Organ Transplant PDF

Organ Transplant Hunter Speeg, DNP, CRNA Outline Overview Kidney Transplant Liver Transplant Organ Procurement History of Organ Transplantation Organ transplantation meets the ↑ demand for life-saving procedures Balancing organ supply and patient need based on severity Organ transpla...

Organ Transplant Hunter Speeg, DNP, CRNA Outline Overview Kidney Transplant Liver Transplant Organ Procurement History of Organ Transplantation Organ transplantation meets the ↑ demand for life-saving procedures Balancing organ supply and patient need based on severity Organ transplantation concept dates back to the early 1900s Alexis Carrel - Pioneer in transplant vascular surgery with anastomosis (Nobel Prize in Medicine in 1912) Techniques still used today Transplantable organs Kidney, liver, pancreas, heart, lungs, cornea, intestines, uterus, stem cells History of Organ Transplant Immune System Challenge Early issue → Organ rejection by the recipient's immune system Peter Medawar - Theory of graft rejection d/t immunologic incompatibility Medawar's Nobel Prize for Medicine Paved the way for immunosuppression therapies Immunosuppression Therapy Early methods → Corticosteroids & whole-body radiation Major development in 1974 - Introduction of Cyclosporine Cyclosporine still used to prevent graft rejection Types of Organ Donation Donation After Brain Death (DBD) Traditional donation where the donor is declared dead d/t the absence of viable brain activity Brain death results from a lack of blood supply & oxygen, causing irreversible brain cell death Most common form today Donation After Cardiac Death (DCD) Introduced to address transplantable organ shortages to meet demands Ethical concerns surrounding timing of death present challenges & hinder widespread acceptance Living Donor Transplants Living individuals donating an organ to another person (family members, friends, or strangers) Thousands performed each year (mostly kidney) In 2019, the US highlighted its significance and recorded a record 7,397 living donor transplants Organ Transplantation Considerations Organ Donation and Transplantation Statistics: Organ donation is an accepted medical treatment for patients with end-stage organ failure ~ 80 people receive organ tx daily, but 20 people die daily while waiting for a tx The number of transplants & donors continues to steadily ↑ In 2019, a record 39,718 transplants were performed in the US Despite the ↑ in tx, more than 112,500 pts remained on the waiting list in 2019 National Organ Transplant List & UNOS: The national organ transplant list is maintained by UNOS UNOS enforces strict standards for fair and ethical organ distribution Criteria considered for organ allocation include: Blood/tissue matching, organ size, medical urgency, wait time, & geographic location of donor & recipient Annual Transplant Data Organ Transplantation Considerations Organ Donor Statistics: Over 120 million people in the US are identified as organ donors A single donor can save as many as 8 lives through organ donation Only 3 out of every 1000 people are estimated to die in a way that allows for organ donation Consideration of Alternative Donation Methods: Due to the limited availability of organs for donation based on DBD criteria, guidelines for DCD & living donor donation have been developed These alternative methods aim to expand the pool of potential donors and save more lives Renal Transplant History of Kidney Transplantation: The 1st kidney tx occurred in 1954, with a living donor providing a kidney to his identical twin Renal tx gained momentum in the 1960s with the development of immunosuppression Kidney Transplantation Today: Kidney transplantation is the most common solid organ transplant procedure It offers an improved quality of life and higher survival rates compared to dialysis Five-year post-transplant survival rates are impressive: 91% for recipients of live donor grafts 83% for standard non-ECD (extended criteria donor) deceased donor recipients 70% for recipients of grafts from ECDs (extended criteria donors) End-Stage Renal Disease Defined as ↓ in kidney function to less than 10% of normal capacity Decline measured using GFR (< 15% necessitates renal replacement tx) Maintain fluid volumes, eliminate nitrogenous wastes, & maintain plasma pH & erythropoietin Has significant societal impacts in terms of cost & resource allocation ESRD pts often have multiple comorbidities & may require HD Incidence steadily ↑ from 1980 to 2001 (plateaued in recent years) Factors contributing to rise include DM & HTN (esp. in older adults) Affects heart, brain, peripheral vessels, GI tract, hematologic system, & CNS Comprehensive preop assessment is crucial, esp. for renal tx Classification & Staging of Chronic Kidney Disease by National Kidney Foundation Stage Description GFR (mL/min/1.73 m2) 1 Kidney damage with normal or ↑ GFR > 90 2 Kidney damage with mild ↓ GFR 60 -89 3 Moderate ↓ GFR 30-59 4 Severe ↓ GFR 15-29 5 Kidney Failure < 15 or dialysis Preoperative Considerations for Renal Tx Renal dysfunction r/t HTN & DM = most common indications for kidney tx in US Average time a pt is on the waiting list for a kidney is > 3 years CHF is most often caused by ischemic heart disease (25% of CKD pts) Focus on managing heart failure, fluid, and electrolyte abnormalities Assess exercise tolerance & metabolic equivalent (MET score) Baseline EKG and hopefully an echocardiogram (EF & valve issues) EF often affected due to heart failure and may improve after transplant Consider coronary angiography & stress echocardiography for high-risk pts Other Common Issues Chronic Anemia S/t ↓ erythropoietin production & hemolysis ↑ CO to compensate for anemia; which ↓O2-carrying capacity → ischemia ↓ hgb (5-8 g/dL) may necessitate erythropoietin adm or blood tx Coagulopathies Result from ↓ platelet adhesion Tx with desmopressin (DDAVP) or cryoprecipitate may be beneficial Electrolyte Abnormalities Hyperphosphatemia = ↓ Ca++ absorption = hypocalcemia = ↑ fracture risk Hyperkalemia is hazardous and often requires dialysis Different Pathophysiological Features of Transplant Recipients Pathophysiologic Features Preoperative Intraoperative Considerations Considerations Cardiovascular Alterations - HTN - Repeated assessment - Intraoperative monitors - CAD - Echocardiography - Goal-directed therapy - Ventricular Dysfunction - PHTN - Peripheral vascular status - Decreased CSI Airway & Lung - ↓ Lung Volume - Prehabilitation Considerations - ↓ Lung Diffusion - Difficult Airway Fluid & Electrolyte - Fluid Status - Previous dialysis not - Nephroprotective strategies Disturbances - Potassium Overload mandatory - Goal- directed therapy - Requirement of HD Blood & Coagulation - Uremic thrombocytopenia - Avoid epidural technique Disturbances - HD-related heparin tx - Hg trigger: - Multifactorial anemia - 7 g/dL - 8 g/dL if previous CV dx Kidney Transplant Overview No kidneys are removed Donor kidney placed in iliac fossa 1. Venous anastomosis with iliac vein 2. Arterial anastomosis with iliac artery 3. Donor ureter connected to bladder 4. Renal, gonadal, and inferior phrenic veins sewn in Recipient Risk Factors for Rejection 1. Previous blood transfusions, particularly if recent 2. Previous pregnancies, particularly if multiple 3. Previous allograft, particularly if rejected early 4. African ethnicity 5. cPRA > 20% 6. Donor-specific antibody (current or historic) Anesthetic Considerations GETA is the standard for kidney transplant surgery Goals → maintaining an appropriate DOA, muscle relaxation, & HD stability ESRD pts are at risk of aspiration d/t gastroparesis → RSI? Succinylcholine may be used cautiously, with attention to potassium levels Rocuronium ok for RSI in high-risk pts Cisatracurium is often preferred in ESRD patients d/t its intermediate DOA Close NMB monitoring is crucial for appropriate management & reversal Intraoperative Monitoring Standard, noninvasive monitoring is usually sufficient for younger, healthier transplant recipients A-line useful in patients with CAD & uncontrolled hypertension CVP monitoring is beneficial when assessing CVP is necessary CVL are common d/t immunosuppressive & vasoactive medication adm In some cases, PA catheter & TEE may be needed Large-bore PIV lines are essential, but challenging d/t AV fistulas & potential venous thrombosis Induction & Maintenance Induction Propofol is safe and effective in ESRD patients (watch EF) Etomidate is common Maintenance Typically combines VA & IV agents Desflurane, isoflurane, & sevoflurane are considered safe in ESRD pts All inhalation agents ↓ RBF & GFR in a dose-dependent fashion Renoprotective effects of inhalation agents are under investigation Pain Management Careful analgesic use in ESRD pts d/t metabolites Morphine's effects may be prolonged d/t morphine-6-glucuronide metabolite Meperidine should be avoided d/t its metabolite, normeperidine, ↑ the risk of CNS excitatory effects & seizures IV Fluids & Pharmacologic Considerations Maintenance of IV volume is crucial for the transplanted kidney's performance Avoid lactated Ringer’s d/t K+ content; prefer PlasmaLyte & NS Caution: hyperchloremic metabolic acidosis from excessive NS can worsen hyperkalemia Colloids like albumin can help maintain IV fluid volume while avoiding acidosis Maintain HD without compromising RBF (dopamine, dobutamine, & fenoldopam) Osmotic & loop diuretics may be used to increase urine output Immunosuppressive Therapy Most U.S. kidney transplant recipients receive tacrolimus, mycophenolate mofetil (MMF), and often steroids Immunotherapy regimens depend on patient factors, organ quality, and vulnerability to side effects Immunosuppressive strategies include induction & maintenance therapy Induction aims for rapid immunosuppression at transplant, while maintenance uses oral agents. Induction therapy varies but may include antibodies or interleukin-2 receptor antagonists Immunotherapy initiation typically begins with corticosteroid adm & then antilymphocyte agents immediately prior to kidney reperfusion Postoperative Considerations Close monitoring of HD parameters (BP & HR) are essential for RBF Any acute changes in UOP should be evaluated for cause & appropriate tx May require aggressive fluid therapy if it’s r/t to a prerenal cause Postrenal causes, such as ureteral kinking or technical issues, may necessitate surgical exploration and intervention Anesthetic Considerations: Short-Hand Summary Preoperative Anesthetic ABO/Cross Match GETA + RSI BMP, CBC, H/H, PT/PTT/INR, etc. Cisat/Roc & VA for maintenance IV Access (18G PIV preferred) Hemodynamic Goals CVP > 12 cmH2O + MAP 90-110 + Hgb > 8 g/dL Invasive Lines CVL (triple lumen) after induction Avoid Hypotension!!! A-line (if CAD) Avoid α1 agonists (NO neo or epi) Dopamine 1-5 mcg/kg/min Fluids Isolyte preferred Immunosuppression NS (be careful not to adm too much) 1. Solumedrol 500mg started in preop or just after induction Usually no LR Plus ……. Colloids ok 1. Thymoglobulin (1.5 mg/kg) via CVL over 6 hrs + alemtuzumab 30 mg over 4 hrs…….or……. Foley Catheter 2. Basiliximab 20 mg over 3 min via PIV Close UOP monitoring + possibly asked to clamp and unclamp Liver Transplant Overview 1st successful liver transplant in 1967 Limited liver transplants in the 1970s, with survival below 20% Introduction of cyclosporine in the early 1980s significantly improved 1-year survival to over 50% Current 1-year survival rates can reach 85%-90%, & 5-year survival is approximately 70%-75% Disparity b/w available donors & patients needing transplant remains a challenge UNOS reports 193,508 liver transplants from 1988 to early 2020 Over 12,550 patients await liver transplantation in the US Liver Transplant Overview Despite ↑ disease severity, graft survival continues to improve Alternative organ donation methods explored to ↑ viable grafts Non-heart-beating donors, ECMO support, ex vivo perfusion, & split liver graft Living donor liver transplantation Allows for partial hepatectomy in healthy donors, with the liver's unique regenerative capacity Benefits → shorter wait times, elective surgery, high-quality graft, & short cold/ischemic time Concerns → significant donor complications = few living donor liver tx (~ 300/year) Liver Transplant Liver Transplantation Indications & Criteria: Liver transplant is the definitive tx for acute liver failure, ESLD, and primary hepatic malignancy ESLD has seven primary etiological categories (Next slide) Acute Liver Failure & ESLD Criteria: Acute liver failure: severe liver injury with encephalopathy & impaired synthetic function (INR > 1.5) without preexisting liver disease Patients with acute liver failure are given the highest priority for liver transplantation (UNOS status 1), as they may recover or face rapid deterioration without transplantation Cirrhosis patients are not immediate transplant candidates Decompensation signs (ascites, hepatic encephalopathy, variceal bleeding) indicate significantly impaired survival and justify evaluation for the transplant waiting list Developing hepatorenal syndrome is a concerning sign necessitating immediate transplantation evaluation Indications for Liver Tx Model for End-Stage Liver Disease (MELD) Score MELD score is a validated system used by UNOS to prioritize patients on the liver transplant waiting list Utilizes serum total bilirubin, creatinine, & INR values to rank adult pts according to their expected survival rate without transplantation ABO compatibility is crucial, but MELD score helps determine pt with the greatest need for tx Variations of the MELD score include MELD sodium & MELD lactate The MELD score has limitations, esp. for pts with primary hepatocellular carcinoma or unique medical hx Exception points can be added to ↑ the MELD score for patients with conditions associated with chronic liver disease not directly accounted for in the standard scoring system Each tx center has protocols for handling pts with unique medical hx, prioritizing on a case-by-case basis 3-Month Mortality According to MELD Score Common Contraindications for Liver Tx Cardiopulmonary disease that is uncorrectable Acquired immunodeficiency syndrome (AIDS) Untreated TB Malignancy not isolated to the liver that does not meet oncologic criteria for cure Hepatocellular carcinoma with metastatic spread Intrahepatic cholangiocarcinoma Hemangiosarcoma Anatomic abnormalities that preclude transplantation Uncontrolled sepsis Acute liver failure with ICP > 50 mm/Hg or CPP < 40 mm/Hg Nonadherence to medical care Lack of a social support system Relative Contraindications for Liver Tx Advanced Age & HIV Advanced age & HIV (not AIDS) are relative contraindications, but successful tx have occurred in pts >65 with appropriate evaluation of comorbid complicating factors Obesity (Class 3) Class 3 obesity (BMI >40) is prevalent in US & may be considered a relative contraindication at many centers Pts are typically encouraged to lose weight before tx Some centers may perform a gastric sleeve procedure to optimize the potential recipient Center-Specific Variations Contraindications can vary by transplant center with own policies & criteria for evaluating potential recipients Individual Assessment Pts with general contraindications assessed on a case-by-case basis to determine appropriateness for liver tx Preoperative Considerations Patient Demographics & Disease Severity Liver tx patient demographics have shifted towards older individuals d/t evolving donor & recipient criteria & advanced medical technologies, allowing pts to survive longer without transplant Anesthetic Pre-evaluation & Planning Crucial d/t complex comorbidities presented by liver failure pts Communication regarding concerns & surgical approach is essential for anesthetic planning Preanesthetic Evaluation Assess the pt’s ability to tolerate sx & post-tx care Standard eval (airway assessment, previous anesthetics, fasting status (NPO), & ROS) Emphasis should be placed on cardiopulmonary & hepatic systems Further testing may be indicated based on initial screening and patient symptoms Preoperative Considerations Laboratory Panels ABO-Rh blood typing, LFTs (including INR), CBC, Cr clearance, serum α-fetoprotein, Ca++, viral & infective serologies, urinalysis, & urine drug screen Cardiopulmonary Assessment Pts with liver dx may have significant cardiac comorbidities TTE, 12-lead EKG, and noninvasive cardiac stress testing Invasive cardiac catheterization may be recommended for specific patients Pulmonary Assessment Evaluate for hepatic hydrothorax and hepatopulmonary syndrome Pulse oximetry & ABG values are used to screen for hepatopulmonary syndrome Differentiate between elevated pulmonary pressures with normal PVR & portopulmonary HTN Preoperative Considerations Cancer Screening Pts with hepatocellular carcinoma should undergo CT & MRI to scan for metastases & staging Assessing vasculature is also important Upper Endoscopy Performed in pts with cirrhosis & portal HTN to evaluate for esophageal varices Psychosocial Evaluation Identify psychosocial issues that may affect post-transplantation outcomes, including lack of insight, knowledge about the transplant procedure, post-transplant care, and substance use disorders Pre-transplant tx for patients with a history of substance abuse is crucial Preoperative Considerations Unique Disease States Hyperdynamic circulation, cirrhotic cardiomyopathy, CAD, & other cardiac issues. Portopulmonary Hypertension Differentiate between portopulmonary hypertension & elevated pulmonary pressures in ESLD patients Severe, untreated portopulmonary hypertension may be a contraindication to tx Hepatopulmonary Syndrome (HPS) HPS is characterized by arterial hypoxemia caused by intrapulmonary vascular dilatations Dx criteria = portal HTN + hypoxemia + pulmonary vascular dilatations Patients with HPS receive MELD exception points Preoperative Considerations Ascites & Hepatic Hydrothorax Ascites can lead to hepatic hydrothorax, which may require preoperative drainage in patients with respiratory compromise Hepatorenal Syndrome Hepatorenal syndrome is a severe form of acute kidney injury in patients with advanced ESLD Dx criteria = cirrhosis with ascites + ↑ serum Cr Hepatic Encephalopathy Hepatic encephalopathy is characterized by the accumulation of neurotoxins, primarily ammonia, in the brain Tx involves ↓ nitrogen load, dietary adjustments, meds like metronidazole & rifaximin, and avoiding benzodiazepines Operating Room Preperation Ensure the operating room is equipped with standard monitors, arterial line, large-bore IV access, central venous catheter, PAC, continuous cardiac output/function monitoring, thromboelastogram (TEG), TEE, cell saver, rapid infuser devices, and immediate access to blood products. Intraoperative Considerations Monitoring & Hemostasis Careful monitoring & measures to maintain hemostasis, normothermia, and normovolemia are crucial Point-of-service laboratory equipment or a "stat laboratory" is needed for real-time data analysis, including electrolytes, glucose, ABGs, ionized calcium and magnesium levels, & hemostasis profiles Coagulopathies Coagulopathies can occur TEG or rotational thromboelastography allows real-time coagulation assessment Intraoperative Considerations Induction of Anesthesia Limit sedative premeds d/t liver disease sensitivity Choice of induction agents includes midazolam, ketamine, propofol, or etomidate Opioid choice depends on center preference Postinduction Hypotension Common in pts with ESLD d/t ↓ peripheral vascular resistance Vasopressors like phenylephrine & vasopressin are used to maintain MAP & organ perfusion Pharmacokinetic Considerations Drugs metabolized by the liver and cytochrome P-450 pathways exhibit altered pharmacokinetics & pharmacodynamics in ESLD patients Aseptic technique is crucial when placing invasive lines Intraoperative Considerations Neuromuscular Blockade Use NDMR cautiously, considering the duration of surgery & need for prolonged mechanical ventilation Quantitative neuromuscular monitoring is recommended Maintenance of Anesthesia Maintain anesthesia with VA titrated to the patient’s HD profile Invasive Monitoring CVL, PAC (if chosen), large-bore peripheral access, oral/nasogastric tube, and TEE probe placement are done after intubation Consideration for esophageal placement is important (varices) Intraoperative Considerations Neurologic Monitoring Intraoperative neurologic monitoring is crucial d/t risk of various neurologic complications in liver disease patients, including cerebral edema, encephalopathy, seizures, & ↑ ICP ICP Monitoring Is typically invasive, but transcranial Doppler to measure CPP noninvasively is under evaluation Antibiotics & Immunosuppression Coordinate antibiotic dosages & timing, as well as immunosuppression administration, in consultation with the surgical team Liver Transplantation Phases 1. Preanhepatic: Starts with surgical incision and ends with cross-clamping of 1portal vein, 2suprahepatic IVC, 3infrahepatic IVC, and 4hepatic artery 2. Anhepatic: Begins with occluding liver vascular inflow & ends with graft reperfusion 3. Neohepatic Associated with ↑ serum K+ & H+ & ↑ preload along with ↓ in SVR & BP Preanhepatic Phase Ascites drainage & fluid shifts can lead to volume depletion Volume expansion with 5% albumin is preferred over large volumes of crystalloids Blood loss can be significant; careful management is required Maintaining low to low-normal CVP aids in reducing blood loss INR has no predictive value for intraoperative blood loss TEG is the gold standard for coagulation management Cell saver can be used to limit transfusion Preanhepatic Phase: Anesthesia Guidelines Modified rapid sequence induction Invasive monitors (CVP, A-line, PAC, TEE) Forced air & rapid infusers with warmers IV antibiotics, baseline laboratory values Norepinephrine (or vasopressin) to keep mean BP >60 mm Hg Dopamine (or epinephrine) to keep CO at >5 L/min Preanhepatic Phase: Anesthesia Guidelines Maintain Hgb >7 g/dL, plt > 40k, MA (TEG) > 45, fibrinogen >100 mg/dL Mannitol 0.5 g/kg IV over 1 hr, prior to anticipating clamping Just before clamping: IV heparin if TEG is normal or hypercoagulable Increase CVP to 10 cm H2O with crystalloids 25% albumin in severe hypoalbuminemia Anhepatic Phase Begins with clamping of hepatic blood supply & venous drainage Surgical approach (bicaval clamp, piggyback, or venovenous bypass) impacts hemodynamic and fluid management Bicaval clamp can lead to profound hypotension & tachycardia; up to 50% ↓ in venous return Piggyback technique preserves some caval flow, reducing blood product use Fluid loading during anhepatic phase targets CVP of 10 to 20 cm H2O Lactic acidosis may occur due to hepatic metabolism cessation Treat acidosis during this phase since it will worsen with reperfusion Bicaval vs Piggyback Techniques Anhepatic Phase: Anesthesia Guidelines IV fluids to keep CVP at at least 5 cm H2O Crystalloids unless hematocrit is < 21%, at which time blood transfusions should be considered Norepinephrine and/or vasopressin to keep MAP >60 mm Hg & CO >5 L/min Bicarbonate infusion to correct base deficit (acidosis) IV calcium chloride to sustain normocalcemia Hypocalcemia is common → citrate in blood ↓ Ca & the liver normally metabolizes citrate Neohepatic Phase Involves reperfusion of the new liver after caval & arterial anastomoses Maintenance of adequate perfusion pressure to the new liver is essential Avoid high CVP to prevent graft venous congestion Diuresis may be appropriate but should be carefully managed Consideration for core body temperature maintenance Monitoring stable glucose & acid-base status Neohepatic: Postreperfusion Syndrome Most significant anesthetic concern during this phase Characterized by ↓ CO, systemic hypotension, bradyarrythmias, asystole, pulmonary artery HTN, and raised pulmonary capillary wedge pressure in conjunction with ↑ CVP Defined as a >30% ↓ in systemic MAP below baseline for at least 1 minute during the first 5 minutes of hepatic reperfusion Thought to be d/t acute left ventricular diastolic dysfunction Primary goal: maintain liver perfusion pressure and avoid high CVP Neohepatic Phase: Anesthesia Guidelines When SVR is declining, IV vasopressin 1-5 unit bolus to keep mean BP at >60 mm Hg Epinephrine 20-100 mcg boluses if heart rate is 5 L/min and mean BP at >60 mm Hg TEE if needed for detailed hemodynamic assessment Maintain Hgb at >7 g/dL, platelets at >40k, fibrinogen at >100 mg/dL TEG: Protamine 30 mg IV, if R is more than twofold compared to heparinase-R Maintain MA at >45 mm with platelet transfusion If Ly30 is >8%, give IV EACA 5 g over 15 min: Consider indication for postoperative mechanical ventilation per usual criteria Transfer to critical care unit Postoperative Considerations Most liver tx recipients are admitted to a specialized ICU post-surgery d/t critical illness Pts typically have at least 1 major organ failure & often multisystem organ failure prior to tx HD & cardiac instabilities, fluid shifts, coagulopathies, bleeding anastomoses, graft failure, & ventilation requirements are common postoperative challenges In the future, fast tracking may be considered for ideal liver transplant candidates Early extubation is beneficial in many ways when appropriate ↓ intraabdominal pressures & aiding graft perfusion Shorter ICU stay, ↓ resource use, & cost savings (up to 13% reduction) Pt selection is crucial for successful early extubation (70% to 80% in some centers) Pain control often involves PCA IV narcotic use and oral medications once the patient can take pills Epidural pain management may be limited in coagulopathic or suspected coagulopathic pts Organ Donation: Anesthetic Considerations Care of the organ donor involves specialized protocols guided by transplant surgeons and coordinators The type of donation (DCD or DBD) and the pt’s underlying condition influence management plan A significant discrepancy exists between pts awaiting transplant & the available organs Physiologic changes vary between DBD and DCD donors DBD: hyper- or hypotension, arrhythmias, pulmonary edema, DIC, hyperglycemia, & hypothermia DCD: longer ischemic times DCD categorized as controlled or uncontrolled based on predefined criteria Transplant teams should not be involved in the decision to withdraw life support in DCD cases An independent physician determines cessation of cardiac function before organ procurement Anesthetists should be familiar with institution-specific DCD guidelines Organ Donation: Living Donor Involves a directed donation from a friend or family member Medical, social, and psychological histories are thoroughly reviewed The procedure is often elective, scheduled, and timely, reducing cold ischemia time Donors are generally in better health, but there are concerns about the impact on their quality of life and medical risks Financial considerations associated with living donation should also be addressed Living organ donation can ↑ the pool of donated organs, especially in liver tx References Barash, P., Cullen, B., Stoelting, R., Cahalan, M., Stock, M., Ortega, R., Sharar, S., & Holt, N. (2017), Clinical Anesthesia. 8th ed. Lippincott Williams & Wilkins Jaffe, Richard A. Anesthesiologists Manual of Surgical Procedures., 2012 Nagelhout JJ, & Elisha, S. (2018) Nurse Anesthesia. 6th ed. St. Louis, MO. Elsevier Saunders