Alex Chan on market design and organ transplants (and how to begin a video)

Alex Chan, at HBS:) 

https://youtu.be/8n6A9wO1yt0?si=VsaT0AVNgYc7VdnB

Redesigning transplant and OPO center incentives (Chan and Roth in JAMA; Bae, Sweat, Melcher and Ashlagi in JAMA Surgery)

 

Chan A, Roth AE. Reimagining Transplant Center Incentives Beyond the CMS IOTA Model. JAMA. Published online January 26, 2026. doi:10.1001/jama.2025.26194 

 "On July 1, 2025, the Centers for Medicare & Medicaid Services (CMS) launched the Increasing Organ Transplant Access (IOTA) model, a national experiment in revising how transplant centers are evaluated and paid.

"For decades, transplant centers were primarily judged by 1-year graft and patient survival for patients who underwent a transplant. That standard, designed to safeguard quality, sometimes constrained access to transplants by rewarding risk avoidance rather than expansion. This contributed to persistent kidney shortages, alongside continued organ nonutilization.1

"The IOTA model marks a deliberate rebalancing. CMS is tying payment not primarily to short-term survival, but to 3 domains: achievement (60 points for transplant volume), efficiency (20 points for kidney offer acceptance), and quality (20 points for graft survival).

...

"A kidney transplant begins with an organ procurement organization (OPO). Yet OPOs remain outside the IOTA payment framework, perpetuating fragmentation between procurement and transplant.

"Recent experience with OPO performance metrics illustrates how narrow incentives can distort behavior. After CMS introduced tier-based OPO evaluations in 2021, lower-performing OPOs increased organ recovery, which also sharply increased discards, reliance on higher-risk organs, and out-of-sequence kidney placements,3 raising concerns about fairness to waitlisted patients.4 

...

"Emerging economic and experimental research suggests that joint accountability—rewarding procurement and transplant entities together for improving population health—can both shift recovery, discard, and transplant numbers and produce improved gains in patient health (Table).1 Without such system-level metrics spanning OPOs and transplant centers, IOTA will operate within a fragmented ecosystem where incentives push procurement and transplant in different, sometimes counterproductive, directions."

############

See also

Bae H, Sweat KR, Melcher ML, Ashlagi I. Organ Procurement Following the Centers for Medicare and Medicaid Services Performance Evaluations. JAMA Surg. 2026;161(1):97–100. doi:10.1001/jamasurg.2025.5074 

 

Offering deceased donor transplants out of sequence when there is a chance the organ will (otherwise) be unutilized (Ashlagi and Roth in AJOB)

 Itai Ashlagi and I weigh in on recent controversy about "out of sequence" offers of organs for transplant, with some ideas about how the current system might be redesigned and maintained so as to reduce organ discards while maintaining transparency about how and to whom organs are offered.

 Itai Ashlagi and Alvin E. Roth (2026). Out of Sequence Offers: Towards Efficient, Equitable Organ Allocation. The American Journal of Bioethics, 26(1), 5–8. https://doi.org/10.1080/15265161.2026.2594937  

"Organs for transplant are very scarce compared to the need, and so the allocation of organs from deceased donors raises questions about both efficiency and fairness. Because offers of organs take time to consider, and because the viability of organs from deceased donors decreases over time, efficiency sometimes requires increasing the chance of reaching a patient who will accept the organ while it remains viable. So fairness and efficiency, concerning who gets to consider the next offer, and the probability that the organ on offer will be accepted in time for it to be transplanted, may sometimes be in conflict, or at least appear to be. And even the appearance of unfairness may undercut trust in the system of organ donation and transplantation. 

"This conflict between fairness and efficiency has resulted in controversy about offers made “out of sequence” (Covered in a lead article in the NYT article (Times 2025)) 

...

"Collecting data is essential for both efficiency and transparency. It is unfair to future patients not to have transparent allocation systems that can be studied with precision (with causal inference from experimentation), so that it can be improved over time. It is also unfair to future patients who will join increasingly congested waiting lists as a result of the failure to utilize a large number of transplantable organs.

Public data about transplant centers’ performance and patients’ waiting times would further allow patients to choose, based on their own preferences, a transplant center that fits their need. 

...

"Policies to expedite the placement of marginal quality organs that can be tested over time and studied with experiments include when to determine an organ is hard-to-place and when and how to adapt the priority list.

"In summary, it is sometimes desirable to expedite an organ that risks being unused, by offering it to a patient or transplant center that is likely to accept it if the offer is received in a timely way. But it is important to make sure that this flexibility does not promote unfairness to patients or transplant centers. Increasing the transparency and efficiency of the system for expediting organs can address both these issues."

########

The same issue of the journal contains a number of articles discussing organ allocation out of sequence  

########

Earlier:

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

Transplant problems and public support for organ donation

 The Kidney Transplant Collaborative is worried about the status of kidney transplants in the US.  Here's the statement they published this month, which expresses concern about a drop in deceased donations.

LOSING TRANSPLANTS FOR ALL THE WRONG REASONS: A STATISTICAL ANALYSIS OF THE REDUCTION IN KIDNEY TRANSPLANTS IN RESPONSE TO REPORTS OF OPO FAILURES

"The kidney transplant waitlist has long exceeded the supply of available kidney organs. The waitlist today includes more than 94,000 Americans, with more than 28,000 deceased and living kidney transplants occurring in 2025. Even more troubling, recent events seem to have led to a decline in overall kidney transplants from 2024 to 2025, driven by a decline in deceased donor transplants. This represents the first time in the 21st century that we see an annual isolated decline in deceased donations and deceased donor kidney transplants, even while living donor kidney transplants increase and the kidney discard rate declines, the latter reflecting increased use of available deceased donor kidneys.

...

"What has caused this unprecedented and isolated decline in deceased kidney donations? While policymakers have been appropriately focused on maintaining the integrity of the
deceased donor process, an unanticipated effect of recent oversight efforts of the kidney transplant system and accompanying negative media reports has shaken the deceased donor
landscape and may have possibly caused the reduction in deceased donor rates. Given this emerging trend, the importance of increasing living donation has come into even sharper focus. Policymakers and all stakeholders in the kidney transplant process will need to focus on the impact of the recent oversight efforts and take clear measures to responsibly increase kidney transplant rates, most likely via a focus on living kidney donor supportive policy.

...

"Unreported until now, however, is the negative impact that this recent Congressional focus may be having on kidney transplant levels themselves. The impact is measurable – from 2024 to 2025, there were 116 fewer kidney transplants. This is due to 218 fewer deceased donor kidney transplants and an increase of 102 living donor kidney transplants for 2025 as compared to 2024 – the first time this century that there appears to be an isolated decline of deceased kidney donations driving the decrease in overall kidney transplants.

...

"Recent, highly publicized revelations involving OPOs have had a serious and harmful effect on public trust in organ donation. As a result, fewer individuals and families appear willing to consent to organ donation after death. Data from the OPTN Transplant Metrics National Dashboard shows that the number of kidneys recovered from deceased donors remained steady during the first half of 2025. However, beginning in June 2025, the number of deceased donors began to decline, and that decline has continued to accelerate. In 2025, a total of 15,274 deceased donors underwent kidney recovery, compared to 15,937 during 2024 for a net percentage change of negative 4.2%."

HT: Martha Gershun
 

 

UNOS continues to run the deceased-donor organ allocation system

 The U.S. Health Resources & Services Administration (HRSA) has published a document outlining its progress in modernizing the Organ Procurement and Transplant Network (OPTN) as required by recent legislation.  The idea was to make the system less dependent on the United Network for Organ Sharing (UNOS), which had been the single federal contractor running the OPTN since its inception.  For the time being, at least, it appears that UNOS will continue to run the organ allocation system.

 Modernizing the Nation’s Organ Donation, Procurement, and Transplantation System

"For more than 35 years, the OPTN was operated through a single national contract.  

"While this structure supported growth in organ donation, procurement and transplantation, the increasing complexity of modern medicine and the demands of real-time technology, safety, data, and public accountability required a new approach.  

"The bipartisan 2023 Securing the U.S. Organ Procurement and Transplant Network Act gave a clear mandate: bring the OPTN into the modern era of governance, technology, and healthcare delivery". 

 

 

A rare -directed- deceased donor kidney transplant

 Most organ transplants come from deceased donors, and the vast majority of these deceased donor organs are allocated by a regulated system of national waiting lists. That is, the organs of a deceased donor go to strangers in need. In contrast, most transplants from living donors (of kidneys and livers) are direct donations from someone healthy enough to donate to someone who they know.*  Living donations are also different in that they can be planned well in advance, while deceased donations have to be hastily arranged following a death.

But it is legal, and sometimes possible, for the next of kin of a deceased potential donor to direct an organ donation to someone they know who needs a transplant.  This will only take place if the potential recipient is available on short notice, and if the donor organ is compatible with the recipient.  So it's a rare event: the next of kin need to know someone in need, and the transplant has to turn out to be feasible.

But rare events happen, and the NYT reports on just such a story:

A Man Who Shunned Cheap Sentiment Left a Gift for Others: Life  By Dan Barry

"Informed that her 55-year-old brother would never regain consciousness, Darlene Costello made the heartbreaking decision to have him removed from his ventilator — only to learn, seconds before it was time, that Brendan was a registered organ donor.

"Once Ms. Costello calmed down — why wasn’t this known before? — she came to embrace the news of her brother’s final selfless act. She also knew someone who desperately needed a kidney. Calls were made, tests done, overwhelming odds overcome."

...

" His lungs went to a woman in Tennessee, his right kidney to a man in Pennsylvania. And his left kidney was received by Ms. Costello’s mentor and employer, Dr. Sylvio Burcescu, 62, whose ability to run his Westchester County clinic had been hampered by a rare kidney disease requiring dialysis."

########

*Nondirected living donors can also start chains of kidney exchange. 

Interview about the new edition of the Chinese translation of Who Gets What and Why

 Last month I was interviewed in connection with the new edition of the Chinese translation of my 2015 book Who Gets What and Why.  

Here is the interview in Chinese, and translated back to English. (You can also click "translate to English" from the Chinese version, to get a more creative translation that among other things renders my name as variations on "Erwin Ross.")

 Below are some excerpts from the better back-translation (from interview in English translated into Chinese, and then back to English):

"In November 2025, LatePost conducted a video interview with Roth. The interview began at 7 a.m. local time, and the 74-year-old had already arrived at his office, walking on a treadmill desk while conversing with us. A white beard, furrowed brow when deep in thought, a smiling expression, and concise communication—these are the impressions Roth gave during the conversation.

'Market design is economics confronting the external world,' Roth told us. A month earlier, his popular book on market design, Who Gets What―and Why, was republished in Chinese under the title Matching. Designing, improving, and maintaining well-functioning matching mechanisms is the work of market design. In Matching, Roth demonstrated how market design could be applied in practice to change people's destinies and the way societies operate. 

...

"Alvin Roth: Significant changes have occurred in both kidney transplantation and kidney exchange. By the way, since 2015, there has been a major transformation in the approach to transplant surgeries in China. Prior to that, most organs used in transplants came from executed prisoners; now, China is developing a voluntary organ donation program, which represents a significant shift. However, China has yet to initiate kidney exchange programs.

"A new global trend is that we are beginning to experiment with cross-border kidney exchanges. This is particularly crucial for smaller countries or regions with limited numbers of kidney transplants, where some patients struggle to find compatible donors. 

...

"Q: In your "Market Design" blog, you previewed a new book to be published next year titled Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work. Why did you write this book? What issues do you discuss and how do you address them?

"Alvin Roth: One issue that economists have yet to fully understand is which markets gain societal support and which ones do not. For instance, I have explored the surrogacy market. Surrogacy is legal in the United States but illegal in China. After the Chinese government relaxed its one-child policy, many people desired to have a second child, but age became an obstacle. In California, where I reside, there are agencies offering surrogacy services where Mandarin is spoken, and many clients come from China.

"This is one of the core questions I attempt to address: why are certain genuinely beneficial practices legal in some places but illegal in others? "

#######

When I search for the new edition on Google I get the following AI overview:

Alvin Roth's book, originally titled

Who Gets What―and Why: The New Economics of Matchmaking and Market Design, has been published in Chinese under two different titles. 

The two Chinese titles are:

• 《共享经济：市场设计及其应用》 (Simplified Chinese: Gòngxiǎng jīngjì: Shìchǎng shèjì jí qí yìngyòng, meaning "Sharing Economy: Market Design and Its Application").
• 《配对：诺奖得主艾文・罗斯教你赢得博弈，突破市场经济赛局的思维》 (Traditional Chinese: Pèiduì: Nuò jiǎng dé zhǔ Ài wén luō sī jiào nǐ yíng dé bó yì, tū pò shìchǎng jīngjì sài jú de sī wéi, meaning "Matching: Nobel Laureate Alvin Roth Teaches You to Win the Game and Break Through Market Economy Game Thinking"). 

The simplified Chinese characters edition was published by Machinery Industry Press in 2015. 

 

Earlier: 

Thursday, January 28, 2016  Who Gets What and Why in Chinese

 

 

The national politics of deceased organ donation

 The U.S. transplant system is relatively open to foreign patients, and the NYT reports with some concern the number of foreign citizens receiving scarce organs from deceased donors, sometimes paying full list price to the hospitals involved.  One question I have that I haven't seen addressed in discussions of this type is how many foreign citizens who happen to die while visiting the US become deceased organ donors?

Here's the NYT:

Hospitals Cater to ‘Transplant Tourists’ as U.S. Patients Wait for Organs
International patients can bring a hospital as much as $2 million for a transplant. In recent years, they have typically gotten organs faster than U.S. patients. By Brian M. Rosenthal and Mark Hansen

  "In the past dozen years, more than 1,400 patients from abroad received a transplant in the United States after traveling specifically for the procedure. That was a small fraction of all U.S. transplants, and most transplant centers did not operate on international patients at all.

"But The Times found that a handful of hospitals are increasingly catering to overseas patients, who make up an ever-larger share of their organ recipients: 11 percent for hearts and lungs at the University of Chicago; 20 percent for lungs at Montefiore Medical Center in the Bronx; 16 percent for lungs at UC San Diego Health; 10 percent for intestines at MedStar Georgetown University Hospital in Washington; and 8 percent for livers at Memorial Hermann-Texas Medical Center in Houston.

"In many countries, this would be illegal. World leaders agreed in 2008 to fight so-called transplant tourism, and most nations do not provide organs to overseas patients. Yet the United States has long allowed it. The policy has drawn criticism in the past, such as when organs went to Saudi royals and a Japanese crime boss. 

...

"Dr. Mark Fox, a former chair of the transplant system’s ethics committee, said the findings were troubling, especially because overseas patients do not contribute to America’s pool of donated organs. “The unfortunate reality is that we don’t have enough organs,” he said. “When people jet in, get an organ and jet home, it’s a problem. It’s not fair.” 

 ##########

I'm reminded of this 2018 article which expressed a similar concern :

Delmonico, F. L., Gunderson, S., Iyer, K. R., Danovitch, G. M., Pruett, T. L., Reyes, J. D., & Ascher, N. L. (2018). Deceased donor organ transplantation performed in the United States for noncitizens and nonresidents. Transplantation, 102(7), 1124-1131. 

Abstract: "Since 2012, the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) has required transplant centers to record the citizenship residency status of patients undergoing transplantation in the United States. This policy replaced the 5% threshold of the non–US citizen/nonresidents (NC/NR) undergoing organ transplantation that could result in an audit of transplant center activity. Since April 1, 2015, the country of residence for the NC/NR on the waitlist has also been recorded. We analyzed the frequency of NC/NR deceased donor organ transplants and waitlist registrations at all US transplant centers by data provided by UNOS for that purpose to the UNOS Ad Hoc International Relations Committee. During the period of 2013 to 2016, 1176 deceased donor transplants (of all organs) were performed in non–US citizen/non–US resident (NC/NR) candidates (0.54% of the total number of transplants). We focused on high-volume NC/NR transplant centers that performed more than 5% of the deceased donor kidney or liver transplants in NC/NR or whose waitlist registrants exceeded 5% NC/NR. This report was prepared to fulfill the transparency policy of UNOS to assure a public trust in the distribution of organs. When viewed with a public awareness of deceased donor organ shortages, it suggests the need for a more comprehensive understanding of current NC/NR activity in the United States. Patterns of organ specific NC/NR registrations and transplantations at high-volume centers should prompt a review of transplant center practices to determine whether the deceased donor and center resources may be compromised for their US patients." 

They note that " a noncitizen/nonresident could be a foreign student or businessperson traveling to the United States, whereas an undocumented individual living in the United States would also be a noncitizen/resident." 

The local politics of deceased organ donation

 "All politics is local" may not be entirely true, but local politics doesn't end at death.

MedPage Today has the story: 

Senators Urge More Localized Use of Donor Organs
— "Too many of our organs are leaving" the geographic area, says Sen. Roger Marshall, MD
by Joyce Frieden, 

"More needs to be done to make sure donated organs are transplanted to recipients within the local geographic area whenever possible, several senators said Thursday at a hearing on the future of the organ procurement and transplantation network.

"The Midwest, where I'm from ... is famous that we have a higher organ donor rate than the [East or West] coasts do typically," said Sen. Roger Marshall, MD (R-Kansas). "And you know, there's a concern that too many of our organs are leaving the Midwest." 

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.

######

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.)

 

View this post on Instagram

A post shared by Folder Group (@foldermiddleeast)

 

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."