “to promote and disseminate multidisciplinary scientific advances in liver transplantation worldwide.” As in past years, annual recurring sessions provided many of the meeting’s highlights. The Vanguard group sessions engaged young ILTS members in clinical discussions facilitated by recognized experts. The Rising Star symposium paired junior researchers with their institutional mentors at established transplant centers in North America, Europe, Brazil, and China. The State-of-the-Art lectures highlighted immunological topics: exploiting tolerance in the treatment of liver disease and the role of natural killer cells in liver disease. ILTS President Juan Carlos Garcia-Valdecassas from the University of Barcelona reviewed the past year in liver transplantation, presented the Distinguished Service Awards to Anthony Demetris, MD, PhD, and Henri Bismuth, MD, then handed the gavel to incoming President Richard Freeman of Dartmouth-Hitchcock Medical Center. Other awards included international scholarships, which provide $10,000 USD for travel and training. Recipients were Hakon Haugaa of Norway and Quirino Lai from Italy. Vanguard awards of $1500 USD went to Armin Goralczyk, MD, and Naohisa Kuriyama, MD, PhD, for the best papers (clinical and basic science) published in 2011. A total of 700 abstracts were presented, the second-most in ILTS history, and double the number of abstracts of a decade ago. Abstract categories included anesthesia/critical care, surgery, basic science, and categories that overlapped specialties, such as outcomes, living donor, patient selection, and acute liver failure. Hepatology topics, immunosuppression, radiology, and pediatrics rounded out the abstract categories. Three oral sessions and 3 poster sessions were dedicated to anesthesia/critical care topics. A symposium on “Patient and graft optimization” reflected our increasing reliance on marginal organs and saw expert presentations on donor critical care management, ex vivo preservation, and recipient pharmacologic treatments, all aiming to improve organ salvage. In observational studies, attainment of specific physiologic donor management goals has been associated with both increased rates of organ procurement and better graft function. Although not yet tested in randomized studies, the data strongly suggest that target-driven critical care management of donors is beneficial. Innovative and promising ex vivo perfusion techniques, very impressive in animal models, were also reviewed in detail. In the laboratory, changes induced by warm ischemia can be reversed, raising the possibility of obtaining excellent grafts from donation-after-cardiac-death donors, which could significantly address the shortage of donor grafts. Last, recent work assessing the effects of pharmacologic interventions in recipients, including administration of glycine, taurine, melatonin, and nitric oxide, was presented. Large studies reporting outcomes are still lacking, but randomized trials are underway and important advances may be imminent. The anesthesia oral abstract session provided new insights into the pathophysiology of liver disease and its intraoperative management. Data from the Mayo Clinic Rochester characterized markers of cirrhotic cardiomyopathy in liver transplant candidates, defining the prevalence of prolonged QTc, increased left atrial volume, and inappropriate heart rate response to stress. They demonstrated a clear association between cirrhotic cardiomyopathy and elevated Model for End-Stage Liver Disease scores. University of Miami investigators showed that liver enzymes adjusted for the ratio of donor-to-recipient body surface area yielded a superior index of early postoperative graft injury. A paper from Penn State University indicated that postreperfusion concentration differences of cyclic guanosine monophosphate in portal versus arterial blood were associated with vasopressor use, implicating nitric oxide in the pathogenesis of postreperfusion hypotension. A series from the University of Southern California described intraoperative hemodialysis in 175 liver recipients, suggesting that this was a safe alternative to continuous renal replacement therapy (hemofiltration). A presentation from Gurgaon, India described coagulation changes observed in 210 living liver donors who received epidural analgesia. Nearly 90% had elevated postoperative international normalized ratio values, which correlated with indexed remnant liver weight. This corrected spontaneously in all donors within 6 days, and no neurological complications were reported. The final oral abstract was an observational study of intraoperative fibrinolysis from the Royal Free Hospital in London. This group showed that fibrinolysis occurred in 24% of nonaprotinin recipients (versus none if given aprotinin), and that the severity of fibrinolysis was associated with increasing product use. However, blood product use overall was not significantly increased, since 50% of patients with fibrinolysis received therapeutic tranexamic acid. The authors concluded that TEG®-based treatment with tranexamic acid was an effective substitute for aprotinin prophylaxis. The last oral session comprised abstract presentations on “Preoperative Work-up and Cardiac Topics.” This featured an audience response system, in which the views of audience members were displayed. The session was very well attended and stimulated lively and entertaining audience participation. The first paper, from the University of Toronto, found a poor correlation between preoperative echo-Doppler estimates of right ventricular systolic pressures and findings on pulmonary artery catheterization in 397 liver recipients. Audience members suggested that a Doppler right ventricular systolic pressures threshold of 30 mm Hg was not an appropriate threshold for the assessment of predictive validity, and agreed that Doppler values above 40 or 50 mm Hg should prompt further work-up. A presentation from the Mayo Clinic Jacksonville reported that 50% to 60% of their recipients without preoperative or surgical indications for intensive care unit care are extubated in the operating room or postanesthesia care unit. The need for intensive care unit admission was predicted by pretransplant hospital length of stay and by increasing age, Model for End-Stage Liver Disease, operative duration, and blood loss. Although fast-tracking appeared safe, and was associated with significant cost savings, data on the effects of comorbidities and donor factors were not presented. Audience responses suggested that operating room/postanesthesia care unit extubation is still not aggressively pursued in most units. A presentation from Hôpital Beaujon in Paris showed that myocardial perfusion imaging in their unit is invalidated by failure to achieve adequate heart rate responses in most debilitated candidates. Audience reaction suggested that dobutamine stress echocardiography remains the screening investigation of choice in many units, and that routine coronary angiography in males/females over 45 to 55 years with a single risk factor is not widely practiced. This was followed by the presentation of a groundbreaking multicenter study describing outcomes in patients undergoing pretransplant coronary angiography. Recipients with obstructive disease (>50% stenosis of a major vessel) who were managed medically or revascularized according to local practice, had outcomes comparable with those without angiographic evidence of obstructive disease. Although data on history and symptoms of coronary disease were not available, this report suggests that, with current treatments, coronary obstruction need not preclude transplantation. Three case presentations followed: one highlighted the value of transesophageal echocardiography monitoring. Another described the management of intraoperative thrombosis, and the benefits of intensive preoperative optimization of high acuity recipients. The last presentation reported on 13 intraoperative cardiac arrests in a series of 1349 transplants over 10 years at the Queen Elizabeth Hospital in Birmingham, United Kingdom. Almost all arrests occurred at reperfusion, and most were associated with hyperkalemia. All were initially resuscitated and survived to the postoperative period. A disproportionate number of grafts were steatotic and/or from extended criteria donors. Ventricular tachycardia and ventricular fibrillation accounted for most arrests, although asystole and pulseless electrical activity also occurred. Nine of these patients survived to discharge and were alive at the time of the report. Many sessions and invited presentations, including those already described, were of value to a wide audience of liver transplant professionals, an advantage of the International Liver Transplantation Society’s multidisciplinary membership and ethos. Similarly, sessions on long-term outcomes and the experiences of new international programs had broad appeal. Also, very successful were the early morning Vanguard Rounds and Vanguard Debates. These didactic sessions are restricted to trainees and younger members of the ILTS, with senior experts serving as discussants. One of these involved an enigmatic case of portopulmonary hypertension with commentary by Michael Ramsay, a founding ILTS member, former society president and world authority on the condition. Another case discussion focused on the controversial role of artificial liver support in acute liver failure. Most of the congress-invited lectures are available to ILTS members on the society’s website (www.ilts.org), courtesy of the presenters. The site has dedicated specialty pages with meeting reports, a discussion forum, audio-linked PowerPoint lectures, selected PubMed abstracts with expert commentary, and topical reviews. A video platform and the ILTS International Directory of Liver Transplant Programs are also featured, along with a Training page showing details of scholarship and fellowship opportunities around the world. Readers are encouraged to use the directory to enter or update training information for their centers. The Anesthesia/Critical Care section is cosponsored by the Liver Intensive Care Group of Europe (LICAGE). ILTS holds a satellite meeting in conjunction with the American Society of Anesthesiologists’ Annual Meeting each year. This meeting is a good opportunity for liver transplant anesthesiologists to update their knowledge, network with experts, and obtain Continuing Medical Education credits. Next year’s 19th Annual International Congress will be held on June 12–15, 2013 at the Sydney Convention & Exhibition Center in Sydney, Australia. Anesthesiologists Randolph Steadman (David Geffen School of Medicine, UCLA, Los Angeles, CA) and John Klinck (Addenbrooke’s Hospital, Cambridge, United Kingdom) provided this report. Both are members of the ILTS Council. Randolph H. Steadman, MD, MS Department of Anesthesiology David Geffen School of Medicine at UCLA Los Angeles, California John R. Klinck, MD, FRCPC, FRCA Division of Perioperative Care Cambridge University Hospitals Cambridge, United Kingdom

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