Freezing, thawing and transplanting a rat kidney: a first step towards organ banking

 A kidney has been frozen, thawed, and successfully transplanted, into a rat.  Maybe we'll live to see organ banking...

Vitrification and nanowarming enable long-term organ cryopreservation and life-sustaining kidney transplantation in a rat model   by Zonghu Han, Joseph Sushil Rao, Lakshya Gangwar, Bat-Erdene Namsrai, Jacqueline L. Pasek-Allen, Michael L. Etheridge, Susan M. Wolf, Timothy L. Pruett, John C. Bischof & Erik B. Finger, Nature Communications volume 14, Article number: 3407 (2023) 

Abstract: Banking cryopreserved organs could transform transplantation into a planned procedure that more equitably reaches patients regardless of geographical and time constraints. Previous organ cryopreservation attempts have failed primarily due to ice formation, but a promising alternative is vitrification, or the rapid cooling of organs to a stable, ice-free, glass-like state. However, rewarming of vitrified organs can similarly fail due to ice crystallization if rewarming is too slow or cracking from thermal stress if rewarming is not uniform. Here we use “nanowarming,” which employs alternating magnetic fields to heat nanoparticles within the organ vasculature, to achieve both rapid and uniform warming, after which the nanoparticles are removed by perfusion. We show that vitrified kidneys can be cryogenically stored (up to 100 days) and successfully recovered by nanowarming to allow transplantation and restore life-sustaining full renal function in nephrectomized recipients in a male rat model. Scaling this technology may one day enable organ banking for improved transplantation.

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Earlier:

Monday, June 12, 2017

Organ preservation could bring big changes to transplantation

Transplantation would be a lot less hectic if organs could be preserved. Here's a 42-author paper (the biggest coauthorship I've been involved in) that discusses some of the possibilities.

The promise of organ and tissue preservation to transform medicine 
 Sebastian Giwa, Jedediah K Lewis, Luis Alvarez, Robert Langer, Alvin E Roth, George M Church, James F Markmann, David H Sachs, Anil Chandraker, Jason A Wertheim, Martine Rothblatt, Edward S Boyden, Elling Eidbo, W P Andrew Lee, Bohdan Pomahac, Gerald Brandacher, David M Weinstock, Gloria Elliott, David Nelson, Jason P Acker, Korkut Uygun, Boris Schmalz, Brad P Weegman, Alessandro Tocchio, Greg M Fahy, Kenneth B Storey, Boris Rubinsky, John Bischof, Janet A W Elliott, Teresa K Woodruff, G John Morris, Utkan Demirci, Kelvin G M Brockbank, Erik J Woods, Robert N Ben, John G Baust, Dayong Gao, Barry Fuller, Yoed Rabin, David C Kravitz, Michael J Taylor & Mehmet Toner

Decreasing kidney discards--review, and a call for clinical trials

 A review of discarded kidneys from a large OPO revealed only modest margins for improved utilization.

Bunnapradist, Suphamai MD1; Rosenthal, J. Thomas MD1; Huang, Edmund MD2; Dafoe, Donald MD3; Seto, Tom PharmD4; Cohen, Aaron BS4; Danovitch, Gabriel MD1. Deceased Donor Kidney Nonuse: A Systematic Approach to Improvement. Transplantation Direct 9(6):p e1491, June 2023. | DOI: 10.1097/TXD.0000000000001491

"Background. A large number of procured kidneys continue not to be transplanted, while the waiting list remains high.

"Methods. We analyzed donor characteristics for unutilized kidneys in our large organ procurement organization (OPO) service area in a single year to determine the reasonableness of their nonuse and to identify how we might increase the transplant rate of these kidneys. Five experienced local transplant physicians independently reviewed unutilized kidneys to identify which kidneys they would consider transplanting in the future. Biopsy results, donor age, kidney donor profile index, positive serologies, diabetes, and hypertension were risk factors for nonuse.

"Results.  Two-thirds of nonused kidneys had biopsies with high degree of glomerulosclerosis and interstitial fibrosis. Reviewers identified 33 kidneys as potentially transplantable (12%).

"Conclusions. Reducing the rate of unutilized kidneys in this OPO service area will be achieved by setting acceptable expanded donor characteristics, identifying suitable well-informed recipients, defining acceptable outcomes, and systematically evaluating the results of these transplants. Because the improvement opportunity will vary by region, to achieve a significant impact on improving the national nonuse rate, it would be useful for all OPOs, in collaboration with their transplant centers, to conduct a similar analysis."

...

"One posited cause for continued high nonuse rates is that transplant physicians are overly conservative, content with doing a small number of cases relative to the need. Both the existence of a “weekend effect”8 and a paper by French investigators stating 62% of kidneys not transplanted in the United States would be transplanted in France9 are used in support of this contention. Mistaken reliance on kidney biopsies is an additional factor implicated in inappropriate kidney nonuse.10 An alternative explanation is that transplant physicians and surgeons have not been persuaded that it is safe to transplant high-risk kidneys into older recipients based on retrospective registry studies.

"With this background in mind, and with a strong desire to respond to the imperative of increasing the use of heretofore nontransplanted kidneys, we undertook an analysis of unused kidneys in our OPO service area. Goal one was to understand the interplay of factors causing nonuse including donor demographics and biopsies. Goal two was to use the information from goal one to devise a plan to increase the kidney utilization rate in our service area.

"OneLegacy is the federally designated OPO for 7 counties in Southern California with a population of approximately 20 million. In 2019, which was chosen as the year of study because it was the last full year before the COVID-19 pandemic, OneLegacy served 10 centers with kidney transplant programs.11

"There were 1064 kidneys procured from 552 donors; 740 were transplanted and 324 were not transplanted. Forty-seven of the 324 (14.5%) were not offered for transplant because of absolute contraindications including cancers in the kidney, infections discovered during procurement, and abnormalities such as multicystic dysplastic kidneys. There were 5 surgical injuries (0.47%)—1 stripped ureter and 4 vascular injuries—all of which were determined to be nonrepairable by a transplant surgeon highly experienced with repair techniques. These kidneys were excluded from the study. The remaining 272 kidneys were offered for transplant and turned down by all local centers and, in turn, by all regional and national centers. Fourteen kidneys were provisionally accepted by and transported to nonlocal centers but, ultimately, not utilized due to prolonged cold ischemic times or findings on biopsies performed at the export center.

...

"One reason that the nonuse problem has proven intractable is that, even though it has been asserted that most nonused kidneys in the United States are safe to transplant, clinicians making the decisions in real time seem not to agree. Nor is there widespread enthusiasm for transplanting suboptimum kidneys into elderly recipients, despite papers promoting it,15 possibly because it is not entirely clear which older dialysis patients really benefit from transplantation.16

"The thought experiment of experienced local physicians reviewing procured but not transplanted kidneys appears to confirm this hypothesis. Despite French studies suggesting that 62% of kidneys not utilized in the United States would be transplanted in France, only 12% of kidneys were thus identified by our team of physicians, each of whom were highly motivated to reduce nonuse kidneys and highly knowledgeable about registry studies claiming safety of expanded donor criteria.10 If highly knowledgeable and experienced transplant physicians and surgeons—highly motivated to decrease nonuse—have not significantly changed kidney acceptance criteria, they are unlikely to be persuaded or respond to regulatory pressure to cause them to perform transplants that they feel would violate their responsibility to patients. Reducing the nonuse rate to ≤5% is unlikely under these conditions. Nonetheless, this experience does inform how improvement can occur.

"The alternative pathway to improvement in our service area is a more systematic prospective approach, in other words, an authentic clinical trial. The elements of such a trial would include codifying as precisely as possible the inclusion criteria for transplantable “suboptimal” donors, determining recipient criteria, extensive informed consent conversations, optimization of the organ offer process to minimize cold ischemia times, and outcomes tracking including quality of life and cognitive assessment. It should be decided in advance what will constitute an acceptable outcome for primary nonfunction and 1-y graft and patient survival."

Organ donation day in Germany

 Yesterday was organ donation day in Germany. Here's a post from the German Health Economics Association (DGGÖ): Day of Organ Donation on June 3, 2023

"In Germany, there are about 8,500 people waiting for an organ donation (www.Bundesärztekammer.de). On the Day of Organ Donation, the German Society for Health Economics (dggö) wants to emphasize the urgency of increasing organ donation rates to improve the lives of these individuals. This applies equally to deceased organ donation and living donation. An international comparison also shows that there is room for improvement in Germany: Both in terms of living and deceased donations per million population, Germany lags behind in the EU (see Figure 1).

...

"On Wednesday, May 31, 2023, Nobel laureate in economics and professor at Stanford University, Alvin Roth, spoke to a broad audience in the 6th virtual dggö Talk (see https://www.dggoe.de/aktuelles for details) about the possibilities of kidney exchange between compatible but previously unknown pairs and the implementation of cross-over donations and exchange chains in the US.

"Unlike in the US, in Germany, living donation outside of close family is only possible if a close relationship between the donor and recipient has been officially confirmed. Alvin Roth noted in the case of cross-over kidney donations, that it was very complicated for German hospitals to build up and prove a close relationship between two pairs of donors in front of a commission. This should be simplified, especially considering the overall strong support for kidney exchange among the German population. As Figure 2 from a survey conducted by Roth and Wang (2020) illustrates, 79% even agree to kidney exchange across borders and outside of family and friends, although such an exchange is currently not legally possible in Germany.

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Earlier: 

Tuesday, May 30, 2023

Kidney exchange, around the world and in Germany? German Health Economics Association (DGGÖ) webinar 

HRSA's Organ Procurement and Transplantation Network Modernization Initiative

 The Health Resources and Services Administration (HRSA) has announced a timeline for moving forward on the proposal to reorganize the system for obtaining and distribution deceased donor organs for transplant, aiming for a request for proposals in the Fall.

Organ Procurement and Transplantation Network Modernization Initiative   May 2023 Updates

"On March 22, 2023, the Health Resources and Services Administration (HRSA) announced a Modernization Initiative to strengthen accountability and transparency in the Organ Procurement and Transplantation Network (OPTN). The initiative is focused on five key areas: technology, data transparency, governance, operations, and quality improvement and innovation. As part of our commitment to transparency around the Modernization Initiative, HRSA is providing an update on our upcoming action steps.

The OPTN Modernization Initiative is centered on putting patients first, prioritizing information flow to clinicians, promoting innovation through continuous competition, and enhancing transparency and accountability. HRSA's planned approach and timelines for the first year of the multi-year modernization process focuses on design, implementation, and oversight, including contract solicitations that will be released Fall 2023 and Spring 2024. In addition, HRSA continues to pursue the legislative changes and increased funding included in the President's Fiscal Year 2024 budget to implement and advance the Modernization Initiative.

Summer 2023

Phase 1: OPTN Modernization Design & Strategy Development  

External Engagement and Design Planning Contract  – HRSA is currently conducting market research to inform the development of the upcoming Fall contract solicitations and will host an Industry Day for interested parties and vendors this Summer. Building on our outreach efforts over the past year, HRSA also will continue to ensure that patient, family, and clinician voices are engaged in this work, including through focus groups and other approaches. HRSA recently awarded a program management contract to support this stakeholder engagement as well as strategic and operational planning and change management.

Fall 2023

Phase 2A: OPTN Transition Management

HRSA recognizes the vital need to maintain uninterrupted access to the critical systems and functionality that support organ matching and transplantation during the modernization process. Working with the best technologists in the U.S. Government, HRSA expects to conduct this work on a dual track so that there are appropriate safeguards to ensure no disruptions in service as part of modernization implementation. Therefore, HRSA will support two significant multi-vendor solicitations between now and Spring 2024 – with the first solicitation to be issued this Fall 2023. This action will be followed by a Spring 2024 solicitation to further the next generation OPTN, as noted below. 

Competitive OPTN Transition Contracts – This Fall, HRSA plans to release a solicitation to establish new contracts that will support and enhance OPTN operations while the modernization process is underway. These contracts will ensure the continuation of critical OPTN support functions and enable appropriate upgrades on a parallel track with modernization. The Fall 2023 solicitation will seek multiple vendors for distinct functions – including supporting a separate OPTN Board of Directors – to ensure service continuity and increase oversight and accountability.

To ensure that the OPTN Transition contracts are developed in a way that meets the needs of all stakeholders, HRSA is committed to soliciting feedback from interested parties during the development and implementation of this work. By involving stakeholders in the process, HRSA can ensure that the Transition contracts advance the goals of the OPTN Modernization Initiative, provide optimal support to protect patient safety, and ensure the efficient functioning of the OPTN.

Spring 2024

Phase 2B: OPTN Modernization Implementation

In Spring 2024, HRSA intends to release a solicitation for multiple vendors to support the next generation of the OPTN, which will include enhancements in technology, governance, data transparency and operations. The separate Board of Directors contract and the deliverables from this next generation solicitation will form the foundation of a new, modernized OPTN. 

OPTN Next Generation Contracts – The proposed OPTN Next Generation contracts will represent a significant step forward in modernizing the OPTN’s foundational IT systems. In Spring 2024, HRSA expects to release a solicitation seeking multiple vendors for the OPTN Next Generation contracts to provide a comprehensive approach to modernizing the OPTN. The goal of this solicitation is to find contractors who will use innovative, best in class approaches to carrying out specific functions, including initial prototyping, testing, scaling, integration, deployment, and adoption support.  

HRSA is committed to transparency in the OPTN Modernization process and will continue to provide updates on our iterative approach toward achieving enhanced accountability, equity, and performance in the organ transplantation system, as appropriate, as this work moves forward."

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Here's a NYT story covering the announcement, with some background:

U.S. Organ Transplant System, Troubled by Long Wait Times, Faces an Overhaul The Biden administration announced a plan to modernize how patients are matched to organs, seeking to shorten wait times, address racial inequities and reduce deaths.  By Sheryl Gay Stolberg

Defining death for deceased organ donation

 Here’s a story from Science, about donation of a heart from a donor declared dead after circulatory death, ie after heart stoppage:

GIVING HEART: A new procedure for donating hearts and other organs is saving lives. But for some it challenges the definition of death   By 

Jennifer Couzin-Frankel

"As is customary regardless of whether organs will be donated, physicians waited 5 minutes to ensure that the heart didn’t start beating again on its own. It did not, and the man was declared dead. The baton then passed to the organ recovery and transplant team. They clamped blood vessels running from the torso to the brain and reconnected his body to machines that circulated oxygenated blood, causing the heart to begin pumping again. "These two interventions—initiating a heartbeat after death is declared and taking steps to prevent blood flow to the brain—are at the core of a raging debate about the ethics of such donations. To some people, the approach risks disrupting the dying process; to others, it allows that process to continue as the family desires, while also honoring individual or family wishes for organ donation.

“The debate touches on the definition of death, Moazami says. “When the heart stops, we say, ‘time of death, 5:20 a.m.’” But, “The fact of the matter is, death is a process. Death is not a time point.” Cells can take hours to die. Sophisticated machinery can induce a heartbeat hours after death, but does that make a person “alive”?

Statement of Policy Principles and Solutions: Living Organ Donation, from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST)

 Here's a joint statement about living-donor kidney transplantation from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST). The statement opposes rethinking the ban on compensation for donors, suggests that other policies should be evidence-based, and opposes increased bureaucratization and cumbersome regulation of the transplant process.

Statement of Policy Principles and Solutions:  Living Organ Donation

"We stand together in our conviction that any policy changes impacting living organ donation, including those aimed at improving access to living donor transplantation and increasing the survival of already transplanted patients, must begin with principled and transparent dialogue with patients and the expert transplant teams who care for them.  

...

"The United States ranks in the top tier of nations in terms of living donor transplant rates,[1] meaning the current system for living donation works. However, disparities in access to living donor transplantation remain, and we must continue to improve and expand living donor transplantation for those in need.  As such, we support policy changes that are patient-centric, fiscally realistic, and ethically and legally sound. 

"Over the past decade some well-intended organizations and advocates have advanced ideas to increase access to living donor transplantation, including direct payments for or large financial incentives for organ transplants, that may appear expedient but can result in serious adverse consequences for transplantation and for patients. Many of these proposals pose serious unintended negative consequences to both donors and to public trust in organ donation. We fundamentally reject efforts to model changes to the current US system based on research or organ transplant practices in nations such as China and Iran whose governments fail to meet or ignore high international and US standards for ethical medical research and basic human rights.

...

"AAKP, ASTS, and AST strongly support the elimination of disincentives to transplantation and adamantly oppose coercive financial incentives to donate.

...

"AAKP, ASTS, and AST believe that improvements to the transplant system can best be made through ethically and legally sound, evidence-based, data driven policies informed and guided by patients and transplant professionals rather than by overhauling the entire transplant system.

"The transplantation system is a public-private partnership between the federal government and the transplant community and is designed, in part, to prevent overt political influence or other governmental interference in shared patient-physician decision making and clinical judgement. The relationship between patients, including living organ donors, and the doctors and medical institutions they choose to care for them must be protected and respected, as should the ability of individual transplant professionals to make clinical decisions in the best interest of those patients.

"Transplantation is heavily regulated by multiple federal agencies, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources Services Administration (HRSA), and two HRSA contractors (the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR)).  Transplant centers are subject to duplicative (and often conflicting) requirements and surveys imposed by CMS and the OPTN. Living donor transplant programs are subject to additional scrutiny to ensure that donors are not pressured, coerced, or intimidated into donating an organ.  All living donor transplant programs are required to have independent living donor advocates that ensure that donors’ full and informed consent is given with a full understanding of the procedure and its potential risks and consequences.

"Into this existing and complex regulatory framework, some organizations are proposing policy and legislative changes that would either expand federal control over transplant by inserting yet another federal agency into the process or overhauling the entire transplant system to give federal agencies, as well as political appointees and politicians, greater authority to regulate living donor transplantation. Exposing the living organ donation system to such political influence and putting decision-making in the hands of non-transplant experts is a mistake with dangerous consequences for patient health, public trust, and donor and patient confidence.

"These proposals raise the possibility that the federal government would mandate a “one-size fits all approach” to an incredibly complex set of clinical problems. Such an approach would likely result in fewer innovations and fewer opportunities to reduce barriers to transplantation, especially for historically underserved communities. There are many potential reforms to the transplant system that can be effective, have been suggested by the wider transplant community over the past decade, and should be adopted by Congress and federal agencies. However, any policy or legislative proposal that seeks to amend or replace the existing system with an even larger federal bureaucratic reach with the potential for federal interference in decisions made among organ donors and patients and the doctors and medical institutions they choose to receive care from should be viewed with skepticism.

"We oppose policy efforts that seek to place any governmental entity in the position of determining clinical criteria for living donor transplantation or otherwise interfering with the relationship between and among potential recipients, potential donors, and their caregivers.

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As a reader of many such joint statements, I wonder if the phrase  "coercive financial incentives" resulted from a compromise between those who believe that all financial incentives are coercive, and those who wish to leave the door open in the future to ordinary, non-coercive financial incentives, of the kinds that attach to so many human activities, and have done so much to relieve other kinds of shortages.

HT: Laurie Lee via Frank McCormick

Transplantation: progress and continued shortcomings

 Here's a guest essay from the NYT that focuses on a different set of shortcomings of organ transplantation than organ availability. The author writes about how her long history of immunosuppression, to keep her transplanted organ(s) alive, has left her vulnerable to cancer.

My Transplanted Heart and I Will Die Soon.  By Marine Buffard

"My 35 years living with two different donor hearts (I was 25 at the time of the first transplant) — finishing law school, getting married, becoming a mother and writing two books — has felt like a quest to outlast a limited life expectancy. 

...

"Organ transplantation is mired in stagnant science and antiquated, imprecise medicine that fails patients and organ donors. And I understand the irony of an incredibly successful and fortunate two-time heart transplant recipient making this case, but my longevity also provides me with a unique vantage point. Standing on the edge of death now, I feel compelled to use my experience in the transplant trenches to illuminate and challenge the status quo.

"Over the last almost four decades a toxic triad of immunosuppressive medicines — calcineurin inhibitors, antimetabolites, steroids — has remained essentially the same with limited exceptions. These transplant drugs (which must be taken once or twice daily for life, since rejection is an ongoing risk and the immune system will always regard a donor organ as a foreign invader) cause secondary diseases and dangerous conditions, including diabetes, uncontrollable high blood pressure, kidney damage and failure, serious infections and cancers. The negative impact on recipients is not offset by effectiveness: the current transplant medicine regimen does not work well over time to protect donor organs from immune attack and destruction.

"My first donor heart died of transplant medicines’ inadequate protection of the donor heart from rejection; my second will die most likely from their stymied immune effects that give free rein to cancer.

...

"Without vigorous pushback, hospitals and physicians have been allowed to set an embarrassingly low bar for achievement. Indeed, the prevailing metric for success as codified by the Health Resources and Services Administration is only one year of post-transplant survival, which relieves pressure for improvement."

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That one year of measured graft survival is both too short, as the author points out, and too long.  By penalizing transplant centers for transplants that fail to survive a year, the current regulations make transplant centers too risk averse, so that kidney transplants that would have only, say, an 85% chance of working well are often not conducted, leaving patients to remain on dialysis, often til death,  for that 85% chance of life.

Transplantation is, still, a modern miracle. But until we can do without it, we'll have to keep trying to do it better.

The World Health Organization (WHO) at 75

 An editorial in Nature considers the complicated history of  the World Health Organization. 

The WHO at 75: what doesn’t kill you makes you stronger. The World Health Organization is emerging from the peak of the pandemic bruised. Its member states must get back to prioritizing universal health care.

"When thinking about the WHO’s 75 years, it’s worth remembering the time and circumstances of its creation. In the aftermath of the Second World War, the newly established United Nations and its specialized agencies, including the WHO, were designed to future-proof the world from another global conflict. Around 80 million people died during the two world wars, many from famine or disease.

"The WHO deserves more money for its core mission — and more respect

"The WHO’s founding constitution states unequivocally: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

"And yet, the agency’s creators chose not to prioritize robust systems of universal health care that would meet these goals. This absent focus is one factor in why infectious diseases continue to impact populations in low- and middle-income countries. The eradication of smallpox in 1980 was a big win. But for other diseases, the agency and its donors have been unable to reach targets, including in the elimination of HIV and AIDS, malaria and tuberculosis.

"The WHO does, however, have a consistent record for establishing itself as the go-to organization for setting global standards for the efficacy, safety and quality of vaccines and medicines. As we have seen during the pandemic, the agency is central to alerting the world to new infectious diseases, helped in no small measure by the revolution in biomedicine and health data, especially genomics."

In general I think the WHO does important work reasonably well, but I have reservations about their policies concerning blood and transplants, which seem to me to reflect some now outdated repugnance to the complexities of “Substances of Human Origin (SoHO)." (Not that these issues don't remain complex.)

Kidney transplants from donors who died from illegal drug use

 There was a time when the modal deceased kidney donor had suffered a head injury in an auto accident, but that time is long gone, due to increased auto safety and to the rise in drug overdose deaths.  Those latter deaths now constitute a large proportion of deceased donors, and here's a report from Canada confirming that those kidneys work well in their new owners.

Xie, Max Wenheng, Sean Patrick Kennan, Amanda Slaunwhite, and Caren Rose. "Observational Study Examining Kidney Transplantation Outcomes Following Donation From Individuals That Died of Drug Toxicity in British Columbia, Canada." Canadian Journal of Kidney Health and Disease 10 (2023): 20543581231156853.

"Abstract:

"Background: The illicit drug toxicity (overdose) crisis has worsened across Canada, between 2016 and 2021 more than 28 000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death has increased in recent years. 

"Objective: This study examines whether graft loss after kidney transplantation differed by donor cause of death. 

Design: Retrospective cohort. 

"Setting: Provincial transplant program of British Columbia, Canada. 

"Patients: Transplant recipients who received kidney transplantation from deceased donors aged 12 to 70 years between 2013 and 2019 (N = 1012). 

"Measurements: Transplant recipient all cause graft loss (graft loss due to any cause including death) was compared by donor cause of death from drug toxicity or other. 

"Methods: Five-year Kaplan-Meier estimates of all-cause graft survival, and 3-year complete as well as stratified inverse probability of treatment weighted Cox proportional hazards models were conducted. 

"Results: Drug toxicity death donors donated to 25% (252/1012) of kidney transplantations. Drug toxicity death donors were more likely to be young, white, males, with fewer comorbidities such as diabetes or hypertension but were more likely to have a terminal serum creatinine ≥1.5 mg/dL or be hepatitis C virus (HCV) positive. Unadjusted 5-year estimate of all cause graft survival was 97% for recipients of drug toxicity donor kidneys and 83% for recipients of non-drug toxicity donor kidneys (P < .001). Recipients of drug toxicity death donor kidneys had decreased risk of all cause graft loss compared to recipients of non-drug toxicity death donor kidneys (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.12-0.77, P = .012). This is primarily due to the reduced risk of all-cause graft loss for recipients of younger (≤35 years) drug toxicity death donor kidneys (HR: 0.05, 95% CI: 0.00-0.55, P = .015). 

"Limitations: Potential selection bias, potential unmeasured confounding. 

"Conclusions: Donation after drug toxicity death is safe and should be considered more broadly to increase deceased donor kidney donation."

...

"illicit drug toxicity remains the leading unnatural cause of death in BC accounting for more deaths than homicides, suicides, and motor vehicle incidents combined.

...

"The United States is also undergoing an opioid epidemic which began earlier than Canada and has recorded similar increases in organ donation from individuals that died of illicit drug toxicity.9-11 Studies in the United States have found that recipient survival after kidney transplantation from individuals who died from drug toxicity was similar for recipients of kidneys from donors that died of any other cause of death."

Brain Death

 Before there was the possibility of organ transplantation, determining that someone was dead could be a relatively leisurely affair. But transplants depend on organs remaining alive after the potential organ donor has died.  If the death is due to irreversible absence of circulation and respiration (Donation after Circulatory Death – DCD), it has to be declared quickly, so that preparation for organ recovery can begin promptly. If the declaration of death is based on brain death, i.e. on irreversible absence of whole brain function (Donation after Death declared by Neurologic Criteria - DDNC), then it must occur while the potential donor is on a ventilator, so that his/her organs continue to be oxygenated.  This means that the declaration of death occurs while the ventilator is still maintaining many of the signs (respiration, heartbeat) that are usually evidence of a living person.  So deciding when someone is brain dead requires both expertise and consensus.

Here's a recent discussion of all this, including some controversy, in JAMA: 

The Uncertain Future of the Determination of Brain Death, by Robert D. Truog, JAMA. 2023;   329(12): 971-972. doi:10.1001/jama.2023.1472

"In 1980, the US Uniform Law Commission (ULC) established the Uniform Determination of Death Act (UDDA), which was subsequently adopted (with some modifications) by all 50 states.1 The law states that death is defined as either (1) the irreversible cessation of circulatory and respiratory functions or (2) the irreversible cessation of all functions of the entire brain, including the brainstem.

...

"The framers of the UDDA rejected the claim that this was a new way of defining death.2 Instead, they pointed to evidence at the time suggesting that the brain is necessary for maintaining biological functioning and that when this brain regulation is absent, homeostatic mechanisms fail, with cardiac arrest invariably occurring within 1 to 2 weeks at most. In other words, brain death and cardiopulmonary arrest were seen as equivalent and equally valid criteria for diagnosing the biological death of a patient.

"However, with improvements in critical care medicine, this equivalency has been called into question. With modern intensive care unit support, some patients can be stabilized and, if provided with mechanical ventilation and tube feedings, their bodies may survive for many years.

...

"In fact, patients with brain death may retain most of the capacities of living people, including the ability to absorb nutrition, excrete waste, heal wounds, grow, undergo puberty, and even gestate. This has led many families to reject the diagnosis and insist on the continuation of medical support for their loved ones.

"In addition, a second issue has been that, although the UDDA requires “the irreversible absence of all functions of the entire brain,” the current guidelines from the American Academy of Neurology (AAN) test for only a select number of functions and most notably do not test for hypothalamic functions, which are sometimes present in patients who are diagnosed with brain death

"In the wake of an increasing number of legal challenges related to the determination of brain death, ULC began a process in 2021 to assess whether the UDDA should be revised.1 At least 3 distinct proposals have been considered.

"Proposal 1: Revise the Guidelines to Align With the Current Definition

"One option would be to leave the UDDA intact, but revise the AAN guidelines to include testing for the absence of hypothalamic function.

...

"Proposal 2: Revise the Definition to Align With the Current Guidelines

"A second proposal has been to change the definition of brain death to be in alignment with the guidelines.

...

"Revising the UDDA so that it required not the irreversible loss of all brain functions, but rather only those functions that support consciousness and spontaneous respiration, would bring the UDDA into alignment with the AAN guidelines. This approach also has precedent, in that it is the definition that was adopted by the United Kingdom in 2008.

...

"Proposal 3: Maintain the Status Quo

"If the position endorsed by commissioner Bopp were to prevail, some states could choose to entirely eliminate the determination of death by neurologic criteria. The impact would be 2-fold: in those states it would no longer be permissible to procure transplantable organs from patients diagnosed with brain death and physicians could be required to continue to provide intensive care unit beds and life support to patients who will never regain consciousness. Such an outcome could have disastrous consequences for our existing systems of organ procurement and transplantation, leading to thousands of otherwise avoidable deaths.

"This has led some commissioners to lean in favor of not making any major revisions to the UDDA, leaving well enough alone."

Deceased-donor transplants: UNOS in the crosshairs

 There is unprecedented political will aiming towards reform of the system by which organs for transplant are recovered from deceased donors in the U.S. and allocated to patients in need of a transplant.  Here are two opposing views about current proposals to reform or replace the current government contractor in charge of this system, UNOS, the United Network for Organ Sharing..

From NPR:

The Government's Plan To Fix A Broken Organ Transplant System, March 28, 2023

You can listen here:

"For nearly 40 years, the United Network for Sharing Organs (UNOS) has controlled the organ transplant system.

"But that's about to change. Last week, the government announced plans to completely overhaul the system by breaking up the network's multi-decade monopoly.

"For those who need an organ transplant, the process is far from easy. On average, 17 people die each day awaiting transplants. More than 100,000 people are currently on the transplant waiting list according to the Health Resources and Services Administration.

"UNOS has been criticized for exacerbating the organ shortage. An investigation by the Senate Finance Committee released last year found that the organization lost, discarded, and failed to collect thousands of life-saving organs each year.

"Can the government reverse decades of damage by breaking up control? And what does this move mean for those whose lives are on the line?

"The Washington Post's Health and Medicine Reporter Lenny Bernstein, Federation of American Scientists Senior Fellow Jennifer Erickson, and Director at the Vanderbilt Transplant Center Dr. Seth Karp join us for the conversation. Dr. Karp was also a former board member for The United Network for Sharing Organs

*********

And here's an alternate view, by three professors of surgery at the University of California San Francisco Medical Center, saying that the system isn't badly broken at all, and that attempts to fix it may lead to coordination failures that, at least in the short term, will cause additional problems.

From MedPageToday:

Our Organ Transplant System Isn't the Failure It's Made Out to Be. — Upholding the system will save lives  by Peter G. Stock, MD, PhD, Nancy L. Ascher, MD, PhD, and John P. Roberts, MD, March 24, 2023

"Thanks to a robust network of hospitals, nonprofit organizations, and government support, the U.S. remains a leader in organ transplantation. This community, which is managed by United Network for Organ Sharing (UNOS), saves tens of thousands of lives every year. Despite this success, opponents of UNOS are advocating to dismantle the transplant system as we know it.

...

"As transplant surgeons with a long history of involvement with the system -- including one of us (Roberts) serving as a past Board President of UNOS/Organ Procurement and Transplantation Network (OPTN) -- we have intimate knowledge of both its successes and its shortcomings. While UNOS has room to improve operationally -- and is working to do so -- we clearly see the organization's life-changing results in our operating rooms and offices. More work lies ahead, however, such as addressing the fact that a rising number of organs are recovered but not transplanted.

"Neither UNOS nor organ procurement organizations (OPOs), which facilitate recovery and organ offers to hospitals, have control over whether medical centers ultimately accept and transplant organs into patients. Though the former two have taken all the blame to date, this remains an issue that concerns the entire system. Leaving our nation's transplant centers out of this critical discussion is a serious oversight. For our entire system to save more lives, transplant centers need to have clear organ acceptance criteria, the appropriate resources to process available organs, and the tools and flexibility to utilize organs from more medically complex donors.

...

"The recommendations for division of labor as suggested this week by Carole Johnson, administrator of the Health Resources and Services Administration (HRSA), may be well intentioned but present a significant risk of further fragmentation and negative consequences due to a lack of coordination between government agencies and contractors. This coordination is essential for a functional and successful system. UNOS specifically has been handicapped by a meager budget for years, and despite this has a well-developed system. We believe that given the recent 10-fold budget increase by the Biden administration, the current contractor has the potential to rectify the shortcomings that have been highlighted in the press."

*********

Earlier posts:

Sunday, August 14, 2022

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

Thursday, March 23, 2023

Health Resources and Services Administration (HRSA) Announces Organ Procurement and Transplantation Network Modernization Initiative.

Obstacles facing liver exchange

 Liver exchange is different than kidney exchange in a number of important dimensions, some of which will present obstacles that need to be overcome in different ways. (Although it looks like in liver exchange the donors will travel to the recipients instead of having the organs shipped, as is now mostly done in U.S. kidney exchange.  That's actually how kidney exchange worked when it began) Here's a recent article from Medscape:

Can a Nationwide Liver Paired Donation Program Work?  by Lucy Hicks

"To expand the number of living liver donations in the United States, the United Network for Organ Sharing (UNOS) has launched the first national paired liver donation pilot program in the United States.

...

"In 2020, 1095 people died while waiting for a liver transplant

...

"Paired kidney donation programs have been running since 2002, but paired liver donation is relatively new. Since the first US living-donor liver transplant in 1989, the procedure has become safer and is a viable alternative to deceased liver donation. A growing number of living donor programs are popping up at transplant centers across the country.

"Still, living-donor liver donation makes up a small percentage of the liver transplants that are performed every year. In 2022, 603 living-donor liver transplants were performed in the United States, compared to 8925 liver transplants from deceased donors

...

"There are several notable differences between living donor kidney transplants and living donor liver transplants. For example, living donor liver transplant is a more complicated surgery and poses greater risk to the donor. According to the OPTN 2020 Annual Report, from 2015–2019, the rehospitalization rate for living liver donors was twice that of living kidney donors up to 6 weeks after transplant (4.7% vs 2.4%). One year post transplant, the cumulative rehospitalization rate was 11.0% for living liver donors and 4.8% for living kidney donors.

"The risk of dying because of living donation is also higher for liver donors compared to kidney donors. The National Kidney Association states that the odds of dying during kidney donation are about 3 in 100,000, while estimates for risk of death for living liver donors range from 1 in 500 to 1 in 1000. But some of these estimates are from 10 or more years ago, and outcomes have likely improved

...

"In addition to a more complex surgery, surgeons also have a smaller time window in which to transplant a liver than than they do to transplant a kidney. A kidney can remain viable in cold storage for 24–36 hours, and it can be transported via commercial airlines cross country. Livers have to be transplanted within 8–12 hours, according to the OPTN website. For living donation, the graft needs to be transplanted within about 4 hours, Samstein noted; this poses a logistical challenge for a national organ paired donation program.

"We worked around that with the idea that we would move the donor rather than the organ," he said. The program will require a donor (and a support person) to travel to the recipient's transplant center where the surgery will be performed. While 3 of the 15 pilot paired donation transplant centers are in New York City, the other programs are scattered across the country, meaning a donor may have to fly to a different city to undergo surgery.

"Including the preoperative evaluation, meeting the surgical team, the surgery itself, and follow-up, the donor could stay for about a month. The program offers up to $10,000 of financial assistance for travel expenses (for both the donor and support person), as well as lost wages and dependent care (for the donor only). Health insurance coverage will also be provided by the pilot program, in partnership with the American Foundation for Donation and Transplant.

...

"The 1-year pilot program is set to begin when the program conducts its first match run — an algorithm will help match pairs who are enrolled in the program. About five to seven enrolled pairs would be ideal for the first match run, a UNOS spokesperson said. It is possible that the 1-year pilot program could run without performing any paired transplants, but that's unlikely if multiple pairs are enrolled in the system, the spokesperson said. At the time of this story's publication, the one enrolled pair are a mother and daughter who are registered at the UCHealth Transplant Center in Colorado."

Tonya Ingram (1991-2022), health activist, died while waiting for a kidney

 Tonya Ingram, a poet and health activist who testified in Congress about the long waiting list for kidney transplants, died last month while still waiting.  Saturday's New York Times had a moving column about her activism, her struggle and her long wait.

Tonya Ingram Feared the Organ Donation System Would Kill Her. It Did. By Kendall Ciesemier (Ms. Ciesemier is a writer, a producer and an organ recipient.) Jan. 28, 2023

Here's her obit in the LA Times:

Tonya Ingram, an inspiring L.A. poet and ‘lupus warrior,’ died waiting for a kidney by Jireh Deng, JAN. 23, 2023

Market design isn't only about trying to allocate scarce resources effectively, it's also about working to make them less scarce.

Cross-border transplantation between China and Hong Kong

 Here are two recent reports of the first cross-border transplant between China proper and Hong Kong.

From the Global Times:

First organ donation between mainland and HK saves 4-month old baby By Wan Hengyi

"A medical team of the Hong Kong Children's Hospital successfully transplanted a heart donated from the mainland to a 4-month-old baby in Hong Kong Special Administrative Region on Saturday, achieving a historic breakthrough in the sharing of human organs for emergency medical assistance between the two places for the first time.

"The donated heart, which had been matched by China's Organ Transplant Response System (COTRS) through several rounds and had no suitable recipient, was successfully matched in Hong Kong through the joint efforts between 24 departments and 65 medical experts in the mainland and Hong Kong.

"Cleo Lai Tsz-hei, the recipient of the transplant from Hong Kong, was diagnosed with heart failure 41 days after birth and was in critical condition. Receiving a heart transplant was the only way to keep her alive, according to media reports.

"Moreover, the acceptable heart donation for Cleo requires a donor weighing between 4.5 kilograms and 13 kilograms, and the chances of a suitable donor appearing in Hong Kong are slim to none.

...

"COTRS initiated the allocation of a donated heart of a child with brain death due to brain trauma in the mainland on December 15. As a very low-weight donor, no suitable recipients were found after multiple rounds of automatic matching with 1,153 patients on a national waiting list for heart transplants in the COTRS system. In the end, the medical assistance human organ-sharing plan between the Chinese mainland and Hong Kong was launched.

"Some netizens from the Chinese mainland asked why a baby from Hong Kong who has not lined up in the COTRS system can get a donated heart when there is a huge shortage of donated organs in the mainland.

"In response, the organ coordinator told the Global Times that the requirements for organ donation are extremely high, noting that all the prerequisites including the conditions of the donor and recipient, the time for the organ to be transported on the road and the preparation for surgery must reach the standards before the donation can be completed.

"The COTRS system has already gone through several rounds of matching, which is done automatically by computer without human intervention, said the organ coordinator. 

"Medical teams from both jurisdictions, as well as customs officers in Shenzhen and Hong Kong, carried out emergency drills to reduce the customs clearance time to eight minutes, racing against the four-hour limit for preserving donated hearts, said Wang Haibo, head of the COTRS for medical assistance contact between the mainland and Hong Kong.

"The collection of donated hearts began at 17:00 pm on Friday, and the hearts were delivered to the Hong Kong Children's Hospital at 20:00 pm under the escort of Hong Kong police on the same day. At 1:00 am on Saturday, Cleo's heart transplant operation in Hong Kong was successfully completed, and she has not required extracorporeal circulation support at present."

********

And from the South China Morning Post:

Hong Kong could greatly benefit from cross-border organ imports mechanism, doctors say after local baby receives heart from mainland China  by Jess Ma

"Hong Kong could greatly benefit from cross-border organ donations given the city’s persistently low rate of residents willing to sign up to become donors, doctors have said after a local baby girl received a heart from mainland China in the first arrangement of its kind.

...

"Hong Kong’s organ donation rate is currently among the lowest in the world, at 3.9 donors per a million people in 2019, down from 5.8 in 2015, according to research conducted by the Legislative Council.

...

"Medical lawmaker David Lam Tzit-yuen and election committee legislators Elizabeth Quat Pei-fan and Rebecca Chan Hoi-yan urged the government to begin discussions on legal frameworks and procedures for cross-border transplants, saying that the mainland had a robust donation system and that organ sharing between the city and the mainland was not unusual.

"Human rights groups and lawyers have accused the mainland of forcibly harvesting organs from executed prisoners, a practice that then health minister Huang Jiefu publicly acknowledged in 2005. The government announced in 2015 that organ donations would only come from “voluntary civilian organ donors,” but critics argued prisoners were not excluded under the system.

But Chan argued that the mainland’s efforts to improve the transparency and ethics of its organ donation system over the past decade should be acknowledged.

“I disagree that this would be the beginning of a slippery slope. The transparency of the mainland’s organ donation system has been a lot clearer and stricter,” Chan said, adding that a lot of work had been done across the border to prohibit organ harvesting and trading."

Sell a kidney to save a life? by Dylan Walsh, in WIRED.

 Martha Gershun alerts me to this story which appeared this morning in WIRED, in which the author, a kidney transplant recipient (24 years ago), considers the history of the long debate about whether kidney donors might be compensated, to end the shortage of life-saving kidney transplants.  It's very well written, and contains some details (e.g. dialog between Al Gore and Barry Jacobs) that I hadn't seen before.  It's well worth reading the whole thing.

Would You Sell One of Your Kidneys? Each year thousands die because there aren’t enough organs for transplants, and I may be one of them. It’s time to start compensating donors. by Dylan Walsh

Here's the first sentence:

"WHEN WE WERE teenagers, my brother and I received kidney transplants six days apart. "

Here's some history of transplantation itself:

"In 1963, the world’s preeminent kidney transplant surgeons met in DC to discuss the state of the field. They were few in number and dispirited. Roughly 300 operations had been performed by then, with only 10 percent of patients surviving more than six months, according to one account. The procedure remained no more than “highly experimental,” in the words of even its fiercest proponents. But the prevailing gloom lifted when two little-known surgeons from Denver, Thomas Starzl and Thomas Marchioro, presented results from a series of transplants they’d performed. They had managed to flip the outcomes: 10 percent failure, 90 percent success. A euphoric shock spread through the crowd, which quickly gave way to skepticism. The results were studied, confirmed, and eventually replicated. "

Here's a bit about the origins of the legal ban on compensating donors (the 1984 National Organ Transplant Act, or NOTA):

"In 1967, one study found that roughly 8,000 people were eligible for a kidney transplant; only 300 received one.

"IT TOOK ABOUT a decade for someone of enterprising disposition to step into this gap. H. Barry Jacobs was a Virginia doctor who lost his license to practice medicine in 1977 for attempting to defraud Medicare. He spent 10 months in jail and shortly after his release turned his energies to the unregulated business of organ brokering. His company, International Kidney Exchange Ltd., was built around the fact that most of us are born with two kidneys but can function with one. If one kidney is removed, the other grows larger and works harder, filtering more blood to cover as best it can for its emigrant twin. This redundancy supported Jacobs’ straightforward business model. He would connect people who wanted to sell one of their kidneys, for a price of their choosing, with people who needed one. As a mi"ddleman, Jacobs would charge a brokerage fee to the recipients.

"At the time, Al Gore, then a member of the US House of Representatives, was developing the National Organ Transplant Act, which centered on establishing a repository to match organ donors with those in need of a transplant. Upon hearing of Jacobs’ plan, Gore also took up the question of compensation. Jacobs appeared before the Subcommittee on Health and the Environment on October 17, 1983, and spoke with truculence. He talked about one doctor who had testified before him “sitting on his butt” and failing to seriously address the problem of organ shortages. He interrupted and challenged his questioners. His testimony, above all, highlighted the likely abuses in an unregulated organ market.

“I have heard you talk about going to South America and Africa, to third-world countries, and paying poor people overseas to take trips to the United States to undergo surgery and have a kidney removed for use in this country,” Gore said. “That is part of your plan, isn't it?”

“Well, it is one of the proposals,” Jacobs said.

...

"This exchange gave public force to a debate that had been unfolding in the dimmer theater of academia ever since transplantation first became possible. ...Proponents of an organ market had historically invoked the crisp—some say cold—logic of utilitarianism. A properly designed market, they suggested, would provide economic surplus to both the organ donor, in the form of money, and to the recipient, in the form of a longer, healthier life. Opponents of a market typically crafted their dissents from the gossamer realm of ethics."

There's more, both personal and policy.  

Good luck to all who need a kidney and to those who donate them. Maybe we'll make some more progress in 2023.

It's not so easy to become a living kidney donor: report from the Cleveland Clinic

 It's not so easy to become a living kidney donor.  Here's a report on the pipeline at the Cleveland Clinic:

Cholin, Liza K., Jesse D. Schold, Med MStat, Susana Arrigain, Emilio D. Poggio, John R. Sedor, John F. O’Toole, Joshua J. Augustine, and Alvin C. Wee. " Characteristics of Potential and Actual Living Kidney Donors: A Single Center Experience, Transplantation (2022).

It's concerning to see that 164 donor candidates were rejected at this center for being "ABO or crossmatch incompatible."  Were they told about the possibility of kidney exchange?

 

"There was a mean of 2.8 and median of 1 (1, 3) potential donors for every 1 transplant candidate that did not receive a kidney. There was a mean of 5.9 and median of 2 (1, 5) potential donors for every 1 transplant candidate that received a kidney."

HT: Frank McCormick

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

The Dr H.L. Trivedi Oration at the Indian Society of Transplantation (ISOT) Meeting 2022

Here's the meeting announcement:

ISOT 2022 NAGPUR

32^nd Annual Conference of The Indian Society of Organ Transplantation
2^nd Mid-term Meeting of Liver Transplantation Society of India
15^th Annual International Conference of NATCO
Dates : 12^th - 16^th October 2022 | Venue : Hotel Le Meridien, Nagpur

My talk, the Dr H.L. Trivedi Oration   is scheduled for 11:00am on Friday the 14th in Nagpur, which means I'll be giving it by zoom tonight, Thursday evening at 10:30 pm Pacific Time.

The presentation, which  will be about "Increasing the availability of transplants in India" is in honor of the late Dr. Hargovind Laxmishanker "H. L." Trivedi (August 1932 – October 2019), who I had the privilege of meeting,

Here's his obituary : 

Kute, Vivek, Himanshu Patel, Pankaj Shah, Pranjal Modi, and Vineet Mishra. "Professor Dr. HL Trivedi pioneering nephrologist and patriot who cared for his country (31-08-1932 TO 2-10-2019)." Indian Journal of Nephrology 29, no. 6 (2019): 379.

*********

Here's my concluding slide:

• India has enormous talent and accomplishment in living-donor transplantation
• To more nearly reach it’s potential, India needs to invest in recovering deceased donor organs.
• In the near term, it can build on it’s accomplishments in kidney transplantation, by 
• establishing national (not just regional) kidney exchange
• Continuing to explore international exchange for the hardest to match pairs
• Reducing restrictions on who can be an exchange donor
• Allowing non-directed donors and chains
• Allowing some chains to begin with a deceased-donor kidney
• Reducing financial barriers by increased investment in public hospitals and government health insurance, for organ donors as well as recipients

***********

Update: 

TTS2022 Awards--Congratulations

 Today at TTS2022, prizes will be awarded.  One that I know is very well deserved, is to Dr. Vivek Kute, for his extraordinary achievements in kidney transplantation in India. Congratulations to all the prize winners.

I've followed Dr. Kute's work over the years in multiple posts.

Ideas to Increase Transplant Organ Donation, in Regulation / SUMMER 2022

 Frank McCormick points out this recent collection of short pieces in the summer issue of Regulation.

Ideas to Increase Transplant Organ Donation, edited by Ike Brannon, in Regulation / SUMMER 2022

Introduction  BY IKE BRANNON

Emulate Israel’s Program of Covering Donors’ Expenses BY JOSH MORRISON AND SAMMY BEYDA

Give Donors a Tax Credit BY SALLY SATEL AND ALAN D. VIARD

Expose OPOs to Competition BY ABE SUTTON

Help People Understand the Benefits of Donation  BY MARIO MACIS