Motorcycles as donorcycles

 Here's an article from JAMA Internal Medicine, noting that motorcycle rallies produce an increase in organ transplants.

Organ Donation and Transplants During Major US Motorcycle Rallies  by David C. Cron, MD, MS; Christopher M. Worsham, MD; Joel T. Adler, MD, MPH; Charles F. Bray, BS; Anupam B. Jena, MD, PhD,  JAMA Intern Med. Published online November 28, 2022. doi:10.1001/jamainternmed.2022.5431

"Key Points

Question  Is the incidence of organ donation and transplants higher during major US motorcycle rallies?

Findings  In this cross-sectional study of 10 798 organ donors and 35 329 recipients of these organs from a national transplant registry from 2005 to 2021, there were 21% more organ donors and 26% more transplant recipients per day during motorcycle rallies in regions near those rallies compared with the 4 weeks before and after the rallies.

Meaning  While safety measures to minimize morbidity and mortality during motorcycle rallies should be prioritized, this study showed the downstream association of these events with organ donation and transplants."

***********

Helmet laws by State (only the States in orange require all motorcycle riders to wear a helmet):

I wonder what would happen if some State passed a helmet law saying that adults are free to ride without a helmet, but doing so automatically registers the rider as a willing deceased donor. (Such a law might decrease deceased donation by convincing more riders to wear helmets.)

HT: Alex Chan

Deceased donor organ discards on weekends, in the the Annals of Transplantation

 Hospital resources and physician incentives can be stressed on weekends, and there is historical evidence that organ discards are higher on weekends.  Here's a study suggesting that is still a thing.

Yamamoto, T., A. Shah, M. Fruscione, S. Kimura, N. Elias, H. Yeh, T. Kawai, and J. F. Markmann.  Revisiting the "Weekend Effect" on Adult and Pediatric Liver and Kidney Offer Acceptance. Annals of Transplantation. 2022 Nov;27:e937825. DOI: 10.12659/aot.937825. PMID: 36329622.

"BACKGROUND: Weekends can impose resource and manpower constraints on hospitals. Studies using data from prior allocation schemas showed increased adult organ discards on weekends. We examined the impact of day of the week on adult and pediatric organ acceptance using contemporary data.

"MATERIAL AND METHODS: Retrospective analysis of UNOS-PTR match-run data of all offers for potential kidney and liver transplant from 1/1/2016 to 7/1/2021 were examined to study the rate at which initial offers were declined depending on day of the week. Risk factors for decline were also evaluated.

"RESULTS: Of the total initial adult/pediatric liver and kidney offers, the fewest offers occurred on Mondays and Sundays. The decline rate for adult/pediatric kidneys was highest on Saturdays and lowest on Tuesdays. The decline rate for adult livers was highest on Saturday and lowest on Wednesday. In contrast, the decline rate for pediatric livers was highest on Tuesdays and lowest on Wednesdays. Independent risk factors from multivariate analysis of the adult/pediatric kidney and liver decline rate were analyzed. The weekend offer remains an independent risk factor for adult kidney and liver offer declines, but for pediatric offers, these were not significant independent risk factors.

"CONCLUSIONS: Although allocation systems have changed, and the availability of kidneys and livers have increased in the USA over the past 5 years, the weekend effect remains significant for adult liver and kidney offers for declines. Interestingly, the weekend effect was not seen for pediatric liver and kidney offers.

Kidney exchange in The Times of India

 The Times of India covers my talk at the Indian Society of Transplantation meeting:

Alvin Roth for legal boost to kidney exchange pool in India by Chaitanya Deshpande, Oct 15, 2022c

 The site makes it hard to extract text, but here's a photo of some comments, which make me hope that some action may be taken:

Update: 

Crowdsourcing organ transplant ethics

 In Slate, an upbeat article about the ethical issues associated with deceased organ allocation and (before that) access to dialysis, and the benefits and difficulties with crowdsourcing the solutions.  

The Kidney Transplant Algorithm’s Surprising Lessons for Ethical A.I.  A more democratic approach to A.I. is messy, but it can work.  BY DAVID G. ROBINSON

This article is adapted from Voices in the Code: A Story About People, Their Values, and the Algorithm They Made, out Sept. 8 from Russell Sage Foundation Press.

" in the world of organ transplants, surgeons and data scientists have an unusual habit of being brutally honest about the human lives behind their work—of inviting others into the impossible choices their field confronts. For better and worse, the organ transplant system is itself a real-life laboratory of more inclusive, accountable techniques for building and using A.I.—approaches that are now being proposed in U.S. and EU legislation that could cover courtrooms, hiring, housing, and many other sensitive domains.

...

"Where did this culture of moral humility—one that’s now shaping the design of a high-stakes A.I. system—come from?

"Collaborative decision-making about hard ethical choices in kidney medicine began before the digital revolution. It began before there were many kidney transplants. "

After the development of dialysis there were..."just a handful of dialysis machines, ...Whom to save? Scribner and his team were inundated with pleas from dying patients and their doctors.

"Faced with this quandary, Scribner and his colleagues chose to do something extraordinary: They shared their moral burden with the Seattle community they served. Rather than pretending that their technical expertise gave them special moral standing, they chose to be morally modest, and to widen the circle. The doctors still decided who was medically eligible for dialysis. But then, they established a second committee, a group of seven laypeople chosen by the local medical society, who would make the non-medical decision of how to allocate the few available slots among the many eligible patients. The committee members were given some basic education about kidney medicine, but weren’t told how to make their moral choices.

“They Decide Who Lives, Who Dies” was the headline of a 1962 Life magazine article about this new group. Its members, who were anonymous, were photographed in shadow. A clerical collar can be seen on one. The lone woman of the group, a homemaker, clasps a pair of reading glasses in her folded hands. The article reported that the committee’s approach was based on “acceptance of the principle that all segments of society, not just the medical fraternity, should share the burden of choice as to which patients to treat and which ones to let die.”

"The Life story described some biases that played out on the committee—they favored male breadwinners who had children to support—and it triggered widespread revulsion. A pair of scholars wrote that the committee was judging people “in accordance with its own middle-class suburban value system: scouts, Sunday school, Red Cross. This rules out creative nonconformists … the Pacific Northwest is no place for a Henry David Thoreau with bad kidneys.” The original Life story never mentioned race, but later reporting suggested the committee had been biased in favor of white applicants. The committee only ran for a few years. Other dialysis facilities used different rationing strategies—including first-come, first-served—and in 1972 Congress passed an extraordinary law to provide dialysis at public expense through Medicare to all patients who needed it. That proved to be a humane, if extremely costly, escape route from the rationing problem that Scribner once faced.

"Along with all its faults, I think the Seattle committee also gave us much to admire. It was profoundly, even uncomfortably, honest about the hard choices at the center of kidney medicine. It refused to pretend that such choices were—or ever could be—entirely technical. And it tried, albeit clumsily, to democratize the values inside a complex, high-tech system. The Seattle physicians and their lay colleagues were rationing a scarce supply of dialysis treatments. But even after Congress provided dialysis for everyone, the shortage of transplantable kidneys was destined to spark similar questions, ones we still face today."

HT: Tom Riley

Organ donor joke from the Edinburgh fringe

 “My dad suggested I register for a donor card. He’s a man after my own heart.” 

That's a joke by Masai Graham, who won the most popular joke vote this year at the Edinburgh fringe, with 52% of 2,000 votes for another one-liner: “I tried to steal spaghetti from the shop, but the female guard saw me and I couldn’t get pasta.”

Here's the Guardian with more:

Pasta one-liner wins best joke award at Edinburgh festival fringe. West Midlands comedian Masai Graham, who works as a part-time care worker, wins title for second time. by Harriet Sherwood 

Opt out organ donation in England and the Netherlands

 

Jansen, N. E., Williment, C., Haase-Kromwijk, B. J. J. M., & Gardiner, D. (2022). Changing to an Opt Out System for Organ Donation—Reflections From England and Netherlands. Transplant International, 133.

Abstract: Recently England and Netherlands have changed their consent system from Opt In to Opt Out. The reflections shared in this paper give insight and may be helpful for other nation considering likewise. Strong support in England for the change in legislation led to Opt Out being introduced without requiring a vote in parliament in 2019. In Netherlands the bill passed by the smallest possible majority in 2018. Both countries implemented a public campaign to raise awareness. In England registration on the Donor Register is voluntary. Registration was required in Netherlands for all residents 18 years and older. For those not already on the register, letters were sent by the Dutch Government to ask individuals to register. If people did not respond they would be legally registered as having “no objection.” After implementation of Opt Out in England 42.3% is registered Opt In, 3.6% Opt Out, and 54.1% has no registration. In contrast in Netherlands the whole population is registered with 45% Opt In, 31% Opt Out and 24% “No Objection.” It is too soon to draw conclusions about the impact on the consent rate and number of resulting organ donors. However, the first signs are positive."

...

"There had been many failed attempts to introduce Opt Out legislation to England over the last 30 years but was achieved on 20th May 2020. In October 2017 the Prime Minister stated her intention to shift “the balance of presumption in favour of organ donation” and “introduce an opt out system for donation.”

"Fortuitously a parliamentarian from the opposition party had successfully had his name drawn from a legislation ballot (a system which allows a few “Private Members Bills” to be considered by parliament from a randomly chosen subset of legislation suggestions), for a new Opt Out Bill. This led to an unusual alignment of opposing political parties, working together on a new policy. Due to this cross party support, the Bill progressed through Parliament and never had to be put to a vote.

"England’s Opt Out legislation built on the positive experience in Wales and Parliament was further reassured by the response to a public consultation on the draft Bill, which asked how Opt Out should be introduced. The Government usually expects between 200 and 500 responses; over 17,000 responses were received. The responses were supportive and gave a strong steer for the issues needing to be addressed.

"The main issues raised by the public were: the need for autonomy and individual choice; the role of the family; the need to respect faith and beliefs through the donation process. The government worked closely with NHSBT to identify ways to ensure that these issues were addressed. Ministerial commitments also secured additional resources such as increased recurrent funding.

"The final inspiration came from two young people—Max Johnson and Keira Ball. When the Bill was introduced, Max Johnson, a 9 year old boy, was in desperate need of a heart transplant. The UK media—particularly the Mirror newspaper—campaigned for the introduction of Opt Out legislation. Max’s life was saved through the gift of donation by Keira Ball, also aged nine, who tragically lost her life in a road traffic collision. The Opt Out legislation is known as Max and Keira’s Law, in their honour.

"Netherlands

"On the 1st of July 2020 the Opt Out system for organ donation was implemented in Netherlands. Changing the organ donation law from an Opt In consent system into an Opt Out system had not been easy. It took more than 12 years of political discussion to reach the milestone of a majority.

"In 2012 a member of the House of Representatives prepared a Bill to change the consent system into an “Active Donor Registration.” On the 16th of September 2016 the Bill was passed by the smallest possible majority in the House of Representatives, 75 members voted in favour of the Bill and 74 members against. On the 16th of February 2018 the vote in the Senate again ended in a close call, 38 senators voted in favour of the Bill and 36 members against. The Bill could only pass after a required amendment to develop a “Quality Standard Donation,” which describes the role of the doctor and the family in the donation conversation, based on the different outcomes of the Donor Register.

"The Active Donor Registration means that Dutch residents without a registration in the Donor Register, 7 million, will be asked by letter to register their donation preferences (same options as in the Opt In system). If they do not respond to a first and second letter, they will receive a third and final letter with the confirmation that they will be registered as having “No Objection” to organ and tissue donation. Under the new legislation “No Objection” would legally be considered the same as a registration of “Yes, I want to be an organ donor.” Registrations can be changed 24 h a day via the Internet. It could therefore be argued that while the change in law was to introduce Opt Out, it has similarities to a model of mandated choice for organ and tissue donation (6).

Returning to your place in the queue following a failed kidney transplant

 Here's a forthcoming paper that proposes that rejections of marginal kidneys could be reduced if recipients were guaranteed a shorter waiting time for a subsequent transplant if a marginal kidney that they accepted failed.

Tunç, Sait, Burhaneddin Sandıkçı, and Bekir Tanrıöver. "A Simple Incentive Mechanism to Alleviate the Burden of Organ Wastage in Transplantation." Management Science (2022).

Abstract: Despite efforts to increase the supply of donated organs for transplantation, organ shortages persist. We study the problem of organ wastage in a queueing-theoretic framework. We establish that self-interested individuals set their utilization levels more conservatively in equilibrium than the socially efficient level. To reduce the resulting gap, we offer an incentive mechanism that recompenses candidates returning to the waitlist for retransplantation, who have accepted a predefined set of organs, for giving up their position in the waitlist and show that it increases the equilibrium utilization of organs whilealso improving social welfare. Furthermore, the degree of improvement increases monotonically with the level of this nonmonetary compensation provided by the mechanism. In practice, this mechanism can be implemented by preserving some fraction of the waiting time previously accumulated by returning candidates. A detailed numerical study for the U.S. renal transplant system suggests that such an incentive helps significantly reduce the kidney discard rate (baseline: 17.4%). Depending on the strength of the population’s response to the mechanism, the discard rate can be as low as 6.2% (strong response), 12.4%(moderate response), or 15.1% (weak response), which translates to 1,630, 724, or 338 more  transplants per year, respectively. Although the average quality of transplanted kidneys deteriorates slightly, the resulting graft survival one-year post transplant remains stable around 94.8% versus 95.0% for the baseline. We find that the optimal Kidney Donor Profile Index score cutoff, defining the set of incentivized kidneys, is around 85%, which coincides with the generally accepted definition of marginal kidneys in the medical community."

More on UNOS in the hot seat and calls for reform of the U.S. deceased donor transplant system

 Here's another report about the recent Senate Finance Committee hearing about UNOS, which includes a redacted version of the U.S. Digital Service report calling for UNOS's functions to be broken up. (UNOS, the United Network for Organ Sharing, is the federal contractor that runs the U.S. deceased donor transplant system.)

Transplant System Urgently Needs Overhaul, Experts Say— UNOS CEO skewered for alleged failures in management during a Senate Finance Committee hearing by Shannon Firth, Washington Correspondent, MedPage Today

"Members of the Senate Finance Committee and fellow witnesses roasted the head of the United Network for Organ Sharing (UNOS) during a hearing on Wednesday, over what Committee Chair Ron Wyden (D-Ore.) characterized as "gross mismanagement and incompetence."

...

"A report from the U.S. Digital Service issued last year determined that the network lacks the technical capacity to modernize the system. The report recommended that the contract for the system, worth $248 million, be separate from a contract for policy management, according to The Washington Post.

"Sen. Elizabeth Warren (D-Mass.), not one to mince words, told Brian Shepard, CEO of UNOS, "I'll just be clear. You should lose this contract. You should not be allowed anywhere near the organ transplant system in this country. And if you try to interfere with the process of turning the contract over to someone who can actually do the job, you should be held accountable for that."

HT: Frank McCormick

**********

And here is a Senate memo issued just prior to the hearing:

“A System in Need of Repair: Addressing  Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network”

"This bipartisan investigation began in February 2020 when then-Chairman Charles Grassley, then-Ranking Member Ron Wyden, Senator Todd Young, and Senator Benjamin Cardin sent a letter to UNOS expressing their concerns about the adequacy of patient safety standards and belief that OPOs are failing to recover thousands of viable organs each year. 16 The letter also highlighted an investigation by the Department of Health and Human Services, Office of Inspector General (HHS OIG) and news reports, shining a light on “lapses in patient safety, misuse of taxpayer dollars, and tens of thousands of organs going unrecovered or not transplanted,” leading to questions about the adequacy of UNOS’ oversight of OPOs.”17

"In 2021, the investigation continued under the leadership of now-Chairman Wyden and Ranking Member Grassley of the Senate Judiciary Committee with a series of bipartisan requests for information sent to HHS,18 CMS,19 HRSA, and the Office of Management and Budget. Staff also broadened the scope of the investigation to include concerns about the inadequacy of the OPTN information technology system and its impact on patients. 

...

Based on documents and internal memoranda, the Committee found that:

• The OPTN is failing to provide adequate oversight of the nation’s 57 OPOs, resulting in fewer organs available for transplant.

• The lack of oversight by UNOS causes avoidable failures in organ procurement and transplantation resulting in risks to patient safety. These failures include testing procedure errors, transportation issues resulting in life saving organs being lost or destroyed in transit, and process and procedure failures.

• UNOS lacks technical expertise to modernize the OPTN IT system, resulting in risk of system interruption or technical failure with the potential to harm patients across the country."

...

"While not the sole focus of the Committee’s investigation, Senator Grassley and Senator Wyden’s staff also heard concerns from patients, transplant center staff, and OPO staff that UNOS lacks technological expertise or the willingness to develop and maintain an adequate IT infrastructure. Staff also heard concerns that the archaic IT system results in delays in placing organs, organs being discarded, and inaccurate data being used to place organs because of its dependence on staff manually entering hundreds of donor and transplant candidate data points rather than upgrading to systems better able to transfer data across Electronic Medical Record platforms.

"These concerns were validated in a report from the independent U.S. Digital Service (USDS), which is housed within the Executive Office of the President and provides consultation services to federal agencies on information technology.115 The report, titled Lives Are at Stake, states that UNOS has been able to wiggle through and around most new contract requirements for the OPTN technology by hand-waving at change with technical jargon, while making no substantive progress. The USDS also states that:116

• UNOS is incapable of modernizing the OPTN IT infrastructure;

• the core systems are fragile;

• OPTN technology limits policy development;

• UNOS is resistant to change; and,

• OPTN system is dependent on a disjointed and inadequate user experience.

"Ultimately, USDS determined that these technological failings are in fact placing lives at stake and recommended that HHS take action to create a better organ transplant system and enable better patient outcomes, including updating NOTA to create flexibility in how the OPTN is serviced by contractors."

...

"Based on the investigation’s findings, Committee staff makes the following recommendations to improve the OPTN:

• Remove barriers to competition by removing the specific requirement for HHS to contract only with a “non-profit entity that has an expertise in organ procurement and transplantation;”

• Increase the pool of potential bidders by clarifying that the OPTN functions described in NOTA and subsequent amendments may be operated by more than one contractor, since few contractors will have adequate clinical knowledge and expertise in IT, policy development, and data collection and reporting, and policy compliance activities;

• Promote innovation in all OPTN functions (e.g., policy development, compliance and patient safety mentoring, IT infrastructure, coordinating transport of organs, etc.) as the best qualified entities with distinct skill sets could compete for contracts for these functions;

• Remove a major barrier for entry for bidders by providing authority for HHS to procure a government owned, contractor operated modern IT system to facilitate the OPTN functions;

• Increase security and innovation in the OPTN system by ensuring the new IT system is based on current technologies and operated and maintained by a contractor with adequate IT knowledge and experience;

• Ensure the continued viability of the OPTN by authorizing HHS to collect fees from transplant hospitals when adding a patient to the national organ transplant waitlist. This would replace a current fee structure authorized by regulation which is not flexible enough to provide funding for multiple contracts;

• Increase transparency and accountability for chain of custody and transportation of organs procured for transplant by providing for public reporting, as appropriate, on the status of organs in transport; and,

• Increase accountability for organs lost, damaged, or delayed in transport by requiring oversight and corrective action for such incidents.

**********

Earlier:

Wednesday, August 3, 2022

UNOS and organ transplant technology

Thursday, August 4, 2022

UNOS hearing in the Senate

UNOS and organ transplant technology

 Organ transplant  communications and logistics are difficult, and current procedures are clunky. But never attribute to malevolence what can be accounted for by incompetence (and difficulty).

The Washington Post has the story:

Thousands of lives depend on a transplant network in need of ‘vast restructuring’. White House Digital Service found that the technology that matches donated organs to patients has failed repeatedly  By Joseph Menn and Lenny Bernstein

"The system for getting donated kidneys, livers and hearts to desperately ill patients relies on out-of-date technology that has crashed for hours at a time and has never been audited by federal officials for security weaknesses or other serious flaws, according to a confidential government review obtained by The Washington Post.

"The mechanics of the entire transplant system must be overhauled, the review concluded, citing aged software, periodic system failures, mistakes in programming and over-reliance on manual input of data.

"In its review, completed 18 months ago, the White House’s U.S. Digital Service recommended that the government “break up the current monopoly” that the United Network for Organ Sharing, the non-profit agency that operates the transplant system, has held for 36 years. It pushed for separating the contract for technology that powers the network from UNOS’s policy responsibilities, such as deciding how to weigh considerations for transplant eligibility.

...

"UNOS is overseen by the Health Resources and Services Administration (HRSA), but that agency has little authority to regulate transplant activity. Its attempts to reform the transplant system have been rejected by UNOS, the report found. Yet HRSA continues to pay UNOS about $6.5 million annually toward its annual operating costs of about $64 million, most of which comes from patient fees.

...

"UNOS considers its millions of lines of code to be a trade secret and has said the government would have to buy it outright for $55 million if it ever gave the contract to someone else, according to the report.

...

"UNOS oversees what is formally known as the Organ Procurement and Transplant Network, a complex collection of about 250 transplant-performing hospitals; 57 government-chartered non-profits that collect organs in their regions; labs that test organs for compatibility and disease; and other auxiliary services.

"Located in Richmond, UNOS sits at the center of the system. It is the only organization to ever hold the 36-year-old contract to run the operation, currently a multi-year pact worth more than $200 million, funded mainly by fees patients pay to be listed for transplants."

HT: Martha Gershun

***********

My understanding is that the contract is occasionally put out to bid, but that any successful bidder would have to be prepared to operate the whole national deceased organ transplant system immediately from a cold start, which is why the issue of who owns the existing software, data, etc. is important.

Legal and illegal sales of body parts

 U.S. law makes it illegal to sell deceased donor organs for transplant, i.e. to save a life, but it's otherwise legal to sell body parts or whole cadavers, for research, for instruction, etc.  Nevertheless, alongside the legal, regulated market, which requires consents and precautions, is an illegal black market which is occasionally prosecuted.  Here's a recent case, as reported in the NYT:

Funeral Home Operator Pleads Guilty in ‘Illegal Body Part Scheme’.  Megan Hess, who pleaded guilty to mail fraud, sold body parts without families’ consent... By Alex Traub

"The operator of a Colorado funeral home who was accused of stealing body parts and selling them to medical and scientific buyers, making hundreds of thousands of dollars in what the authorities called an “illegal body part scheme,” pleaded guilty to mail fraud on Tuesday, the Justice Department said.

...

"Here’s how prosecutors said the scheme worked: From about 2010 to 2018 Ms. Hess was in charge of Donor Services, a nonprofit “body broker service,” and Sunset Mesa Funeral Directors, which offered to arrange cremations, funerals and burials in the small western Colorado city of Montrose.

"Ms. Hess and her mother sometimes obtained consent from families to donate small tissue samples or tumors of their dead relative, according to an indictment in the case. On other occasions, their request was rejected, and sometimes, they never brought up the topic at all.

"In any case, the documents say, on hundreds of occasions the funeral home operators would sell heads, torsos, arms, legs or entire human bodies. Frequently, they delivered cremated remains to families with the suggestion they were the remains of their relative when, in fact, they were not, according to the indictment.

...

"The scheme included forging paperwork, such as signatures on authorization forms for donating body parts, and misleading buyers about the results of medical tests performed on the deceased, court documents said. Ms. Hess altered lab reports so that they said that people had tested negative for diseases like H.I.V. and hepatitis when they had actually tested positive, according to the authorities."

Prospects for improving kidney exchange in France

A recent article in Néphrologie & Thérapeutique simulates how kidney exchange in France could possibly be made substantially more effective, following liberalizations in the law. (The article is in French, but also has an English abstract.) A promising feature is that the article is a collaboration between physicians and market design economists.

Perspectives pour une évolution du programme de don croisé de reins en France

Perspectives for future development of the kidney paired donation programme in France by Julien Combe, Victor Hiller, Olivier Tercieux,  Benoît Audry, Jules Baudet, Géraldine   Malaquin, François Kerbaul, Corinne Antoine, Marie-Alice Macher, Christian Jacquelinet, Olivier Bastien, and Myriam Pastural

Abstract: "Almost one third of kidney donation candidates are incompatible (HLA and/or ABO) with their directed recipient. Kidney paired donation allows potential donors to be exchanged and gives access to a compatible kidney transplant. The Bioethics Law of 2011 authorised kidney paired donation in France with reciprocity between 2 incompatible “donor-recipient” pairs. A limited number of transplants have been performed due to a too restricted authorization compared to other European practices. This study presents the perspectives of the new Bioethics Law, enacted in 2021, which increases the authorised practices for kidney paired donation in France. The two simulated evolutions are the increase of the number of pairs involved in a kidney paired donation to 6 (against 2 currently) and the use of a deceased donor as a substitution to one of living donor. Different scenarios are simulated using data from the Agence de la Biomedecine; incompatible pairs registered in the kidney paired donation programme in France between December 2013 and February 2018 (78 incompatible pairs), incompatible transplants performed during the same period (476 incompatible pairs) and characteristics of deceased donors as well as proposals made over this period. Increasing the number of pairs has a limited effect on the number of transplants, which increases from 18 (23% of recipients) in the current system to 25 (32% of recipients) when 6 pairs can be involved. The use of a deceased donor significantly increases the number of transplants to 41 (52% of recipients). This study makes it possible to evaluate the increase in possibilities of kidney transplants by kidney paired donation following the new bioethics law. A working group and an information campaign for professionals and patients will be necessary for its implementation."

While the paper focuses on the situation in France, it's opening lines could have been written anywhere:

"La France, comme l’ensemble des pays du monde, souffre d’une pénurie de greffons rénaux de sorte que le nombre de malades en attente d’une greffe de rein ne cesse de croître." [France, like all countries in the world, suffers from a shortage of kidney transplants so that the number of patients waiting for a kidney transplant continues to grow."

Here's hoping that the authors will succeed in their plans to use deceased-donor initiated chains to save more lives in France.

*********

Earlier related posts:

Sunday, April 3, 2022

Kidney Paired Donation Chains Initiated by Deceased Donors

Monday, November 22, 2021

A naturally occurring deceased-donor-initiated kidney exchange chain, by Maghen and Veale

Sunday, August 23, 2020

More on Deceased donors as non‐directed donors in kidney exchange chains

Tuesday, August 7, 2018

Deceased donor chains: Market design language is entering transplantation

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

 

Opioid deaths are behind increases in deceased organ donation

 Medpage Today warns us not to take credit for increases in organ donation that are due to rising numbers of opioid overdose deaths. 

'Shocking Mismanagement' in Our Organ Donation System Is Causing Needless Death— OPTN and OPOs are mischaracterizing organ donation data to block system reform  by DJ Patil, PhD, Greg Segal, Ebony Hilton, MD, and Lachlan Forrow, MD

"The magnitude of the opioid crisis shows no signs of peaking. New data from the CDC's National Center for Health Statistics show that deaths from the opioid epidemic soared by 50% from October 2019 to October 2021, some of which reflected second-order effects of the COVID-19 pandemic. Similarly, alcohol-related deaths, according to recent CDC reports, were also up by a shocking 25% in 2020, from an average increase of 3.6% per year from 1999-2019.

"What does this have to do with organ donation? Drug overdoses and alcohol-related deaths fall into the subset of deaths that allow for organ donation to occur, so this sharp rise in opioid deaths has driven record-breaking organ donation numbers. That might sound like a silver lining to a very dark cloud, but as is often the case with public health data, the picture is much more complex.

"The government contractors in charge of organ donation -- both organ procurement organizations (OPOs), which oversee local organ recovery, and the organ procurement transplantation network (OPTN), which manages the system -- are hiding behind increases in these deaths of despair to deflect criticism from what the House Oversight Committee has characterized as "shocking mismanagement" in organ procurement.

"In fact, HHS has deemed the majority of OPOs to be failing key performance metrics, contributing to 33 Americans dying every day for lack of an organ transplant. And the Senate Finance Committee is investigating the United Network for Organ Sharing (UNOS), the OPTN contractor, over "serious concerns related to [its] role in overseeing our nation's OPOs, which have been severely underperforming for decades."

...

"We have more organ donors in America not because we have a strong -- or even remotely adequate -- organ procurement system, but because on a per capita basis among wealthy nations, we have many times more deaths in those subsets of deaths that allow for organ donation to occur. This includes 20 to 30 times more opioid deaths, 25 times as many gun deaths, the highest suicides rates, and more than twice as many fatal car accidents -- a number that spiked again precipitously last year."

"Execution by organ procurement: Breaching the dead donor rule in China," by Matthew P. Robertson, and Jacob Lavee in the AJT

 Prior to 2015, it was legal in China to transplant organs recovered from executed prisoners. When I visited China in those days to talk about kidney transplantation from living donors, it was sometimes pointed out to me that, as an American, I shouldn't object to the Chinese use of executed prisoner organs, because we also had capital punishment in the US, but we "wasted the organs."  I replied that in the US we had both capital punishment and transplantation, but were trying to limit one and increase the other, and that I didn’t think that either would be improved by linking it to the other.  

So here's a just-published retrospective paper looking at Chinese language transplant reports prior to 2015, which identifies at least some instances that it regards as "execution completed by organ procurement."

Execution by organ procurement: Breaching the dead donor rule in China, by Matthew P. Robertson1, and Jacob Lavee2, American Journal of Transplantation, Early View, First published: 04 April 2022 https://doi.org/10.1111/ajt.16969

1 Australian National University |  Victims of Communism Memorial Foundation, Washington, D.C., USA

2 Heart Transplantation Unit, Leviev Cardiothoracic Center, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel

Abstract: The dead donor rule is fundamental to transplant ethics. The rule states that organ procurement must not commence until the donor is both dead and formally pronounced so, and by the same token, that procurement of organs must not cause the death of the donor. In a separate area of medical practice, there has been intense controversy around the participation of physicians in the execution of capital prisoners. These two apparently disparate topics converge in a unique case: the intimate involvement of transplant surgeons in China in the execution of prisoners via the procurement of organs. We use computational text analysis to conduct a forensic review of 2838 papers drawn from a dataset of 124 770 Chinese-language transplant publications. Our algorithm searched for evidence of problematic declarations of brain death during organ procurement. We find evidence in 71 of these reports, spread nationwide, that brain death could not have properly been declared. In these cases, the removal of the heart during organ procurement must have been the proximate cause of the donor's death. Because these organ donors could only have been prisoners, our findings strongly suggest that physicians in the People's Republic of China have participated in executions by organ removal.

"how should we understand the physician's role in a context where executed prisoners are the primary source of transplant organs? Might the transplant surgeon become the de facto executioner? Evidence suggestive of such behavior has emerged over many years from the People's Republic of China (PRC).8-14 To investigate these reports, this paper uses computational methods to examine 2838 Chinese transplant-related medical papers published in scientific journals, systematically collecting data and testing hypotheses about this practice. By scrutinizing the clinical procedures around intubation and ventilation of donors, declaration of brain death, and commencement of organ procurement surgery, we contribute substantial new evidence to questions about the role of PRC physicians in state executions.

...

"The data we rely on in this paper involves transplant surgeries from 1980 to 2015. During this period, there was no voluntary donation system and very few voluntary donors. According to three official sources, including the current leader of the transplant sector, the number of voluntary (i.e., non-prisoner) organ donors in China cumulatively as of 2009 was either 120 or 130,30-32 representing only about 0.3% of the 120 000 organs officially reported to be transplanted during the same period (on the assumption that each voluntary donor gave three organs).18, 33, 34 The leader of China's transplant sector wrote in 2007 that effectively 95% of all organ transplants were from prisoners.35 According to official statements, it was only in 2014 that a national organ allocation system could be used by citizens.36

...

"Procuring vital organs from prisoners demands close cooperation between the executioner and the transplant team. The state's role is to administer death, while the physician's role is to procure a viable organ. If the execution is carried out without heed to the clinical demands of the transplant, the organs may be spoiled. Yet if the transplant team becomes too involved, they risk becoming the executioners.

"Our concern is whether the transplant surgeons establish first that the prisoners are dead before procuring their hearts and lungs. This translates into two empirical questions: (1) Is the donor intubated only after they are pronounced brain dead? And (2) Is the donor intubated by the procurement team as part of the procurement operation? If either were affirmative the declaration of brain death could not have met internationally accepted standards because brain death can only be determined on a fully ventilated patient. Rather, the cause of death would have been organ procurement.

...

"We define as problematic any BDD in which the report states that the donor was intubated after the declaration of brain death, and/or the donor was intubated immediately before organ procurement, as part of the procurement operation, or the donor was ventilated by face mask only.

...

"The number of studies with descriptions of problematic BDD was 71, published between 1980 and 2015. Problematic BDD occurred at 56 hospitals (of which 12 were military) in 33 cities across 15 provinces. 

...

"We have documented 71 descriptions of problematic brain death declaration prior to heart and lung procurement. From these reports, we infer that violations of the DDR took place: given that the donors could not have been brain dead before organ procurement, the declaration of brain death could not have been medically sound. It follows that in these cases death must have been caused by the surgeons procuring the organ.

"The 71 papers we identify almost certainly involved breaches of the DDR because in each case the surgery, as described, precluded a legitimate determination of brain death, an essential part of which is the performance of the apnea test, which in turn necessitates an intubated and ventilated patient. In the cases where a face mask was used instead of intubation48, 49—or a rapid tracheotomy was followed immediately by intubation,50 or where intubation took place after sternal incision as surgeons examined the beating heart44—the lack of prior determination of brain death is even more apparent.

"If indeed these papers document breaches of the DDR during organ procurement from prisoners as we argue, how were these donors prepared for organ procurement? The textual data in the cases we examine is silent on the matter. Taiwan is the only other country we are aware of where death penalty prisoners’ vital organs have been used following execution. This reportedly took place both during the 1990s and then once more in March 2011.51, 52

...

"The PRC papers we have identified do not describe how the donor was incapacitated before procurement, and the data is consistent with multiple plausible scenarios. These range from a bullet to the prisoner's head at an execution site before they are rushed to the hospital, like Tsai's description, or a general anesthetic delivered in the operating room directly before procurement. Paul et al. have previously proposed a hybrid of these scenarios to explain PRC transplant activity: a lethal injection, with execution completed by organ procurement. 

...

"We think that our failure to identify more DDR violations relates to the difficulty of detecting them in the first instance, not to the absence of actual DDR violations in either the literature or practice. Our choice to tightly focus only on papers that made explicit reports of apparent DDR violations likely limited the number of problematic papers we ultimately identified.

...

"As of 2021, China's organ transplant professionals have improved their reputation with their international peers. This is principally based on their claims to have ceased the use of prisoners as organ donors in 2015."

Kidney Paired Donation Chains Initiated by Deceased Donors

 Starting kidney exchange chains with a deceased donor is a good idea whose time is coming.  

Wen Wang, Alan B. Leichtman, Michael A. Rees, Peter X.-K. Song, Valarie B. Ashby, Tempie Shearon, John D. Kalbfleisch,  Kidney Paired Donation Chains Initiated by Deceased Donors, Kidney International Reports, 2022, https://doi.org/10.1016/j.ekir.2022.03.023.

(https://www.sciencedirect.com/science/article/pii/S2468024922012438)

"Abstract:

• Introduction: Rather than generating one transplant by directly donating to a candidate on the waitlist, deceased donors (DD) could achieve additional transplants by donating to a candidate in a kidney paired donation (KPD) pool, thereby, initiating a chain that ends with a living donor (LD) donating to a candidate on the waitlist. We model outcomes arising from various strategies that allow DDs to initiate KPD chains. 

• Methods: We base simulations on actual 2016-2017 US DD and waitlist data and use simulated KPD pools to model DD initiated KPD chains. We also consider methods to assess and overcome the primary criticism of this approach, namely the potential to disadvantage Blood Type O waitlisted candidates. 

• Results: Compared to shorter DD initiated KPD chains, longer chains increase the number of KPD transplants by up to 5% and reduce the number of DDs allocated to the KPD pool by 25%. These strategies increase the overall number of Blood Type O transplants and make LDs available to candidates on the waitlist. Restricting allocation of Blood Type O DDs to require ending KPD chains with LD Blood Type O donations to the waitlist markedly reduces the number of KPD transplants achieved. 

• Conclusion: Allocating fewer than 3% of DD to initiate KPD chains could increase the number of kidney transplants by up to 290 annually. Such use of DDs allows additional transplantation of highly sensitized and Blood Type O KPD candidates. Collectively, patients of each blood type, including Blood Type O, would benefit from the proposed strategies."

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Earlier:

Monday, November 22, 2021

A naturally occurring deceased-donor-initiated kidney exchange chain, by Maghen and Veale

Sunday, August 23, 2020

More on Deceased donors as non‐directed donors in kidney exchange chains

Tuesday, August 7, 2018

Deceased donor chains: Market design language is entering transplantation

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

Queuing for ridesharing and organ allocation

 Queues for ridesharing drivers at airports (where some trips are much better than others) lead to lots of rejected trips by those at the head of the line, while they wait for a good one.  This is of course something that also occurs in deceased donor waiting lists.

Here's a paper that tackles the ridesharing problem:

Randomized FIFO Mechanisms by Francisco Castro, Hongyao Ma, Hamid Nazerzadeh, Chiwei Yan

Abstract: "We study the matching of jobs to workers in a queue, e.g. a ridesharing platform dispatching drivers to pick up riders at an airport. Under FIFO dispatching, the heterogeneity in trip earnings incentivizes drivers to cherry-pick, increasing riders' waiting time for a match and resulting in a loss of efficiency and reliability. We first present the direct FIFO mechanism, which offers lower-earning trips to drivers further down the queue. The option to skip the rest of the line incentivizes drivers to accept all dispatches, but the mechanism would be considered unfair since drivers closer to the head of the queue may have lower priority for trips to certain destinations. To avoid the use of unfair dispatch rules, we introduce a family of randomized FIFO mechanisms, which send declined trips gradually down the queue in a randomized manner. We prove that a randomized FIFO mechanism achieves the first best throughput and the second best revenue in equilibrium. Extensive counterfactual simulations using data from the City of Chicago demonstrate substantial improvements of revenue and throughput, highlighting the effectiveness of using waiting times to align incentives and reduce the variability in driver earnings."

"Many ridesharing platforms now maintain virtual queues at airports for drivers who are waiting in  designated  areas,  and  dispatch  drivers  from  the  queue  in  a  first-in-first-out  (FIFO)  manner.4 This resolves the congestion issues and is also considered more fair by many since drivers who havewaited the longest in the queue are now the first in line to receive trip offers.  At major U.S. airports,however, a driver at the head of the queue will receive the next trip offer in a few seconds under FIFO dispatching, if she declines an offer from the platform (see Figure 12).  As we shall see, thislowered cost of cherry-picking substantially exacerbates existing problems on incentive alignment.

...

"During busy hours, instead of accepting an average trip, drivers who are close to the head of the queue are better off declining most trip offers and waiting for only the highest earning trips.  Riders, however, have finite patience, despite being willing to wait for some time for a match.  When each driver decline takes an average of 10 seconds, 2 minutes had passed after a trip with low or moderate earnings (e.g.  trips to downtown Chicago) was offered to and declined by the top 12 drivers in the queue.5 At this point, it is very likely that the rider cancels her trip request, not knowing when a driver will be assigned, if at all.

...

"To  achieve  optimal  throughput  and  revenue  without  the  use  of  an  unfair  dispatch  rule,  weintroduce a family ofrandomized FIFO mechanisms.  A randomized FIFO mechanism is specifiedby a set of “bins” in the queue (e.g., the top 10 positions, the 10th to 20th positions, and so on).Each trip request is first offered to a driver in the first bin uniformly at random.  After each decline, the mechanism then offers the trip to a random driver in the next bin.  By sending trips gradually down the queue in this randomized manner, the randomized FIFO mechanisms appropriately align incentives using waiting times,  achieving the first best throughput and second best net revenue: the option to skip the rest of the line incentivizes drivers further down the queue to accept trips with  lower  earnings;  randomizing  each  dispatch  among  a  small  group  of  drivers  increases  each individual driver’s waiting time for the next dispatch, thereby allowing the mechanism to prioritize drivers closer to the head of the queue for trips to every destination without creating incentives for excessive cherry-picking."

Access and transparency in transplantation at the TTS 2022 meeting in September

 Covid-permitting, I'll be flying to Buenos Aires in September to participate in person in the 2022 international meeting of The Transplantation Society (TTS), with a focus on access and transparency in transplantation.

Plenary on transparency and access

 Monday, September 12, 2022 – 09:40 to 11:10

Transplantation in a moving world; migrants, refugees & organ trafficking

Dominique Martin, Australia

Short Biography

Steps towards increasing deceased donation worldwide

Beatriz Dominguez-Gil, Spain

Short Biography

How can we optimize local economics to achieve self-sufficiency and ethical transplantation in an unequal global economy

Alvin E. Roth, United States

Short Biography

A brief history of deceased organ donation in one career--Howard Nathan retires

Organ donation and transplantation is still new enough that significant parts of its history can have been experienced in one career.  The WSJ reports on Howard Nathan's retirement from the Gift of Life Organ Procurement Organization, which he joined in 1978:

Howard Nathan Spent Decades ‘On Call’ for Organ Transplants. The CEO of the Gift of Life Donor Program is stepping down after a long career connecting organ donors with patients in need.  By Emily Bobrow

"When Mr. Nathan, 68, first joined the nonprofit that would become Gift of Life, he was one of three employees. Working around the clock, he traveled to hospitals in Pennsylvania, Delaware and New Jersey for hard conversations with grieving families and then made calls to surgeons in the hope of matching a donated organ with a waiting patient. “We would be driving on the Turnpike with a kidney in the car at three in the morning,” Mr. Nathan recalls on a video call from Gift of Life headquarters in central Philadelphia. “In the early days we had to make it up as we went along.”

"In 1994 he helped to draft Pennsylvania’s landmark organ donation law, which mandated that hospitals call organ-procurement organizations whenever a patient died. “Hospitals used to call when they wanted to. We were like Maytag repairmen waiting by the phone,” Mr. Nathan remembers. The law, which included funds for public-awareness campaigns and gave people a chance to register as organ donors when getting or renewing a driver’s license, increased donations by 43% in three years, he says. It became the model for a federal law in 1998.

...

"Brain death was a fairly new concept when Mr. Nathan first worked as an organ-donation coordinator—a job held by maybe 200 people around the country at the time. “We really had to teach and train people in the medical and legal aspects of donation,” he says.

...

"When Mr. Nathan entered the field, the success rate for transplants hovered at 30-35%. With the discovery in the early 1980s of immunosuppressant drugs, which curb the body’s natural rejection of foreign body parts, success rates have climbed above 90%."

HT: Frank McCormick

Evictions and coalitions in the housing market of hermit crabs--shell trafficking in the wild

 I've previously blogged about the observation that hermit crabs, who live in the shells of other animals and have to get new shells as they grow, sometimes engage in chains of exchange, that resemble kidney exchange chains, or vacancy chains in labor markets.

In particular, they resemble kidney exchange chains initiated by a deceased donor, in this case initiated by an empty shell.

 Here's a new article about hermit crabs which reports that they also engage in something that looks like organ trafficking, with a hermit crab being forcibly removed from its shell by two smaller crabs acting in concert, so that one of them may occupy the now vacant shell while the other moves into the shell of its partner in crime.

Laidre, Mark E. "The Architecture of Cooperation Among Non-kin: Coalitions to Move Up in Nature’s Housing Market." Frontiers in Ecology and Evolution (2021): 928.

"Coalitions typically involve two individuals (a pair), with a third individual being the target that the two-member coalition seeks to evict from its shell (Figure 1). Both members of the coalition have shells of their own, but these individuals and their shells are virtually always smaller than that of the target individual and its shell. Sometimes, based on the commotion and struggle generated during an attempted eviction, additional individuals—beyond the target and the core two-member coalition—are attracted to the area. These additional individuals—referred to as “third parties” or “bystanders”—are not part of the actual coalition, since they do not help at all to evict the target. Generally, third parties simply wait in the vicinity and sometimes position themselves in a social chain, which emanates from the back of the shell of one or both of the coalition members (Figure 2). This positioning in a social chain enables third parties to indirectly benefit, since in the event an eviction succeeds, it can catalyze a succession of back-to-back shell swaps (see Laidre, 2019a). Third parties are thus, in effect, “free riders” (Sigmund, 2010), since their positioning around the coalition offers no advantage whatsoever to the coalition itself as it works to evict the target. Indeed, whether third parties are positioned in a chain or not, they merely wait, performing no pulling actions and never adding any strength or providing any help to the two-member coalition. Interestingly, based on precisely where third parties position themselves, some may potentially even undermine the coalition (see below), effectively acting not merely as “free riders” but as “cheaters” (Sigmund, 2010). Finally, if too many bystanders accumulate, it can lead to chaotic jockeying and repositioning, with the original coalition separating.

"Whether with third parties present or not, the two members of the coalition attempt to physically evict the target. The target remains flipped on its back (i.e., with the dorsal side of its shell on the ground) and the opening of the target’s shell faces upward, allowing both coalition members to use their claws and legs to grab at and pull the anterior portion of the target’s body. As the coalition forcibly pulls, the target attempts to resist by clinging inside its shell. Typically, the two coalition members both pull simultaneously; though at times the two may alternate attempts at pulling, each doing so sequentially as one or the other member briefly rests. Both members of a coalition appear strongly involved, in terms of time and effort. Yet coalitions are not always successful. In some cases, one or both coalition members may give up; or the target individual may manage to flip itself over, escape from being pinned down, and run away. If a coalition is successful at evicting the target, the time till eviction occurs can vary widely, from just minutes up to hours (Laidre, personal observation). Once a coalition is successful and the target individual is evicted from its shell, then the evictee is pushed to the side and remains naked and shell-less as one of the coalition members moves into its now empty shell."

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Earlier:

Saturday, July 21, 2012

Hermit Crab Vacancy Chains

Thursday, January 16, 2020

Vacancy chains and hermit crab housing, revisited