By Alexander Moore
The CSA Committee on the History of Anesthesia congratulates the runner-up for the CSA 2026 History of Anesthesia Essay Contest: Alexander Moore, author of “Making the Extraordinary Routine: A History of Liver Transplant Anesthesia and Living Donation.”
Alex Moore, a fourth-year medical student at California University of Science and Medicine, was born and raised in Sonoma, California. In recent years, he has resided in Southern California, where he enjoys surfing and snowboarding in his spare time.
On January 7, 2009, I stayed over at a friend’s house on a school night. Hardly a noteworthy event in the annals of anesthesia history, but in my own life, it was a markedly irregular event that had been carefully prearranged. The next morning, both my parents would be undergoing major surgery. My dad needed a new liver, and fortunately my mother was a match. My parents were one of nine living donor liver transplants that occurred at the University of California, San Francisco (UCSF) in 2009.1 Despite being such a significant event in my life, my parents’ story is hardly significant in the history of liver transplant anesthesia. But their surgery represented a culmination of progress that made living donor liver transplants a reality.
The first attempted liver transplantation occurred in 1963 by Dr. Thomas Starzl at the University of Colorado.2 Although Dr. Starzl’s first liver transplant was unsuccessful, by the late 1960s, the procedure for transplantation of deceased donor liver grafts had been refined, and survivorship extended beyond one year. This was a time of rapid progress in the advancement of organ transplantation. The advancement of surgical techniques opened new doors for patients who had previously been considered terminal with end-stage liver disease. These early surgical cases would not have been possible without the parallel advancement of anesthesia care.
Dr. Jorge Antonio Aldrete, most famous for creating the Postanesthetic Recovery, provided anesthetic care for the first successful liver transplant performed by Dr. Starzl in 1967.2 Dr. Aldrete went on to perform anesthesia for numerous liver transplants at the University of Colorado and published the first insights on liver transplant anesthesia in 1969.2 Dr. Aldrete’s work called attention to the profound complexity of hemodynamics brought on by liver transplants. These findings set the framework for the development of a subspecialty in anesthetic care for liver transplant procedures. Dr. Aldrete passed away in January 2025.3
Liver transplant anesthesia progressed with the establishment of the International Liver Transplantation Society (ILTS) in 1974. The first formal gathering of the society occurred in 1982 and was titled “Anesthesia and Perioperative Care in Liver Transplantation.”4 As time went on, mortality rates in liver transplantation improved. The development of immunosuppressants, along with technological advancements, permitted prolonged survival in recipients.2 Collaboration within societies like ILTS led to improved protocols for common perioperative complications such as lactic acidosis, coagulopathy, postperfusion syndrome, arrhythmias and electrolyte imbalances.5 By refining intraoperative management, liver transplant anesthesiologists laid the foundation for a new type of liver transplantation: living donor liver transplants.
Living donor liver transplants were born out of a scarcity of deceased donor grafts for pediatric patients with end-stage liver disease. To save pediatric patients, the first successful adult-to-child living donor liver transplantation took place in Australia in 1989 by Dr. Russell Strong.6 The segmental anatomy of the liver, along with its unique ability to regenerate, allowed for living donation to be a realistic therapeutic alternative to deceased donor grafts in children. The small size of pediatric patients necessitated smaller portions of adult liver donations, which meant less complications for the donors.5 With the success of adult-to-child living donor liver transplants and the growing need for livers in countries with inadequate deceased donor supplies, the stage was set for the next advancement in living donor liver transplantation: the adult-to-adult procedure.
Living donor hepatectomies are technically more demanding due to the need for preservation of the function of the lobe graft or segment graft in children. Hepatectomies have been performed since the 1920s. The first right hepatic lobectomy was performed in Japan by Dr. Ichio Honjo in 1949.7 Drawing from expertise in lobectomies, liver transplant surgeons were finally able to utilize living donor liver grafts for use in adult-to-adult transplantation. The first adult-to-adult liver transplant occurred in Japan by Dr. Masatoshi Makuuchi at Shinshu University in 1994.6 Living donor liver transplants rapidly expanded in countries with low supply of deceased organ donors.
The first living donor adult-to-adult liver transplant performed in California occurred at UCSF by Dr. Nancy Asher and Dr. John Roberts in 2000.8 The liver transplant program at UCSF grew to become the second largest living donor liver transplant program in the United States.9 Since its beginnings, anesthesiologist Dr. Manuel Pardo, who joined the liver transplant team at UCSF starting in 1997, has witnessed growth of the living donor liver transplant program firsthand.
I interviewed Dr. Pardo to understand the evolution of the living donor liver transplant program at UCSF. He recounted initial concerns about significant blood loss and the need for invasive arterial and central venous monitoring lines and large-bore vascular access in donor hepatectomies. As institutional knowledge accumulated, invasive lines were minimized, and transfusions of allogeneic and autologous blood decreased during donor hepatectomies. Today, donors can undergo robotic hepatectomies, further reducing the need for invasive surgery and decreasing postoperative complications.10,11 Although Dr. Pardo has participated in hundreds of liver transplants over the course of his 28-year career, one surgery stood out during our conversation. He had performed the anesthesia for my mother’s liver donation to my father 16 years ago.
By 2009, the year of my parents’ surgery, adult-to-adult living donor liver transplants had become routine in California. Today, these procedures occur annually in numerous transplant centers across the state. Although living donor liver transplantation subjects donors to risks incurred by a major operation, experienced transplant centers mitigate these risks, leading to low postoperative morbidity.12 Advancements in the safety of donor lobectomies and living donor liver transplantation ultimately allowed my mother to help save my father’s life. At 16 years old during the time of my parents’ surgeries, I was unaware of the history of liver transplantation. Now 16 years later, I see that my family’s story is inseparable from the innovations that made their surgeries possible. In my world, that meant a life with both my parents in it.
References
1. Center data. Organ Procurement and Transplantation Network (OPTN) — HRSA/UNOS. U.S. Department of Health & Human Services, Health Resources and Services Administration. https://hrsa.unos.org/data/view-data-reports/center-data/?type=center&selectAreaValue=CA. Accessed December 30, 2025.
2. Sharma S, Saner FH, Bezinover D. A brief history of liver transplantation and transplant anesthesia. BMC Anesthesiol. 2022;22(1):363. Published 2022 Nov 26. doi:10.1186/s12871-022-01904-1
3. Degrandi CR. Dr Jorge Antonio Aldrete (1937-2025). Anaesthesia Pain & Intensive Care. 2025;29(1):150-151. doi:https://doi.org/10.35975/apic.v29i1.2683
4. Rashid M, Deshpande R. Transplant Anesthesiology – Then and Now. Socca.org. Published March 2024. Accessed December 29, 2025. https://www.socca.org/vol35-iss1-transplant-anesthesiology—then-and-now
5. Wagener G. Liver transplantation: Anesthetic management. O’Connor M, Nussmeier N, eds. Uptodate. Published online May 13, 2025.
6. Chan SC, Fan ST. Historical perspective of living donor liver transplantation. World Journal of Gastroenterology. 2008;14(1):15. doi:https://doi.org/10.3748/wjg.14.15
7. Kokudo N, Takemura N, Ito K, Mihara F. The history of liver surgery: Achievements over the past 50 years. Annals of Gastroenterological Surgery. 2020;4(2):109-117. doi:https://doi.org/10.1002/ags3.12322
8. Whiting S. Liver Lovers / A day in the life of a husband and wife liver transplant team at UCSF Transplant Service. SFGATE. Published December 18, 2005. Accessed December 29, 2025. https://www.sfgate.com/magazine/article/Liver-Lovers-A-day-in-the-life-of-a-husband-and-2587450.php
9. Liver Transplant | Anesthesia. Ucsf.edu. Published 2025. Accessed December 29, 2025. https://anesthesia.ucsf.edu/specialties/liver-transplant
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11. Raptis DA, Elsheikh Y, Alnemary Y, Marquez KAH, Bzeizi K, Alghamdi S, Alabbad S, Alqahtani SA, Troisi RI, Boehnert MU, Malago M, Wu YM, Broering DC; OTCE KFSHRC Collaborative (Appendix). Robotic living donor hepatectomy is associated with superior outcomes for both the donor and the recipient compared with laparoscopic or open – A single-center prospective registry study of 3448 cases. Am J Transplant. 2024 Nov;24(11):2080-2091. doi: 10.1016/j.ajt.2024.04.020. Epub 2024 May 7. PMID: 38723867.
12. Ghobrial RM, Freise CE, Trotter JF, Tong L, Ojo AO, Fair JH, Fisher RA, Emond JC, Koffron AJ, Pruett TL, Olthoff KM; A2ALL Study Group. Donor morbidity after living donation for liver transplantation. Gastroenterology. 2008 Aug;135(2):468-76. doi: 10.1053/j.gastro.2008.04.018. Epub 2008 Apr 22. PMID: 18505689; PMCID: PMC3731061.