American Journal of Transplantation最新文献

Organ procurement organizations (OPOs) recover deceased donor kidneys and place them with matched recipients according to ranked match runs of patients, but offer notification practices differ across the OPOs and have changed following updates to allocation policy (KAS250). This national registry study used batch notification data to quantify time spent on kidney allocation and identify variation in batch notification practices across OPOs before and after KAS250. Overall allocation time between first and last offer notifications increased from a median of 1 to 7 hours under KAS250. For match runs of unplaced kidneys, allocation time increased from a median of 18 to 28 hours. Out-of-sequence (OOS) allocation, used by OPOs to limit non-utilization due to excess cold ischemia time, more than doubled in frequency between 2018 and 2022, with median time from first offer to initiation of OOS varying across OPOs from 0 to 47 hours. Increasing rates of organ non-utilization and the observed allocation practice differences based on organ quality demonstrate the urgent need for new approaches to achieve more efficient placement of hard-to-place kidneys. Data-driven approaches to optimize kidney allocation efforts will help ensure fairness in a system that currently allows for wide practice variation and frequent OOS allocation.

Blood type O liver transplantation (LT) candidates in the United States face the highest waitlist mortality due to the broader compatibility of type O grafts. Although blood-type compatible transplant is a gold standard, type O candidates might benefit from listing for A2 donors, whose antigen is known for its decreased immunogenicity. This study examines the trends and impact on waitlist outcomes of listing for A2 donors among 67,756 type O LT candidates listed between 2010 and 2023 using data from the United Network for Organ Sharing database. The number of A2-to-O LTs increased steadily, with 117 LTs performed in 2023. 61.1% of type O candidates were listed for A2 donors, with considerable regional variations. Fine-Gray competing risk analysis revealed that listing for A2 donors was associated with reduced waitlist dropout rates (subdistribution hazard: 0.94, P < 0.001) and increased transplant probabilities (subdistribution hazard: 1.07, P < 0.001), especially in regions with longer wait times, among candidates with listing Model for End-Stage Liver Disease (MELD)-Na scores between 15 and 34, and candidates listed after the Acuity Circles policy implementation. These findings suggest listing for A2 donors should be encouraged to improve waitlist outcomes for type O candidates.

This article examines the economic value of transplant nephrologists and the need for adequate compensation. Kidney transplantation is a health and lifespan-extending procedure that relies on the expertise of transplant nephrologists. However, current compensation models, primarily based on relative value units (RVUs), often fail to capture the full scope of their work, particularly non-billable activities essential to patient care. Additionally, regulatory compliance issues, particularly those related to the Physician Self-Referral Law (also known as the Stark Law), complicate compensation structures. The Stark Law mandates that physician compensation must align with fair market value to avoid conflicts of interest, adding complexity to designing compensation packages that accurately reflect the value of transplant nephrologists' contributions. This article critiques the RVU-based system, highlighting its limitations in adequately compensating these specialists, and proposes solutions such as integrating customized RVUs (cRVUs) and Outcome Value Units (OVUs) to better account for non-billable work and incentivize high-quality care. The use of Medicare Organ Acquisition Cost (OAC) reports is also suggested to align compensation more closely with the actual economic value generated. A comprehensive approach that addresses both the quantitative and qualitative aspects of transplant nephrologists' work, while navigating regulatory requirements, is essential for adequate and equitable compensation.

Islet transplantation in mice serves as a crucial preclinical model for understanding alloimmune and autoimmune mechanisms, optimizing immunosuppressive strategies, and developing novel therapies for diabetes. This review provides a comprehensive overview of best practices in murine islet transplantation, including diabetes induction models, technical aspects of islet transplantation, and criteria for transplant graft and rejection. We discuss the immunological challenges posed by MHC disparities, the impact of various transplantation sites, and the limitations of murine models in translating findings to clinical settings. Special emphasis is placed on emerging strategies such as stem cell-derived insulin-producing cells, immune tolerance induction, and alternative transplantation sites. While mouse models have significantly advanced our understanding of diabetes and β-cell replacement, their inherent differences from human physiology necessitate careful interpretation of findings. The review also highlights novel imaging modalities, immunosuppressive protocols, and biomarkers for graft monitoring, underscoring the need for further refinement of these models to bridge the gap between experimental research and clinical application. By standardizing methodologies and addressing translational limitations, murine islet transplantation studies remains a key model in transplantation and can continue to shape the future of β-cell replacement therapies for insulin dependent diabetes.

We report on living kidney donation from a prison inmate on death row. Thirty years ago we were involved in an unusual set of circumstances that we assumed would never arise again. That assumption is incorrect as a current death row inmate wishes to be a living kidney donor and we speak now to describe the lessons learned and to help others. This report is focused on living donation, excluding posthumous donation, and discusses the ethical, legal, medical and logistic considerations underpinning prisoner donation for both the general prison population and death row inmates. We believe inmates on death row can be considered as living organ donors and the ethical, logistic and medical hurdles surmounted to enable donation. This experience with death row inmates should serve to encourage donation from the general prison population.