1
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Sawinski D, Lai JC, Pinney S, Gray AL, Jackson AM, Stewart D, Levine DJ, Locke JE, Pomposelli JJ, Hartwig MG, Hall SA, Dadhania DM, Cogswell R, Perez RV, Schold JD, Turgeon NA, Kobashigawa J, Kukreja J, Magee JC, Friedewald J, Gill JS, Loor G, Heimbach JK, Verna EC, Walsh MN, Terrault N, Testa G, Diamond JM, Reese PP, Brown K, Orloff S, Farr MA, Olthoff KM, Siegler M, Ascher N, Feng S, Kaplan B, Pomfret E. Addressing sex-based disparities in solid organ transplantation in the United States - a conference report. Am J Transplant 2023; 23:316-325. [PMID: 36906294 DOI: 10.1016/j.ajt.2022.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/17/2022] [Accepted: 11/04/2022] [Indexed: 01/15/2023]
Abstract
Solid organ transplantation provides the best treatment for end-stage organ failure, but significant sex-based disparities in transplant access exist. On June 25, 2021, a virtual multidisciplinary conference was convened to address sex-based disparities in transplantation. Common themes contributing to sex-based disparities were noted across kidney, liver, heart, and lung transplantation, specifically the existence of barriers to referral and wait listing for women, the pitfalls of using serum creatinine, the issue of donor/recipient size mismatch, approaches to frailty and a higher prevalence of allosensitization among women. In addition, actionable solutions to improve access to transplantation were identified, including alterations to the current allocation system, surgical interventions on donor organs, and the incorporation of objective frailty metrics into the evaluation process. Key knowledge gaps and high-priority areas for future investigation were also discussed.
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Affiliation(s)
- Deirdre Sawinski
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois, USA
| | - Alice L Gray
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Annette M Jackson
- Department of Surgery, Duke University, Department of Surgery, Durham, Carolina, USA
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | - Jayme E Locke
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama, USA
| | - James J Pomposelli
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | | | | | - Darshana M Dadhania
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA
| | - Rebecca Cogswell
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Richard V Perez
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jon Kobashigawa
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
| | - John S Gill
- Division of Nephrology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Gabriel Loor
- Baylor College of Medicine Lung Institute, Houston, Texas, USA
| | | | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mary Norine Walsh
- Ascension St Vincent Heart Center, Indianapolis, Indianapolis, Indiana, USA
| | - Norah Terrault
- Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - Guiliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Division of Renal, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Susan Orloff
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Portland, Oregon, USA
| | - Maryjane A Farr
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kim M Olthoff
- Department of Surgery, Penn Transplant Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Siegler
- University of Chicago Medicine, Chicago, Illinois, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Nancy Ascher
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Kaplan
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Elizabeth Pomfret
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
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2
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Stewart D, Mupfudze T, Klassen D. Does anybody really know what (the kidney median waiting) time is? Am J Transplant 2023; 23:223-231. [PMID: 36695688 DOI: 10.1016/j.ajt.2022.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/05/2022] [Indexed: 01/13/2023]
Abstract
The median waiting time (MWT) to deceased donor kidney transplant is of interest to patients, clinicians, and the media but remains elusive due to both methodological and philosophical challenges. We used Organ Procurement and Transplantation Network data from January 2003 to March 2022 to estimate MWTs using various methods and timescales, applied overall, by era, and by candidate demographics. After rising for a decade, the overall MWT fell to 5.19 years between 2015 and 2018 and declined again to 4.05 years (April 2021 to March 2022), based on the Kaplan-Meier method applied to period-prevalent cohorts. MWTs differed markedly by blood type, donor service area, and pediatric vs adult status, but to a lesser degree by race/ethnicity. Choice of methodology affected the magnitude of these differences. Instead of waiting years for an answer, reliable kidney MWT estimates can be obtained shortly after a policy is implemented using the period-prevalent Kaplan-Meier approach, a theoretical but useful construct for which we found no evidence of bias compared with using incident cohorts. We recommend this method be used complementary to the competing risks approach, under which MWT is often inestimable, to fill the present information void concerning the seemingly simple question of how long it takes to get a kidney transplant in the United States.
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Affiliation(s)
| | | | - David Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing
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3
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Wall AE, Johannesson L, Reddy V, Warren AM, Gordon EJ, Testa G. Living uterus donors' perceptions of decision-making and informed consent: a qualitative study of the Dallas Uterus Transplant Study participants. Am J Transplant 2023; 23:265-271. [PMID: 36695701 DOI: 10.1016/j.ajt.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/15/2022] [Accepted: 12/02/2022] [Indexed: 01/03/2023]
Abstract
Uterus transplantation is a growing field, but little is known about living uterus donors' perceptions of informed consent or their decision-making processes. This study used semistructured interviews to collect information regarding uterus donors' experiences with uterus donation, perceptions of the informed consent process, and information on how they decided to pursue uterus donation. Interviews were coded for thematic analysis. Three major themes emerged in this study. First, the decision-making process was based on individuals' motivations, rationale, and considerations of alternative contributions to help other women with infertility. Second, participants described how they felt about the process of informed consent, their decision-making processes, and how their experiences compared with their expectations. Third, participants discussed how uterus donation was a valuable experience. This study found that living uterus donors are motivated to give another woman the opportunity to experience pregnancy and childbirth. They were satisfied with the informed consent process, their experiences were in line with their expectations, and the value of uterus donation was associated with the act of donation itself. Our findings suggest that living donor uterus programs should develop robust informed consent processes that provide detailed information about uterus donation and encourage shared decision-making with potential uterus donors.
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Affiliation(s)
- Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA.
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA; Division of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas, USA
| | - Vikrant Reddy
- Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ann Marie Warren
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, Texas, USA; Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elisa J Gordon
- Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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4
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Perakslis E, Knechtle SJ. Information design to support growth, quality, and equity of the US transplant system. Am J Transplant 2023; 23:5-10. [PMID: 36695621 DOI: 10.1016/j.ajt.2022.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/03/2022] [Accepted: 10/17/2022] [Indexed: 01/13/2023]
Abstract
The Organ Procurement and Transplantation Network, an arm of the Health Resources and Services Administration, has a contract with the United Network for Organ Sharing since 1986 to provide central oversight of organ donation and transplants in the United States. The United Network for Organ Sharing has recently come under scrutiny, prompting a review by the National Academies of Sciences, Engineering, and Medicine as summarized in its recent report and also by the US Senate Finance Committee. The national news services have opined about organ donation ethics, access to transplantation particularly for medically underserved populations, and management of organ transplantation data. These critiques raise important concerns that deserve our best response as a transplant community. Broadly, we suggest that the data management approach of the Organ Procurement and Transplantation Network be replaced with a patient-centric omnichannel network in which all donor and recipient data exist in a single longitudinal record that can be used by all applications. A more comprehensive and standardized approach to donor data collection would drive quality improvement across organ procurement organizations and help address inequities in transplantation. Finally, a substantial increase in organ donation would be prompted by considering organ donors as a public health resource, meriting transparent publicly available data collection with respect to organ donor referral, screening, and management.
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Affiliation(s)
- Eric Perakslis
- Duke Clinical Research Institute, Population Health Sciences, Durham, North Carolina, USA
| | - Stuart J Knechtle
- Department of Surgery, Duke Transplant Center, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA.
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5
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Dalton JE, Lehr CJ, Gunsalus PR, Mourany L, Valapour M. Miscalibration of lung allocation models leads to inaccurate waitlist mortality predictions. Am J Transplant 2023; 23:72-77. [PMID: 36695624 PMCID: PMC10016684 DOI: 10.1016/j.ajt.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
The importance of waitlist (WL) mortality risk estimates will increase with the adoption of the US Composite Allocation Score (CAS) system. Calibration is rarely assessed in clinical prediction models, yet it is a key factor in determining access to lung transplant. We assessed the calibration of the WL-lung allocation score (LAS)/CAS models and developed alternative models to minimize miscalibration. Scientific Registry of Transplant Recipients data from 2015 to 2020 were used to assess the calibration of the WL model and for subgroups (age, sex, diagnosis, and race/ethnicity). Three recalibrated models were developed and compared: (1) simple recalibration model (SRM), (2) weighted recalibration model 1 (WRM1), and (3) weighted recalibration model 2 (WRM2). The current WL-LAS/CAS model underestimated risk for 78% of individuals (predicted mortality risk, <42%) and overpredicted risk for 22% of individuals (predicted mortality risk, ≥42%), with divergent results among subgroups. Error measures improved in SRM, WRM1, and WRM2. SRM generally preserved candidate rankings, whereas WRM1 and WRM2 led to changes in ranking by age and diagnosis. Differential miscalibration occurred in the WL-LAS/CAS model, which improved with recalibration measures. Further inquiry is needed to develop mortality models in which risk predictions approximate observed data to ensure accurate ranking and timely access to transplant. IMPACT: With changes to the lung transplant allocation system planned in 2023, evaluation of the accuracy and precision of survival models used to rank candidates for lung transplant is important. The waitlist model underpredicts risk for 78% of US transplant candidates with an unequal distribution of miscalibration across subgroups leading to inaccurate ranking of transplant candidates. This work will serve to inform future efforts to improve modeling efforts in the US lung transplant allocation system.
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Affiliation(s)
- Jarrod E Dalton
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carli J Lehr
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul R Gunsalus
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lyla Mourany
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maryam Valapour
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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6
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Crannell WC, Perkins JD, Leca N, Kling CE. Deceased donor kidneys are discarded at higher rates when labeled as high kidney donor profile index. Am J Transplant 2022; 22:3087-3092. [PMID: 36088649 DOI: 10.1111/ajt.17197] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/10/2022] [Accepted: 09/07/2022] [Indexed: 01/25/2023]
Abstract
The kidney donor risk index (KDRI) and percentile conversion, kidney donor profile index (KDPI), provide a continuous measure of donor quality. Kidneys with a KDPI >85% (KDPI85 ) are referred to as "high KDPI." The KDPI85 cutoff changes every year, impacting which kidneys are labeled as KDPIHIGH . We examine kidney utilization around the KDPI85 cutoff and explore the "high KDPI" labeling effect. KDRI to KDPI Mapping Tables from 2012 to 2020 were used to determine the yearly KDRI85 value. Organ Procurement and Transplantation Network data was used to calculate discard rates and model organ use. KDRI85 varied between 1.768 and 1.888. In a multivariable analysis, kidney utilization was lower for KDPI 86% compared with KDPI 85% kidneys (p = .046). Kidneys with a KDRI between 1.785-1.849 were classified as KDPIHIGH in the years 2015-2017 and KDPILOW in the years 2018-2020. The discard rate was 44.9% when labeled as KDPIHIGH and 39.1% when labeled as KDPILOW (p < .01). For kidneys with the same KDRI, the high KDPI label is associated with increased discard. We should reconsider the appropriateness of the "high KDPI" label.
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Affiliation(s)
- William Christian Crannell
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA.,Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, Washington, USA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA.,Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, Washington, USA
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7
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Garry MG, Caplan AL, Garry DJ. Emerging technologies and ethics-exogenic chimeric humanized organs. Am J Transplant 2022; 22:2786-2790. [PMID: 36052557 PMCID: PMC10087366 DOI: 10.1111/ajt.17188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 08/08/2022] [Accepted: 08/25/2022] [Indexed: 01/25/2023]
Abstract
Organ transplantation is limited due to the scarcity of donor organs. In order to expand the supply of organs for transplantation, interspecies chimeras have been examined as a potential future source of humanized organs. Recent studies using gene editing technologies in combination with somatic cell nuclear transfer technology and hiPSCs successfully engineered humanized skeletal muscle in the porcine embryo. As these technologies progress, there are ethical issues that warrant consideration and dialogue.
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Affiliation(s)
- Mary G Garry
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, Minnesota, USA.,Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA.,Regenerative Medicine and Sciences Program, University of Minnesota, Minneapolis, Minnesota, USA.,NorthStar Genomics, LLC, Eagan, Minnesota, USA
| | - Arthur L Caplan
- Division of Medical Ethics, New York University Langone Medical Center, New York, New York, USA
| | - Daniel J Garry
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, Minnesota, USA.,Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA.,Regenerative Medicine and Sciences Program, University of Minnesota, Minneapolis, Minnesota, USA.,NorthStar Genomics, LLC, Eagan, Minnesota, USA
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8
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Tchana-Sato V, Hans G, Brouckaert J, Detry O, Van Cleemput J, Rex S, Jaquet O, De Troy E, Trung MLN, Ancion A, Van den Eynde R, Lievens I, Lagny MG, Delbouille MH, Defraigne JO, Ledoux D, Rega F. Successful heart transplantation from donation after euthanasia with distant procurement using normothermic regional perfusion and cold storage. Am J Transplant 2022; 22:3146-3149. [PMID: 36131641 DOI: 10.1111/ajt.17204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 01/25/2023]
Abstract
While euthanasia has been legalized in a growing number of countries, organ donation after euthanasia is only performed in Belgium, the Netherlands, Spain, and Canada. Moreover, the clinical practice of heart donation after euthanasia has never been reported before. We describe the first case of a heart donated after euthanasia, reconditioned with thoraco-abdominal normothermic regional perfusion, preserved using cold storage while being transported to a neighboring transplant center, and then successfully transplanted following a procurement warm ischemic time of 17 min. Heart donation after euthanasia using thoraco-abdominal normothermic regional perfusion is feasible, it could expand the heart donor pool and reduce waiting lists in countries where organ donation after euthanasia can be performed.
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Affiliation(s)
| | - Gregory Hans
- Department of Anesthesiology, CHU, Liege, Belgium
| | - Janne Brouckaert
- Department of Cardiac Surgery, University Hospitals, Leuven, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU, Liege, Belgium
| | | | - Steffen Rex
- Department of Anesthesiology, University Hospitals, Leuven, Belgium
| | | | - Erwin De Troy
- Department of Intensive Care Medicine, University Hospitals, Leuven, Belgium
| | | | | | | | | | | | | | | | - Didier Ledoux
- Department of Intensive Care Medicine, CHU, Liege, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals, Leuven, Belgium
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9
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Gragert L, Kadatz M, Alcorn J, Stewart D, Chang D, Gill J, Liwski R, Gebel HM, Gill J, Lan JH. ABO-adjusted calculated panel reactive antibody (cPRA): A unified metric for immunologic compatibility in kidney transplantation. Am J Transplant 2022; 22:3093-3100. [PMID: 35975734 PMCID: PMC10087664 DOI: 10.1111/ajt.17175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/17/2022] [Accepted: 08/13/2022] [Indexed: 01/25/2023]
Abstract
Implementation of the kidney allocation system in 2014 greatly reduced access disparity due to human leukocyte antigen (HLA) sensitization. To address persistent disparity related to candidate ABO blood groups, herein we propose a novel metric termed "ABO-adjusted cPRA," which simultaneously considers the impact of candidate HLA and ABO sensitization on the same scale. An ethnic-weighted ABO-adjusted cPRA value was computed for 190 467 candidates on the kidney waitlist by combining candidate's conventional HLA cPRA with the remaining fraction of HLA-compatible donors that are ABO-incompatible. Consideration of ABO sensitization resulted in higher ABO-adjusted cPRA relative to conventional cPRA by HLA alone, except for AB candidates since they are not ABO-sensitized. Within cPRA Point Group = 99%, 43% of the candidates moved up to ABO-adjusted cPRA Point Group = 100%, though this proportion varied substantially by candidate blood group. Nearly all O and most B candidates would have elevated ABO-adjusted cPRA values above this policy threshold for allocation priority, but relatively few A candidates displayed this shift. Overall, ABO-adjusted cPRA more accurately measures the proportion of immune-compatible donors compared with conventional HLA cPRA, especially for highly sensitized candidates. Implementation of this novel metric could enable the development of allocation policies permitting more ABO-compatible transplants without compromising equity.
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Affiliation(s)
- Loren Gragert
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Matthew Kadatz
- Vancouver Coastal Health Research Institute, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - James Alcorn
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Doris Chang
- Providence Health Research Institute, Vancouver, Canada
| | - Jagbir Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Providence Health Research Institute, Vancouver, Canada.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada
| | - Robert Liwski
- Department of Pathology, Dalhousie University, Halifax, Canada
| | - Howard M Gebel
- Department of Pathology, Emory University, Atlanta, Georgia, USA
| | - John Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada.,Providence Health Research Institute, Vancouver, Canada
| | - James H Lan
- Vancouver Coastal Health Research Institute, Vancouver, Canada.,Division of Nephrology, University of British Columbia, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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10
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Wall AE, Borries T, Reddy V, Asrani SK, Testa G, Trotter J. The carbon footprint of organ acquisition in the United States. Am J Transplant 2022; 22:3184-3185. [PMID: 36088644 DOI: 10.1111/ajt.17196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/17/2022] [Accepted: 09/07/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Anji E Wall
- Baylor University Medical Center, Dallas, Texas, USA
| | | | - Vikrant Reddy
- Baylor University Medical Center, Dallas, Texas, USA
| | | | | | - James Trotter
- Baylor University Medical Center, Dallas, Texas, USA
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11
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Burton AM, Goldberg DS. Center-level and region-level variations in liver transplantation practices following acuity circles policy change. Am J Transplant 2022; 22:2668-2674. [PMID: 35758538 DOI: 10.1111/ajt.17131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/19/2022] [Accepted: 06/17/2022] [Indexed: 01/25/2023]
Abstract
Although early studies suggest the Acuity Circles (AC) allocation policy has increased access to deceased donor liver transplants (DDLTs) for patients with the highest MELD scores, changes in center- and region-level practices among patients with the highest MELD scores in response to AC are not well-characterized. OPTN/UNOS data were analyzed to compare center-level changes in the number of DDLTs based on allocation-MELD (aMELD) categories used for AC sharing performed in the 18-month periods before and after AC enactment on February 4, 2020. There was large center-level variation in the number and proportion of aMELD ≥ 37 DDLTs performed from pre-AC to AC period; 13 centers accounted for 196 of the 198 total net increase in aMELD ≥ 37 DDLTs performed after AC, 5 of these being from UNOS region 5. Similar center-level variation was seen for MELD 33-36 and MELD 29-32 DDLTs, with 17 centers and 14 centers, respectively, accounting for the entire net increase in DDLTs in the aMELD categories. In conclusion, AC increased access to livers for transplantation for high MELD patients nationally, but imbalances remain in transplant practice patterns at the center and regional levels. Longer-term study is necessary to assess effectiveness of AC in improving equitability of liver transplantations.
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Affiliation(s)
- Adam M Burton
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David S Goldberg
- Department of Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, USA
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12
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Lazaridis C. Normothermic regional perfusion: Ethically not merely permissible but recommended. Am J Transplant 2022; 22:2285-2286. [PMID: 35451186 DOI: 10.1111/ajt.17066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/19/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Christos Lazaridis
- Department of Neurology, MacLean Center for Clinical Ethics, University of Chicago Medical Center, Chicago, Illinois, USA
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13
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Troppmann C, Perez RV. Letter to the Editor in reply to: "Hardest-to-place kidney transplant outcomes in the United States" (published in: Am J Transplant 2021; 21:3663-3672.). Am J Transplant 2022; 22:2281-2282. [PMID: 35338695 DOI: 10.1111/ajt.17043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/06/2022] [Accepted: 03/22/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Christoph Troppmann
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Richard V Perez
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
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14
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Heldal TF, Åsberg A, Ueland T, Reisæter A, Pischke SE, Mollnes TE, Aukrust P, Hartmann A, Heldal K, Jenssen T. Inflammation in the early phase after kidney transplantation is associated with increased long-term all-cause mortality. Am J Transplant 2022; 22:2016-2027. [PMID: 35352462 PMCID: PMC9540645 DOI: 10.1111/ajt.17047] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/04/2022] [Accepted: 03/24/2022] [Indexed: 01/25/2023]
Abstract
In the general population, low-grade inflammation has been established as a risk factor for all-cause mortality. We hypothesized that an inflammatory milieu beyond the time of recovery from the surgical trauma could be associated with increased long-term mortality in kidney transplant recipients (KTRs). This cohort study included 1044 KTRs. Median follow-up time post-engraftment was 10.3 years. Inflammation was assessed 10 weeks after transplantation by different composite inflammation scores based on 21 biomarkers. We constructed an overall inflammation score and five pathway-specific inflammation scores (fibrogenesis, vascular inflammation, metabolic inflammation, growth/angiogenesis, leukocyte activation). Mortality was assessed with Cox regression models adjusted for traditional risk factors. A total of 312 (29.9%) patients died during the follow-up period. The hazard ratio (HR) for death was 4.71 (95% CI: 2.85-7.81, p < .001) for patients in the highest quartile of the overall inflammation score and HRs 2.35-2.54 (95% CI: 1.40-3.96, 1.52-4.22, p = .001) for patients in the intermediate groups. The results were persistent when the score was analyzed as a continuous variable (HR 1.046, 95% CI: 1.033-1.056, p < .001). All pathway-specific analyses showed the same pattern with HRs ranging from 1.19 to 2.70. In conclusion, we found a strong and consistent association between low-grade systemic inflammation 10 weeks after kidney transplantation and long-term mortality.
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Affiliation(s)
- Torbjørn Fossum Heldal
- Department of Internal MedicineTelemark Hospital TrustSkienNorway,Institute of Clinical MedicineUniversity of OsloOsloNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Anders Åsberg
- Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway,Norwegian Renal RegistryOslo University Hospital – RikshospitaletOsloNorway,Department of PharmacyUniversity of OsloOsloNorway
| | - Thor Ueland
- Institute of Clinical MedicineUniversity of OsloOsloNorway,K.G. Jebsen Thrombosis Research and Expertise CenterUniversity of TromsøTromsøNorway,Research Institute of Internal MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Anna Varberg Reisæter
- Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway,Norwegian Renal RegistryOslo University Hospital – RikshospitaletOsloNorway
| | - Søren E. Pischke
- Department of ImmunologyUniversity of Oslo and Oslo University HospitalOsloNorway,Department of AnesthesiologyDivision of Emergencies and Critical CareOslo University HospitalOsloNorway
| | - Tom Eirik Mollnes
- K.G. Jebsen Thrombosis Research and Expertise CenterUniversity of TromsøTromsøNorway,Department of ImmunologyUniversity of Oslo and Oslo University HospitalOsloNorway,Research LaboratoryNordland Hospital BodøBodøNorway,Center of Molecular Inflammation ResearchNorwegian University of Science and TechnologyTrondheimNorway
| | - Pål Aukrust
- K.G. Jebsen Thrombosis Research and Expertise CenterUniversity of TromsøTromsøNorway,Research Institute of Internal MedicineOslo University Hospital – RikshospitaletOsloNorway,Section of Clinical Immunology and Infectious DiseasesOslo University Hospital – RikshospitaletOsloNorway
| | - Anders Hartmann
- Institute of Clinical MedicineUniversity of OsloOsloNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Kristian Heldal
- Department of Internal MedicineTelemark Hospital TrustSkienNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Trond Jenssen
- Institute of Clinical MedicineUniversity of OsloOsloNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
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15
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Robertson MP, Lavee J. Execution by organ procurement: Breaching the dead donor rule in China. Am J Transplant 2022; 22:1804-1812. [PMID: 35377533 PMCID: PMC9542006 DOI: 10.1111/ajt.16969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/27/2021] [Accepted: 01/19/2022] [Indexed: 01/25/2023]
Abstract
The dead donor rule is fundamental to transplant ethics. The rule states that organ procurement must not commence until the donor is both dead and formally pronounced so, and by the same token, that procurement of organs must not cause the death of the donor. In a separate area of medical practice, there has been intense controversy around the participation of physicians in the execution of capital prisoners. These two apparently disparate topics converge in a unique case: the intimate involvement of transplant surgeons in China in the execution of prisoners via the procurement of organs. We use computational text analysis to conduct a forensic review of 2838 papers drawn from a dataset of 124 770 Chinese-language transplant publications. Our algorithm searched for evidence of problematic declarations of brain death during organ procurement. We find evidence in 71 of these reports, spread nationwide, that brain death could not have properly been declared. In these cases, the removal of the heart during organ procurement must have been the proximate cause of the donor's death. Because these organ donors could only have been prisoners, our findings strongly suggest that physicians in the People's Republic of China have participated in executions by organ removal.
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Affiliation(s)
- Matthew P. Robertson
- Australian National UniversityVictims of Communism Memorial FoundationWashingtonD.C.USA
| | - Jacob Lavee
- Heart Transplantation UnitLeviev Cardiothoracic CenterSheba Medical CenterFaculty of MedicineTel Aviv UniversityRamat GanIsrael
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16
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Opole IO, Deep NN, Snyder Sulmasy L. On the ethics of NRP and the American College of Physicians NRP statement. Am J Transplant 2022; 22:1725-1726. [PMID: 35247291 DOI: 10.1111/ajt.17014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Isaac O Opole
- University of Kansas Medical Center, Kansas City, Kansas
| | - Noel N Deep
- Medical College of Wisconsin, Aspirus Langlade Hospital, Antigo, Wisconsin
| | - Lois Snyder Sulmasy
- Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania
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17
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Hippen BE, Axelrod DA, Maher K, Li R, Kumar D, Caliskan Y, Alhamad T, Schnitzler M, Lentine KL. Survey of current transplant center practices regarding COVID-19 vaccine mandates in the United States. Am J Transplant 2022; 22:1705-1713. [PMID: 35143100 PMCID: PMC9111251 DOI: 10.1111/ajt.16995] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 01/25/2023]
Abstract
An electronic survey canvassing current policies of transplant centers regarding a COVID-19 vaccine mandate for transplant candidates and living donors was distributed to clinicians at US solid organ transplant centers performing transplants from October 14, 2021-November 15, 2021. Responses were received from staff at 141 unique transplant centers. These respondents represented 56.4% of US transplant centers, and responding centers performed 78.5% of kidney transplants and 82.4% of liver transplants in the year prior to survey administration. Only 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported that vaccination was not required. A minority (42%) of responding centers with a vaccine mandate for transplant candidates also mandated vaccination for living organ donors. Centers with a vaccine mandate most frequently cited clinical evidence supporting the efficacy of pre-transplant vaccination (82%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64%). Centers without a vaccine mandate cited a variety of reasons including administrative, equity, and legal considerations for their decision. Transplant centers in the United States exhibit significant heterogeneity in COVID-19 vaccination mandate policies for transplant candidates. While all centers encourage vaccination, most centers have not mandated COVID-19 vaccination for candidates and living donors, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants.
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Affiliation(s)
- Benjamin E. Hippen
- Fresenius Medical Care, Charlotte, North Carolina,Correspondence Benjamin E. Hippen, 729 East Worthington Avenue, Charlotte, NC 28203, USA.
| | | | - Kennan Maher
- Saint Louis University Transplant Center, St. Louis, Missouri
| | - Ruixin Li
- Saint Louis University Transplant Center, St. Louis, Missouri
| | | | - Yasar Caliskan
- Saint Louis University Transplant Center, St. Louis, Missouri
| | | | - Mark Schnitzler
- Saint Louis University Transplant Center, St. Louis, Missouri
| | - Krista L. Lentine
- Saint Louis University Transplant Center, St. Louis, Missouri,Krista L. Lentine, Saint Louis University Transplant Center, 1201 S. Grand Blvd., St. Louis, MO, 63104, USA.
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18
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Doby BL, Ross-Driscoll K, Yu S, Godwin M, Lee KJ, Lynch RJ. Examining utilization of kidneys as a function of procurement performance. Am J Transplant 2022; 22:1614-1623. [PMID: 35118830 PMCID: PMC9762681 DOI: 10.1111/ajt.16985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/05/2022] [Accepted: 01/27/2022] [Indexed: 01/25/2023]
Abstract
Questions have arisen around new metrics for organ procurement organizations (OPO) due to the perception that low-performing OPOs may be limited by local centers' acceptance of marginal organs. We reviewed 2013-2019 Organ Procurement and Transplantation Network (OTPN) and National Centers for Health Statistics (NCHS) data to explore the relationship between objectively measured OPO performance and utilization of deceased donor kidneys. We found that although donor recovery declined with rising age and kidney donor profile index (KDPI), OPO performance differences were evident within each age/KDPI group. By contrast, the number of discards per donor did not vary with OPO performance. Centers in donor service areas (DSAs) with lower-performing OPOs had higher local utilization and greater import of high-KDPI kidneys than did those with higher-performing OPOs. Lower rates of donor availability relative to waitlist additions may contribute to observed center acceptance behavior. Differences in center-level performance were highly visible in Scientific Registry of Transplant Recipients (SRTR) organ acceptance metrics, while SRTR OPO metrics did not detect large or persistent variation in procurement performance. Cumulatively, our findings suggest that objective measures of procurement performance can inform discussions of organ utilization, allowing for alignment of metrics in all elements of the procurement-transplantation system.
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Affiliation(s)
- Brianna L. Doby
- Positive Rhetoric LLC, Bowling Green, Kentucky, USA,College of Health, Education, and Social Transformation, Department of Public Health Sciences, New Mexico State University, Las Cruces, New Mexico, USA
| | - Katie Ross-Driscoll
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sharon Yu
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Miriam Godwin
- National Kidney Foundation, Washington, District of Columbia, USA
| | - Kevin J. Lee
- Mid-America Transplant Services, St. Louis, Missouri, USA
| | - Raymond J. Lynch
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
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19
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Parent B, Caplan A, Moazami N, Montgomery RA. Regarding normothermic regional perfusion: Arguing by insistence is not a strong argument. Am J Transplant 2022; 22:1729-1730. [PMID: 35352473 DOI: 10.1111/ajt.17046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Brendan Parent
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Arthur Caplan
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Nader Moazami
- NYU Langone Medical Center, Transplant Institute, New York, New York, USA
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20
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Sun BZ, Wightman A, Diekema DS. Caregiver COVID-19 vaccination for solid organ transplant candidates. Am J Transplant 2022; 22:2135-2138. [PMID: 35485987 PMCID: PMC9111252 DOI: 10.1111/ajt.17078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 01/25/2023]
Abstract
An increasing proportion of transplant centers have implemented a mandate for vaccination against COVID-19 for solid organ transplant candidates. There has been comparatively little exploration of the ethical considerations of mandating vaccination of a candidate's primary caregiver, despite a high risk of transmission given the close nature of contact between the candidate and caregiver. We examine how a caregiver mandate can improve overall utility in organ allocation, particularly in circumstances where vaccine effectiveness at preventing transmission and serious disease is low among recipients but high in caregivers. Our analysis reveals how sensitive such mandates must be to the evolving circumstances of disease severity, transmissibility, and vaccine effectiveness: as the facts change, the degree of benefit gained and therefore the degree of infringement on access to transplant and caregiver choice that is tolerated will likewise change.
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Affiliation(s)
- Bob Z. Sun
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA
| | - Aaron Wightman
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA,Treuman Katz Center for Pediatric BioethicsSeattle Children’s HospitalSeattleWashingtonUSA
| | - Douglas S. Diekema
- Department of PediatricsUniversity of WashingtonSeattleWashingtonUSA,Treuman Katz Center for Pediatric BioethicsSeattle Children’s HospitalSeattleWashingtonUSA
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21
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Parent B, Caplan A, Moazami N, Montgomery RA. Response to American College of Physician's statement on the ethics of transplant after normothermic regional perfusion. Am J Transplant 2022; 22:1307-1310. [PMID: 35072337 DOI: 10.1111/ajt.16947] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 01/25/2023]
Abstract
This paper responds to the position statement released by the American College of Physicians (ACP) entitled "Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern." The ACP's statement engages with critical ethical issues surrounding cDCD NRP, but several of their conclusions are flawed. Contrary to the statement, the practice respects the dead donor rule and the legal definition of death while honoring the wishes of the deceased and their loved ones to help save the lives of those in need of organ transplants. cDCD NRP is well established in many countries, it can enhance trust in medical practice and organ donation, and will increase the availability of optimal organs for life-saving transplants.
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Affiliation(s)
- Brendan Parent
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York
| | - Arthur Caplan
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York
| | - Nader Moazami
- NYU Langone Medical Center, Transplant Institute, New York, New York
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22
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Wall AE, Fiedler A, Karp S, Shah A, Testa G. Applying the ethical framework for donation after circulatory death to thoracic normothermic regional perfusion procedures. Am J Transplant 2022; 22:1311-1315. [PMID: 35040263 DOI: 10.1111/ajt.16959] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
The novel approach of thoracic normothermic regional perfusion (TA-NRP) for in-situ preservation of organs prior to removal presents a new series of ethical questions about donation after circulatory determination of death (DCD) procedures. This manuscript describes the framework used for the analysis of ethical acceptability of DCD donation and analyzes the specific practice of TA-NRP DCD within that framework to demonstrate that TA-NRP DCD can be performed within the ethical boundaries of DCD donation. We argue that TA-NRP DCD organ procurements meet the ethical standards of informed consent, non-maleficence, adherence to the dead donor rule, and irreversibility, and as such, are ethically acceptable. We also describe the potential benefits of TA-NRP DCD procedures that result from higher organ yields and better recipient outcomes. Finally, we call for open and transparent support of TA-NRP DCD by professional organizations as a necessary cornerstone for the advancement of TA-NRP DCD procedures.
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Affiliation(s)
- Anji E Wall
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Amy Fiedler
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Seth Karp
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish Shah
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Giuliano Testa
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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23
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Subramanian V, Anderson C, Karp S, Pastan S, Gerber D, Locke J, Cohen A, Shah M, Casingal V, Strata R, Singh N, DuBay D, Dhanireddy K. COVID-19 and transplantation-Data censoring. Am J Transplant 2022; 22:1958-1962. [PMID: 35451211 PMCID: PMC9111342 DOI: 10.1111/ajt.17065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/05/2022] [Accepted: 04/19/2022] [Indexed: 01/25/2023]
Abstract
During the early wave of the COVID-19 pandemic, the Scientific Registry of Transplant Recipients (SRTR) designated a "black out" period between March 12, 2020, and June 12, 2020, for transplant outcomes reporting. We discuss the implications and potential bias it has introduced as it may selectively favor the outcomes for certain regions and harm other regions due to varied effects of different waves of COVID-19 infections across the United States.
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Affiliation(s)
| | | | - Seth Karp
- Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - David Gerber
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jayme Locke
- University of Alabama School of MedicineBirminghamAlabamaUSA
| | - Ari Cohen
- Ochsner Clinic FoundationJeffersonLouisianaUSA
| | - Malay Shah
- University of KentuckyLexingtonKentuckyUSA
| | | | - Robert Strata
- Atrium Health Wake Forest BaptistWinston‐SalemNorth CarolinaUSA
| | - Neeraj Singh
- Willis‐Knighton Medical CenterShreveportLouisianaUSA
| | - Derek DuBay
- Medical University of South CarolinaMt PleasantSouth CarolinaUSA
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24
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Wayda B, Cheng XS, Goldhaber-Fiebert JD, Khush KK. Optimal patient selection for simultaneous heart-kidney transplant: A modified cost-effectiveness analysis. Am J Transplant 2022; 22:1158-1168. [PMID: 34741786 PMCID: PMC8983443 DOI: 10.1111/ajt.16888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/12/2021] [Accepted: 10/31/2021] [Indexed: 01/25/2023]
Abstract
Increasing rates of simultaneous heart-kidney (SHK) transplant in the United States exacerbate the overall shortage of deceased donor kidneys (DDK). Current allocation policy does not impose constraints on SHK eligibility, and how best to do so remains unknown. We apply a decision-analytic model to evaluate options for heart transplant (HT) candidates with comorbid kidney dysfunction. We compare SHK with a "Safety Net" strategy, in which DDK transplant is performed 6 months after HT, only if native kidneys do not recover. We identify patient subsets for whom SHK using a DDK is efficient, considering the quality-adjusted life year (QALY) gains from DDKs instead allocated for kidney transplant-only. For an average-aged candidate with a 50% probability of kidney recovery after HT-only, SHK produces 0.64 more QALYs than Safety Net at a cost of 0.58 more kidneys used. SHK is inefficient in this scenario, producing fewer QALYs per DDK used (1.1) than a DDK allocated for KT-only (2.2). SHK is preferred to Safety Net only for candidates with a lower probability of native kidney recovery (24%-38%, varying by recipient age). This finding favors the implementation of a Safety Net provision and should inform the establishment of objective criteria for SHK transplant eligibility.
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Affiliation(s)
- Brian Wayda
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California
| | - Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Jeremy D Goldhaber-Fiebert
- Center of Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Kiran K Khush
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California
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25
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Durand CM, Florman S, Motter JD, Brown D, Ostrander D, Yu S, Liang T, Werbel WA, Cameron A, Ottmann S, Hamilton JP, Redd AD, Bowring MG, Eby Y, Fernandez RE, Doby B, Labo N, Whitby D, Miley W, Friedman-Moraco R, Turgeon N, Price JC, Chin-Hong P, Stock P, Stosor V, Kirchner V, Pruett T, Wojciechowski D, Elias N, Wolfe C, Quinn TC, Odim J, Morsheimer M, Mehta SA, Rana MM, Huprikar S, Massie A, Tobian AA, Segev DL. HOPE in action: A prospective multicenter pilot study of liver transplantation from donors with HIV to recipients with HIV. Am J Transplant 2022; 22:853-864. [PMID: 34741800 PMCID: PMC9997133 DOI: 10.1111/ajt.16886] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 01/25/2023]
Abstract
Liver transplantation (LT) from donors-with-HIV to recipients-with-HIV (HIV D+/R+) is permitted under the HOPE Act. There are only three international single-case reports of HIV D+/R+ LT, each with limited follow-up. We performed a prospective multicenter pilot study comparing HIV D+/R+ to donors-without-HIV to recipients-with-HIV (HIV D-/R+) LT. We quantified patient survival, graft survival, rejection, serious adverse events (SAEs), human immunodeficiency virus (HIV) breakthrough, infections, and malignancies, using Cox and negative binomial regression with inverse probability of treatment weighting. Between March 2016-July 2019, there were 45 LTs (8 simultaneous liver-kidney) at 9 centers: 24 HIV D+/R+, 21 HIV D-/R+ (10 D- were false-positive). The median follow-up time was 23 months. Median recipient CD4 was 287 cells/µL with 100% on antiretroviral therapy; 56% were hepatitis C virus (HCV)-seropositive, 13% HCV-viremic. Weighted 1-year survival was 83.3% versus 100.0% in D+ versus D- groups (p = .04). There were no differences in one-year graft survival (96.0% vs. 100.0%), rejection (10.8% vs. 18.2%), HIV breakthrough (8% vs. 10%), or SAEs (all p > .05). HIV D+/R+ had more opportunistic infections, infectious hospitalizations, and cancer. In this multicenter pilot study of HIV D+/R+ LT, patient and graft survival were better than historical cohorts, however, a potential increase in infections and cancer merits further investigation.
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Affiliation(s)
- Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sander Florman
- Recanati-Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY
| | - Jennifer D. Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Diane Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Darin Ostrander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tao Liang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James P. Hamilton
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Wendell Miley
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | | | | | - Jennifer C. Price
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Peter Chin-Hong
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Peter Stock
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Valentina Stosor
- Divisions of Infectious Diseases and Organ Transplantation Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Cameron Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Thomas C. Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Megan Morsheimer
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Sapna A. Mehta
- New York University Langone Transplant Institute, New York, NY
| | - Meenakshi M. Rana
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York NY
| | - Shirish Huprikar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York NY
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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26
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M Courtwright A, Patel N, Chandraker A, J Goldberg H. Human leukocyte antigen antibody sensitization, lung transplantation, and health equity. Am J Transplant 2022; 22:698-704. [PMID: 34379882 DOI: 10.1111/ajt.16795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/18/2021] [Accepted: 08/05/2021] [Indexed: 01/25/2023]
Abstract
Women with advanced lung disease, particularly Black and Hispanic women, are more likely than other patients to have anti-human leukocyte (HLA) antibodies against potential donors. Sensitized patients, especially those who are highly sensitized, are less likely to be listed for lung transplant or to be considered candidates for mechanical circulatory support. They are also at higher risk for waitlist death. Institutional variability in approach to HLA antibody screening and pre-transplant management creates barriers to transplant that disproportionately impact Black and Hispanic women. At the same time, our understanding of the clinical significance of pre-transplant antibodies lags behind the sophistication of our screening assays. The lack of national data on pre- and post-transplant HLA antibody characteristics hinders research into strategies to mitigate concerns about these antibodies and to improve access to lung transplant among sensitized patients. Ongoing work should be done to identify clinically higher risk antibodies, to develop better strategies for safely crossing antibodies at the time of transplant, and to model changes in lung allocation to give priority to sensitized patients for a HLA antibody-antigen compatible donors. These priorities mandate a commitment to collaborative, multicenter research and to real time translation of results to clinical practice and allocation policy.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Namrata Patel
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anil Chandraker
- Renal Transplant Program, Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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27
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Sypek MP, Howell M, Howard K, Wong G, Duncanson E, Clayton PD, Hughes P, McDonald S. Healthcare professional and community preferences in deceased donor kidney allocation: A best-worst scaling survey. Am J Transplant 2022; 22:886-897. [PMID: 34839582 DOI: 10.1111/ajt.16898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 01/25/2023]
Abstract
Deceased donor kidneys are a scarce community resource; therefore, the principles underpinning organ allocation should reflect societal values. This study aimed to elicit community and healthcare professional preferences for principles guiding the allocation of kidneys from deceased donors and compare how these differed across the populations. A best-worst scaling survey including 29 principles in a balanced incomplete block design was conducted among a representative sample of the general community (n = 1237) and healthcare professionals working in transplantation (n = 206). Sequential best-worst multinomial logistic regression was used to derive scaled preference scores (PS) (range 0-100). Thematic analysis of free text responses was performed. Five of the six most valued principles among members of the community related to equity, including priority for the longest waiting (PS 100), difficult to transplant (PS 94.5) and sickest (PS 93.9), and equitable access for men and women (PS 94.0), whereas the top four principles for healthcare professional focused on maximizing utility (PS 89.9-100). Latent class analysis identified unmeasured class membership among community members. There are discordant views between community members and healthcare professionals. These should be considered in the design, evaluation, and implementation of deceased donor kidney allocation protocols.
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Affiliation(s)
- Matthew P Sypek
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Emily Duncanson
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Philip D Clayton
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter Hughes
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen McDonald
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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28
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Hann A, Hartog H, Nutu A, Quist K, Sanabria-Mateos R, Greenhall GHB, Ushiro-Lumb I, Nicolson PLR, Cain O, Oo YH, Chauhan A, Lester W, Pollok JM, Prachalias A, Isaac JR, Thorburn D, Forsythe J, Sharif K, Neil DAH, Mirza DF, Perera MTPR. Liver graft outcomes from donors with vaccine induced thrombosis and thrombocytopenia (VITT): United Kingdom multicenter experience. Am J Transplant 2022; 22:996-998. [PMID: 34662508 DOI: 10.1111/ajt.16869] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Angus Hann
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Centre for liver and gastrointestinal research, Institute of Immunology and Immunotherapy, NIHR Birmingham BRC, University of Birmingham, Birmingham, UK
| | - Hermien Hartog
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Birmingham Children's Hospital, Birmingham, UK
| | - Anisa Nutu
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | | | - Ines Ushiro-Lumb
- National Health Service Blood and Transplant Service, Bristol, UK
| | | | - Owen Cain
- Department of Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ye H Oo
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Centre for liver and gastrointestinal research, Institute of Immunology and Immunotherapy, NIHR Birmingham BRC, University of Birmingham, Birmingham, UK
| | - Abhishek Chauhan
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Centre for liver and gastrointestinal research, Institute of Immunology and Immunotherapy, NIHR Birmingham BRC, University of Birmingham, Birmingham, UK
| | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Joerg-Matthias Pollok
- Liver Unit, Royal Free Hospital, London, UK.,Department of surgery & Interventional Science, University College London, London, UK
| | | | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Douglas Thorburn
- Liver Unit, Royal Free Hospital, London, UK.,National Health Service Blood and Transplant Service, Bristol, UK
| | - John Forsythe
- National Health Service Blood and Transplant Service, Bristol, UK
| | | | - Desley A H Neil
- Centre for liver and gastrointestinal research, Institute of Immunology and Immunotherapy, NIHR Birmingham BRC, University of Birmingham, Birmingham, UK.,Department of Haematology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Centre for liver and gastrointestinal research, Institute of Immunology and Immunotherapy, NIHR Birmingham BRC, University of Birmingham, Birmingham, UK.,Birmingham Children's Hospital, Birmingham, UK
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Birmingham Children's Hospital, Birmingham, UK
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29
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Merani S, Urban M, Um JY, Maskin A, Vargas LM, Castleberry AW, Mercer DF, Grant W, Langnas AN. A North American single-center experience with liver transplantation using thoracoabdominal normothermic regional perfusion for donation after circulatory death. Am J Transplant 2022; 22:666-668. [PMID: 34455701 DOI: 10.1111/ajt.16820] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/08/2021] [Accepted: 08/22/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Shaheed Merani
- Division of Transplant, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - John Y Um
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alexander Maskin
- Division of Transplant, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Live On Nebraska, Omaha, Nebraska, USA
| | - Luciano M Vargas
- Division of Transplant, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anthony W Castleberry
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - David F Mercer
- Division of Transplant, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Wendy Grant
- Division of Transplant, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alan N Langnas
- Division of Transplant, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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30
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Hippen BE. Mandating COVID-19 vaccination prior to kidney transplantation in the United States: No solutions, only decisions. Am J Transplant 2022; 22:381-385. [PMID: 34780109 PMCID: PMC8652664 DOI: 10.1111/ajt.16891] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/02/2021] [Accepted: 11/13/2021] [Indexed: 02/06/2023]
Abstract
The question of whether transplant clinicians should mandate COVID-19 vaccination as a condition of transplant candidacy is complex. A vaccine mandate may be defensible on the grounds that transplant clinicians are obligated to ensure transplantation is conducted safely, and in a manner that entails the best use of a scarce public good. However, mandate proponents will inexorably predicate their arguments on contingent clinical judgments that meliorate rather than resolve core value disagreements. Vaccine mandates are conceivably defensible on narrow grounds, but may prove to be purchased at the expense of an attenuation of shared decision-making, proffering claims of risk reduction from a vaccine mandate beyond what the current evidence base supports, and unintentionally exacerbating durable inequities in access to transplantation.
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Affiliation(s)
- Benjamin E. Hippen
- Department of Transplant Medicine, Fresenius Medical Care, Charlotte, North Carolina,Correspondence Benjamin E. Hippen, Department of Transplant Medicine, Fresenius Medical Care, Charlotte, NC.
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31
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Silverstein A. Vaccine mandates: A transplant recipient's perspective. Am J Transplant 2022; 22:335-336. [PMID: 34860466 PMCID: PMC9811900 DOI: 10.1111/ajt.16908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 11/14/2021] [Accepted: 11/24/2021] [Indexed: 01/25/2023]
Abstract
COVID-19 vaccination mandates: A patient’s view from the transplant trenches (see Kates et al. and Hippen, pages 371 and 381).
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Affiliation(s)
- Amy Silverstein
- New York, New York, USA,Correspondence Amy Silverstein, Author, Attorney, and Speaker, 50 Shadow Brook Parkway, Chappaqua, New York, NY, USA.
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32
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Farmer DG, Abu-Elmagd K. The liver and intestinal allocation policy: Decades of disparity calling for action. Am J Transplant 2022; 22:341-343. [PMID: 34837465 DOI: 10.1111/ajt.16897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/24/2021] [Accepted: 11/09/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Douglas G Farmer
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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33
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Mathur AK. New metrics to measure OPO performance are here: How do we ensure organizations receive feedback and improve organ donation? Am J Transplant 2022; 22:339-340. [PMID: 34784099 DOI: 10.1111/ajt.16892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 01/25/2023]
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34
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Kates OS, Stock PG, Ison MG, Allen RD, Burra P, Jeong JC, Kute V, Muller E, Nino-Murcia A, Wang H, Wall A. Ethical review of COVID-19 vaccination requirements for transplant center staff and patients. Am J Transplant 2022; 22:371-380. [PMID: 34706165 PMCID: PMC8653143 DOI: 10.1111/ajt.16878] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/03/2021] [Accepted: 10/24/2021] [Indexed: 01/25/2023]
Abstract
Transplant centers seeking to increase coronavirus disease 2019 (COVID-19) vaccine coverage may consider requiring vaccination for healthcare workers or for candidates. The authors summarize current data to inform an ethical analysis of the harms, benefits, and individual and societal impact of mandatory vaccination, concluding that vaccine requirements for healthcare workers and transplant candidates are ethically justified by beneficence, net utility, and fiduciary duty to patients and public health. Implementation strategies should mitigate concerns about respect for autonomy and transparency for both groups. We clarify how the same arguments might be applied to related questions of caregiver vaccination, allocation of other healthcare resources, and mandates for non-COVID-19 vaccines. Finally, we call for effort to achieve global equity in vaccination as soon as possible.
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Affiliation(s)
- Olivia S. Kates
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Peter G. Stock
- Department of Surgery, University of California, San Francisco, San Francisco, California,Correspondence Peter G. Stock, Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Michael G. Ison
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Richard D.M. Allen
- Bosch Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Patrizia Burra
- Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Vivek Kute
- Department of Nephrology and Transplantation Science, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Elmi Muller
- Transplant Unit, Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | | | - Haibo Wang
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Anji Wall
- Baylor University Medical Center, Annette C. and Harold C. Simmons Transplant Institute, Dallas, Texas
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35
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Robert JS. Misconduct in research administration: What is it? How widespread is it? And what should we do about it? Account Res 2022:1-20. [PMID: 34989302 DOI: 10.1080/08989621.2021.2020110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Virtually all of the scholarly literature on responsible conduct in research (RCR) focuses on the integrity of scientists - including why scientists misbehave, and how to improve training and enhance compliance with institutional and federal policies and regulations to prevent research misconduct. What this literature does not yet address is the integrity of those responsible for research administration. This article explores the responsible conduct of research administration and the potential for administrative misconduct. I highlight ways in which a lack of integrity in research administration can jeopardize the progress of science, the careers of researchers, and the reputation of institutions just as much as research misconduct can. Accordingly, I call for policies and appropriate oversight of research administration that are on par with policies governing research misconduct by scientists.
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36
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So M, Hand J, Forrest G, Pouch SM, Te H, Ardura MI, Bartash RM, Dadhania DM, Edelman J, Ince D, Jorgenson MR, Kabbani S, Lease ED, Levine D, Ohler L, Patel G, Pisano J, Spinner ML, Abbo L, Verna EC, Husain S. White paper on antimicrobial stewardship in solid organ transplant recipients. Am J Transplant 2022; 22:96-112. [PMID: 34212491 PMCID: PMC9695237 DOI: 10.1111/ajt.16743] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/17/2021] [Accepted: 06/25/2021] [Indexed: 01/25/2023]
Abstract
Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, although ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid organ transplant recipients in particular are at increased risk of infections from multidrug-resistant organisms, due to host and donor factors and immunosuppressive therapy, there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus, no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in situ may modify the risk of infection. As such, it is not feasible to have a "one-size-fits-all" style of stewardship for this patient population. The objective of this white paper is to identify opportunities, risk factors, and ASP strategies that should be assessed with solid organ transplant recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance and identification of research opportunities.
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Affiliation(s)
- Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Medical Center, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Graeme Forrest
- Department of Internal Medicine, Division of Infectious Diseases, Rush Medical College, Chicago, Illinois
| | - Stephanie M. Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Helen Te
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, Illinois
| | - Monica I. Ardura
- Department of Pediatrics, Infectious Diseases and Host Defense, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio
| | - Rachel M. Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Darshana M. Dadhania
- Department of Transplantation Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Jeffrey Edelman
- Transplant Services at UW Medical Center, Seattle, Washington
| | - Dilek Ince
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Health Care, Carver College of Medicine, Iowa City, Iowa
| | | | - Sarah Kabbani
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erika D. Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Deborah Levine
- Division of Pulmonary and Critical Care Medicine and CT Surgery, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Linda Ohler
- Transplant Institute New York University Langone Health, New York, New York
| | - Gopi Patel
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Pisano
- Antimicrobial Stewardship and Infection Control, U Chicago Medicine, Chicago, Illinois
| | | | - Lilian Abbo
- Department of Medicine, Miami Transplant Institute, Jackson Health System, University of Miami, Miller School of Medicine, Miami, Florida
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, New York
| | - Shahid Husain
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Ajmera Transplant Center, Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
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37
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Gill JS, Shrolff S. Response to "Comment - Bold policy changes are needed to meet the need for organ transplantation in India". Am J Transplant 2022; 22:326-327. [PMID: 34355497 DOI: 10.1111/ajt.16787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/02/2021] [Indexed: 01/25/2023]
Affiliation(s)
- John S Gill
- University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Sunil Shrolff
- Urology and Transplantation, Madras Medical Mission Hospital, Chennai, India
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38
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Wood NL, VanDerwerken DN, King EA, Segev DL, Gentry SE. Life expectancy without a transplant for status 1A liver transplant candidates. Am J Transplant 2022; 22:274-278. [PMID: 34487636 PMCID: PMC8720063 DOI: 10.1111/ajt.16830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 01/25/2023]
Abstract
Status 1A liver transplant candidates are given the highest medical priority for the allocation of deceased donor livers. Organ Procurement and Transplantation Network (OPTN) policy requires physicians to certify that a candidate has a life expectancy without a transplant of less than 7 days for that candidate to be given status 1A. Additionally, candidates receiving status 1A must have one of six medical conditions listed in policy. Using Scientific Registry of Transplant Recipients data from all prevalent liver transplant candidates from 2010 to 2020, we used a bias-corrected Kaplan-Meier model to calculate the survival of status 1A candidates and to determine their life expectancy without a transplant. We found that status 1A candidates have a life expectancy without a transplant of 24 (95% CI 20-46) days-over three times longer than what policy requires for status 1A designation. We repeated the analysis for subgroups of status 1A candidates based on the medical conditions that grant status 1A. We found that none of these subgroups met the life expectancy requirement. Harmonizing OPTN policy with observed data would sustain the integrity of the allocation process.
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Affiliation(s)
- Nicholas L. Wood
- Department of Mathematics, United States Naval Academy, Annapolis, MD
| | | | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Sommer E. Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, MD
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39
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Noreen SM, Klassen D, Brown R, Becker Y, O'Connor K, Prinz J, Cooper M. Kidney accelerated placement project: Outcomes and lessons learned. Am J Transplant 2022; 22:210-221. [PMID: 34582630 DOI: 10.1111/ajt.16859] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 01/25/2023]
Abstract
Opportunities continue to be lost with a high rate of kidneys recovered for transplant but not utilized, particularly those considered less than ideal quality. The Organ Procurement and Transplantation Network (OPTN) Organ Center is tasked with allocating arguably the most difficult-to-place kidneys, and we hypothesized an accelerated placement pathway would increase utilization of kidneys placed by the Organ Center. The Kidney Accelerated Placement (KAP) project, implemented by the Organ Center from July 18, 2019 to July 15, 2020, aimed to offer kidneys with a high kidney donor profile index to programs that had a history of accepting such organs. We compared OPTN kidney match run, donor, and transplant recipient data during the project period and 1 year prior. There was no statistically significant change in the percentage of KAP-eligible donors accepted during the project period (16.4%) compared to the prior year (17.5%). Conversion from acceptance to transplant was higher under KAP (72.7% vs. 71.2%), though not significant. Waiting to accelerate placement after kidneys have been declined by multiple transplant programs locally and regionally is an intervention that may come too late to effectively increase utilization. Transplant rates of nationally shared and marginal kidneys remain a challenge, and future iterations of this project should be investigated.
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Affiliation(s)
| | - David Klassen
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Roger Brown
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Yolanda Becker
- University of Chicago Medical Center, Chicago, Illinois, USA
| | | | | | - Matthew Cooper
- MedStar Georgetown Transplant Institute, Washington, District of Columbia, USA
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40
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Servin-Rojas M, Olivas-Martinez A, Ramirez Del Val F, Torres-Gomez A, Navarro-Vargas L, García-Juárez I. Transplant trends in Mexico during the COVID-19 pandemic: Disparities within healthcare sectors. Am J Transplant 2021; 21:4052-4060. [PMID: 34387936 PMCID: PMC8441748 DOI: 10.1111/ajt.16801] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/29/2021] [Accepted: 08/07/2021] [Indexed: 01/25/2023]
Abstract
Healthcare systems worldwide were challenged during the COVID-19 pandemic. In Mexico, the public hospitals that perform most transplants were adapted to provide care for COVID-19 patients. Using a nationwide database, we describe the first report of the impact of COVID-19 and related transplantation healthcare policies in a middle-income country by comparing statistics before and during the pandemic (pre-COVID: March 2019-February 2020 vs. COVID era: March 2020-February 2021) and by type of institution (public vs. private). The global reduction in transplantation was higher in public institutions compared with private institutions, 89% versus 62%, respectively, p < .001. When analyzing by organ, kidney transplantation decreased by 89% at public versus 57% at private, p < .001; cornea by 88% at public versus 64% at private, p < .001; liver by 88% at public versus 35% at private, p < .001; and heart by 88% in public versus 67% at private institutions, p = .4. The COVID-19 pandemic along with the implemented health policies were associated with a decrease in donations, waiting list additions, and a decrease in transplantation, particularly at public institutions, which care for the most vulnerable.
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Affiliation(s)
| | | | | | | | | | - Ignacio García-Juárez
- Hepatology and Liver Transplant Unit, Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico,Correspondence Ignacio García-Juárez, Hepatology and Liver Transplant Unit, Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico.
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41
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Romagnoli R, Gruttadauria S, Tisone G, Maria Ettorre G, De Carlis L, Martini S, Tandoi F, Trapani S, Saracco M, Luca A, Manzia TM, Visco Comandini U, De Carlis R, Ghisetti V, Cavallo R, Cardillo M, Grossi PA. Liver transplantation from active COVID-19 donors: A lifesaving opportunity worth grasping? Am J Transplant 2021; 21:3919-3925. [PMID: 34467627 PMCID: PMC8653300 DOI: 10.1111/ajt.16823] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/29/2021] [Accepted: 08/29/2021] [Indexed: 01/25/2023]
Abstract
COVID-19 pandemic dramatically impacted transplantation landscape. Scientific societies recommend against the use of donors with active SARS-CoV-2 infection. Italian Transplant Authority recommended to test recipients/donors for SARS-CoV-2-RNA immediately before liver transplant (LT) and, starting from November 2020, grafts from deceased donors with active SARS-CoV-2 infection were allowed to be considered for urgent-need transplant candidates with active/resolved COVID-19. We present the results of the first 10 LTs with active COVID-19 donors within an Italian multicenter series. Only two recipients had a positive molecular test at LT and one of them remained positive up to 21 days post-LT. None of the other eight recipients was found to be SARS-CoV-2 positive during follow-up. IgG against SARS-CoV-2 at LT were positive in 80% (8/10) of recipients, and 71% (5/7) showed neutralizing antibodies, expression of protective immunity related to recent COVID-19. In addition, testing for SARS-CoV-2 RNA on donors' liver biopsy at transplantation was negative in 100% (9/9), suggesting a very low risk of transmission with LT. Immunosuppression regimen remained unchanged, according to standard protocol. Despite the small number of cases, these data suggest that transplanting livers from donors with active COVID-19 in informed candidates with SARS-CoV-2 immunity, might contribute to safely increase the donor pool.
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Affiliation(s)
- Renato Romagnoli
- Liver Transplant Center -General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Giuseppe Tisone
- Surgical Sciences and Medical Sciences, University of Rome-Tor Vergata, Rome, Italy
| | - Giuseppe Maria Ettorre
- POIT Transplant Department, San Camillo Hospital and National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | - Luciano De Carlis
- General Surgery and Abdominal Transplantation Unit, Hepatology, University of Milano-Bicocca and Niguarda-Cà Granda Hospital, Milan, Italy
| | - Silvia Martini
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesco Tandoi
- Liver Transplant Center -General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Silvia Trapani
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Margherita Saracco
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Angelo Luca
- Abdominal Surgery and Organ Transplantation Unit, ISMETT, Palermo, Italy
| | - Tommaso Maria Manzia
- Surgical Sciences and Medical Sciences, University of Rome-Tor Vergata, Rome, Italy
| | - Ubaldo Visco Comandini
- POIT Transplant Department, San Camillo Hospital and National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | - Riccardo De Carlis
- General Surgery and Abdominal Transplantation Unit, Hepatology, University of Milano-Bicocca and Niguarda-Cà Granda Hospital, Milan, Italy
| | - Valeria Ghisetti
- Laboratory of Microbiology and Virology, Ospedale Amedeo di Savoia, ASL “Città di Torino”, Turin, Italy
| | - Rossana Cavallo
- Microbiology and Virology Unit, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Massimo Cardillo
- Italian National Transplant Center, Istituto Superiore di Sanità, Rome, Italy
| | - Paolo Antonio Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy,Correspondence Paolo A. Grossi, Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy.
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42
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Cheng XS, Held PJ, Dor A, Bragg-Gresham JL, Tan JC, Scandling JD, Chertow GM, Roberts JP. The organ procurement costs of expanding deceased donor organ acceptance criteria: Evidence from a cost function model. Am J Transplant 2021; 21:3694-3703. [PMID: 33884757 DOI: 10.1111/ajt.16617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/25/2021] [Accepted: 04/14/2021] [Indexed: 01/25/2023]
Abstract
A potential solution to the deceased donor organ shortage is to expand donor acceptability criteria. The procurement cost implications of using nonstandard donors is unknown. Using 5 years of US organ procurement organization (OPO) data, we built a cost function model to make cost projections: the total cost was the dependent variable; production outputs, including the number of donors and organs procured, were the independent variables. In the model, procuring one kidney or procuring both kidneys from double/en bloc transplantation from a single-organ donor resulted in a marginal cost of $55 k (95% confidence interval [CI] $28 k, $99 k) per kidney, and procuring only the liver from a single-organ donor results in a marginal cost of $41 k (95% CI $12 k, $69 k) per liver. Procuring two kidneys for two candidates from a donor lowered the marginal cost to $36 k (95% CI $22 k, $66 k) per kidney, and procuring two kidneys and a liver lowers the marginal cost to $24 k (95% CI $17 k, $45 k) per organ. Economies of scale were observed, where high OPO volume was correlated with lower costs. Despite higher cost per organ than for standard donors, kidney transplantation from nonstandard donors remained cost-effective based on contemporary US data.
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Affiliation(s)
- Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Philip J Held
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Avi Dor
- Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | | | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - John D Scandling
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - John P Roberts
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
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43
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Wilk AR, Booker SE, Stewart DE, Wiseman A, Gauntt K, Mulligan D, Formica RN. Developing simultaneous liver-kidney transplant medical eligibility criteria while providing a safety net: A 2-year review of the OPTN's allocation policy. Am J Transplant 2021; 21:3593-3607. [PMID: 34254434 DOI: 10.1111/ajt.16761] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 01/25/2023]
Abstract
The OPTN's simultaneous liver-kidney (SLK) allocation policy, implemented August 10, 2017, established medical eligibility criteria for adult SLK candidates and created Safety Net kidney allocation priority for liver-alone recipients with new/continued renal impairment. OPTN SLK and kidney after liver (KAL) data were analyzed (registrations as of December 31, 2019, transplants pre-policy [March 20, 2015-August 9, 2017] vs. post-policy [August 10, 2017-December 31, 2019]). Ninety-four percent of SLK registrations met eligibility criteria (99% CKD: 50% dialysis, 50% eGFR). SLK transplant volume decreased from a record 740 (2017) to 676 (2018, -9%), with a subsequent increase to 728 (2019, 1.6% below 2017 volume). For KAL listings within 1 year of liver transplant, waitlist mortality rates declined post-policy versus pre-policy (27 [95% CI = 20.6-34.7] vs. 16 [11.7-20.5]) while transplant rates increased fourfold (46 [32.2-60.0] vs. 197 [171.6-224.7]). There were 234 KAL transplants post-policy (94% Safety Net priority eligible), and no significant difference in 1-year patient/graft survival vs. kidney-alone (patient: 95.9% KAL, 97.0% kidney-alone [p = .39]; graft: 94.2% KAL, 94.6% kidney-alone [p = .81]). From pre- to post-policy, the proportion of all deceased donor kidney and liver transplants that were SLK decreased (kidney: 5.1% to 4.3%; liver: 9.7% to 8.7%). SLK policy implementation interrupted the longstanding rise in SLK transplants, while Safety Net priority directed kidneys to liver recipients in need with thus far minimal impact to posttransplant outcomes.
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Affiliation(s)
- Amber R Wilk
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Sarah E Booker
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | | | - Katrina Gauntt
- United Network for Organ Sharing, Richmond, Virginia, USA
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44
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Bittermann T, Abt PL. MELD-based allocation at 20: Can we evolve and mature? Am J Transplant 2021; 21:3511-3512. [PMID: 34375509 DOI: 10.1111/ajt.16792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Therese Bittermann
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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45
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Stock PG, Lentine KL. Maximizing the use of hard to place kidneys: Getting the right kidney to the right recipient at the right time. Am J Transplant 2021; 21:3516-3518. [PMID: 34327810 DOI: 10.1111/ajt.16771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Peter G Stock
- University of California San Francisco (UCSF), San Francisco, California, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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46
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Wood NL, VanDerwerken D, Segev DL, Gentry SE. Correcting the sex disparity in MELD-Na. Am J Transplant 2021; 21:3296-3304. [PMID: 34174151 PMCID: PMC8500920 DOI: 10.1111/ajt.16731] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/28/2021] [Accepted: 06/19/2021] [Indexed: 02/06/2023]
Abstract
MELD-Na appears to disadvantage women awaiting liver transplant by underestimating their mortality rate. Fixing this problem involves: (1) estimating the magnitude of this disadvantage separately for each MELD-Na, (2) designing a correction for each MELD-Na, and (3) evaluating corrections to MELD-Na using simulated allocation. Using Kaplan-Meier modeling, we calculated 90-day without-transplant survival for men and women, separately at each MELD-Na. For most scores between 15 and 35, without-transplant survival was higher for men by 0-5 percentage points. We tested two proposed corrections to MELD-Na (MELD-Na-MDRD and MELD-GRAIL-Na), and one correction we developed (MELD-Na-Shift) to target the differences we quantified in survival across the MELD-Na spectrum. In terms of without-transplant survival, MELD-Na-MDRD overcorrected sex differences while MELD-GRAIL-Na and MELD-Na-Shift eliminated them. Estimating the impact of implementing these corrections with the liver simulated allocation model, we found that MELD-Na-Shift alone eliminated sex disparity in transplant rates (p = 0.4044) and mortality rates (p = 0.7070); transplant rates and mortality rates were overcorrected by MELD-Na-MDRD (p = 0.0025, p = 0.0006) and MELD-GRAIL-Na (p = 0.0079, p = 0.0005). We designed a corrected MELD-Na that eliminates sex disparities in without-transplant survival, but allocation changes directing smaller livers to shorter candidates may also be needed to equalize women's access to liver transplant.
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Affiliation(s)
- Nicholas L. Wood
- Department of Mathematics, United States Naval Academy,
Annapolis, MD
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of
Public Health, Baltimore, MD
| | - Sommer E. Gentry
- Department of Mathematics, United States Naval Academy,
Annapolis, MD
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47
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Ishaque T, Kernodle AB, Motter JD, Jackson KR, Chiang TP, Getsin S, Boyarsky BJ, Garonzik-Wang J, Gentry SE, Segev DL, Massie AB. MELD is MELD is MELD? Transplant center-level variation in waitlist mortality for candidates with the same biological MELD. Am J Transplant 2021; 21:3305-3311. [PMID: 33870635 DOI: 10.1111/ajt.16603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 04/05/2021] [Accepted: 04/05/2021] [Indexed: 01/25/2023]
Abstract
Recently, model for end-stage liver disease (MELD)-based liver allocation in the United States has been questioned based on concerns that waitlist mortality for a given biologic MELD (bMELD), calculated using laboratory values alone, might be higher at certain centers in certain locations across the country. Therefore, we aimed to quantify the center-level variation in bMELD-predicted mortality risk. Using Scientific Registry of Transplant Recipients (SRTR) data from January 2015 to December 2019, we modeled mortality risk in 33 260 adult, first-time waitlisted candidates from 120 centers using multilevel Poisson regression, adjusting for sex, and time-varying age and bMELD. We calculated a "MELD correction factor" using each center's random intercept and bMELD coefficient. A MELD correction factor of +1 means that center's candidates have a higher-than-average bMELD-predicted mortality risk equivalent to 1 bMELD point. We found that the "MELD correction factor" median (IQR) was 0.03 (-0.47, 0.52), indicating almost no center-level variation. The number of centers with "MELD correction factors" within ±0.5 points, and between ±0.5-± 1, ±1.0-±1.5, and ±1.5-±2.0 points was 62, 41, 13, and 4, respectively. No centers had waitlisted candidates with a higher-than-average bMELD-predicted mortality risk beyond ±2 bMELD points. Given that bMELD similarly predicts waitlist mortality at centers across the country, our results support continued MELD-based prioritization of waitlisted candidates irrespective of center.
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Affiliation(s)
- Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amber B Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer D Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Teresa P Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samantha Getsin
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Sommer E Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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48
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Kwong AJ, Lai JC, Kim WR. Correcting the sex disparity in access to liver transplantation: Lest perfect be the enemy of better. Am J Transplant 2021; 21:3217-3218. [PMID: 34403193 PMCID: PMC9576125 DOI: 10.1111/ajt.16805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/01/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Allison J. Kwong
- Division of Gastroenterology and Hepatology, Stanford
University, Stanford, California, USA
| | - Jennifer C. Lai
- Division of Gastroenterology, University of California, San
Francisco, California, USA
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Stanford
University, Stanford, California, USA
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49
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Wood NL, Mogul DB, Perito ER, VanDerwerken D, Mazariegos GV, Hsu EK, Segev DL, Gentry SE. Liver simulated allocation model does not effectively predict organ offer decisions for pediatric liver transplant candidates. Am J Transplant 2021; 21:3157-3162. [PMID: 33891805 DOI: 10.1111/ajt.16621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 01/25/2023]
Abstract
The SRTR maintains the liver-simulated allocation model (LSAM), a tool for estimating the impact of changes to liver allocation policy. Integral to LSAM is a model that predicts the decision to accept or decline a liver for transplant. LSAM implicitly assumes these decisions are made identically for adult and pediatric liver transplant (LT) candidates, which has not been previously validated. We applied LSAM's decision-making models to SRTR offer data from 2013 to 2016 to determine its efficacy for adult (≥18) and pediatric (<18) LT candidates, and pediatric subpopulations-teenagers (≥12 to <18), children (≥2 to <12), and infants (<2)-using the area under the receiver operating characteristic (ROC) curve (AUC). For nonstatus 1A candidates, all pediatric subgroups had higher rates of offer acceptance than adults. For non-1A candidates, LSAM's model performed substantially worse for pediatric candidates than adults (AUC 0.815 vs. 0.922); model performance decreased with age (AUC 0.898, 0.806, 0.783 for teenagers, children, and infants, respectively). For status 1A candidates, LSAM also performed worse for pediatric than adult candidates (AUC 0.711 vs. 0.779), especially for infants (AUC 0.618). To ensure pediatric candidates are not unpredictably or negatively impacted by allocation policy changes, we must explicitly account for pediatric-specific decision making in LSAM.
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Affiliation(s)
- Nicholas L Wood
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
| | - Douglas B Mogul
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Emily R Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Douglas VanDerwerken
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Evelyn K Hsu
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sommer E Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
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50
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Galvan NTN, Rath S, Washburn L, Moolchandani P, Goss J. Response to "Public attitude to imminent death donation". Am J Transplant 2021; 21:3202-3203. [PMID: 34043879 DOI: 10.1111/ajt.16699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 04/18/2021] [Accepted: 05/12/2021] [Indexed: 01/25/2023]
Affiliation(s)
| | - Smruti Rath
- Baylor College of Medicine, Houston, Texas, USA
| | | | | | - John Goss
- Baylor College of Medicine, Houston, Texas, USA
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