Follow-up to the ILTS scholarship: report in relation to the training experience and the
implications for our National Liver Transplant Program in Uruguay.
I was born in Uruguay in 1970 and graduated as a Medical Doctor from the State University in 1997 and
finished the Anaesthesia Residency in Clinicas Hospital of Montevideo in 2003. My academic career
started in 1994 as an Assistant Professor in the Pathophysiology Department at the University Hospital
and continued with the post of Assistant and then Associated Professor of Anaesthesia in the Anaesthesia
Cathedra of the same Hospital. In 2004, I joined the Complex Liver Diseases Service at the Military
Hospital and in 2005 I was select as Anesthesiologist of the Bi-institutional Unit of Liver Transplant.
Uruguay was planning to start a National Liver Transplant Program and we needed to be trained on how
to organize the infrastructure and select the resources in agreement with the Health Ministry. I had no
experience in Liver Transplantation – Anesthesia, so I went to Madrid as a clinical observer to different
Hospitals for 3 months (12 de Octubre, Marañón, Ramón y Cajal and Puerta de Hierro Hositals). This trip
was supported by the University and the Military Hospital and was my first contact with liver
transplantation.
I was not yet prepared to decide the equipment and infrastructure needed to set up the program and
politicians were not involved enough in the decision of creating a program and support it for the long term.
I also needed to finish my training in programs with different practices than Spain’s to be able to choose
the best ones for Uruguayan situation.
I went to the ASA-ILTS meeting in Chicago in 2006 and had the opportunity to meet and explain the
necessities of our country to outstanding, well-known anesthesiologists from different countries. I met
faculty members from San Francisco (UCSF) that offered their help. I stayed in San Francisco for 40 days
at the UCSF as a clinical observer and organized the first National Liver and Pancreas Transplant Meeting
in Uruguay.
Portugal, Addenbrooke’s and UCSF professionals influenced the opinion of the Ministry of Health meeting
with them in person during this joint Political and Academic meeting.
The collaboration with staff members at UCSF and Addenbrooke’s Hospital’s was invaluable. In that
meeting, the idea of presenting a project to the ILTS was born: "Evidence-based model for cost-effective
provision of anaesthesia care in resource-limited health economies." I won the first International Travel
Scholar Award - ILTS (International Liver Transplant Society) in 2007 with the double aim to finish
the project and complete my training in Barcelona (Spain), Cambridge (England) and San Francisco-Los
Angeles (United States).
After 3 years of training and finishing the project, I was recognized and responsible for the Anesthesia
Department in the Uruguayan´s National Liver Transplant Program and we started operating on July 14th
2009.
A paper was published in the Liver Transplantation Journal with an updated part of our research:
“Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to
medium-income countries”; authors: Rando K, Niemann CU, Taura P, Klinck J. (1)
After the program started, we organized a Latin American Meeting of Liver Transplantation with the
support of the ILTS, UCSF and Portugal Embassy. It was a great success and the first step to joining the
Latin American starting programs. "We are seeing an explosion of interest from the attending countries
in developing their own liver transplantation programs and I think everyone is truly inspired," Dr. Nancy
Ascher said at the end of the first day of the meeting.
http://www.ucsfhealth.org/news/2011/03/ucsf_liver_transplant_team_shares_expertise_in_latin_americ
a.html
Latin American Meeting of Liver Transplantation in Uruguay in 2011 - UCSF and Addenbrokes´
faculties: Drs. Nancy Ascher, Peter Stock, Claus Niemann, Ryutano Hirosse and John Klinck in the
closing reception of the meeting with Drs. Paola Scalone and Karina Rando.
The benefits of the scholarship were impressive for the Transplant Program and in my personal career,
it encouraged the government to support us by buying the necessary equipment and resources based in
the evidence from experienced centers. The Uruguayan Press spread the news that international
institutions like the ILTS support the program and that mentors from prestigious centers and in developed
countries (England, USA, Portugal, Spain) were going to be next to us
(http://historico.elpais.com.uy/08/02/29/pciuda_332879.asp). That helped the Uruguayan population and
the Uruguayan government to trust our team. We learned that all members must be trained, not only
doctors, but also nurses and auxiliary personnel in different experienced high volume centers.
Therefore, we could take the best of each practice and adapt our protocols to the Uruguayan reality.
The benefits for my personal career began when I was recognized as responsible of the anaesthesia
department in the Transplant Team. I learned anaesthesia for liver transplantation in different centres in
the framework of the scholarship and that was a unique experience. Therefore, I was invited as a faculty
member to several Latin American meetings in Perú (APEH- Asociación Peruana para Estudio del
Hígado), Ecuador (CLASA – Confederación Latinoamericana de Sociedades de Anestesia), Nicaragua
(CLASA), Brazil (FITX – Foro Internacional de Trasplanet Hepático – Universidad de San Pablo) and
Argentina (WFAS – World Federation of Anaesthesia Society). I participated in the Scientific Committee
of the World Anaesthesia Congress in Argentina organized by the World Federation Society. I was
responsible for organizing all the transplant sessions of the meeting.
World Congress of Anaesthesia (WFAS) – Buenos Aires 2012 (Scientific Committee)
I was recently invited as a faculty member to the World Congress of Transplantation (San Francisco July
2014) where I gave a speech about outcomes and cost optimization in Liver Transplantation.
I published several papers related to anaesthesia in transplantation, anaesthesia for transplanted
patients, anaesthesia for liver surgery, transfusion, invasive monitoring and related topics (2-9). A lot of
the papers were in Spanish with a Latin American target of readers: Argentina (Revista Argentina de
Anestesiología), Peru (Revista Peruana de Anestesiología), México (Revista Cirugía y Cirujanos),
Colombia (Revista Colombiana de Anestesia) and Uruguay (Revista de Anestesiología del Uruguay y
Revista Médica del Uruguay).
Now, (August 2014) our Liver Transplant Program in Uruguay is 5 years old.
(http://www.sermedico.com.uy/trabajo-medico/-/asset_publisher/BW27mRDLyEsb/content/cinco-anos-d
el-programa-nacional-de-trasplante-hepatico?template_sofis=10719).
Part of the Uruguayan National Liver Transplant team – August 2014 at the Liver Diseases Service - Military
Hospital, Montevideo - Uruguay
We have about 17 donors per million people, per year and we have performed 94 transplants. The
average number of transplants is less than 20 per year; however, we tend to be a medium volume centre
because the number is growing every year. We are satisfied with the outcomes of our program as well
as the government and its population. We have 11% mortality in one year. We implemented a fast track
practice with very good results; patients stay an average of 1.5 days in intensive care unit and 16 days
of hospitalization. We select the resources and we use them carefully: minimizing blood products
transfusions, don´t use albumin or costly monitoring equipment if it is not necessary and we optimize
human resources by concentrating the dedication time and training in a single team. With those practices,
we are happy to achieve incredible low cost transplants with very good outcomes. This has made our
program prestigious, stable and reliable in our country and the region.
Nevertheless, there are still many things to improve, for example, we need to do living donor transplants.
We must solve the problem of late transplantation in fulminant failures and we need to increase and train
team members according to the growth of the program.
Permanent training, supported by the ILTS (scholarship and meetings) and mentoring from expert
faculties was necessary to start and is essential to continue.
Bibliography.
1. 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.
2. Calidad de asistencia en cirugía hepática: un esfuerzo multidisciplinario. Karina Rando, Martín
Harguindeguy, Alejandro Leites, et all. Rev Med Urug 2010; 26: 117-119.
3. Transfusión masiva y manejo del paciente traumatizado: enfoque fisiopatológico del tratamiento.
Graciela Zunini, Karina Rando, Francisco Javier Martínez. Cir Cir 2011;79:473-480.
4. Hepatectomía con técnica de Takasaki: seguridad y costos de la anestesia combinada generalepidural (Hepatectomy with Takasaki technique: safety and costs of general-epidural combined
anaesthesia). Karina Rando, Martín Harguindeguy, Avelleira, et all. Actas Peru Anestesiol. 2012;
20:75-9.
5. Mielinolisis pontina central e hiponatremia perioperatoria: particularidades en la cirugía de trasplante
hepático. Rando K, Valverde M, Menéndez J, et all. Salud Militar. 2013; Vol. 32 Nº 1:
33-9.
6. Manejo anestésico del donante cadavérico con muerte encefálica (Anesthetic management of
deceased donor with brain death). Karina Rando, Laura Lezama, Javier Díaz, et. All. Actas Peru
Anestesiol. 2013; 21(2).
7. Hipocalcemia, hiperpotasemia y hemorragia masiva en el trasplante de hígado. Karina Rando,
María Vázquez, Gabriela Cervino et all. Rev Colomb Anestesiol . 2014;42(3):214–219
8. Ultrasound-guided internal jugular vein catheterization: a randomized controlled trial. K. Rando, J.
Castelli, J.P. Pratt, et all. Heart, Lung and Vessels 2014; 6(1): 13-23.
9. Anestesia en paciente trasplantado. Karina Rando, Silvina Longo, Graiela Zunini. Rev. Arg.
Anest. 2014. 72(1):30-42.