Anji Wall M.D.

Wall, A., Lee, G.H., Maldonado, J. and Magnus, D. (2020). “Genetic disease and intellectual disability as contraindications to transplant listing in the United States: A survey of heart, kidney, liver, and lung transplant programs.” Pediatr Transplant Sep 30;e13837. [Epub ahead of print.]. e13837.

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Discrimination based on disability is prohibited in organ transplantation, yet studies suggest it continues in listing practices for intellectual disability and genetic diseases. It is not known if this differs between adult and pediatric programs, or by organ type. We performed an online, forced-choice survey of psychosocial listing criteria for adult and pediatric heart, kidney, liver, and lung transplant programs in the United States. Of 650 programs contacted, 343 (52.8%) submitted complete. A minority of programs had formal listing guidelines for any condition considered (Down Syndrome, Duchenne Muscular Dystrophy, Becker Muscular Dystrophy, DiGeorge Syndrome, and Wolf Hirschhorn Syndrome; and mild [IQ < 70] and severe [IQ < 35] intellectual disability), although a majority had encountered most. Pediatric programs were significantly (P < .02) more lenient in the level of contraindication to listing for all genetic conditions considered except Duchenne Muscular Dystrophy, and for mild and severe intellectual disability. Level of contraindication differed significantly by organ type (heart, lung, liver, and kidney) for Duchenne Muscular dystrophy (P = <.001), Becker Muscular Dystrophy (P < .001), DiGeorge Syndrome (P < .001), Wolf-Hirschhorn syndrome (P = .0012), and severe intellectual disability (P < .001). There is significant variation among transplant programs in availability of guidelines for as well as listing practices regarding genetic diseases and intellectual disability, differing by both adult vs pediatric program, and organ type. Programs with absolute contraindications to listing for specific genetic diseases or intellectual disability should reframe their approach, ensuring individualized assessments and avoiding elimination of patients based on membership in a particular group.

Cheng, X.S., Wall, A. and Teuteberg, J. (2020). “Ethical decision-making in simultaneous heart-liver transplantation.” Curr Opin Organ Transplant Aug 31. [Epub ahead of print.].

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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.

Testa, G., G. J. McKenna, J. Bayer, A. Wall, H. Fernandez, E. Martinez, A. Gupta, R. Ruiz, N. Onaca, R. T. Gunby, A. R. Gregg, M. Olausson, E. C. Koon and L. Johannesson (2020). “The Evolution of Transplantation From Saving Lives to Fertility Treatment: DUETS (Dallas UtErus Transplant Study).” Ann Surg Jul 9. [Epub ahead of print.].

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OBJECTIVE: We report the results of the first 20 uterus transplants performed in our institution. SUMMARY BACKGROUND DATA: Uterus transplantation (UTx) aims at giving women affected by absolute uterine-factor infertility the possibility of carrying their own pregnancy. UTx has evolved from experimental to an established surgical procedure. METHODS: The Dallas Uterus Transplant Study (DUETS) program started in 2016. The uterus was transplanted in orthotopic position with vascular anastomoses to the external iliac vessels and removed when 1 or 2 live births were achieved. Immunosuppression lasted only for the duration of the uterus graft. RESULTS: Twenty women, median age 29.7 years, enrolled in the study, with 10 in phase 1 and 10 in phase 2. All but 2 recipients had a congenital absence of the uterus. Eighteen recipients received uteri from living donors and 2 from deceased donors. In phase 1, 50% of recipients had a technically successful uterus transplant, compared to 90% in phase 2. Four recipients with a technical success in phase 1 have delivered 1 or 2 babies, and the fifth recipient with a technical success is >30 weeks pregnant. In phase 2, 2 recipients have delivered healthy babies and 5 are pregnant. CONCLUSIONS: UTx is a unique type of transplant; whose only true success is a healthy child birth. Based on results presented here, involving refinement of the surgical technique and donor selection process, UTx is now an established solution for absolute uterine-factor infertility.

Stock, P. G., A. Wall, J. Gardner, B. Domínguez-Gil, S. Chadban, E. Muller, I. Dittmer and S. G. Tullius (2020). “Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden.” Transplantation 104(7): 1316-1320.

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The same ethical principles that have always been used to guide transplant practices continue to apply during the COVID-19 era, but the balance between autonomy, beneficence, nonmaleficence, and justice will be inherently fluid, dependent on baseline resources, local practices, and where a given region resides—and is headed—on the COVID-19 incidence curve (Figure 1).4 Programmatic decisions about transplantation will weigh more heavily on distributive justice, beneficence and nonmaleficence than respect for autonomy. The overriding material principle of distributive justice will change, and be weighted more or less heavily, throughout the stages of the incidence curve based on available resources. Beneficence and nonmaleficence calculations must be continually reassessed as more data become available regarding the risk of COVID-19 infections in transplant patients, the availability and accuracy of testing, and the efficacy of new therapeutic modalities. While the complexity, threats, and consequences of COVID-19 are immense, it is reassuring to see the transplant and medical communities rallying together in such a time, and to see, as a result, such thoughtful and consistent responses to dealing with this situation around the globe. Putting aside the jargon of classical medical ethics, these global responses reflect the straightforward principles of doing the right thing for our patients, at the right time, for the right reasons. [No abstract; excerpt from article.].

Testa, G., L. Johannesson and A. E. Wall (2020). “Considering Uterus Transplantation for a Same-Sex Couple: A Case Study.” J Clin Ethics 31(2): 154-157.

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A woman with congenital absence of a uterus applied for participation in a clinical trial for uterus transplantation. She was married to a woman who had the potential to carry a child without the need for aggressive medical intervention. Thus, the question arose regarding whether the infertile partner should be considered for uterus transplantation. In this article we discuss the ethical issues with uterus transplantation for a member of a same-sex couple, whose partner could carry a pregnancy. We review the medical criteria for uterus transplantation, discuss the additional options for parenthood in same-sex couples, examine how to determine if this meets the criteria of just distribution of uterus grafts, and ultimately argue that the value of gestation is at the level of the individual rather than the couple.