Anji Wall M.D.

Wall, A. E., T. Pruett, P. Stock and G. Testa (2020). “Coronavirus disease 2019: Utilizing an ethical framework for rationing absolutely scarce health-care resources in transplant allocation decisions.” Am J Transplant Apr 13. [Epub ahead of print].

Full text of this article.

The novel Coronavirus disease 2019 (COVID-19) is impacting transplant programs around the world, and, as the center of the pandemic shifts to the United States, we have to prepare to make decisions about which patients to transplant during times of constrained resources. In this paper, we discuss how to transition from the traditional justice vs utility consideration in organ allocation to a more nuanced allocation scheme based on ethical values that drive decisions in times of absolute scarcity. We recognize that many decisions are made based on the practical limitations that transplant programs face, especially at the extremes. As programs make the transition from a standard approach to a resource-constrained approach to transplantation, we utilize a framework for ethical decisions in settings of absolutely scarce resources to help guide programs in deciding which patients to transplant, which donors to accept, how to minimize risk, and how to ensure the best utilization of transplant team members.

Cheng, X. S., J. Goldhaber-Fiebert, J. C. Tan, G. M. Chertow, W. R. Kim and A. E. Wall (2020). “Defining a Willingness-to-transplant Threshold in an Era of Organ Scarcity: Simultaneous Liver-kidney Transplant as a Case Example.” Transplantation 104(2): 387-394.

Full text of this article.

BACKGROUND: Organ scarcity continues in solid organ transplantation, such that the availability of organs limits the number of people able to benefit from transplantation. Medical advancements in managing end-stage organ disease have led to an increasing demand for multiorgan transplant, wherein a patient with multiorgan disease receives >1 organ from the same donor. Current allocation schemes give priority to multiorgan recipients compared with single-organ transplant recipients, which raise ethical questions regarding equity and utility. METHODS: We use simultaneous liver and kidney (SLK) transplant, a type of multiorgan transplant, as a case study to examine the tension between equity and utility in multiorgan allocation. We adapt the health economics willingness-to-pay threshold to a solid organ transplant setting by coining a new metric: the willingness-to-transplant (WTT) threshold. RESULTS: We demonstrate how the WTT threshold can be used to evaluate different SLK allocation strategies by synthesizing utility and equity perspectives. CONCLUSIONS: We submit that this new framework enables us to distill the question of SLK allocation down to: what is the minimum amount of benefit we require from a deceased donor kidney to allocate it for a particular indication? Addressing the above question will prove helpful to devising a rational system of SLK allocation and is applicable to other transplant settings.

Ramani, A., G. Testa, Y. Ghouri, E. C. Koon, M. Di Salvo, G. J. McKenna, J. Bayer, A. M. Warren, A. Wall and L. Johannesson (2019). “DUETS (Dallas UtErus Transplant Study):Complete report of 6-month and initial 2-year outcomes following open donor hysterectomy.” Clin Transplant Nov 22. [Epub ahead of print].

Full text of this article.

INTRODUCTION: Uterus transplantation has shown success in treating women with uterine-factor infertility who want to carry their own pregnancy. METHODS: We report the medical, sexual, and psychological outcomes of our first cohort of 13 living-donor hysterectomies. As we have transitioned from open to robotically assisted hysterectomy, this report represents the complete series of open-donor hysterectomies at our center, all with >/=6-month postoperative outcomes. RESULTS: The open donor hysterectomy had a median of a 6.5-hour surgical time, 0.8 L estimated blood loss, 6-day hospital stay, and 28-day sick leave. Three donors had a grade III or IV complications, one reported new-onset psychological symptoms, and 9 experienced transient sexual discomfort. All complications were addressed and resolved, and all donors returned to their presurgical social and physical activities. CONCLUSION: Since uterus transplantation is not life-saving or life-extending, the risks in living uterus donation must be weighed against the benefit of giving another woman the opportunity to give birth to her own child. This report provides data to support more detailed informed consent regarding the medical, psychological, and sexual complications of open living donor hysterectomy and allows for further evaluation of the ethical acceptability of this procedure.

Wall, A. (2019). “The Qualitative Value of Social Support for Liver Transplantation.” Am J Bioeth 19(11): 25-26.

Full text of this article.

Last week, I had to respect the decision of my patient’s family to withdraw ventilatory support on a patient who was 3 months post liver transplant with a functional liver and a reversible disease process. Not only did we lose a completely salvageable patient, but we also lost the liver graft and we lost the opportunity to transplant a different patient who might have had a better outcome. This type of loss (salvageable patient with a functioning graft) is thankfully uncommon in liver transplantation, but when it happens, it leaves a mark on the entire team. We question what we could have done better to affect a different outcome and we relive all the decisions that led up to this ultimate decision to stop fighting for the life of the patient and the life of the graft. In this case, my team kept returning to the social-work evaluation and the decision that we made to push the limits of our social support criteria for post-transplant care. This patient’s family members all lived far away so his support consisted of a neighbor and paid nursing staff. After getting out of the hospital, the patient continually fired the nursing staff so there was always a different caregiver to communicate with. When the patient got readmitted for a complication, the neighbor came with him but had to leave to get back to his own work . . . One of the comments that Berry and colleagues make in their article is that if weakly supported patients are less able to manage the extreme demands of transplantation, which includes follow-up care, new medications, and the ongoing risk of organ rejection, then the use of social support criteria can be supported from a utilitarian standpoint. The extreme demands of liver transplantation are not the frequent clinic appointments or the medication regimens. Those are the standard requirements for routine postoperative care . . . The true extreme demands of liver transplantation happen to the minority of patients who have complicated postoperative courses, spend weeks to months in the intensive care unit, and have to build themselves back up from nothing through rehabilitation; learning to walk, talk, and eat again. These are the patients who need the strong emotional component of social support. They need their family and friends to be with them, encourage them, push them and support them through the intense recovery process. They also need adequate preoperative physical functioning and reserve, which is why frailty in liver transplantation has become such an important predictive tool. Frail patients who have severe complications do not have the physical reserve to rebound. Likewise, unsupported patients who have severe complications do not have the emotional support reserve to rebound . . . The evidence for social support is weak and is biased, as every program has some threshold for social support as a criterion for listing. While this commentary describes a single case, it is not a fluke. I would argue that every liver transplant surgeon can discuss a situation in which the lack of social support contributed in a real way to the loss of a patient after transplantation. I have been in practice for 1 year, and I can name five patients whose lack of social support significantly impacted their postoperative care, leading to complications, and in some cases death. On the other hand, I can name five patients who are alive and thriving today almost solely because of the support of their families and friends . . . While social support will always have subjectivity and will never be studied in a randomized control trial, it remains qualitatively important and should not be abandoned in the considerations for listing for liver transplantation. (Excerpts from text of this commentary, p. 25-26, which refers to a study in the same issue, Berry, K., N. Daniels, and K. Ladin. 2019. Should lack of social support prevent access to organ transplantation? The American Journal of Bioethics 19(11): 13–24.)

Johannesson, L., A. Wall, J. M. Putman, L. Zhang, G. Testa and C. Diaz-Garcia (2019). “Rethinking the Time Interval to Embryo Transfer after Uterus Transplantation – Duets (Dallas Uterus Transplant Study).” BJOG 126(11): 1305-1309.

Full text of this article.

Uterus transplant can allow women to carry their own pregnancy. Because of the transplant operation, infectious disease risks, and immunosuppressive medications, these pregnancies require careful planning. Conditions to achieve before ET include stable uterine graft function, absence of active rejection, stable immunosuppressive medication with agents with low teratogenic risk, and low‐risk status for harmful opportunistic infections. Our experience, the experience of other uterus transplant programmes, and results of successful pregnancies in other solid organ transplant recipients suggest ET could be considered as soon as 3 months after uterus transplantation if the above criteria are met. Given the unique characteristics of uterus transplantation and the recipient population, the transplant‐to‐ET interval should differ from recommendations in other organ and vascular allograft transplantations. The incentive of minimising the recipient‐graft time and concomitant exposure to immunosuppressants in this young, healthy patient population strongly supports shortening the transplant‐to‐ET time. (Excerpt from text, p. 1308; no abstract available.)