Inconsistent values and algorithmic fairness: a review of organ allocation priority systems in the United States.

BACKGROUND: The Organ Procurement and Transplant Network (OPTN) Final Rule guides national organ transplantation policies, mandating equitable organ allocation and organ-specific priority stratification systems. Current allocation scores rely on mortality predictions. METHODS: We examined the alignment between the ethical priorities across organ prioritization systems and the statistical design of the risk models in question. We searched PubMed for literature on organ allocation history, policy, and ethics in the United States. RESULTS: We identified 127 relevant articles, covering kidney (19), liver (60), lung (24), and heart transplants (23), and transplant accessibility (1). Current risk scores emphasize model performance and overlook ethical concerns in variable selection. The inclusion of race, sex, and geographical limits as categorical variables lacks biological basis; therefore, blurring the line between evidence-based models and discrimination. Comprehensive ethical and equity evaluation of risk scores is lacking, with only limited discussion of the algorithmic fairness of the Model for End-Stage Liver Disease (MELD) and the Kidney Donor Risk Index (KDRI) in some literature. We uncovered the inconsistent ethical standards underlying organ allocation scores in the United States. Specifically, we highlighted the exception points in MELD, the inclusion of race in KDRI, the geographical limit in the Lung Allocation Score, and the inadequacy of risk stratification in the Heart Tier system, creating obstacles for medically underserved populations. CONCLUSIONS: We encourage efforts to address statistical and ethical concerns in organ allocation models and urge standardization and transparency in policy development to ensure fairness, equitability, and evidence-based risk predictions.

A novel two-stage network data envelopment analysis model for kidney allocation problem under medical and logistical uncertainty: a real case study.

Organ transplantation is one of the most complicated and challenging treatments in healthcare systems. Despite the significant medical advancements, many patients die while waiting for organ transplants because of the noticeable differences between organ supply and demand. In the organ transplantation supply chain, organ allocation is the most significant decision during the organ transplantation procedure, and kidney is the most widely transplanted organ. This research presents a novel method for assessing the efficiency and ranking of qualified organ-patient pairs as decision-making units (DMUs) for kidney allocation problem in the existence of COVID-19 pandemic and uncertain medical and logistical data. To achieve this goal, two-stage network data envelopment analysis (DEA) and credibility-based chance constraint programming (CCP) are utilized to develop a novel two-stage fuzzy network data envelopment analysis (TSFNDEA) method. The main benefits of the developed method can be summarized as follows: considering internal structures in kidney allocation system, investigating both medical and logistical aspects of the problem, the capability of expanding to other network structures, and unique efficiency decomposition under uncertainty. Moreover, in order to evaluate the validity and applicability of the proposed approach, a validation algorithm utilizing a real case study and different confidence levels is used. Finally, the numerical results indicate that the developed approach outperforms the existing kidney allocation system.

The OPTN Expeditious Task Force: Improved Organ Utilization and Efficiency to Drive Transformational Growth in Solid Organ Transplant in the United States.

The Organ Procurment and Transplant Network (OPTN) Expeditious Task Force (ETF) was conceived and initiated in response to a need to move quickly to greatly expand successful deceased-donor transplant across the U.S. The ETF, using data from the top 20% of transplant programs ranked by ability to manage successful growth in transplant volume, came up with a bold aim of facilitating 60,000 successful transplants by 2026 to save more lives. In order to achieve this transformational growth, the ETF will use a data-driven approach, partnering with key stakeholders across the transplant system to secure commitments, reduce barriers, obtain data, align metrics, evaluate new technologies, and run short trials that will better inform future policy developments. To achieve this growth, the two primary aims of the ETF are increasing system efficiency and improving organ and donor utilization. The initial ETF workstreams will focus on 6 areas that include assessments of organ non-utilization (where donors are consented but organs not recovered) and non-use (where organs are recovered but not transplanted), facilitating community events to address challenges in utilization and efficiency; hosting transplant growth collaboratives focused on securing resources needed for transformational growth; creating tools for patient empowerment; evaluating OPTN policies to remove barriers; and designing short trials of rescue pathways for organs at risk for non-use.

Program Report: Expanding the Deceased Donor Pool in Manitoba With an Age-Targeted Kidney Transplant Program.

Purpose of program: The ongoing shortage of organs for transplant combined with the highest prevalence of end-stage kidney disease (ESKD) in Canada has resulted in long wait times for a deceased donor transplant in Manitoba. Therefore, the Transplant Manitoba Adult Kidney Program has ongoing quality improvement initiatives to expand the deceased donor pool. This clinical transplant protocol describes an age-targeted program intended to increase the use of transplants with a kidney donor profile index (KDPI) >85 by allocating them to suitable pre-consented recipients age ≥65 with low wait times. The goal is to improve survival and quality of life for older recipients by maximizing a previously under-utilized donor pool. Sources of information: Scoping literature review; Transplant Manitoba deceased donor audit; and key stakeholder engagement with patient partners, inter-disciplinary health care providers, and health system leaders. Methods: The alternative donor pool criteria include deceased donor kidneys with KDPI 86-100 or another concern for graft longevity but are otherwise suitable for transplantation. Patients with no living donor, age ≥65, low wait times and otherwise eligible for transplant listing will be educated, and if suitable, pre-consented for the age-targeted program. All patients remain eligible for a standard criteria donor according to the local allocation criteria. The age-targeted program waitlist follows the same provincial allocation rules using wait time, panel reactive antibody (PRA), and human leukocyte antigen (HLA) match points for determining rank order. If an age-targeted recipient experiences early graft loss from a KDPI 86-100 kidney within 12 months from transplant, their cumulative wait time, including time with the transplant, will be reinstated upon relisting. Key findings: Transplant Manitoba's provincial allocation rules do not permit bypassing top of the list recipients for kidney offers; therefore, transplant providers were previously reluctant to utilize KDPI 86-100 donor kidneys to top of the list recipients eligible for higher quality kidneys. This age-targeted program facilitates allocation of KDPI 86-100 kidneys to suitable older pre-consented recipients with low wait times, who may obtain a survival and quality of life benefit from these transplants. This approach expands the utilized deceased donor pool to benefit all Manitobans awaiting a deceased donor kidney transplant. Limitations: This program was launched in January 2023, and there are no data reported on outcomes given the small numbers and abbreviated follow-up. Implications: The goal of this quality improvement project is to improve access to deceased donor kidney transplantation for Manitobans with ESKD. This program was developed with patient and provider feedback, including multimedia patient education materials which may be helpful for other programs. We anticipate this program is a safe and effective way to expand access to deceased donor kidney transplantation using a previously under-utilized donor pool.

Objectif du programme: La pénurie actuelle d'organes disponibles pour la transplantation, combinée au fait que le Manitoba présente la plus forte prévalence d'insuffisance rénale terminale au Canada, entraîne de longs délais d'attente dans cette province pour un organe provenant d'un donneur décédé. C'est pourquoi le programme de transplantation rénale pour les adultes du Manitoba (Transplant Manitoba) a mis en place des initiatives d'amélioration continue de la qualité en vue d'élargir le bassin de donneurs décédés. Ce protocole clinique de transplantation décrit un programme axé sur l'âge visant à accroître l'utilisation de greffons provenant de donneur avec un indice KDPI (Kidney Donor Profile Index) supérieur à 85 et leur attribution à des receveurs compatibles âgés (65+ ans), avec de faibles temps d'attente et ayant préconsenti au programme. L'objectif est d'améliorer la survie et la qualité de vie des receveurs âgés en exploitant au maximum un bassin de donneurs auparavant sous-utilisés. Sources de l'information: Analyse bibliographique de la documentation; évaluation des donneurs décédés de Transplant Manitoba; collaborations des principaux intervenants avec les patients partenaires, les prestataires de soins de santé interdisciplinaires et les dirigeants du système de santé. Méthodologie: Le critère alternatif du bassin de donneurs inclut les reins de donneurs décédés avec un indice KDPI 86-100 ou un autre souci de longévité du greffon, mais autrement appropriés pour la transplantation. Les patients de plus de 65 ans sans donneur vivant, avec de faibles temps d'attente et autrement admissibles à la liste d'attente seront éduqués et, s'ils remplissent les conditions, préconsentiront au programme axé sur l'âge. Tous les patients demeurent admissibles pour un donneur satisfaisant aux critères standard, conformément aux critères d'attribution locaux. La liste d'attente du programme axé sur l'âge suit les mêmes règles d'attribution que la province, soit l'utilisation du temps d'attente, du taux d'immunisation (PRA - Panel Reactive Antibody) et du degré de compatibilité HLA, pour déterminer le rang sur la liste. Si, dans les 12 mois suivant la greffe, un receveur ciblé par l'âge subit la perte précoce du greffon d'un rein d'indice KDPI 86-100, son temps d'attente cumulé, incluant le temps passé avec le greffon, sera rétabli lors de sa réinscription. Principales observations: Les règles provinciales d'allocation de Transplant Manitoba ne permettent pas de passer devant les receveurs haut placés sur la liste pour les offres de reins. Par conséquent, les prestataires de greffes ont longtemps été réticents à utiliser les reins de donneurs avec indice IPKD 86-100 pour les attribuer à des receveurs du haut de la liste qui sont admissibles à des reins de meilleure qualité. Ce programme axé sur l'âge facilite l'attribution de reins avec indice KDPI 86-100 à des receveurs compatibles plus âgés, avec un faible temps d'attente et ayant préconsenti au programme, qui pourraient améliorer leur survie et leur qualité de vie grâce à ces greffes. Cette approche élargit le bassin de donneurs décédés pouvant être utilisés au profit de tous les Manitobains en attente d'une greffe de rein d'un donneur décédé. Limites: Ce programme a été lancé en janvier 2023; aucune donnée n'a été rapportée sur les résultats étant donné le faible échantillon et la courte période de suivi. Conclusion: L'objectif de ce programme d'amélioration de la qualité est d'accroître l'accès des Manitobains atteints d'IRT à la transplantation rénale d'organes de donneurs décédés. Ce programme a été développé en tenant compte du point de vue des patients et des prestataires; il comprend notamment du matériel éducatif multimédia destiné aux patients qui pourrait être utile à d'autres programmes. Nous pensons que ce programme est un moyen sûr et efficace d'accroître l'accès à la transplantation rénale d'organes de donneurs décédés en exploitant un bassin de donneurs auparavant sous-utilisés.

Implications of the Composite Allocation Score System for Lung Transplantation in the United States: Review of the New System.

Due to criticism regarding undue adherence to fixed geographic boundaries, the Lung Allocation Score system was recently replaced by the more holistic allocation via continuous distribution. This review highlights the historical evolution of US lung allocation paradigms, outlines rationale for continuous distribution under the Composite Allocation Score system and discusses expected implications of this new system.

Crossing national borders for transplantation: A focused evaluation of deceased donor lung exports from the United States.

Organ transplantation is a life-saving treatment for end-stage organ failure patients, but the United States (US) faces a shortage of available organs. US policies incentivize identifying recipients for all recovered organs. Technological advancements have extended donor organ viability, creating new opportunities for long-distance transport and international sharing. We aimed to assess organ exports from deceased US donors to candidates abroad, a component of allocation policy allowed without suitable domestic candidates. Based on the national Scientific Registry of Transplant Recipients data from January 2014 to September 2023, 388 342 organs were recovered for transplantation, with 511 (0.13%) exported. Most exported organs were lungs (80%). Exported lung donors were older (41 vs 34 years, P < .001), more likely hepatitis C positive (22% vs 4%, P < .001), and more likely donors after circulatory death (20% vs 7%, P < .001). Lungs that were eventually exported were offered to more US potential transplant recipients (median = 65) than those kept in the US (median = 21 and 41 for lungs recovered by nonexporting and exporting organ procurement organizations, respectively; P < .001). Our study highlights the necessity for further research and clear policy initiatives to balance the benefits of cross-border sharing while considering potential opportunities for more aggressive organ allocation within the US.

Introduction of the donor centre virtual crossmatch in Eurotransplant.

On 24 January 2023, Eurotransplant has introduced the virtual crossmatch for kidney and pancreas allocation as a better alternative for the physical Complement Dependent Cytotoxicity (CDC) crossmatches at the donor centre, which were associated with a longer cold ischaemia time and false positive reactions. For the time being, the physical CDC crossmatch at the recipient centre will remain in place as the final histocompatibility check. While Eurotransplant is certainly not the first organ allocation organisation to introduce virtual crossmatching, several novel aspects have been introduced, such as calculation of the virtual panel reactive antibody (vPRA) on 11 loci at the second-field level in addition to the serological broad and split level, electronic HLA typing data transmission using Histoimmunogenetics Markup Language (HML) file format, and the actual virtual crossmatch based on ambiguous, second-field HLA typing of the donor on all 11 loci. This short communication will focus on these novel aspects of the virtual crossmatch in Eurotransplant.

Impact of removing OPTN region from vascularized composite allograft allocation.

On 6/18/2020, the Organ Procurement and Transplantation Network (OPTN) implemented new policy replacing OPTN region with a 500 nautical mile (NM) circle around the donor hospital for the purpose of vascularized composite allograft (VCA) allocation. We used OPTN data to assess deceased donor VCA transplants in the 3 years pre- (6/19/2017-6/17/2020) vs. post-implementation (6/18/2020-6/17/2023). A total of 19 deceased donor VCA transplants were performed pre-policy (10 uterus, 3 bilateral upper limb, 1 unilateral upper limb, 3 face, 1 abdominal wall and 1 penis), and 11 post-policy (4 uterus, 1 bilateral upper limb, 2 face, 1 trachea, 2 abdominal wall, and 1 bilateral upper limb and face). Median distance from donor hospital to transplant hospital increased from 70 NM (range: 0-524 NM) pre-policy to 119 NM (range: 0-464 NM) post-policy. The majority of transplants in both policy eras were within 500 NM of the donor hospital [89.5% (N = 17/19) vs. 100% (N = 11/11)] and most remained within the same OPTN region as the donor hospital [68.4% (N = 13/19) vs. 90.9% (N = 10/11)]. Although it is difficult to draw strong conclusions about the policy's impact due to the low transplant volume and timing of implementation relative to the COVID-19 pandemic, data in the 3 years post-implementation suggest that 500 NM circles were a reasonable replacement for OPTN region in VCA allocation. The OPTN will continue to review data to monitor the policy's impact and inform future changes to VCA allocation, such as the transition to continuous distribution, a points-based framework expected to replace the current framework.

The Equitable Benefit Approach to guide the assessment of medical and psychosocial factors in liver transplant candidacy.

Lack of available organs poses a significant challenge in meeting the needs of patients with life-threatening liver disease who could benefit from liver transplantation (LT). Psychosocial vulnerability markers have been linked to post-transplant outcomes, raising questions about their use in patient selection. However, their incorporation into selection criteria raises concerns about health equity and potential discrimination. As a result, there is a pressing need to refine fair allocation systems that consider both clinical and psychosocial factors to ensure equitable access and optimize post-transplant outcomes. The Equitable Benefit Approach (EBA) proposed in this paper by the multidisciplinary group of clinical experts in LT from the Italian Society for the Study of the Liver seeks to address these concerns. It presents four procedural principles, the two allocative principles usually applied in transplantation (urgency and utility) and introduces a new one, the principle of health equity. The EBA aims to prioritize patients with the highest transplant benefit while addressing health inequalities. It emphasizes evidence-based decision-making and standardized assessment tools to reliably evaluate psychosocial risk factors. Implementing the EBA involves a multi-step process, including stakeholder engagement, prospective studies to validate its efficacy, development of institutional policies and algorithms, and ongoing monitoring and revision. By following these steps, health care providers can ensure that LT allocation decisions are transparent and responsive to evolving clinical and social contexts. Ultimately, the EBA should offer a comprehensive framework for fair patient selection in LT, considering both biomedical and psychosocial aspects.

Kidney transplant candidates' perspectives on the implementation of a Canadian Willingness to Cross program: A strategy to increase access to kidney transplantation for highly sensitized patients.

BACKGROUND: Kidney transplantation is the optimal treatment for end-stage renal disease. However, highly sensitized patients (HSPs) have reduced access to transplantation, leading to increased morbidity and mortality on the waiting list. The Canadian Willingness to Cross (WTC) program proposes allowing transplantation across preformed donor specific antibodies (DSA) determined to be at a low risk of rejection under the adaptive design framework. This study collected patients' perspectives on the development of this program. METHODS: Forty-one individual interviews were conducted with kidney transplant candidates from three Canadian transplant centers in 2022. The interviews were digitally recorded and transcribed for subsequent analyses. RESULTS: Despite limited familiarity with the adaptive design, participants demonstrated trust in the researchers. They perceived the WTC program as a pathway for HSPs to access transplantation while mitigating transplant-related risks. HSPs saw the WTC program as a source of hope and an opportunity to leave dialysis, despite acknowledging inherent uncertainties. Some non-HSPs expressed concerns about fairness, anticipating increased waiting times and potential compromise in kidney graft longevity due to higher rejection risks. Participants recommended essential strategies for implementing the WTC program, including organizing informational meetings and highlighting the necessity for psychosocial support. CONCLUSION: The WTC program emerges as a promising strategy to enhance HSPs' access to kidney transplantation. While HSPs perceived this program as a source of hope, non-HSPs voiced concerns about distributive justice issues. These results will help develop a WTC program that is ethically sound for transplant candidates.

Evaluation of a delayed liver transplantation strategy for patients with HCC receiving bridging therapy: the DELTA-HCC study.

BACKGROUND & AIMS: To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy (DS) was adopted in France in 2015 in patients listed for any single HCC treated with resection or thermal ablation during the waiting phase. The DS involves postponing LT until recurrence. The purpose of this study was to evaluate the DS to make sure that it did not hamper pre- and post-LT outcomes. METHODS: Patients listed for HCC in France between 2015 and 2018 were studied. After data extraction from the national LT database, 2,025 patients were identified and classified according to six groups: single tumor entering DS, single tumor not entering DS, multiple tumors, no curative treatment, untreatable HCC or T1 tumors. Kaplan-Meier estimates of the 18-month risk of dropout for death, too sick to be transplanted or tumor progression before LT, 5-year post-LT HCC recurrence and post-LT survival rates were compared. RESULTS: Median waiting-time in the DS group was 910 days. Pre-LT dropout probability was significantly lower in the DS group compared to other groups (13% vs. 19%, p = 0.0043) and significantly higher in the T1 group (25.4%, p = 0.05). Post-LT HCC recurrence rate in the multiple nodules group was significantly higher (19.6%, p = 0.019), while 5-year post-LT survival did not differ among groups and was 74% in the DS group (p = 0.22). CONCLUSION: The DELTA-HCC study shows that DS does not negatively impact either pre- nor post-LT patient outcomes, and has the potential to allow for redistribution of organs to patients in more urgent need of LT. It can reasonably be proposed and pursued. The unexpectedly high risk of dropout in T1 patients seems related to the MELD-based offering rules underserving this subgroup. IMPACTS AND IMPLICATIONS: To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy was adopted in France in 2015. It involves postponing LT until recurrence in patients listed for any single HCC curatively treated by surgical resection or thermal ablation. The DELTA-HCC study was conducted to evaluate this nationwide strategy. It shows in a European LT program that delayed strategy does not negatively impact pre- nor post-LT patient outcomes and is relevant to up to 20% of LT candidates; thus, it could potentially enable the redistribution of organs to patients in more urgent need of LT. Such a delayed strategy can reasonably be pursued and extended to other LT programs. Of note, an unexpectedly high risk of dropout in T1 patients, seemingly related to MELD-based offering rules which underserve these patients, calls for further scrutinization and revision of allocation rules in this subgroup.

Impact of removing donation service area and region from pancreas allocation.

On March 15, 2021, the Organ Procurement and Transplantation Network (OPTN) replaced donation service area (DSA) and OPTN region as units of pancreas (PA) allocation with a 250 nautical mile (NM) circle with proximity points. We analyzed OPTN data for kidney-pancreas (KP) and PA candidates, transplants, and donors in the 2 years pre-policy (March 16, 2019, to March 14, 2021) and post-policy (March 15, 2021, to March 14, 2023). As expected, more transplants occurred at hospitals outside the recovering organ procurement organization's DSA post-policy (KP: 32.1% vs 57.3%, P < .001; PA: 61.6% vs 69.3%, P = .09), but the majority stayed within 250 NM (KP: 79.7% vs 85.0%, P < .001; PA: 55.4% vs 61.5%, P = .19). Median preservation time increased from 9.5 to 10.3 hours for KP (P < .001); there was little change for PA (8.5 vs 8.6 hours; P = .99). There were no statistically significant differences in 1-year posttransplant patient mortality or graft failure after implementation for KP (mortality: 3.6% vs 3.2%, P = .60; kidney graft failure: 4.9% vs 5.0%, P = .95; PA graft failure: 9.5% vs 8.9%, P = .65) or PA (mortality: 1.7% vs 2.2%, P = .72; PA graft failure: 12.2% vs 12.6%, P = .88). The removal of DSA and OPTN region from PA allocation has resulted in broader distribution with minimal impact on preservation time or posttransplant outcomes.

Impact of the Kidney Allocation Revision on Access to Kidney Transplantation and Outcomes in the United States.

BACKGROUND: The 2014 Kidney Allocation System (KAS) revision aimed to enhance equity in organ allocation and improve patient outcomes. This study assesses the impacts of the KAS revision on renal transplantation demographics and outcomes in the United States. METHODS: We conducted a retrospective study utilizing the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) database from 1998 to 2022. We compared recipient and donor characteristics, and outcomes (graft failure and recipient survival) pre- and post-KAS revision. RESULTS: Post-KAS, recipients were significantly older (53 vs 48, P < .001) with an increase in Medicaid beneficiaries (7.3% vs 5.5%, P < .001). Despite increased graft survival, HR = .91 (95% CI 0.80-.92, P < .001), overall recipient survival decreased, HR = 1.06 (95% CI 1.04-1.09, P < .001). KAS revision led to greater racial diversity among recipients and donors, enhancing equity in organ allocation. However, disparities persist in graft failure rates and recipient survival across racial groups. DISCUSSION: The 2014 Kidney Allocation System revision has led to important changes in the renal transplantation landscape. While progress has been made towards increasing racial equity in organ allocation, further refinements are needed to address ongoing disparities. Recognizing the changing patient profiles and socio-economic factors will be crucial in shaping future policy modifications.

Smart match: revolutionizing organ allocation through artificial intelligence.

In this transformative era of organ transplantation, integrating Smart Match and artificial intelligence (AI) emerges as a pivotal advancement, revolutionizing organ allocation processes. Smart Match employs AI algorithms, enhancing organ matching precision and optimizing transplantation outcomes. Leveraging machine learning addresses complexities in donor-recipient pairing, immunosuppression management, and post-operative care, promising to minimize waitlist mortality and improve patient wellbeing. The multifaceted potential of Smart Match lies in its ability to not only streamline current practices but also pave the way for future innovations in solid organ transplantation. As technology continues to evolve, the collaboration between Smart Match and AI exemplifies a beacon of progress, promising increased efficiency, equitable organ distribution, and improved patient care. This article delves into the paradigm shift facilitated by Smart Match and AI, emphasizing their transformative impact on the landscape of organ allocation and patient outcomes.

Effect of the opioid crisis on the liver transplantation donor pool: A national analysis.

BACKGROUND: Over the last decade there has been a surge in overdose deaths due to the opioid crisis. We sought to characterize the temporal change in overdose donor (OD) use in liver transplantation (LT), as well as associated post-LT outcomes, relative to the COVID-19 era. METHODS: LT candidates and donors listed between January 2016 and September 2022 were identified from the Scientific Registry of Transplant Recipients database. Trends in LT donors and changes related to OD were assessed pre- versus post-COVID-19 (February 2020). RESULTS: Between 2016 and 2022, most counties in the United States experienced an increase in overdose-related deaths (n = 1284, 92.3%) with many counties (n = 458, 32.9%) having more than a doubling in drug overdose deaths. Concurrently, there was an 11.2% increase in overall donors, including a 41.7% increase in the number of donors who died from drug overdose. In pre-COVID-19 overdose was the 4th top mechanism of donor death, while in the post-COVID-19 era, overdose was the 2nd most common cause of donor death. OD was younger (OD: 35 yrs, IQR 29-43 vs. non-OD: 43 yrs, IQR 31-56), had lower body mass index (≥35 kg/cm2, OD: 31.2% vs. non-OD: 33.5%), and was more likely to be HCV+ (OD: 28.9% vs. non-OD: 5.4%) with lower total bilirubin (≥1.1 mg/dL, OD: 12.9% vs. non-OD: 20.1%) (all p < .001). Receipt of an OD was not associated with worse graft survival (HR .94, 95% CI .88-1.01, p = .09). CONCLUSIONS: Opioid deaths markedly increased following the COVID-19 pandemic, substantially altering the LT donor pool in the United States.

OPTN/SRTR 2022 Annual Data Report: Lung.

For the first time since the COVID-19 pandemic, the annual number of lung transplants performed in the United States increased. The year 2022, encompassed in this report, marks the last full calendar year where the Lung Allocation Score was used for ranking transplant candidates based on their estimated transplant benefit and donor lung allocation in the United States. In March 2023, a major change in transplant allocation policy occurred with the implementation of the Composite Allocation Score. Transplant rates have increased over the past decade, although there is variability among age, diagnosis, racial and ethnic, and blood groups. Over half of candidates received a lung transplant within 3 months of placement on the waiting list, with nearly 75% of candidates accessing transplant by 1 year. Pretransplant mortality rates remained stable, with approximately 13% of lung transplant candidates dying or being removed from the waiting list within a year of listing. Posttransplant survival remained stable; however, variability exists by age, diagnosis, and racial and ethnic groups.

Do Infectious Diseases After Kidney Retransplantation Differ From Those After First Kidney Transplantation?

Background: Infectious diseases (IDs) are highly relevant after solid organ transplantation in terms of morbidity and mortality, being among the most common causes of death. Patients undergoing kidney retransplantation (re-K-Tx) have been already receiving immunosuppressive therapy over a prolonged period, potentially facilitating subsequent infections. Comparing ID events after re-K-Tx and first kidney transplantation (f-K-Tx) can delineate patterns and risks of ID events associated with prolonged immunosuppression. Methods: We included adult patients with records on f-K-Tx and re-K-Tx in the Swiss Transplant Cohort Study. We analyzed ID events after f-K-Tx and re-K-Tx within the same patients and compared infection rates, causative pathogens, and infection sites. Recurrent time-to-event analyses were performed for comparison of infection rates. Results: A total of 59 patients with a median age of 47 years (range, 18-73) were included. Overall, 312 ID events in 52 patients occurred. In multivariable recurrent event modeling, the rate of ID events was significantly lower after re-K-Tx (hazard ratio, 0.70; P = .02). More bacterial (68.9% vs 60.4%) and fungal (4.0% vs 1.1%) infections were observed after f-K-Tx but fewer viral infections (27.0% vs 38.5%) as compared with re-K-Tx (P = .11). After f-K-Tx, urinary and gastrointestinal tract infections were more frequent; after re-K-Tx, respiratory tract and surgical site infections were more frequent (P < .001). Conclusions: ID events were less frequent after re-K-Tx. Affected sites differed significantly after f-K-Tx vs re-K-Tx.

The impact of high volumes of COVID-related lung transplant on waitlist mortality for non-COVID candidates in the United States.

Some patients with coronavirus disease 19 (COVID) develop serious, irreversible lung disease, including acute respiratory distress syndrome or pulmonary fibrosis. For select candidates, lung transplant is the only option to improve quality and length of life. Because of the severity of end-stage COVID-related lung disease, these candidates receive high allocation priority in the United States, including higher priority than many patients without COVID-related lung disease. This study assessed whether transplant centers with a large volume of COVID-related lung transplants experienced an increase in waitlist mortality for non-COVID transplant candidates. Nineteen centers were included as high-volume programs, defined as being in the top third of centers who transplanted COVID patients. Of the 2867 non-COVID patients waitlisted at these centers, there was no significant difference in waitlist mortalities of non-COVID transplant candidates between the pre-COVID transplant era (January 2018-February 2020) and during the period of high COVID transplant volume (March 2020-October 2022) (subhazard ratio: .92 [95% CI = .81-1.05], p = .22). Among high volume centers, the decision to transplant and to prioritize patients with COVID-related lung disease did not significantly impact the waitlist mortality of other candidates.