Gregory J. McKenna M.D.

Johannesson, L., K. Wallis, E. C. Koon, G. J. McKenna, T. Anthony, S. G. Leffingwell, G. B. Klintmalm, R. T. Gunby, Jr. and G. Testa (2018). “Living uterus donation and transplantation: experience of interest and screening in a single center in the United States.” Am J Obstet Gynecol 218(3): 331.e331-331.e337.

Full text of this article.

BACKGROUND: Little is known about attitudes toward uterus donation and transplantation in society and the interest of the women the treatment is aimed to assist. OBJECTIVE: This study examined the interest of recipients and living donors in our uterus transplantation program; it describes the screening protocol we developed and the results of the screening and reports demographic data and characteristics of screened candidates. STUDY DESIGN: Initial screening and evaluation included physical examinations by a gynecologist and a transplant surgeon; psychological evaluation; imaging (x-ray, computed tomography, ultrasound); blood tests; immunological testing; viral, bacterial, and fungal testing; drug screen; hormonal testing; Papanicolau smear; urinalysis; and electrocardiogram. For selected recipients, the process also included in vitro fertilization. RESULTS: A total of 351 women contacted our department with interest in participating in uterus transplantation; 272 were potential recipients and 79 were potential donors. Among these women, 179 potential recipients and 62 potential donors continued the evaluation after the initial telephone screening. The mean age of the donor candidates was 40 years; all had completed their own family, and 80% were nondirected. Most recipient candidates (92%) had an anatomical lack of the uterus, and of these, 36% had a congenital malformation. The women with a congenital uterine absence were in general younger than the women in the group whose uterus had been removed (mean of 28 and 33 years, respectively). In every step of the initial screening and evaluation process, there were donor and recipient candidates that chose not to continue the process. The reasons for self-withdrawal after expressing interest were not returning phone calls or e-mails (17 donors and 76 recipients); after initial phone screening, no longer interested (1 donor and 9 recipients); in step 1, health history questionnaire not returned after 1 reminder (10 donors and 9 recipients); step 2, not right in their current life situation (2 donors and 2 recipients), and in step 3, chose another way to achieve motherhood (1 recipient). Most donor and recipient candidates (52% and 78%, respectively) could be screened out (because of self-withdrawal or transplant team’s decision) during the noninvasive and cost-efficient initial screening. CONCLUSION: Our initial experience shows a great interest in participating in a trial of uterus transplantation by both potential recipients and donors. It is the first study to show interest in nondirected donation. A sufficient but thoughtful screening process of living donors and recipients is essential and should aim both to assure donor/recipient safety and to provide good quality grafts.

Testa, G., T. Anthony, G. J. McKenna, E. C. Koon, K. Wallis, G. B. Klintmalm, J. C. Reese and L. Johannesson (2018). “Deceased donor uterus retrieval: A novel technique and workflow.” Am J Transplant 18(3): 679-683.

Full text of this article.

Uterus transplantation has proven successful when performed with a living donor. Subsequently, interest in the novel field of reproductive transplantation is growing. The procedure is still considered experimental, with fewer than 25 cases performed worldwide, and the techniques of both uterus procurement and transplantation are still developing. We detail a new approach to deceased donor uterus procurement. In contrast to reported techniques and our own initial experience, in which the deceased donor uterus was procured post cross-clamp and after other organs were procured, our approach now is to perform the uterus procurement prior to the procurement of other organs in a multiorgan donor and hence prior to cross-clamp. We describe our practical experience in developing and implementing the logistical workflow for deceased donor uterus procurement in a deceased multiorgan donor setting.

Asrani, S. K., G. Saracino, J. G. O’Leary, S. Gonzales, P. Kim, G. McKenna, G. Klintmalm and J. Trotter (2018). “Recipient characteristics and morbidity and mortality after liver transplantation.” J Hepatol. Feb 14. [Epub ahead of print].

Full text of this article.

BACKGROUND: Over the last decade, liver transplantation of sicker, older non-hepatitis C cirrhotics with multiple co-morbidities has increased in the United States. METHODS: We sought to identify a parsimonious set of recipient factors among HCV negative adult transplant recipients associated with significant morbidity and mortality within 5 years after liver transplantation using national (n=31,829, 2002-2015) and center specific data. Coefficients of relevant recipient factors were converted to weighted points and scaled from 0-5. Recipient factors associated with graft failure included: ventilator support (5 pts; HR 1.59, 95% CI 1.48-1.72); recipient age >60 years (3 pts; HR 1.29, 95% CI 1.23-1.36); hemodialysis (3 pts; HR 1.26, 95% CI 1.16-1.37); diabetes (2 pts; HR 1.20, 95% CI 1.14-1.27); or serum creatinine >/=1.5mg/dL without hemodialysis (2 pts; HR 1.15, 95% CI 1.09-1.22). RESULTS: Graft survival within 5 years based on points (any combination) was 77.2% (0-4), 69.1% (5-8) and 57.9% (>8). In recipients with > 8 points, graft survival was 42% (MELD<25) and 50% (MELD 25-35) in recipients receiving donors with donor risk index >1.7. In center specific data within the first year, subjects with >/= 5 points (vs. 0-4) had longer hospitalization (11 vs. 8 days, p<0.01), higher admissions for rehabilitation (12.3% versus 2.7%, p<0.01), and higher incidence of cardiac disease (14.2% vs. 5.3%, p<0.01) and stage 3 chronic kidney disease (78.6% vs. 39.5%, p=0.03) within 5 years. CONCLUSION: The impact of co-morbidities in a MELD based organ allocation system needs to be reassessed. The proposed clinical tool may be helpful for center specific assessment of risk of graft failure in non HCV patients and discussion regarding relevant morbidity in selected subsets. LAY SUMMARY: Over the last decade, liver transplantation of sicker, older patient with multiple co-morbidities has increased. In this study, we show that a set of recipient factors (recipient age>60 years, ventilator status, diabetes, hemodialysis and creatinine>1.5mg/dL) can help identify patients that may not do well after transplant. Transplanting sicker organs in patients with certain combinations of these characteristics further leads to lower survival.

Warren, A. M., G. Testa, T. Anthony, G. J. McKenna, G. B. Klintmalm, K. Wallis, E. C. Koon, R. T. Gunby, Jr. and L. Johannesson (2018). “Live nondirected uterus donors: Psychological characteristics and motivation for donation.” Am J Transplant. Jan 24. [Epub ahead of print].

Full text of this article.

Emerging research suggests that uterus transplantation is a viable option for women without a uterus who want to become pregnant and carry a child to term. Currently, no knowledge exists regarding nondirected uterus donors. This study (NCT 02656550) explored the baseline psychological characteristics of nondirected uterus donors at a single study site. Of the 62 potential donors who underwent initial screening, six nondirected donors were chosen and participated in uterus donation. Participants received a comprehensive evaluation, which included clinical history and psychological assessments. The mean age of the donors was 42 years; most (83%) were white/not Hispanic, and all had a college degree. Current depression was reported by two participants, past depression was reported in two participants, and past anxiety was reported in three participants. Based on several different psychological measures, donors had a higher general well-being than the normative sample, and none of the participants’ scores indicated psychological distress. All six women indicated that giving another woman an opportunity to carry her own child was a motivation for pursuing uterus donation. Further research on potential psychological motives and gains for the donor as well as long-term effects on donors is crucial for ethical practice.

Johannesson, L., K. Wallis, E. C. Koon, G. J. McKenna, T. Anthony, S. G. Leffingwell, G. B. Klintmalm, R. T. Gunby, Jr. and G. Testa (2017). “Living uterus donation and transplantation: experience of interest and screening in a single center in the United States.” Am J Obstet Gynecol.

Full text of this article.

BACKGROUND: Little is known about attitudes toward uterus donation and transplantation in society and the interest of the women the treatment is aimed to assist. OBJECTIVE: This study examined the interest of recipients and living donors in our uterus transplantation program; it describes the screening protocol we developed and the results of the screening and reports demographic data and characteristics of screened candidates. STUDY DESIGN: Initial screening and evaluation included physical examinations by a gynecologist and a transplant surgeon; psychological evaluation; imaging (x-ray, computed tomography, ultrasound); blood tests; immunological testing; viral, bacterial, and fungal testing; drug screen; hormonal testing; Papanicolau smear; urinalysis; and electrocardiogram. For selected recipients, the process also included in vitro fertilization. RESULTS: A total of 351 women contacted our department with interest in participating in uterus transplantation; 272 were potential recipients and 79 were potential donors. Among these women, 179 potential recipients and 62 potential donors continued the evaluation after the initial telephone screening. The mean age of the donor candidates was 40 years; all had completed their own family, and 80% were nondirected. Most recipient candidates (92%) had an anatomical lack of the uterus, and of these, 36% had a congenital malformation. The women with a congenital uterine absence were in general younger than the women in the group whose uterus had been removed (mean of 28 and 33 years, respectively). In every step of the initial screening and evaluation process, there were donor and recipient candidates that chose not to continue the process. The reasons for self-withdrawal after expressing interest were not returning phone calls or e-mails (17 donors and 76 recipients); after initial phone screening, no longer interested (1 donor and 9 recipients); in step 1, health history questionnaire not returned after 1 reminder (10 donors and 9 recipients); step 2, not right in their current life situation (2 donors and 2 recipients), and in step 3, chose another way to achieve motherhood (1 recipient). Most donor and recipient candidates (52% and 78%, respectively) could be screened out (because of self-withdrawal or transplant team’s decision) during the noninvasive and cost-efficient initial screening. CONCLUSION: Our initial experience shows a great interest in participating in a trial of uterus transplantation by both potential recipients and donors. It is the first study to show interest in nondirected donation. A sufficient but thoughtful screening process of living donors and recipients is essential and should aim both to assure donor/recipient safety and to provide good quality grafts.