Anji Wall M.D.

Wall, A.E., McKenna, G.J., Onaca, N., Ruiz, R., Bayer, J., Fernandez, H., Martinez, E., Gupta, A., Askar, M., Spak, C.W. and Testa, G. (2022). “Utilization of a SARS-CoV-2-positive donor for liver transplantation.” Proc (Bayl Univ Med Cent) 35(1): 62-63.

Full text of this article.

Liver transplantation rates have been negatively affected by the pandemic caused by coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Current practice in the liver transplant community is to avoid utilizing SARS-CoV-2-positive donors for liver transplantation unless there is a compelling reason such as recipient illness severity. In this case, we report the use of a donor who had a positive exposure to and symptom history for COVID-19 and tested positive for SARS-CoV-2 on admission for a liver transplant recipient with primary sclerosing cholangitis and a Model of End-Stage Liver Disease score of 23 with no known COVID-19 exposures. We focus on the decision to accept this particular organ, as well as the discussion with the recipient about the unknowns of disease transmission and risk associated with this donor. The current case argues that transplant programs should begin to consider low-risk donors with positive SARS-CoV-2 testing for recipients who have the potential to benefit from liver transplantation, which may not only be those with the most severe illness.

da Graca, B., Johannesson, L., Testa, G. and Wall, A. (2021). “Uterus transplantation: ethical considerations.” Curr Opin Organ Transplant 26(6): 664-668.

Full text of this article.

PURPOSE OF REVIEW: Uterus transplantation (Utx) offers women with absolute uterine factor infertility the opportunity to carry their own pregnancies. As Utx transitions from an experimental to standard clinical procedure, we review the status of the ethical issues applicable to the stakeholders involved. RECENT FINDINGS: With more than 65 Utx procedures reported to date, evidence is accruing that enables the chance of success – a live birth – for the recipient to be weighed against the risks the recipient incurs through the Utx process, as well as risks to living donors undergoing surgery, to children exposed in utero to immunosuppressants and the uterine graft environment, and to third parties related to uterus procurement from multiorgan deceased donors. Experience has also informed aspects of recipient and donor autonomy that must be safeguarded. SUMMARY: Clinical trial results provides a basis for weighing the interests of the stakeholders implicated in Utx, and so can inform transplant centers’ and regulatory bodies’ development of policies and protocols that will determine access to Utx and allocation of organs, together with other considerations of justice. Additional evidence, particularly on long-term outcomes, is needed, and new questions can be expected to arise as access to and indications for Utx broaden.

Johnson, N., Wall, A. and Johannesson, L. (2021). “Implementing regulations and policies for uterus transplantation.” Curr Opin Organ Transplant 26(6): 660-663.

Full text of this article.

PURPOSE OF REVIEW: Policy development for uterus transplantation (UTx) is in its infancy. Understanding current oversight of UTx programmes can inform further development. RECENT FINDINGS: Currently, the United States has the most comprehensive regulations for UTx. Much of the policy outside the USA is focused on candidate selection. In the USA, UTx is categorized as, and follows policies of, a vascular composite allograft. Some considerations for UTx have not yet been addressed in policy, including the need for candidates to have a viable embryo before listing and transplantation, additional factors that may be warranted in organ allocation and the need to report data on the infant as well as the recipient. SUMMARY: Oversight of UTx falls within the governance of solid organ transplantation with unique aspects to be considered. Guidelines for multidisciplinary care, transplant-focused infrastructure and defined outcome metrics found in other solid organ transplant programmes provide a useful framework for UTx programmes.

Kates, O. S., P. G. Stock, M. G. Ison, R. D. M. Allen, P. Burra, J. C. Jeong, V. Kute, E. Muller, A. Nino-Murcia, H. Wang and A. Wall (2021). “Ethical review of COVID-19 vaccination requirements for transplant center staff and patients.” Am J Transplant Oct 27. [Epub ahead of print].

Full text of this article.

Transplant centers seeking to increase 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.

Wall, A. E., B. da Graca, S. K. Asrani, R. Ruiz, H. Fernandez, A. Gupta, E. Martinez, J. Bayer, G. J. McKenna, R. Goldstein, N. Onaca, J. F. Trotter and G. Testa (2021). “Cost Analysis of Liver Acquisition Fees Before and After Acuity Circle Policy Implementation.” JAMA Surg.

Full text of this article.

IMPORTANCE: Acuity circles (AC) liver allocation policy was implemented to eliminate donor service area geographic boundaries from liver allocation and to decrease variability in median Model of End-stage Liver Disease (MELD) score at transplant and wait list mortality. However, the broader sharing of organs was also associated with more flights for organ procurements and higher costs associated with the increase in flights. OBJECTIVE: To determine whether the costs associated with liver acquisition changed after the implementation of AC allocation. DESIGN, SETTING, AND PARTICIPANTS: This single-center cost comparison study analyzed fees associated with organ acquisition before and after AC allocation implementation. The cost data were collected from a single transplant institute with 2 liver transplant centers, located 30 miles apart, in different donation service areas. Cost, recipient, and transportation data for all cases that included fees associated with liver acquisition from July 1, 2019, to October 31, 2020, were collected. EXPOSURES: Primary liver offer acceptance with associated organ procurement organization or charter flight fees. MAIN OUTCOMES AND MEASURES: Specific fees (organ acquisition, surgeon, import, and charter flight fees) and total fees per donor were collected for all accepted liver donors with at least 1 associated fee during the study period. RESULTS: Of 213 included donors, 171 were used for transplant; 90 of 171 (52.6%) were male, and the median (interquartile range) age of donors was 41.0 (30.0-52.8) years in the pre-AC period and 36.9 (24.0-48.8) years in the post-AC period. There was no significant difference in the post-AC compared with pre-AC period in median (range) MELD score (24 [8-40] vs 25 [6-40]; P = .27) or median (range) match run sequence (15 [1-3951] vs 10 [1-1138]; P = .31), nor in mean (SD) distance traveled (155.83 [157.00] vs 140.54 [144.33] nautical miles; P = .32) or percentage of donors requiring flights (58.5% [69 of 118] vs 56.8% [54 of 95]; P = .82). However, costs increased significantly in the post-AC period: total cost increased 16% per accepted donor (mean [SD] of $52 966 [13 278] vs $45 725 [9300]; P < .001) and 55% per declined donor (mean [SD] of $15 865 [3942] vs $10 217 [4853]; P < .001). Contributing factors included more than 2-fold increases in the proportions of donors incurring import fees (31.4% [37 of 118] vs 12.6% [12 of 95]; P = .002) and surgeon fees (19.5% [23 of 118] vs 9.5% [9 of 95]; P = .05), increased acquisition fees (10% increase; mean [SD] of $43 860 [3266] vs $39 980 [2236]; P < .001), and increased flight expenses (43% increase; mean [SD] of $12 904 [6066] vs $9049 [5140]; P = .002). CONCLUSIONS AND RELEVANCE: The unintended consequences of implementing broader sharing without addressing organ acquisition fees to account for increased importation between organ procurement organizations must be remedied to contain costs and ensure viability of transplant programs.