Kidney exchange updates

 Here are three kidney papers and proposals that I've noted recently,  which will have implications for the growing interest in international kidney exchange on a global scale:

Klaassen MF., de Klerk M, Dor FJ.M.F., Heidt S, van de Laar SC., Minnee RC., van de Wetering J, Pengel LH.M. and de Weerd AE. (2025) Navigating a Quandary in Kidney Exchange Programs: A Review of Donor Travel versus Organ Shipment. Transpl. Int. 38:14804. doi: 10.3389/ti.2025.14804

Abstract:  In multicenter kidney exchange programs (KEPs), either the explanted kidney must be shipped, or the donor must travel to the transplanting center. This review describes the available data on these two approaches and formulates recommendations for practice. We searched for studies addressing organ shipment or donor travel in KEPs. Data were categorized into four domains: cold ischemia time (CIT), logistics, donor/recipient perspectives and professional perspectives. From 547 articles screened, 105 were included. Kidneys are shipped in most countries. Prolonged CIT due to shipment may increase the risk of delayed graft function, but does not seem to impact graft survival. Planning the shipment requires a robust logistical framework with guaranteed operating room availability. Donor travel is reported to be both emotionally and financially distressing for donors and exposes them to inconsistencies in donor evaluation and counseling across centers. Reduced willingness to participate in KEP when travelling was reported by 36%–51% of donors. Professionals generally support offering organ shipment to donors not willing to travel. In conclusion, the decision between donor travel or organ shipment should be tailored to local circumstances. Healthcare professionals should prioritize minimizing barriers to KEP participation, either by facilitating organ shipment or reducing the burden of donor travel. 

######

Neetika Garg, Joe Habbouche, Elisa J. Gordon, AnnMarie Liapakis, Michelle T. Jesse, Krista L. Lentine,
Practical and ethical considerations in kidney paired donation and emerging liver paired exchange,
American Journal of Transplantation,
Volume 25, Issue 11,  2025, Pages 2292-2302,
ISSN 1600-6135,  https://doi.org/10.1016/j.ajt.2025.07.2459.
(https://www.sciencedirect.com/science/article/pii/S1600613525028382)
 

Abstract: Since the first kidney paired donation (KPD) transplant in the United States in 1999, the volume and scope of KPD has expanded substantially, accounting for nearly 20% of living donor kidney transplants in 2021-2022. This review article discusses the practical and ethical issues specific to paired donor exchange that patients, transplant centers, and exchange programs commonly encounter. Access to paired donor exchange and education of candidates regarding the potential benefits, risks, and logistics of KPD are important considerations. Transplant centers and patients must consider practical issues including wait times, allocation and matching strategies, assessment of organ quality, complex donors, cold ischemia time, and risks of broken chains. Protections available to donors from current KPD programs, the potential psychosocial effects, and the ethical concerns related to variable access and the proprietary nature of private exchange programs are also discussed. More detailed, timely data collection at a national level, and ability to merge national data with individual donor exchange registries will enable the analysis of the impact and outcomes of future trends in paired donation. KPD experience and key concepts may inform liver paired exchange, which has been used internationally to expand living donor liver transplantation and is emerging in the United States.

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Alliance for Paired Kidney Donation (APKD) Launches Wish Upon a Donor: A Hope-Focused Advocacy Program Helping Kids Who Need Kidneys Find Living Donors

"TOLEDO, OHIO / ACCESS Newswire / December 9, 2025 / The Alliance for Paired Kidney Donation (APKD) is proud to announce Wish Upon a Donor, a groundbreaking program that amplifies the voices of families fighting for a better and brighter future for their child. While pediatric kidney patients cannot advocate for themselves, their parents can - and too often, they face this battle alone. Wish Upon a Donor helps families share their child's story, shining a light on their hopes, dreams, and urgent need for a living kidney donor.

...

"The onboarding process is fast and simple, taking just 10-15 minutes to complete, and finalized videos are sent to patients in just one to three days. Participation is free, and patients retain full control over how and where their stories are shared.

Wish Upon a Donor offers a range of support for families as they seek living donors, including:

Production of a personalized, high-quality video designed to reflect the patient's wishes, personality, and future - not just their disease

Dedicated campaign webpage to make it easy to convert interest into action

QR-coded postcards and magnets for sharing in local communities

Social media guidance to help families and supporters spread the word

Spanish- and English-language outreach materials for broader access

A living donor mentor to answer any non-medical questions about the process

"Wish buddy" volunteers to assist with video narration and/or sharing patient videos with a broader audience

When interest is generated through the Wish Upon a Donor campaign, APKD ensures both patients and transplant centers are effectively supported with guidance grounded in real-life experience from a dedicated living donor mentor. The organization manages all incoming donor inquiries, educates potential donors on the process, protections, and realities of living donations, and then refers qualified donors to an appropriate transplant center partner. APKD maintains communication and support throughout the evaluation and donation process. This approach empowers potential donors with education while easing the burden on transplant centers."
 

Facing up to face transplants: Pioneering transplants and their pioneering patients

The history of transplantation involves not only pioneering surgeons, but also pioneering patients.  Face transplants are yet another complex case. 

 The Guardian has this (skeptical) story:

Face transplants promised hope. Patients were put through the unthinkableTwenty years after the first face transplant, patients are dying, data is missing, and the experimental procedure’s future hangs in the balance   Fay Bound Alberti 

"On 27 November 2005, Isabelle received the world’s first face transplant at University Hospital, CHU Amiens-Picardie, in northern France. The surgery was part of an emerging field called vascularized composite allotransplantation (VCA), that transplants parts of the body as a unit: skin, muscle, bone and nerves.

...

"The case for face transplants seemingly made, several teams scrambled to perform their nation’s first. The US saw the first partial face transplant (2008), then the first full one (2011); the first African American recipient (2019); the first face and double hand transplant combined (2020); the first to include an eye (2023). There have been about 50 face transplants to date, and each milestone brought new grants, donations and prestige for the doctors and institutions involved.

...

"Add to this picture a set of ethical challenges: face transplants take otherwise healthy people with disfigured faces and turn them into lifetime patients.

...

"In the US, now the world’s leader in face transplants, the Department of Defense has bankrolled most operations, treating them as a frontier for wounded veterans while private insurers refuse to cover the costs.

"With insurance unwilling to pay until the field proves its worth, surgeons have been eager to show results. A 2024 JAMA Surgery study reported five-year graft survival of 85% and 10-year survival of 74%, concluding that these outcomes make face transplantation “an effective reconstructive option for patients with severe facial defects”.

"Yet patients like Dallas tell a different story. The study measures survival, but not other outcomes such as psychological wellbeing, impact on intimacy, social life and family functioning, or even comparisons with reconstruction. 

...

"It’s a double-bind. Without proof of success, face transplants are experimental. And because the procedures are experimental, patients’ long-term needs aren’t covered by grants, leaving patients to carry the burden

...

"Which path will face transplants take? The numbers are already slipping – fewer procedures since the 2010s as outcomes falter and budgets shrink. And unless the field raises its standards, enforces rigorous follow-up, and commits to transparent, systematic data sharing that actually includes patients and their families, there’s no way to demonstrate real success. Without that, face transplants aren’t headed for evolution or stability; they’re headed straight for the dustbin of medical history." 

Organ procurement centers (OPOs) are responding to changes in their performance evaluations (by Bae, Sweat, Melcher and Ashlagi in JAMA Surgery)

 Here

Bae H, Sweat KR, Melcher ML, Ashlagi I. Organ Procurement Following the Centers for Medicare and Medicaid Services Performance Evaluations. JAMA Surg. Published online November 19, 2025. doi:10.1001/jamasurg.2025.5074 

"In 2024, 4639 patients died in the United States while waiting for a transplant from deceased donors.1 Organ procurement organizations (OPOs) are government contractors responsible for identifying potential donors in a geographical region, recovering their organs, and implementing the offering processes to patients on the waiting list. In 2020, 10% of potential donors—individuals younger than 76 years with inpatient death and organs suitable for transplant—became organ donors, suggesting an opportunity to increase donation and transplant rates.2

"Toward this goal, the Centers for Medicare and Medicaid Services issued a final rule in December 2020 to increase transparency of OPO performances by monitoring several metrics. OPOs are placed into 3 tiers based on donation rate and donor age–adjusted transplant rates, although acceptance of organ offers is up to patients and transplant centers. OPOs that perform poorly on both metrics are placed into tier 3 and are at risk of decertification in 2026.3 This longitudinal study examines changes in OPOs’ organ recovery practices following the initial report released in September 2021, focusing on the number and quality of organs recovered and the resulting transplant rates. 

 

 

 

 

 

 

 "The findings suggest that the 2021 release of the report on OPO performance was associated with increased organ recovery among low-performing OPOs, narrowing the gap in organ donation with high-performing OPOs. Even though the gap in the transplant rate has narrowed, much of it is linked to increased organ recovery from older donors, which may limit improvements in transplant rates. This is despite an increase in organs placed out of sequence by low-performing OPOs."

Ethical considerations and global cooperaton in transplantation, Wednesday in Cairo

It's Wednesday morning in Cairo, and here's today's conference schedule, which will include discussion of (and voting on) global cooperation in transplantation. (See my earlier post for context.) 

 

8:00 AM 08:30 AM	Opening Session of Ethical Consensus Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration	HALL A
Strategic Co-Leaders (Alphabetical)	Alvin E. Roth (Stanford University, USA) John Fung (University of Chicago, USA) Mark Ghobrial (Methodist Hospital, Houston, USA) Osama A Gaber (Methodist Hospital, Houston, USA) Sandy Feng (UCSF, USA) Valeria Mas (University of Maryland, USA)
Chairs (Alphabetical)	Ahmed Elsabbagh (University of Pittsburgh, USA) Medhat Askar (Baylor University, USA) Mohamed Ghaly (Hamad Bin Khalifa University, Qatar) Mohamed Hussein (National Guard Hospital, KSA)
Scientific Committee (Alphabetical)	Abdul Rahman Hakeem (King’s College Hospital, UK) Dieter Broering (KFSHRC, KSA) Hermien Hartog (Groningen, the Netherlands) Hosam Hamed (Mansoura University, Egypt) Manuel Rodriguez (Universidad Nacional Autónoma de México, Mexico) Matthew Liao (Center for Bioethics, New York University, USA) Nadey Hakim (King’s College, Dubai, UAE) Stefan Tullius (Harvard Medical School, USA) Varia Kirchner (Stanford University, USA) Wojciech Polak (Erasmus Medical Center, Rotterdam, the Netherlands)
Leadership of Jury Committee (Alphabetical)	Chair: John Fung (University of Chicago, USA) Vice-Chairs Hatem Amer (Mayo Clinic, Rochester, USA) Lloyd Ratner (Columbia University, USA) Maye Hassaballa (Cairo University, Egypt)
08:30 AM 09:30 AM	State of Art Lecture (1, 2)	HALL A
Chairpersons (Alphabetical)	Mahmoud El-Meteini (Ain Shams University, Egypt) Mehmet Haberal (Baskent University, Turkey) Sandy Feng (UCSF, USA)
08:30 AM 09:00 AM	From Dr. Starzl to the Future: The Evolution of Transplantation and the Call to Continue the Journey John Fung (University of Chicago, USA)
09:00 AM 09:30 AM	Organ Transplant Ethics: How Technoscientific Developments Challenge Us to Reaffirm the Status of the Human Body so as to Navigate Innovation in a Responsible Manner Hub A.E. Zwart (Erasmus University Rotterdam, Netherlands)
09:30 AM 11:00 AM	Working Group 1:	HALL A
Chairpersons (Alphabetical)	Ali Alobaidli (Chairman of UAE National transplant committee) Hermien Hartog (Groningen, The Netherlands) Khalid Amer (Military Medical Academy, Egypt) Lloyd Ratner (Columbia University, NY, USA) Thomas Müller (University Hospital Zurich, Switzerland)
09:30 AM 09:50 AM	Keynote Lecture: Xenotransplantation: Scientific Milestones, Clinical Trials, Risks, and Opportunities Jay Fishman (MGH, USA)
09:50 AM 11:00 AM	WG1 Presentation & Panel Voting Matthew Liao (Center for Bioethics, New York University, USA) Hosam Hamed (Mansoura University, Egypt) Daniel fogal (New York University, USA)
11:00 AM 11:30 AM	Coffee Break
11:30 AM 01:00 PM	Working Group 2:	HALL A
Chairpersons (Alphabetical)	Daniel Maluf (University of Maryland, USA) Karim Soliman (University of Pittsburgh, USA) Marleen Eijkholt (Leiden University Medical Centre, Netherlands) Refaat Kamel (Ain Shams University, Egypt) Varia Krichner (Stanford University, USA)
11:30 AM 11:50 AM	Keynote Lecture: Smart Transplant: How AI & Machine Learning Are Shaping the Future Dorry Segev (NYU Langone, USA)
11:50 AM 01:00 PM	WG2 Presentation & Panel Voting Hub A.E. Zwart (Erasmus University Rotterdam, Netherlands) Varia Krichner (Stanford University, USA) Eman Elsabbagh (Duke University, USA) Mohammad Alexanderani (University of Pittsburgh, USA)
01:00 PM 02:30 PM	Working Group 3:	HALL A
Chairpersons (Alphabetical)	Ahmed Marwan (Mansoura University, Egypt) Ashraf S Abou El Ela (Michigan, USA) Mostafa El Shazly (Cairo University, Egypt) Peter Abt (UPenn, USA) Philipp Dutkowski (University Hospital Basel, Switzerland)
01:00 PM 01:20 PM	Keynote Lecture: Ischemia-Free Transplantation: A New Paradigm in Organ Preservation and Transplant Medicine Zhiyong Guo (The First Affiliated Hospital of Sun Yat-sen University, China)
01:20 PM 02:30 PM	WG3 Presentation & Panel Voting Jeffrey Pannekoek (Center for Bioethics, Cleveland Clinic, USA) Abdul Rahman Hakeem (King’s College Hospital, UK) Georgina Morley (Center for Bioethics, Cleveland Clinic, USA)
02:30 PM 03:30 PM	Lunch Symposium	HALL B
03:30 PM 05:00 PM	Working Group 4:	HALL A
Chairpersons (Alphabetical)	David Thomson (Cape Town University, South Africa) Lucrezia Furian (University Hospital of Padova, Italy) May Hassaballa (Cairo University, Egypt) Abidemi Omonisi (Ekiti State University, Nigeri) Vivek Kute (IKDRC-ITS, Ahmedabad, India)
03:30 PM 03:50 PM	Keynote Lecture: Framing the Conversation: Ethical considerations at the foundation for global transplant collaboration Marleen Eijkholt (Leiden University Medical Centre, Netherlands)
03:50 PM 05:00 PM	WG4 Presentation & Panel Voting Alvin Roth (Stanford University, USA) Marleen Eijkholt (Leiden University Medical Centre, Netherlands) Michael Rees (University of Toledo, USA) Ahmed Elsabbagh (University of Pittsburgh, USA) Nikolas Stratopoulos (Leiden University Medical Centre, Netherlands)
05:00 PM 05:30 PM	Closing Session of Ethical Consensus Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration	HALL A
Strategic Co-Leaders (Alphabetical)	Alvin E. Roth (Stanford University, USA) John Fung (University of Chicago, USA) Mark Ghobrial (Methodist Hospital, Houston, USA) Osama A Gaber (Methodist Hospital, Houston, USA) Sandy Feng (UCSF, USA) Valeria Mas (University of Maryland, USA)
Chairs (Alphabetical)	Ahmed Elsabbagh (University of Pittsburgh, USA) Medhat Askar (Baylor University, USA) Mohamed Ghaly (Hamad Bin Khalifa University, Qatar)
05:10 PM 05:30 PM	State of Art Lecture (3): Reflections from a Transplant Pioneer: Ethics, Policy, and the Future of Global Collaboration Ignazio R. Marino (Thomas Jefferson University, Italy/USA)

 

Join the global call for change at DLE--Invitation to Cairo

  After being invited to this week's International Transplant Week in Egypt, , I was invited to invite others.

 (To hear my very brief invitation, which the conference published on Instagram, you may have to click on the speaker symbol in the lower right corner of the image.)

 

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International Transplant Week in Egypt, 2025

 I'm preparing to spend next week in Cairo at the Donate Life Egypt 2025 International Transplant Week, where I'll give a talk on Thursday.  But much of my preparation is for Wednesday, when something potentially much more exciting is scheduled.

 

 

Wednesday (Nov. 12) will be devoted to an attempt to reach a new Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration

I'll be involved in Working Group 4: Ethical Frameworks for Regulated International Collaboration
 

Co-Chairs

    Prof. Alvin Roth — Stanford University, USA
    Dr. Michael Rees — University of Toledo, USA
    Prof. Marleen Eijkholt — Leiden University Medical Centre, Netherlands

Scientific Committee Liaison / Editorial Lead

    Dr. Ahmed Elsabbagh — University of Pittsburgh, USA<

Members (alphabetical)

    Dr. Ali Obaidli — Department of Health, Abu Dhabi, UAE
    Dr. David Thomson — University of Cape Town, South Africa
    Dr. Frederike Ambagtsheer — Erasmus University Rotterdam, Netherlands
    Dr. Gustavo Ferreira — University of São Paulo, Brazil
    Prof. Ignazio Marino — Thomas Jefferson University, Italy/USA
    Dr. Juan Navarro — Leiden University Medical Centre, Netherlands
    Dr. Lucrezia Furian — University of Padua, Italy
    Dr. Manuel Rodríguez — UNAM, Mexico (President of SPLIT)
    Dr. Mignon McCulloch — University of Cape Town, South Africa
    Dr. Nikolas Stratopoulos — Leiden UMC, Netherlands
    Dr. Vivek Kute — IKDRC-ITS, India
    Dr. Wendy Spearman — University of Cape Town, South Africa

It may be a long shot, but my hope is we can reach some consensus to replace the longstanding dogma that countries should be self-sufficient in transplantation.
 

Funeral expense reimbursement to enhance organ donation and transplantation , by Chan and Sweat

 It's legal to pay funeral expenses for whole-body donors (for research) but not for organ donors for transplantation.  Here's a call to change that:

Chan, A., Sweat, K. Funeral expense reimbursement as a strategy to enhance organ donation and transplantation access. npj Health Syst. 2, 39 (2025). https://doi.org/10.1038/s44401-025-00046-z 

Abstract: We propose amending the National Organ Transplant Act to permit reimbursement of funeral expenses for deceased organ donors, analogous to current practices for whole-body donors. This ethically consistent policy could increase organ donation rates by 9–35%, saving 105,000–419,000 life-years and generating $200–800 million annually in Medicare savings—without commodifying human organs, compromising altruism, or undermining established ethical standards governing organ donation. 

Pig liver to human transplant: in China: a short story that may get longer...

 Here's a forthcoming article in the Journal of Hepatology.

Pioneering transplantation often provides tragic short stories of first attempts, that over time become longer, much more hopeful stories. 

Genetically engineered pig-to-human liver xenotransplantation

Zhang, Wenjie et al., Journal of Hepatology,

"In China alone, hundreds of thousands of individuals experience liver failure every year, but only approximately 6000 received a liver transplant in 2022[6]. Compared to the heart and kidney, the human liver exhibits more complex functions, including metabolism, detoxification, and immune regulation, which present unique challenges in xenotransplantation and might limit the success of cross-species transplantation[7, 8]. Encouragingly, xenotransplantation of pig livers has experienced a surge in 2024. In January, a United States based team connected a genetically modified pig liver outside the body of a brain-dead person, and the liver circulated the patient’s blood for three days[9]. In March, a Chinese team transplanted a 6-gene edited pig liver into a brain-dead individual and lasted for 10 days[10]. The pig liver exhibited signs of functionality, including the daily secretion of more than 30 milliliters of bile, which aids in digestion and is indicative of its metabolic activity[11]. These studies provide evidence of the feasibility and functionality of genetically modified porcine-to-human liver xenotransplantation. ... Unlike full xenotransplantation, which requires complete removal of the native liver, auxiliary xenotransplantation preserves a portion of the recipient’s liver while providing additional hepatic support. This less invasive strategy offers potential as a bridging therapy for patients awaiting recovery or subsequent human liver transplantation. In this groundbreaking study, a 71-year-old patient was the first living individual to receive a liver transplant from a genetically modified pig. During the initial 31 postoperative days, the patient showed no signs of infection or rejection, with gradual improvements in liver function and coagulation parameters. 

"However, on day 31, symptoms of xenotransplantation-associated thrombotic microangiopathy (xTMA) emerged, and antibody therapy was ineffective. As a result, the porcine liver was removed, relying on regeneration of the patient's left hepatic lobe. Following a course of antibody treatment, the xTMA symptoms resolved. Unfortunately, on postoperative day 135, the patient experienced sudden upper gastrointestinal hemorrhage. Despite repeated medical interventions, the bleeding episodes persisted. ultimately leading to the patient’s death on postoperative day 171."

 

Grace Guan defends her dissertation at Stanford

 Grace Guan defended her Ph.D. dissertation this past Friday.

Welcome to the club, Grace. 

 

 

 Here's my earlier post about one of the papers she spoke about--for extra credit, see if you can identify four of her coauthors in the above post-defense photo:

Friday, May 23, 2025  Deceased organ allocation: deciding early when to move fast

 

Race to the bottom: NLDAC and NY State both aim to be payers of last resort for reimbursing kidney donors

A tale of bureaucracy, in two acts 

1.  NLDAC, the federally funded National Living Donor Assistance Center, was for a long time the only organization that would reimburse  some expenses of living organ donors who qualified by not having high incomes, or any other sources for reimbursements.  That is NLDAC is a funder of last resort:

" Individuals considering becoming a living organ donor can apply for help with their travel expenses, lost wages, and dependent care expenses from NLDAC if they cannot be reimbursed for these costs by their recipient, a state program, or an insurance company.

2. In (very) late 2022,  New York State's Living Donor Support Act (LDSA, S. 1594) became law, and it is about to go into effect this year. The Act provides "state reimbursement to living organ donors, who are state residents, for medical and associated expenses incurred as a result of the organ donation, when the organ donation is made to another resident of the state" 

It further defines NY State as a payer of last resort:, and explicitly rules out payments to donors eligible for payment by NLDAC.

" THE  PROGRAM  SHALL  NOT  PAY  REIMBURSEMENT FOR EXPENSES PAID OR  REQUIRED TO BE PAID FOR BY ANY THIRD-PARTY  PAYER,  INCLUDING  WAGES  OR  OTHER  EXPENSES THAT WERE COVERED UNDER PAID MEDICAL LEAVE BY THE LIVING  DONOR'S EMPLOYER OR THAT ARE COVERED BY OTHER SOURCES  OF  REIMBURSEMENT  SUCH  AS  THE  FEDERAL  NATIONAL  LIVING  DONOR  ASSISTANCE PROGRAM. THE  PROGRAM SHALL BE THE PAYER OF LAST RESORT WITH RESPECT  TO  ANY  BENEFIT  UNDER THE PROGRAM. " 

 

I'm on NLDAC's mailing list, and  a few days ago received an email containing their policy statement on the NY State law. They say they will no longer make payments to NY residents who are covered by the NY State law.

 

 

 

Incidentally, here's my blog post from when the NY State law was passed:

Sunday, January 1, 2023 New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul on Dec. 29

 "like the authorization for NLDAC,  the NY State law (https://www.nysenate.gov/legislation/bills/2021/S1594) "requires that the Program shall be payer of last resort..." I hope that this doesn't turn into a competition to be the payer of last resort in a way that might cause some NY donors to fall between the cracks, and not be reimbursed either by NLDAC or the State of New York."

 

I suppose the larger lesson is that designers of competing markets can create paradoxical situations. 

########

Related:

Sunday, July 16, 2023  National Living Donor Assistance Center (NLDAC): I rotate off the advisory board

 

Recommendations From the International Society of Uterus Transplantation Ethics Committee

 The arc of history turns towards technology.

I didn't expect recommendation #2, although I've heard it discussed. 

Evolving Ethical Challenges After a Decade of Uterus Transplantation: Recommendations From the International Society of Uterus Transplantation Ethics Committee
by Wall, Anji E. MD, PhD1; Brännström, Mats MD, PhD2; Lotz, Mianna PhD3; Racowsky, Catherine PhD4; Stock, Peter MD, PhD5; Järvholm, Stina PhD2; Sustek, Petr PhD6; Brucker, Sara MD, PhD7; Tullius, Stefan G.8;  on behalf of The International Society of Uterus Transplantation Ethics Committee and endorsed by The Transplantation Society Ethics Committee*
Transplantation, August 26, 2025. | DOI: 10.1097/TP.0000000000005507 

---

Abstract:Uterus transplantation (UTx) became a clinical reality with the birth of the first baby in 2014. Following increased success, the procedure has now transitioned to clinical practice in many institutions throughout the world. With a rising number of donors, recipients, and babies born from this procedure, and with more institutions offering UTx, ethical challenges have evolved while novel aspects gained prominence. Here, the Ethics Committees of the International Uterus Transplantation Society, a section of The Transplantation Society, summarize current and future ethical challenges in UTx and provide recommendations for addressing these challenges. Ethical considerations covered here span (i) donor and recipient selection, (ii) living versus deceased donation, (iii) use of assisted reproductive technologies, (iv) informed consent, (v) clinical provision of UTx, and (vi) research protocols for further studies of UTx. For each topic considered, ethical analysis and recommendations are offered to ensure the practice of UTx remains within an acceptable foundational ethical framework that balances respect for autonomy, beneficence, and justice.

...

"Recommendation 2: Animal research is needed to determine the feasibility of UTx in, and uterus donation from, transgender patients and UTx in cisgender males who want to experience pregnancy. If medically and surgically acceptable, gender identity and reproductive status should not be exclusionary factors for uterus donation or transplantation." 

Transplants and trust

Much of medicine's effectiveness depends on trust, and that is nowhere clearer than in organ transplantation, which depends on organ donation.  And hearts are uniquely time-sensitive.  Here's a reflection on how to move forward, maintaining trust while promoting efficacy, including by monitoring current policies and carefully analyzing alternatives. (Kurt Sweat is the market design economist on this medical team...) 

 Skowronski, J., K. Sweat, and M. Farr (2025). In transplant we trust? Perspectives on the erosion of trust in the United States transplant system. Journal of Cardiac Failure

 Here's the concluding paragraph:

"Heart transplantation is both a resource-intensive and symbolically resonant form of organ donation. It is also particularly vulnerable: donor scarcity, limited ischemic time, and increasing utilization and scrutiny of DCD magnify the consequences of every unused heart and every erosion of trust. The controversies facing the broader transplant system—questions of allocation, oversight, and ethics—are felt acutely in heart transplantation. The US has long been a leader in transplantation, and as we move forward, we must sustain excellence in outcomes and volume. Avoidable missteps put those on the waitlist at greater risk of deterioration and death. It is essential that OPOs, transplant centers, and policy makers increase transparency in outcomes and the policymaking process. This would entail prospective policy analyses and improved information sharing through OPO and transplant center dashboards. Enacting these policies is vital to restore and enhance trust in the transplant system. In hearts, ischemic time is short, waitlist mortality is high, and donor utilization is low, presenting an opportunity for especially impactful improvements in procedures. In an era that feels perilous and bleak, enhancements to policymaking procedures and outcome reports can improve trust and save lives." 

Psycho-social criteria for being accepted as a transplant candidate

 Not all decisions made in transplant centers are made on exclusively medical grounds.  Given the dire shortage of transplantable organs, other factors that predict transplant success are also examined.

The Harvard Gazette interviews Dr. Wei Zhang, a transplant hepatologist at Mass General Hospital.

Facing life-or-death call on who gets liver transplants
Surgeons, medical professionals apply risk calculus that gets even more complex for patients with drinking problems  by Anna Lamb

"Patients with decompensated liver disease, or what commonly has been referred to as end-stage liver disease, have drastically shortened life expectancies without transplantation. In one study, patients in this stage who developed complications lived only two years after diagnosis.

"But a transplant is not always a final solution. As many as 20 percent of all patients with a history of alcohol use disorder will relapse after surgery.

“If we know a patient is going to relapse after liver transplant, the evidence is that the chance of them developing recurrent cirrhosis in three years is about 50 percent and the chance of dying from the recurrent liver disease in five years is about 50 percent,” Zhang said. “We do a lot of interventions to prevent them from going back to drinking and improve their quality of life.”

...

“I also understand that if a patient receives an organ, it means that another patient is not able to receive the organ,” he said. “So when I think of that, I find a little bit of comfort.”

"In the last decade, the field of transplant hepatology has changed drastically. In the not-so-distant past, all patients coming into the hospital with a failing liver and any history of alcohol abuse were denied life-saving surgery.

“When I was doing my residency, most of those patients did not have any chance of being evaluated for liver transplantation,” Zhang said.

"Now, he added, there are still quite a few hurdles that patients need to clear to be approved for transplantation. But there’s hope — especially for those with strong support at home.

...

“Some of the factors that we look at is if a patient has insights, meaning, does the patient think that the liver disease is caused by alcohol?” Zhang said. “There are patients who, for various reasons — one of them is probably stigma — don’t acknowledge that the liver disease is caused by alcohol. The risk is that if they get a liver transplantation, and don’t think they need treatments, they may relapse.”

"The other piece of psychosocial criteria, Zhang said, is social support. This includes having strong family ties, stable housing, and the overall ability to seek support after surgery.

“Then those patients would be considered as good candidates with acceptable risk for post-liver-transplant relapse, and we can move on for a liver transplant evaluation,” Zhang said."

"Better to exchange kidneys than bombs."

 Some coffee cups  should naturally come in pairs, so that you have one for a friend in need. (These recently arrived in the mail, from Laurie Lee)

Better to exchange kidneys than bombs

I was quoted as having said that to Marco della Cava, the USA Today reporter who wrote about the first kidney exchange between Israel and the UAE.

“Better to exchange kidneys than bombs,” says Roth, adding that using computers to search the world for medical solutions radically increases the chances of patients getting help. “International boundaries are artificial markers. Kidney disease doesn’t care about that.”

Thursday, September 30, 2021 Kidney Exchange between Israel and the UAE (in USA Today, yesterday)

How three Jewish and Arab families swapped kidneys, saved their mothers and made history by Marco della Cava, USA TODAY, Wed, September 29, 2021 AM