Giuliano Testa M.D.

Testa, G., Wall, A., Lee, S. H. and Fine, R. (2022). “Executive orders prohibiting vaccine mandates: implications for transplant patients and physicians.” Am J Transplant.

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There is ongoing discussion within the transplant community, lay press and US government leaders about the appropriateness for vaccine mandates for transplant patients. In Texas, transplant centers are faced with the reality of having an executive order widely interpreted by hospitals administrations as prohibiting vaccine mandates in the provision of medical care.1 This policy is based on the laudable goal of providing all citizens access to life-saving medical care without discrimination based on their personal choices or personal responsibility for their medical problems. However, applying the executive order to ignore vaccination status to patients awaiting an organ transplant submits patients to a perfectly avoidable risk and puts transplant programs in a difficult predicament. The efficacy of the vaccine is inferior when it is given after the transplant and the severity of illness and mortality due to COVID -19 infection are significantly higher in unvaccinated transplant recipients.2-3 This translates into a higher risk of graft loss and patient death following transplantation which leads to a negative impact on outcomes for transplant programs that cannot consider vaccination status as part of their evaluation for listing or transplantation.

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

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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.

Dorafshar, A.H., Jahromi, A.H., Horen, S.R., Schechter, L.S., Johannesson, L., Testa, G., Hertl, M., Dewdney, S., Aschkenasy, J., Molo, M.W., Brincat, C., Cherullo, E., Behel, J.M., Hebert, C., Shulman, R., Bassi, S., Alecci, A.T. and Konety, B. (2021). “Strategic Planning and Essential Steps for Establishing a Uterine Transplant and Rehabilitation Program: From Idea to Reality.” Ann Surg Nov 18. [Epub ahead of print].

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Uterine transplant (UTx) is performed to address absolute uterine infertility in the presence of uterine agenesis, a non-functional uterus, or following a prior hysterectomy. Following the initial success of UTx resulting in a livebirth (2014) in Sweden, there are over 70 reported UTx surgeries resulting in more than 40 livebirths worldwide. Currently, UTx has been performed in over 10 countries. As UTx is transitioning from an “experimental procedure” to a clinical option, an increasing number of centers may contemplate a UTx program. This article discusses essential steps for establishment of a successful UTx program. These principles may be implemented in cis- and transgender UTx candidates.

Gupta, A. and G. Testa (2021). “Pure Laparoscopic Donor Right Posterior Sectionectomy for Living Donor Liver Transplantation: Finding the Balance.” Liver Transpl. Sep 30. Epub ahead of print].

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Live donor liver transplant (LDLT) continues to be an important tool to mitigate the substantial organ shortage worldwide, and in many Eastern countries it remains the only viable option for liver transplantation (1). As donor safety remains an important pillar of LDLT, many potential donors are excluded due to inadequate remnant liver size or anatomical variations. As interest in minimally invasive donor hepatectomy grows this emphasis on patient safety must remain in the forefront.

Bottiglieri, T., X. Wang, E. Arning, H. Fernandez, A. Wall, G. McKenna, R. Ruiz, N. Onaca, J. Trotter, M. Lawrence, B. Naziruddin, S. K. Asrani and G. Testa (2021). “Longitudinal profiling of plasma and urine metabolites during liver regeneration in living liver donors.” Clin Transplant: e14490.[Epub ahead of print].

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BACKGROUND: Knowledge of metabolic processes affected by major hepatectomy (MHx), and the metabolic pathways involved in liver regeneration and recovery of function, is limited and mainly derived from animal models. Assessment of restoration of hepatic function is essential in human living liver donors (LD). METHODS: We used a targeted metabolomic approach to longitudinally quantify changes in plasma and urine biomarkers from healthy LD. The biomarkers were analyzed before MHx and at scheduled intervals up to 12 months thereafter. RESULTS: Marked changes were found in the concentration of 15 primary and secondary plasma bile acids. Most significant changes occurred 2 days after MHx and persisted for up to 3 months. In addition, there were significant changes in acylcarnitine, phospholipid, and amino acid metabolism. The sum of aromatic amino acids and the Fischer ratio, both metabolic markers of liver damage, and the symmetrically demethylated arginine to arginine ratio, a marker of kidney function, were affected. CONCLUSIONS: This is the first comprehensive longitudinal study investigating metabolic processes during recovery of liver function after MHx in LD. It provides further evidence of full restoration of metabolic processes 3 months after MHx and supports future investigation to understand how metabolic changes affect donors’ hepatic function.