Showing posts with label liver exchange. Show all posts
Showing posts with label liver exchange. Show all posts

Saturday, May 25, 2024

Size is important in liver exchange

 Liver exchange has a lot in common with kidney exchange, in the sense that the issues involved in forming cycles and chains once you know which donors are compatible with which patients are very similar.  But a big difference is what constitutes a compatible donor: for livers, size (of the donor, and the donor liver) is very important, sensitively so.

Here's a paper forthcoming in the American Journal of Transplantation, by a team of transplant physicians and economists (with kidney exchange experience), on the importance of size.

"Enhanced Role of Multi-Pair Donor Swaps in Response to Size Incompatibility: The First Two 5-Way and the First 6-Way Liver Paired Exchanges" by Sezai Yilmaz, MD, FACS, Tayfun Sönmez, PhD, M. Utku Ünver, PhD, Volkan Ince, MD, Sami Akbulut, MD, PhD, FACS, Kemal Baris Sarici, MD, and Burak Isik, MD, American Journal of Transplantation, Brief communication, in press.

Abstract: A significant portion of liver transplantations in many countries is conducted via living-donor liver transplantation (LDLT). However, numerous potential donors are unable to donate to their intended recipients due to factors such as blood-type incompatibility or size incompatibility. Despite this, an incompatible donor for one recipient may still be a viable donor for another patient. In recent decades, several transplant centers have introduced liver paired exchange (LPE) programs, facilitating donor exchanges between patients and their incompatible donors, thereby enabling compatible transplants. Initially, LPE programs in Asia primarily involved ABO-i pairs, resulting in 2-way exchanges mainly between blood-type A and B recipients and donors. This practice has led to a modest 1-2% increase in LDLTs at some centers. Incorporating size incompatibility alongside blood-type incompatibility further enhances the efficacy and significance of multiple-pair LPEs. Launched in July 2022, a single-center LPE program established at Inönü University Liver Transplant Institute in Malatya, Türkiye, has conducted thirteen 2-way, nine 3-way, four 4-way, two 5-way, and one 6-way LPEs until February 2024. In 2023 alone, this program facilitated 64 LDLTs, constituting 27.7% of the total 231 LDLTs performed. This paper presents the world's first two 5-way LPEs and the first 6-way LPE.

*********

Another (not entirely unrelated) domain in which size is important, and exchange involves many pairs, involves the exchange of shells among hermit crabs. See these earlier posts (which included this short video):

xx

Saturday, July 21, 2012

Thursday, November 30, 2023

UNOS ends its liver exchange pilot program

UNOS has shuttered it's liver exchange pilot program, after less than a year, without having performed any liver exchange transplants. (My understanding is that this wasn't part of UNOS's OPTN contract, but part of its activities as a private company.)

A colleague forwarded me this announcement:

"After careful consideration and evaluation, we regret to announce the discontinuation of the UNOS Liver Paired Donation Pilot Program (LPDPP).

The UNOS LPDPP was launched with the noble goal of matching candidates in need of a liver transplant with living donors from across the United States. Top-tier transplant programs from around the country participated in the program, entering pairs to be matched for transplantation.

 Despite the enthusiasm and dedication of the UNOS LPDPP Steering Committee, participating hospitals, a visionary funder and UNOS Labs staff, we must acknowledge that the program faced significant challenges. Regrettably, no matches were made, and no transplants occurred during the course of the pilot.

 This decision to discontinue the program is a result of several factors, primarily the depletion of funding allocated to the pilot and other barriers to widespread adoption. While practical constraints have led us to this difficult decision, we are still committed to uncovering key insights that may help future efforts toward a national liver paired donation program and apply to other challenges facing the organ donation and transplant community.

 We would like to express our heartfelt gratitude to the Steering Committee, participating transplant programs’ staff, candidates and donors who agreed to be entered and the generous living liver recipient who funded this endeavor. Your dedication to saving lives through organ transplantation is truly commendable. These efforts have yielded valuable data and insights that will allow our community to continue to advance.

 While this chapter may be closing, our commitment to increasing the number of lives saved through organ donation and transplant remains unwavering. We will continue to explore innovative ways to improve access to organ transplants for those in need. We will be doing more investigation into the program’s barriers to success, unexpected challenges and opportunities for improvement, and we plan to share our discoveries with the community so we may all learn from the results.

 The program will officially end November 30, 2023, with the last match run on September 30, 2023."

###########

Earlier:

Friday, January 27, 2023

Liver exchange pilot program at UNOS


see also, from UNOS:

and this, from Medscape:

"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.
...
"The pilot program requires that the donor bring one support person with them if they need to travel for the surgery, but undergoing major abdominal surgery from a transplant team they are not familiar with may be stressful, said Peter Abt, MD, a transplant " at the Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia. "That's a big ask," he said, "and I'm not sure many potential donors would be up to that."

"John Roberts, MD, a transplant surgeon at the University of California, San Francisco, agreed that the travel component may put additional stress on the donor, but "if it's the only way for the recipient to get a transplant, then the donor might be motivated," he added.
...
"Leishman agreed that the travel aspect appears to one of the greatest barriers to participants entering the program but noted that a goal of the pilot program is to understand better what works — and what doesn't — when considering a liver paired donation program on a national scale. "[Our] steering committee has put together a really nice framework that they think will work, but they know it's not perfect. We're going to have to tweak it along the way," she said."

Saturday, July 8, 2023

Liver exchange in Turkey


Here's a forthcoming article in the AJT, reporting on a collaboration between physicians and market designers with experience in kidney exchange:

The First 4-Way Liver Paired Exchange from an Interdisciplinary Collaboration between Healthcare Professionals and Design Economists by Sezai Yilmaz, MD, FACS  Tayfun Sönmez, PhD  M. Utku Ünver, PhD  Volkan Ince, MD  Sami Akbulut, MD, FACS  Burak Isik, MD  Sukru Emre, MD  American Journal of Transplantation, BRIEF COMMUNICATION|ARTICLES IN PRESS, Open Access Published: July 05, 2023 DOI:https://doi.org/10.1016/j.ajt.2023.06.016 

Abstract: We report initial results of a Liver Paired Exchange (LPE) program established at the Liver Transplant Institute at Inonu University through collaboration with design economists. Since June 2022, the program has been using a matching procedure that maximizes the number of living donor liver transplants (LDLTs) to the patients in the pool subject to the ethical framework and the logistical constraints of the program. In one 4-way and four 2-way exchanges, twelve LDLTs have been performed via LPE in 2022. The 4-way exchange, generated in the same match run with a 2-way exchange, is a first worldwide. This match run generated LDLTs for six patients, revealing the value of the capacity to carry out larger than 2-way exchanges. With only 2-way exchanges, only four of these patients would receive LDLT. The number of LDLTs from LPE can be increased by developing the capacity to perform larger than 2-way exchanges in either high-volume centers or multi-center programs.

 

Thursday, June 29, 2023

Kidney Exchange in Hong Kong

While liver exchanges have been done for some time in Hong Kong, possibly the first kidney exchange  has recently been reported by China Daily:

Exchanging the hope of life By Li Bingcun | HK EDITION |  2023-06-16 

"It was the first time that paired kidney transplants had been carried out in the city. Following a pilot program launched in 2018, if a patient's family member is willing to donate a kidney to the patient but their conditions do not match, the family is allowed to make a cross-donation with another family in the same situation. Previously, organ donations from living donors could be made only by close blood relatives and spouses.

"In addition to kidney transfers, Hong Kong has accomplished several cross-family liver transplants since 2009 with special approvals made by the Human Organ Transplant Board on a case-by-case basis. Facing a severe shortage of organ donations, Hong Kong is drawing on overseas experiences to widen the scope of donations from living donors by trying to overcome restrictions concerning blood type and marriage, seeking greater matching possibilities to achieve more life-saving miracles.

"These attempts involve considerable efforts to update traditional mindsets, address the accompanying ethical and legal issues, and protect the safety and interests of donors and recipients to the fullest extent.

However, because of risks to donors, medical experts suggest that organ donations from living people should never be the first choice, and that the priority should be boosting people's willingness to register as organ donors, allowing organs to be reused after registered people die.

"Globally, such kidney exchange programs have been introduced in South Korea, the United States, the United Kingdom, Australia and Canada, with surgeries performed two decades ago.

"Besides paired donations, the US also allows "nondirected donations", which means a donor can donate his or her kidney to any compatible patient. The largest kidney swaps were completed in 2014, involving 70 participants. Some global exchange programs have also carried out transnational kidney donations.

"With Hong Kong's relatively low organ-donation rate, more than 2,000 local residents are awaiting kidney transplants each year, with an average waiting time of about five years, and the longest 29 years. The number of kidney donations from living family members is less than 20 annually, while the number of cadaveric donations declined from 84 in 2012 to 45 in 2022.

"Although renal-failure patients can receive dialysis to sustain their lives, organ transplantation is still the best option. Moreover, the quality of organs of living donors is considered better than that of cadaveric organs.

"To offer patients another option, Hong Kong had been preparing to introduce the paired kidney donation (PKD) program since 2012, according to Chau Ka-foon, former co-chairperson of the Hospital Authority's Paired Kidney Donation Working Group. After extensive discussions, the city revised the law in 2018 and officially launched the program.

...

"two families that were successfully matched in 2020 canceled their planned surgeries due to personal concerns. Chau explains that the families might have worried that the organ received was of lower quality than the one they donated. It would also be a heavy blow if a family donating a kidney were unable to receive one if an operation were to fail.

...

"Attempts to swap organs among strangers have also encountered complex legal and technical problems.

"In Hong Kong's first-ever cross-family transplant in 2009, the medical team made a lot of efforts explaining to the Human Organ Transplant Board that the operation wasn't a transaction. "We repeatedly emphasized that the two families did not intend to exchange organs. It was simply the medical workers' proposal to raise the success rate of organ transplants," says Lo Chung-mau, chief surgeon of the operation and also director of the liver transplantation center at Queen Mary Hospital at that time.

...

"The 2019 social unrest and the following COVID-19 pandemic presented even greater challenges for Hong Kong's PKD program. In 2021, there were 26 eligible families in the city's organ matching pool.

"The Hospital Authority expects the number of participating families to climb to 50 to 100 in a few years. It will consider expanding the program to liver donations and collaborating with overseas matching pools. Chau hopes that kidney swaps will not be limited to just two families, and that multiple swaps among several families will be allowed to increase the chances of matching.

...

"Wang Haibo, a member of China's National Organ Donation and Transplantation Committee, says the pair-donation program is worth looking into and being discussed. The mainland is also conducting clinical research on paired-kidney donations. Alvin Roth, who won the 2012 Nobel Memorial Prize in Economic Sciences and developed a global kidney-exchange program, visited China before the COVID-19 pandemic to seek collaboration in this area, he recalls.

"Wang says both Hong Kong's and the mainland's organ donation rates still lag far behind those of developed economies. "They have reached a plateau and have made relatively adequate utilization of organ donations from the deceased. We have much room to develop in this regard."

"He says that while officials explore innovative approaches concerning living-organ donations, the priority should still focus on how to boost people's willingness to register as organ donors and better utilize the organs. "These are the so-called 'low hanging fruit'. It would be wise to concentrate our limited resources on the most rewarded option."

**********


Monday, February 6, 2023

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."

Friday, January 27, 2023

Liver exchange pilot program at UNOS

 In another step for liver exchange, here's the announcement from UNOS, which recently registered its first patient-donor pair:

UNOS launches first national liver paired donation pilot program

"An innovative approach to matching livers to patients in need aims to increase lifesaving transplants by expanding the number of living liver donations. United Network for Organ Sharing (UNOS) has launched the UNOS Liver Paired Donation (LPD) pilot program, the first nation-wide initiative facilitating liver paired donation matches; the project is led by UNOS Labs in collaboration with transplant and donation professionals from across the country.

"More than 10,000 people are currently waiting for a liver transplant, and increasing paired donation can make a difference. “The community recognized a critical need,” said Ruthanne Leishman, who manages UNOS paired donation programs. “While the idea of swapping livers is new, transplant programs have successfully been swapping kidneys since 2002.” Leishman was part of the UNOS team that initiated the Organ Procurement and Transplantation Network (OPTN) Kidney Paired Donation (KPD) pilot program in 2010, at a time when there were fewer living liver donor transplants. Since that time, living liver donations have become safer and more viable, contributing to the development of living liver donation programs throughout the country. There were 603 living liver donor transplants in the United States in 2022.

"The UNOS LPD pilot program includes 15 experienced transplant programs across the country who have together performed hundreds of living liver transplants over the years. “UNOS Labs has collaborated with a team of some of the most respected transplant professionals in the country. Working with this high caliber of transplant professionals has helped UNOS build a strong program that will increase living donor transplants,” said Leishman.

"While some transplant hospitals have swapped livers within their own or neighboring hospitals, the UNOS LPD program now makes it possible to swap livers across the country. The larger pool of potential living donors means candidates can have increased access to living liver donations, and transplant hospitals have the opportunity to grow their living transplants programs through collaboration.

"The first donor and recipient pair registered in the program are at UCHealth Transplant Center in Aurora, Colo., and are waiting for a match.

“The UNOS LPD program has totally shifted our frame of mind,” says Jaime Cisek, Living Donor Coordinator at UC Health Transplant Center. “It used to be that if someone was incompatible because of their blood type, or there was a significant size discrepancy, then there was no point in working them up. Now, nobody is off the table. Now we’re able to consider that there is somebody out there who is compatible and make that swap.”

"The UNOS LPD program offers living liver donors assistance with both medical and non-medical expenses related to donation, such as travel expenses, lost wages and dependent care. This financial assistance was made possible through a partnership with the National Living Donor Assistance Center (NLDAC) and a generous gift from living liver transplant recipient and UNOS financial supporter David Landes. "

Wednesday, December 21, 2022

Paired liver exchange in India

 Here's a report on 2-way liver exchanges conducted at Max Center for Liver and Biliary Sciences, Max Saket Hospital, New Delhi, India, each between two manually matched, non-anonymous patient-donor pairs.

Paired Exchange Living Donor Liver Transplantation: A Nine-year Experience From North India by Agrawal, Dhiraj MD, DM1; Saigal, Sanjiv MD, DM, MRCP, CCST1; Jadaun, Shekhar Singh MD, DM1; Singh, Shweta A. MD, DM1; Agrawal, Shaleen MS, MCh1; Gupta, Subhash MS, MCh1 


"Background: Paired exchange liver transplantation is an evolving strategy to overcome ABO blood group incompatibility and other barriers such as inadequate graft-to-recipient weight ratio and low remnant liver volume in donors. However, for the transplant team to carry 4 major operations simultaneously is a Herculean effort. We analyzed our experience with liver paired exchange (LPE) program over the past 9 y."

...

"Although the basic framework for LPE was adopted from the kidney paired exchange program, LPE or swap LDLT is inherently distinct, more complex, and associated with more technical, logistical, and ethical challenges.11 Both recipient and donor surgeries are long-duration surgeries and must be flawless to ensure minimum morbidity and mortality. The living donor partial hepatectomy is associated with approximately 10 times greater mortality than living donor nephrectomy, and the morbidity ranges from 9% to 24%, depending on the type of hepatectomy performed.12,13

"The logistics involved in a single-center simultaneous LPE are extensive with 4 simultaneous operations: 4 sets of teams of anesthetists, surgeons, nurses, and technicians. The blood bank must be equipped with requirements for major surges. For a single LDLT operation, it is estimated that >18 skilled team members may be needed, and in LPE, this number is doubled. Furthermore, any unanticipated difficulty due to operative anatomical variations may potentially impact both recipients’ outcomes. These constraints limit the LPE to a few high-volume centers.

...

"After the recipients and donors of an incompatible pair showed willingness for LPE, the medical suitability of each donor and recipient pair and the equity of the exchange were confirmed by a multidisciplinary forum comprising transplant hepatologists, transplant surgeons, social workers, and psychiatrists. Once 2-by-2 donor-recipient pairs were successfully matched, the transplant team informed the pairs and arranged a meeting wherein each recipient could meet their intended donor in the presence of the transplant team to discuss any anticipated issues. All participants who participated in the exchange program underwent a thorough psychosocial assessment to minimize the possibility of conflict. Donors have clarified that a poor outcome is possible in any LDLT, and in rare circumstances, their intended recipient can have a poor outcome. Through several in-depth counseling sessions, all 4 parties were independently and jointly informed about the suitability and structure of the exchange, the entire procedure, and the expected results. They were also provided with alternative options such as ABOi transplantation, deceased donor liver transplantation (DDLT), and associated risks and cost-effectiveness. Donors were allowed to opt out at any step during the process, and care was taken to avoid coercion. After the development of basic trust between all 4 participants, informed consent and a confidential agreement were signed. In India, there is a strict legal requirement for LDLT that the donor and recipient should be related to either blood or marriage. However, since LPE is an unrelated, directed donation, special approval was obtained from the ethical committee of the local authority.

...

"The 17 pairs of LPE donations included 34 directed living donors with a median age of 38.5 y (19–51 y), of which 27 were females. All donors were first-degree relatives of the recipients and included 18 spouses, 11 children, and 5 siblings. 

...

"ABO-incompatible donor-recipient pairs are encouraged to visit our center regularly, and as this is a common problem, not surprisingly, they are often able to meet another ABOi pair at the center. Furthermore, our coordinators have the telephone numbers of recipients looking for paired exchanges, and they facilitate such pairs to speak to each other on the phone. Once they show willingness to participate in the paired exchange program, their papers are submitted to the government-appointed authorization committee for clearance. Theoretically, in LPE donations, there is a potential for emotional disconnect, as opposed to ABO-incompatible LDLT. Interestingly, in our series of 34 transplants, the donor felt that they had donated to their own recipient, and on follow-up, all 4 participants seemed to have developed great emotional bonding.

"At our center, >75% of donors are first-degree relatives as “nonnear relatives” find very difficult to get governmental clearance. LPE is a transplantation between unrelated people and is, therefore, liable for exploitation. However, The Transplant Act has built in safety features as it allows only “first degree relatives” to be considered for paired exchange and also bars the organ exchanges between Indian and foreigners.

...

"It is possible that, in the future, transplant centers in India will act in tandem, and we will be able to operate pairs at 2 different centers. However, under the existing hospital-based government-appointed authorization committee, this may not be feasible unless a central clearing agency is set up."

Thursday, December 8, 2022

Three way liver exchange in Pakistan, reported in JAMA Surgery by Salman, Arsalan, and Dar, in collaboration with economist Alex Chan

 Here's an exciting account, just published in JAMA Surgery, of a three way liver exchange in Pakistan, achieved in part by collaboration with economist and market designer Alex Chan (who is on the job market this year).

Launching Liver Exchange and the First 3-Way Liver Paired Donation by Saad Salman, MD, MPH1; Muhammad Arsalan, MBBS2; Faisal Saud Dar, MBBS2, JAMA Surg. Published online December 7, 2022. doi:10.1001/jamasurg.2022.5440 (pdf)

Here are the first paragraphs:

"There is a shortage of transplantable organs almost everywhere in the world. In the US, about 6000 transplant candidates die waiting each year.1 In Pakistan, 30% to 50% of patients who needed a liver transplant are unable to secure a compatible donor, and about 10 000 people die each year waiting for a liver.2 Kidney paired donations, supported by Nobel Prize–winning kidney exchange (KE) algorithms,3 have enabled living donor kidneys to become an important source of kidneys. Exchanges supported by algorithms that systematically identify the optimal set of paired donations has yet to take hold for liver transplant.

"The innovation reported here is the successful implementation of a liver exchange mechanism4 that also led to 3 liver allotransplants and 3 hepatectomies between 3 incompatible patient-donor pairs with living donor–patient ABO/size incompatibilities. These were facilitated by one of the world’s first documented 3-way liver paired donations (LPD) between patient-donor pairs.

"Since 2018 and 2019, we have explored LPD as a strategy to overcome barriers for liver failure patients in Pakistan in collaboration with economist Alex Chan, MPH.2 With LPD, the incompatibility issues with relative donors can be solved by exchanging donors. The Pakistan Kidney and Liver Institute (PKLI) adopted a liver exchange algorithm developed by Chan4 to evaluate LPD opportunities that prioritizes clinical urgency (Model for End-stage Liver Disease [MELD] scores) while maximizing transplant-enabling 2-way or 3-way swaps that ensures that hepatectomies for every donor within each swap has comparable ex ante risk (to ensure fairness). As of March 2022, 20 PKLI liver transplant candidates had actively coregistered living and related but incompatible liver donors. Evaluating these 20 incompatible patient-donor pairs with the algorithm,4 we found 7 potential transplants by two 2-way swaps and the 3-way swap reported. In contrast to ad hoc manual identification of organ exchange opportunities, the hallmark of a scalable organ exchange program is the regular deployment of algorithms to systematically identify possible exchanges. Regular deployment of LPD algorithms is novel.

"A total of 6 procedures took place on March 17, 2022. Patient 1, a 57-year-old man, received a right liver lobe from donor 2, a 28-year-old coregistered donor of patient 2 (56-year-old man), who in turn received a right liver lobe from donor 3, a 35-year-old woman who was a coregistered donor of patient 3. Patient 3, a 46-year-old man, received a right liver lobe from donor 1, a 22-year-old woman who was a coregistered donor of patient 1, completing the cycle (Figure). Five PKLI consultant surgeons and 7 senior registrars led the hepatectomies and liver allotransplants; 6 operating rooms were used simultaneously. One month postsurgery, all patients and donors are robust with no graft rejection. All the donors are doing well in the follow-up visits and have shown no psychological issues."



Here's a sentence in the acknowledgements:

"We thank Alex Chan, MPH (Stanford University, Palo Alto, California), whose initiative and expertise in economics were the key driving forces for launching liver exchange."

*********
NB: this is a "Surgical Innovation" article, for which the journal requires that there be no more than three authors.

And here are the references cited:

1.
Chan  A, Roth  AE. Regulation of organ transplantation and procurement: a market design lab experiment. Accessed April 28, 2022. https://www.alexchan.net/_files/ugd/a47645_99b1d4843f2f42beb95b94e43547083b.pdf
2.
Salman  S, Gurev  S, Arsalan  M, Dar  F, Chan  A. Liver exchange: a pathway to increase access to transplantation. Accessed April 1, 2022. http://www.hhpronline.org/articles/2021/1/14/liver-exchange-a-pathway-to-increase-access-to-transplantation
3.
Henderson  D. On marriage, kidneys and the Economics Nobel. Wall Street Journal. October 15, 2012. Accessed March 5, 2022. https://www.wsj.com/articles/SB10000872396390443675404578058773182478536
4.
Chan  A. Optimal liver exchange with equipoise. Accessed April 23, 2022. https://www.alexchan.net/_files/ugd/a47645_36e252f4df0c4707b6431b0559b03143.pdf
5.
Hwang  S, Lee  SG, Moon  DB,  et al.  Exchange living donor liver transplantation to overcome ABO incompatibility in adult patients.   Liver Transpl. 2010;16(4):482-490. doi:10.1002/lt.22017PubMedGoogle ScholarCrossref
6.
Patel  MS, Mohamed  Z, Ghanekar  A,  et al.  Living donor liver paired exchange: a North American first.   Am J Transplant. 2021;21(1):400-404. doi:10.1111/ajt.16137PubMedGoogle ScholarCrossref
7.
Braun  HJ, Torres  AM, Louie  F,  et al.  Expanding living donor liver transplantation: report of first US living donor liver transplant chain.   Am J Transplant. 2021;21(4):1633-1636. doi:10.1111/ajt.16396

 ********

Here's a Stanford story on this collaboration:

Stanford student devises liver exchange, easing shortage of organs. A rare three-way exchange of liver transplants in Pakistan was made possible with a new algorithm developed by a Stanford Medicine student.  by Nina Bai

"The liver exchange idea actually came out of a term paper in a first-year market design class at Stanford," Chan said.

"As he learned more about liver transplants, Chan realized there were important biological and ethical differences from kidney transplants. 

...

"Instead of just finding compatible swaps, we want to find swaps that prioitize the most urgent patients first in order to prevent the most deaths," Chan said.

*******

Here are some contemporaneous stories from March in the newspaper Dawn (now that the JAMA embargo on the story is lifted):

Mar 18, 2022 — A highly-trained team of the surgeons headed by PKLI Dean Prof Faisal Dar had performed liver transplants at the institute and other members ...

Saturday, November 5, 2022

Liver exchange--a review by Agrawal, Gupta and Saigal

 

 Here's a review of liver exchange in the transplant literature, with some comparisons to kidney exchange.

Paired exchange Living donor Liver Transplantation: Indications, stumbling blocks, and future considerations by Dhiraj Agrawal, Subhash Gupta,  and Sanjiv Saigal, Journal of Hepatology, In Press,  Pre-proof https://doi.org/10.1016/j.jhep.2022.10.019 

Abstract: "The last decade has seen Liver Paired exchange (LPE) as an increasingly used modality across the transplant community by which pairs of incompatible living Liver donors and their intended recipients swap Livers resulting in compatible transplants. The feasibility and benefit of LPE in providing excellent recipient outcomes and robust donor safety have been proven in uncomplicated swaps. Began initially as single-centre two-way or three-way exchanges, LPE has tremendous potential to grow into more complicated chains over days and over multiple centres. Also, LPE is associated with unique technical, logistical, ethical and legislative challenges. This review discusses the indications, potential types of LPE, unique solutions to stumbling blocks in performing LPE, and future considerations on how LPE can expand the living donor liver pool and the armamentarium of living donor liver transplantation (LDLT)".


"
The published literature on LPE has nine reports (5 original articles and 4 case reports), including 74 LPEs from Asia and North America.1), 2), 3), 4), 5), 6), 7), 8), 9) LPE constitutes approximately 1.2 to 8.3 % of the total LDLTs performed at the individual centre1), 2), 3), 4), signifying a substantial potential of this form of LDLT to mitigate the liver allograft shortage."

...

1. D. Agrawal, S. Saigal, S.S. Jadaun, S.A. Singh, S. Agrawal, S. Gupta
Paired Exchange Living Donor Liver Transplantation: A Nine-year Experience From North India
Transplantation (2022 Jun 30), 10.1097/TP.0000000000004210
Epub ahead of print. PMID: 35777310
2)
S. Hwang, S.G. Lee, D.B. Moon, G.W. Song, C.S. Ahn, K.H. Kim, et al.
Exchange living donor liver transplantation to overcome ABO incompatibility in adult patients
Liver Transpl, 16 (4) (2010 Apr), pp. 482-490, 10.1002/lt.22017
PMID: 20222052
3)
D.H. Jung, S. Hwang, C.S. Ahn, K.H. Kim, D.B. Moon, S.G. Lee, et al.
Section 16. Update on experience in paired-exchange donors in living donor liver transplantation for adult patients at ASAN Medical Center
Transplantation, 97 (Suppl 8) (2014 Apr 27), pp. S66-S69, 10.1097/01.tp.0000446280.81922.bb
PMID: 24849838
4)
V. Gunabushanam, S. Ganesh, K. Soltys, G. Mazariegos, A. Ganoza, M. Molinari, et al.
Increasing Living Donor Liver Transplantation Using Liver Paired Exchange
J Am Coll Surg, 234 (2) (2022 Feb 1), pp. 115-120, 10.1097/XCS.0000000000000036
PMID: 35213430
5)
A. Kaplan, R. Rosenblatt, W. Jackson, B. Samstein, R.S. Brown Jr.
Practices and Perceptions of Living Donor Liver Transplantation, Non-directed Donation, and Liver Paired Exchange: A National Survey
Liver Transpl, 28 (5) (2022 May), pp. 774-781, 10.1002/lt.26384
Epub 2021 Dec 26. PMID: 34862704; PMCID: PMC9018478
6)
H.J. Braun, A.M. Torres, F. Louie, S.D. Weinberg, S.M. Kang, N.L. Ascher, et al.
Expanding living donor liver transplantation: Report of first US living donor liver transplant chain
Am J Transplant, 21 (4) (2021 Apr), pp. 1633-1636, 10.1111/ajt.16396
Epub 2020 Dec 8. PMID: 33171017; PMCID: PMC8016700
7)
M.S. Patel, Z. Mohamed, A. Ghanekar, G. Sapisochin, I. McGilvray, N. Selzner, et al.
Living donor liver paired exchange: A North American first
Am J Transplant, 21 (1) (2021 Jan), pp. 400-404, 10.1111/ajt.16137
Epub 2020 Jul 10. PMID: 32524750
8)
S.C. Chan, C.M. Lo, B.H. Yong, W.J. Tsui, K.K. Ng, S.T. Fan
Paired donor interchange to avoid ABO-incompatible living donor liver transplantation
Liver Transpl, 16 (4) (2010 Apr), pp. 478-481, 10.1002/lt.21970
PMID: 20373459
9)
S.C. Chan, Chok KSh, W.W. Sharr, A.C. Chan, S.H. Tsang, W.C. Dai, et al.
Samaritan donor interchange in living donor liver transplantation
Hepatobiliary Pancreat Dis Int, 13 (1) (2014 Feb), pp. 105-109, 10.1016/s1499-3872(14)60016-3
PMID: 24463089