Anji Wall M.D.

Wall, A.E. (2021). “Why is self-advocacy a barrier to living donor kidney transplantation?” Am J Surg Feb 4;S0002-9610(21)00069-6. [Epub ahead of print].

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Living donor kidney transplantation (LDKT) offers patients with end stage renal disease an opportunity to skip the long waiting list for deceased donor grafts and get the highest quality kidney graft in terms of both patient and graft survival. LDKT is truly life-saving as one in five patients die within the first year and two out of three die within 5 years of initiating dialysis. Despite the huge advantages associated with living donor kidney transplantation (LDKT), fewer than 20,000 are performed each year in the US. Barriers to LDKT include both a lack of knowledge about LDKT and a lack of knowledge about how to ask someone to be a kidney donor. [No abstract; excerpt from Editorial].

Wall, A.E., Johannesson, L., Sok, M., Warren, A.M., Gordon, E.J. and Testa, G. (2021). “Decision making and informed consent in uterus transplant recipients: A mixed-methods study of the Dallas uterus transplant study (DUETS) participants.” Am J Surg Feb 4;S0002-9610(21)00057-X. [Epub ahead of print].

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BACKGROUND: Uterus transplantation (Utx) has achieved clinical success but little is known about motivations and experiences of UTx recipients. METHODS: We conducted semi-structured interviews with 20 UTx recipients in addition to collecting quantitative demographic and clinical data. Closed-ended interview questions were treated as categorical variables. Thematic analysis was performed on qualitative data. Bivariate analysis tested associations between categorical variables. RESULTS: Themes that emerged included: the decision to pursue UTx is a process, primary motivations for UTx are specific to the experience of gestation, and alternative options did not offer the same value as UTx. There was no association between disease etiology, clinical status, or perception of UTx risk with information needs or donor preference. CONCLUSIONS: Our findings suggest that UTx is a unique treatment option that some women with AUFI find preferable to adoption and surrogacy and, as such, should be discussed as a parenthood option with women diagnosed with AUFI.

Johannesson, L., Wall, A., Tzakis, A., Quintini, C., Richards, E.G., O’Neill, K., Porrett, P.M. and Testa, G. (2020). “Life underneath the VCA umbrella: perspectives from the United States Uterus Transplant Consortium.” Am J Transplant Dec 14. [Epub ahead of print].

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The parallel emergence of uterus transplantation (UTx) and other transplantation innovations including face and hand transplantation led to the categorization of the uterus as a vascular composite allograft (VCA). With >60 transplants and >20 births worldwide, UTx is transitioning rapidly from a research endeavor to an effective treatment option for women with uterine-factor infertility. While it originally made sense to group the innovations under one umbrella, it is time to revisit the designation of UTx as a VCA. We describe how UTx needs unique policy, procedural codes, insurance contracts and educational initiatives. We contend that separating UTx from VCAs may become necessary in the future to avoid hindering the growth and regulation of this field.

Johannesson, L., Koon, E.C., Bayer, J., McKenna, G.J., Wall, A., Fernandez, H., Martinez, E.J., Gupta, A., Ruiz, R., Onaca, N. and Testa, G. (2021). “Dallas UtErus Transplant Study: Early Outcomes and Complications of Robot-assisted Hysterectomy for Living Uterus Donors.” Transplantation 105(1): 225-230.

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BACKGROUND: Uterus transplantation is a treatment for absolute uterine infertility and can be performed with living and deceased donors. Given the safety and increased utilization of robotic assistance with other gynecologic and transplant donor operations, we adopted a robot-assisted approach to donor hysterectomy. This study compared early outcomes and morbidity of the robot-assisted approach to donor hysterectomy with the traditionally performed open approach and addressed whether the robot-assisted approach is safe and offers advantages for the donor. METHODS: Our institution has performed 18 living donor hysterectomies for uterus transplantation. This retrospective review compared the last 5 cases utilizing a robot-assisted technique and vaginal extraction of the uterus graft with the first 13 cases performed with an open laparotomy technique. Demographic, intraoperative, and postoperative data were examined. RESULTS: There were no differences between the robot-assisted and the open living donor group with respect to age, body mass index, or gynecological history. Although the median operative time was shorter for the open approach (6.27 versus 10.46 h), the donors’ median estimated blood loss, length of hospital stay, and length of sick leave were less with the robot-assisted approach. There was no conversion to open hysterectomy in the robot-assisted cases, and the incidence of complications was similar between the 2 groups. There was no difference in early graft function. CONCLUSIONS: These preliminary results show that robot-assisted living donor hysterectomy is feasible and safe for the donors; it allows a faster postoperative recovery and the same early graft function.

Cheng, X.S., Wall, A. and Teuteberg, J. (2020). “Ethical decision-making in simultaneous heart-liver transplantation.” Curr Opin Organ Transplant 25(5): 519-525.

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PURPOSE OF REVIEW: Simultaneous heart-liver (SHL) transplants are only a small proportion of overall heart and liver transplantation, they have been increasing in frequency and thus challenge the equitable allocation of organs. RECENT FINDINGS: The incidence of SHL transplants is reviewed along with the outcomes of SHL transplants and their impact on the waitlist, particularly in the context of solitary heart and liver transplantation. The ethical implications, most importantly the principles of utility and equity, of SHL transplant are addressed. In the context of utility, the distinction of a transplant being life-saving versus life-enhancing is investigated. The risk of hepatic decompensation for those awaiting both solitary and combined organ transplantation is an important consideration for the principle of equity. Lastly, the lack of standardization of programmatic approaches to SHL transplant candidates, the national approach to allocation, and the criteria by which programs are evaluated are reviewed. SUMMARY: As with all multiorgan transplantation, SHL transplantation raises ethical issues of utility and equity. Given the unique patient population, good outcomes, lack of alternatives, and overall small numbers, we feel there is continued ethical justification for SHL, but a more standardized nationwide approach to the evaluation, listing, and allocation of organs is warranted.