Gambling and Sports

A class of repugnant transactions (gambling, subject to many legal restrictions designed to limit its availability) and  protected transactions (sports events, subject to many regulations designed to protect their integrity) have come a bit closer together through a recent Supreme Court decision about a complicated law.

Here's the news story from Inside Higher Ed:
Gambling on Sports Legal
The Supreme Court has opened the way for states to legalize betting on athletics, a defeat for the National Collegiate Athletic Association and professional leagues.

"The U.S. Supreme Court on Monday struck down a law that had forbidden gambling on college and professional sports outside Nevada."

The link above goes to the Supreme Court decision.
But what makes the law that they struck down complicated is that it didn't make sports betting a crime, rather it forbade States from allowing it.

Here's some legal commentary on the decision from a law firm involved in the case:
https://www.gibsondunn.com/supreme-court-strikes-down-federal-limits-on-sports-gambling/

"The Supreme Court held 7-2 that a federal law prohibiting States from authorizing sports betting violates the Tenth Amendment because it impermissibly commandeers state legislatures.

"Background: A federal law – the Professional and Amateur Sports Protection Act of 1992 (PASPA) – prohibits States from authorizing or licensing sports gambling.  In 2014, the New Jersey legislature repealed existing prohibitions on sports gambling at casinos and racetracks.  The NCAA and the four major professional sports leagues sued the State, arguing that the decision to allow sports gambling violated PASPA.

"Issue: Whether PASPA’s federal prohibition on state authorization of sports gambling violates the Tenth Amendment because it commandeers state legislatures.

"Court’s Holding: Yes.  PASPA unconstitutionally commandeers state legislatures by dictating the content of state law regarding sports gambling (i.e., preventing States from legalizing sports gambling).

“A more direct affront to state sovereignty is not easy to imagine.”

***********
Here's the Volokh conspiracy on possible broader implications of this decision

Broader Implications of the Supreme Court's Sports Gambling Decision
Commentators are right to suggest that Murphy v. NCAA will help sanctuary cities, but wrong to claim it is like to undermine federal laws restricting state taxes.

Still bleeding for Canada

Here's a paper on the ongoing debate in Canada about whether it should be legal to pay plasma donors.

Moral NIMBY-ism? Understanding Societal Support for Monetary Compensation to Plasma Donors in Canada
by
Nicola Lacetera, Mario Macis
NBER Working Paper No. 24572 May 2018

Abstract: "The growing demand for plasma, especially for the manufacture of therapeutic products, prompts discussions on the merits of different procurement systems. We conducted a randomized survey experiment with a representative sample of 826 Canadian residents to assess attitudes toward legalizing payments to plasma donors, a practice that is illegal in several Canadian provinces. We found no evidence of widespread societal opposition to payments to plasma donors. On the contrary, over 70% of respondents reported that they would support compensation. Our Canadian respondents were more in favor of paying plasma donors elsewhere than in Canada, but the differences were small, suggesting a weak role for moral “NIMBY-ism” or relativism. Moral concerns were the respondents’ main reason for opposing payments, together with concerns for the safety of plasma from compensated donors, although most of the plasma in Canada does come from paid U.S. donors. Among those in favor of legalizing payments to donors, the main rationale was to guarantee a higher domestic supply. Finally, roughly half of those who declared to be against payments reported that they would reconsider their position if domestic supply plus imports did not cover domestic demand. Most Canadians, therefore, seem to espouse a consequentialist view on issues related to the procurement of plasma.

Forbes Health Forum in Mexico City, May 23

I'm travelling to Mexico today, to speak about kidney exchange at a health forum sponsored by Forbes, and to meet with colleagues at Pro-Renal, the new kidney exchange program there.

Here's a brief news story:
Alvin E. Roth, el Nobel de Economía que ha salvado miles de vidas
No es médico, pero el doctor Roth ha ayudado a miles de personas a recibir un trasplante de riñón, lo que le valió un Nobel en 2012.

And here's the conference program:

FORO FORBES SALUD
May 23,
HACIENDA DE LOS MORALES, CDMX

Agenda (via Google translate)

08:30 HRS. WELCOME

MANAGING TEAM OF FORBES MEDIA LATAM

08:40 HRS. FORBES HEALTH FORUM RECOGNITION

ALFREDO QUIÑONES-HINOJOSA , "DOCTOR Q", MD, FAANS, FACS. WILLIAM J. AND CHARLES H. MAYO PROFESSOR | CHAIR, NEUROLOGIC SURGERY

Dr. Alfredo Quiñones is an example to follow. His history as a migrant in the United States is a reflection of tenacity, dedication, inspiration. He is currently one of the most recognized doctors in the United States for his contributions to neurosurgery. And it's Mexican.

09:00 HRS. INAUGURAL DISCOURSE

TBD

An economic-financial diagnosis of the sector and the challenges it faces such as increased investment in health services.

09:30 HRS. CONFERENCE.

"THE ECONOMY CURES THE HUMANS"

ALVIN E. ROTH , NOBEL PRIZE OF ECONOMY 2012

The work of Dr. Roth has allowed the realization of more than 4 thousand kidney transplants in the United States. This economist developed a "Algorithm of Compatibility" based on technology, big data and the economy applied to health that is solving two of the main public health problems in the world: chronic renal failure and incompatibility between couples of donors and recipients of transplants.

10:00 HRS. RECESS | EXPO | NETWORKING OPPORTUNITY 

10:30 HRS. PANEL. 1

"HEALTHY SOCIETY = HEALTHY ECONOMY"

Investing in health can mean big business, but above all the best practice to build a better future. The principle is basic: if we have healthy Mexicans, companies and the public sector would register a better performance and, consequently, economic activity would register better numbers. How to face costs, have the necessary infrastructure, treat chronic degenerative diseases and maintain a decent level of quality of life?

DR. DAVID KERSHENOBICH STALNIKOWITZ , DIRECTOR GENERAL OF THE NATIONAL INSTITUTE OF MEDICAL SCIENCES AND NUTRITION SALVADOR ZUBIRÁN

ÁNGELES DE GYVES , CEO OF THE CORPORATE HEALTH AND WELFARE COUNCIL

11:00 HRS. PANEL. 2

"THE DIGITAL WORLD IN HEALTH"

The patient has changed and that forces companies in the sector to adapt to the new circumstances. The digital revolution is largely responsible for this transformation. How to understand the new consumption habits? How to transmit the information to customers? This table will be aimed at understanding and applying the best techniques to know the voice of the e-patient.

JENNIFER BARBA , FOUNDER AND CEO OF FRAME CONSULTING

ALEJANDRO PAOLINI , MANAGING DIRECTOR OF SIEMENS HEALTHINEERS MESOAMÉRICA AND MEXICO

HÉCTOR VALLE MESTO , EXECUTIVE PRESIDENT OF THE MEXICAN FOUNDATION FOR HEALTH, AC

JORGE RUIZ ESCAMILLA

11:30 HRS. PANEL. 3

"HACKING HEALTH"

New forms emerge as a muscle for efficient use and maximization of resources, patient management and electronic records. Along with this, home care, mobile applications and regulatory challenges begin to be promoted. Also, the best practices of IT companies. This space will serve to know the best strategies that allow the Health Sector to capitalize on the new trends.

MARTHA GONZÁLEZ , DIRECTOR OF IBM WATSON & amp; CLOUD PLATFORM

JAVIER CORDERO , PRESIDENT OF ORACLE MEXICO

FERNANDO OLIVEROS , CEO OF MEDTRONIC

GABRIEL LOOR MD., FACC , SURGICAL DIRECTOR, LUNG TRANSPLANT PROGRAM BAYLOR AT ST. LUKE'S MEDICAL CENTER

MODERATOR : ARMANDO SANDERS , CO-FOUNDER OF GENO +

12:00 HRS. PANEL. 4

"HEALTH AS A BUSINESS AND INVESTMENT"

Health is a good investment. The Mexican Pharmaceutical Industry as a contributor to the productive capacity of the country. Multinational and Mexican companies will share their success stories and strategies to adapt to market conditions.

RODRIGO PUGA , CEO OF PFIZER MEXICO

ANA LONGORIA , CEO OF NOVARTIS MEXICO

RAFAEL GUAL , DIRECTOR GENERAL OF CANIFARMA

VLADIMIRO DE LA MORA , PRESIDENT OF GE MEXICO

MODERATOR : JUANA RAMÍREZ , FOUNDER AND PRESIDENT OF SOHIN

12:30 HRS. CONFERENCE.

"EXPONENTIAL HEALTH", ACCORDING TO SINGULARITY UNIVERSITY

RAYMOND MCCAULEY , CHAIR OF THE BIOTECH TRACK OF SINGULARITY UNIVERSITY

13:00 HRS. TIME FOR FOOD

14:30 HRS. PANEL. 5

"THE NEW FINANCING"

Pharmaeconomics, changing the health dialogue. Going from asking for "budget" and "demonstrating that health brings productivity". This space has a clear objective: to understand public finances and the impact it has on the country's fiscal balance. What are the new financing models? Topics such as investment in infrastructure, private equity and health financing models will be put on the table.

PATRICK DEVLYN , PRESIDENT OF THE CCE HEALTH COMMISSION

PABLO ESCANDÓN , PRESIDENT AND DIRECTOR GENERAL OF GRUPO NADRO

FRÈDÈRIC GARCÍA , PRESIDENT OF THE EXECUTIVE BOARD OF GLOBAL COMPANIES (CEEG)

FÁTIMA MASSE , CONSULTANT IN URBAN URBAN DEVELOPMENT

ANTONIO CHEMOR RUIZ , NATIONAL COMMISSIONER OF SOCIAL PROTECTION IN HEALTH / PEOPLE'S INSURANCE

MODERATOR : GUSTAVO CANTÚ , CEO OF SEGUROS MONTERREY NEW YORK LIFE

15:00 HRS. PANEL. 6

"THE END OF THE TRADITIONAL DISTRIBUTION"

New disruptive models of distribution and access to primary health care. The customer service in the last chain of the process in the distribution of the drug is being transformed.

MAX LEONARDO , ATTORNEY GENERAL OF PHARMACIES OF SAVINGS

RICARDO MARTÍ , DIRECTOR OF WALMART FARMACIAS

15:30 HRS. CONFERENCE.

"BENEFITS OF AEROSPACE MEDICINE ON EARTH"

EMMANUEL URQUIETA, MD, MS , SENIOR RESEARCH PORTFOLIO MANAGER OF THE TRANSLATIONAL RESEARCH INSTITUTE FOR SPACE HEALTH

16:00 HRS. HEALTH VIEWED BY THE NEXT SEXENIUM

The political times are already here and, under this environment, this table will convene the links of the candidates to the Presidency of the Republic to share with the audience the great tasks that would be carried out in the next six years.

JORGE ALCOCER VARELA , REPRESENTATIVE OF ANDRÉS MANUEL LÓPEZ OBRADOR, PRESIDENTIAL CANDIDATE FOR THE COALITION TOGETHER WE WILL HISTORY

16:30 HRS. CLOSING

***********

And here's an article in the Mexican edition of Forbes describing some of the health problems faced in Mexico:

La biotecnología puede ser una cura para muchos males en México
México está enfermo: Cada año unas 100 mil personas mueren a causa de diabetes, 80 mil por infartos y 80 mil por tumores, sin embargo, la tecnología podría estar cerca de cambiar las reglas del juego. Este tema y otros se tocarán en el Foro Forbes de Salud.

Google translate:
"Biotechnology can be a cure for many ills in Mexico
Mexico is sick: Every year about 100 thousand people die from diabetes, 80 thousand from heart attacks and 80 thousand from tumors, however, technology could be close to changing the rules of the game. This theme and others will be played at the Forbes Health Forum."

Safe injection sites in New York City? Learning from Canada...

The NY Times has two recent stories, one perhaps a reaction to the other.  First this:
De Blasio Moves to Bring Safe Injection Sites to New York City

"Mayor Bill de Blasio is championing a plan that would make New York City a pioneer in creating supervised injection sites for illegal drug users, part of a novel but contentious strategy to combat the epidemic of fatal overdoses caused by the use of heroin and other opioids.

"Safe injection sites have been considered successful in cities in Canadaand Europe, but do not yet exist in the United States. Leaders in San Francisco, Philadelphia and Seattle have declared their intention to create supervised sites, although none have yet done so because of daunting obstacles. Among them: The sites would seem to violate federal law.

"The endorsement of the strategy by New York, the largest city in the country, which last year saw 1,441 overdose deaths, may give the movement behind it impetus.

"For the sites to open, New York City must still clear some significant hurdles. At minimum, the plan calls for the support of several district attorneys, and, more critically, the State Department of Health, which answers to Gov. Andrew M. Cuomo. The city sent a letter on Thursday to the state, asserting its intention to open four injection centers.

 ...
"The most serious obstacle to the safe injection sites may be the federal government. A section of federal law known as the crack house statute makes it illegal to own, rent or operate a location for the purpose of unlawfully using a controlled substance.

The enforcement of the statute in the case of safe injection sites, however, would be up to the discretion of federal authorities. While it is unclear how the Trump Justice Department will respond to the city’s proposal, the attorney general, Jeff Sessions, has taken a hard line on drug policy.

“We don’t believe a president who has routinely voiced concern about the national opioid epidemic will use finite federal law enforcement resources to prevent New York City from saving lives,” Eric F. Phillips, the mayor’s press secretary, said in a written statement.

Advocates for the sites point out that needle exchanges were considered illegal when they began, and they are now commonplace; in 2015, for example, when Mike Pence was governor of Indiana, he put aside his moral opposition to needle exchanges and allowed a program to stem the flood of H.I.V. cases."

************

And, today, this:

Opioid Crisis Compels New York to Look North for Answers
Supervised injection sites for heroin users have prevented overdose deaths in Canada. But is New York City ready for the scenes that come with them?

"As Mayor Bill de Blasio has come out in support of supervised injection centers in New York, his stance has been shaped by Canada’s lead.

The country has been a pioneer; its first supervised injection facility, where heroin can be used under supervision, opened in Vancouver in 2003. A decade of political and legal wrangling followed, culminating with the Canadian Supreme Court ruling in favor of the approach in 2011."

A quick look back at the politics of electricity markets

This, from the RTO Insider, which bills itself as "Your Eyes and Ears on the Organized Electric Markets."

Former FERC Chairs Reminisce, Sound Off at EBA

"The Energy Bar Association closed its annual meeting last week with a panel discussion with five former FERC chairs whose terms collectively spanned two decades. The former chairs offered entertaining anecdotes about the past while expressing pride over the growth of competitive markets — and frustration over forces they said threaten them."

Afshin Nikzad defends (x2)

Defense 2, (Offense 0).
Afshin Nikzad defended twice in eight days, to qualify for two Ph.D.s, one from Management Science and Engineering, in Operations Research, and one from Economics (in economics:).  Here are photos from his Economics defense.

Afshin Nikzad and some of his admirers: Philip Strack, Fuhito Kojima, Daniela Saban, Niloufar Salehi, Al Roth, Afshin, Paul Milgrom, and Itai Ashlagi

The papers he presented for his Economics defense were
Thickness and Competition in Ride-sharing Markets 
and 
Financing Transplant Costs of the Poor: A Dynamic Model of Global Kidney Exchange 

The papers he presented for his MS&E defense were 
Approximate Random Allocation Mechanisms 
and
What matters in tie-breaking rules? How competition guides design 


Welcome to the club(s), Afshin

Eric Budish on (expensive) blockchain technology

The Economic Limits of the Blockchain
by Eric Budish
May 3, 2018

Abstract: The amount of computational power devoted to blockchains such as Bitcoin’s must simultaneously satisfy two conditions in equilibrium: (1) a zero-profit condition among miners,who engage in a rent-seeking competition for the prize associated with adding the next block to the chain; and (2) an incentive compatibility condition on the system’s vulnerability to a“majority attack”, namely that the computational costs of such an attack must exceed the benefits. Together, these two equations imply that (3) the recurring, “flow”, payments to miners for running the blockchain must be large relative to the one-off, “stock”, benefits of attacking it. The constraint is softer (i.e., stock versus stock) if both (i) the mining technology used to run the blockchain is both scarce and non-repurposable, and (ii) any majority attack is a “sabotage” in that it causes a collapse in the economic value of the blockchain; however, reliance on non-repurposable technology for security and vulnerability to sabotage each raise their own concerns, and point to specific collapse scenarios. Overall the results place potentially serious economic constraints on the applicability of the Nakamoto (2008) blockchain innovation. The anonymous, decentralized trust enabled by the blockchain, while ingenious, is expensive.

Liver exchange in the U.S.?

 From  Liver Transplantation 24 677–686 2018 

Liver paired exchange: Can the liver emulate the kidney?
Ashish Mishra  Alexis Lo  Grace S. Lee  Benjamin Samstein  Peter S. Yoo Matthew H. Levine  David S. Goldberg  Abraham Shaked  Kim M. Olthoff Peter L. Abt

Abstract: Kidney paired exchange (KPE) constitutes 12% of all living donor kidney transplantations (LDKTs) in the United States. The success of KPE programs has prompted many in the liver transplant community to consider the possibility of liver paired exchange (LPE). Though the idea seems promising, the application has been limited to a handful of centers in Asia. In this article, we consider the indications, logistical issues, and ethics for establishing a LPE program in the United States with reference to the principles and advances developed from experience with KPE. 

...

"The potential number of donor and recipient pairs that might be suitable for LPE in the United States is unknown and is dependent on numerous factors. However, the Asan Medical Center experience from South Korea provides some perspective; among 2182 LDLT patients, 26 involved LPE.3 In the United States, most donors selected for LPE will likely be those where the donor is appropriate to donate with regard to the usual anatomical, medical, and psychosocial dimensions, but for 1 reason or another not appropriate for his or her intended recipient. Centers that evaluate living liver donors follow a stepwise approach to determining eligibility for donation. Some donors are rejected early in the evaluation process for obesity or other comorbidities, age, or being psychosocially unfit to proceed with donation.16, 17 Those who pass the initial screening process are assessed further for blood type, liver volumes, and other anatomical considerations, as well as general medical and psychosocial concerns. The donors who are rejected at this stage in the evaluation are the ones who could be considered for LPE. It is estimated that 3.5%‐17.0% of donors are rejected for ABOi, 4.1%‐14.0% for inadequate hepatic mass to support the recipient, and 1.5%‐6.0% due to vascular or biliary anatomic variations.17-20 There is considerable variation of these estimates based on the order of tests and the screening processes used to evaluate potential donors based on transplant center‐specific donor criteria. These barriers to donation represent opportunities for a variety of exchanges between donor and recipient pairs, such that the total number of lives saved through LDLT could be increased."
...

Examples of Potential LPE

In the following section, we provide some examples of potential LPE. If the history of KPE serves as a guide for the trajectory of LPE, the number of pairs involved, the indications for participation, and the complexity of exchanges are likely to increase (Fig. 2).

1. Two‐way swap: ABOi pair and a pair where the estimated weight of the donor lobe is inadequate for the intended recipient (Fig. 2A).
2. Three‐way swap: ABO compatible pair where the remnant volume is too small for the donor; ABOi donor to small child where the left lateral segment (LLS) is also too large for the child; and an ABOi pair (Fig. 2B).
3. Nondirected donor starts a chain (Fig. 2C).
4. Patient with familial amyloid polyneuropathy (FAP) receives a deceased donor organ or LDLT and starts a chain with a domino liver (Fig. 2D).

"Economics that works" in Bloomberg, celebrates Parag Pathak as a reply to some critics of economics

A Top Econ Prize for a Theory That Works
This economist figured out a better way to assign students to public schools.
By Noah Smith, May 15

Here are the opening lines:

"What do people think economic theorists do? The pundits who regularly criticize the profession, particularly in the pages of British magazines, seem to think that they spend all their time making abstruse, unrealistic theories about how free markets are the best of all possible worlds. And it's true that there are still a few economists out there who are essentially doing that. But a lot of theorists are doing something much more humble and practical work on small-bore theories that can be immediately applied to make the real world a little more efficient.

Parag Pathak is a theorist of this latter type. "

And here are the closing lines (what's in between is well worth reading too:)

"In an age when bashing economics is in vogue, the critics should pay attention to researchers like Pathak. Their theories are not as grandiose as the macroeconomic ideas that appear in the press — but they really work, and every day they improve people’s lives."

Dick Thaler reflects on nuts to nudges--The economist as story teller

Some Thaler stories, from the horse's mouth

Behavioral economics from nuts to ‘nudges’
A bowl of cashews led to a research breakthrough
by Richard H. Thaler

"People think in stories, or at least I do. My research in the field now known as behavioral economics started from real-life stories I observed while I was a graduate student at the University of Rochester. Economists often sneer at anecdotal data, and I had less than that—a collection of anecdotes without a hint of data. Yet each story captured something about human behavior that seemed inconsistent with the economic theory I was struggling to master in graduate school. Here are a few examples:..."

Kidney Exchange in India: current conditions and recommendations for the future

The Indian Society of Organ Transplantation has published guidelines for expanding kidney exchange in India:

Kute VB, Agarwal SK, Sahay M, Kumar A, Rathi M, Prasad N, Sharma RK, Gupta KL, Shroff S, Saxena SK, Shah PR, Modi PR, Billa V, Tripathi LK, Raju S, Bhadauria DS, Jeloka TK, Agarwal D, Krishna A, Perumalla R, Jain M, Guleria S, Rees MA. Kidney-paired donation to increase living donor kidney transplantation in India: Guidelines of Indian Society of Organ Transplantation – 2017. Indian J Nephrol 2018;28:1-9

Here's the summary of their recommendations:

"Evidence-based recommendations, suggestions, and expert consensus statements in this document aim to expand KPD and may serve as a model for other developing countries. For these guidelines, all reference articles in the English literature related to KPD transplantation in India from MEDLINE (PubMed from 2000 to 2017) database were included and reviewed.

We recommend that each potential DRP should be educated, encouraged, and counseled about KPD transplant in an easy-to-understand format as early as possible in the process of chronic kidney disease (CKD) care.

We recommend that all the transplant team members including transplant coordinator in addition to other regular training should also be trained for counseling about risk, benefits of KPD, nonexchange options, consent process, financial screening of DRP, data entry-related issues of KPD, and overall support for KPD.

We recommend that a standard written informed consent should be obtained from each DRP. We suggest that DRP should be given information about expected waiting time before transplantation, and every attempt should be made to reduce waiting time, particularly for hard-to-match pairs with the innovative ways in KPD matching.

We suggest that easy-to-match pairs (A donor and B recipient and vice versa) and sensitized pairs should be encouraged for KPD over ABO-incompatible kidney transplantation (ABOiKT) and desensitization protocol.

We recommend that all types of KPD should be practiced only after legal permission as per the existing transplant law.

We suggest that three-way exchange has optimum quality and quantity of matching.

We suggest that potential KPD transplant centers should study the key elements of success of other successful KPD program.

We suggest that computerized algorithms should be encouraged over manual allocation.

We recommend that all patients should be screened for pretransplant immunological risk, occult infections, and other risk factors to prevent and reduce posttransplant unequal outcome due to patient-related factors.

We suggest that the age difference between KPD donors should not be the key issue in allocation and better immunological match may counteract the effect of higher donor–recipient age difference.

We recommend that participating transplant teams should make the decision by consensus about kidney donor travel versus kidney transport as per local resources and logistics, though donor travel rather than kidney transport is likely to be simple.

We suggest that transplant surgery should be performed at the place where patient is evaluated, admitted, and willing to do posttransplant follow-up and simultaneous rather than sequential surgery should be preferred.

We recommend that the formation of KPD registry is one of the principal strategies to improve the quality of matching and number of KPD.

We suggest that DRP needs to be cognizant of transcultural, language, and legal barriers in national program when patients and their donors may belong to different regions or states of India."


And here's the introductory summary of the background in India:

The Indian CKD registry in 2010 reported that at the time of enrolment in registry, 61% of end-stage renal disease (ESRD) patients were not on any form of renal replacement therapy (RRT), while 32% were on hemodialysis, 5% on peritoneal dialysis, and only 2% were being worked up for kidney transplantation.^[1] There is a gross disparity between supply and demand of the transplant organs across the world, including India. All efforts are to be made to increase the supply of quality organs to the waiting transplant recipients. KPD is one such process for increasing supply of organs to patients waiting for transplant. ABO-compatible living donor kidney transplant (LDKT) is the ideal and cost-effective RRT modality for ESRD patients in resource-limited developing country such as India, where morbidity and mortality on long-term dialysis is unacceptably high. Access to RRT is mainly prevented by paucity of facilities and affordability. Up to 80% of kidney donors are living donors, while DDKT programs are still evolving in most parts of India.

KPD transplant enables two incompatible DRP to receive more compatible kidneys. In this, a living kidney donor who is otherwise incompatible with the recipient exchanges kidneys with another DRP. KPD can be performed at any transplant center that is doing kidney transplantation without the need of extra facilities as required for ABOiKT and transplant with desensitization protocol.