Perpetuating Disparity: Failure of the Kidney Transplant System to Provide the Most Kidney Transplants to Communities With the Greatest Need.

BACKGROUND: The burden of end-stage kidney disease (ESKD) and kidney transplant rates vary significantly across the United States. This study aims to examine the mismatch between ESKD burden and kidney transplant rates from a perspective of spatial epidemiology. METHODS: US Renal Data System data from 2015 to 2017 on incident ESKD and kidney transplants per 1000 incident ESKD cases was analyzed. Clustering of ESKD burden and kidney transplant rates at the county level was determined using local Moran's I and correlated to county health scores. Higher percentile county health scores indicated worse overall community health. RESULTS: Significant clusters of high-ESKD burden tended to coincide with clusters of low kidney transplant rates, and vice versa. The most common cluster type had high incident ESKD with low transplant rates (377 counties). Counties in these clusters had the lowest overall mean transplant rate (61.1), highest overall mean ESKD incidence (61.3), and highest mean county health scores percentile (80.9%, P <0.001 vs all other cluster types). By comparison, counties in clusters with low ESKD incidence and high transplant rates (n=359) had the highest mean transplant rate (110.6), the lowest mean ESKD incidence (28.9), and the lowest county health scores (20.2%). All comparisons to high-ESKD/low-transplant clusters were significant at P value <0.001. CONCLUSION: There was a significant mismatch between kidney transplant rates and ESKD burden, where areas with the greatest need had the lowest transplant rates. This pattern exacerbates pre-existing disparities, as disadvantaged high-ESKD regions already suffer from worse access to care and overall community health, as evidenced by the highest county health scores in the study.

Clinical Pig Kidney Xenotransplantation: How Close Are We?

Patients with ESKD who would benefit from a kidney transplant face a critical and continuing shortage of kidneys from deceased human donors. As a result, such patients wait a median of 3.9 years to receive a donor kidney, by which time approximately 35% of transplant candidates have died while waiting or have been removed from the waiting list. Those of blood group B or O may experience a significantly longer waiting period. This problem could be resolved if kidneys from genetically engineered pigs offered an alternative with an acceptable clinical outcome. Attempts to accomplish this have followed two major paths: deletion of pig xenoantigens, as well as insertion of "protective" human transgenes to counter the human immune response. Pigs with up to nine genetic manipulations are now available. In nonhuman primates, administering novel agents that block the CD40/CD154 costimulation pathway, such as an anti-CD40 mAb, suppresses the adaptive immune response, leading to pig kidney graft survival of many months without features of rejection (experiments were terminated for infectious complications). In the absence of innate and adaptive immune responses, the transplanted pig kidneys have generally displayed excellent function. A clinical trial is anticipated within 2 years. We suggest that it would be ethical to offer a pig kidney transplant to selected patients who have a life expectancy shorter than the time it would take for them to obtain a kidney from a deceased human donor. In the future, the pigs will also be genetically engineered to control the adaptive immune response, thus enabling exogenous immunosuppressive therapy to be significantly reduced or eliminated.

Redefining the Influence of Ethnicity on Simultaneous Kidney and Pancreas Transplantation Outcomes: A 15-year Single-center Experience.

OBJECTIVE: To examine the largest single-center experience of simultaneous kidney/pancreas transplantation (SPK) transplantation among African-Americans (AAs). BACKGROUND: Current dogma suggests that AAs have worse survival following SPK than white recipients. We hypothesize that this national trend may not be ubiquitous. METHODS: From August 30, 1999, through October 1, 2014, 188 SPK transplants were performed at the University of Alabama at Birmingham (UAB) and 5523 were performed at other US centers. Using Kaplan-Meier survival estimates and Cox proportional hazards regression, we examined the influence of recipient ethnicity on survival. RESULTS: AAs comprised 36.2% of the UAB cohort compared with only 19.1% nationally (P < 0.01); yet, overall, 3-year graft survival was statistically higher among UAB than US cohort (kidney: 91.5% vs 87.9%, P = 0.11; pancreas: 87.4% vs 81.3%; P = 0.04, respectively) and persisted on adjusted analyses [kidney adjusted hazard ratio (aHR): 0.58, 95% confidence interval (95% CI) 0.35-0.97, P = 0.04; pancreas aHR: 0.54, 95% CI 0.34-0.85, P = 0.01]. Among the UAB cohort, graft survival did not differ between AA and white recipients; in contrast, the US cohort experienced significantly lower graft survival rates among AA than white recipients (kidney 5 years: 76.5% vs 82.3%, P < 0.01; pancreas 5 years: 72.2% vs 76.3%, P = 0.01; respectively). CONCLUSION: Among a single-center cohort of SPK transplants overrepresented by AAs, we demonstrated similar outcomes among AA and white recipients and better outcomes than the US experience. These data suggest that current dogma may be incorrect. Identifying best practices for SPK transplantation is imperative to mitigate racial disparities in outcomes observed at the national level.

Alemtuzumab induction in renal transplantation.

BACKGROUND: There are few comparisons of antibody induction therapy allowing early glucocorticoid withdrawal in renal-transplant recipients. The purpose of the present study was to compare induction therapy involving alemtuzumab with the most commonly used induction regimens in patient populations at either high immunologic risk or low immunologic risk. METHODS: In this prospective study, we randomly assigned patients to receive alemtuzumab or conventional induction therapy (basiliximab or rabbit antithymocyte globulin). Patients were stratified according to acute rejection risk, with a high risk defined by a repeat transplant, a peak or current value of panel-reactive antibodies of 20% or more, or black race. The 139 high-risk patients received alemtuzumab (one dose of 30 mg, in 70 patients) or rabbit antithymocyte globulin (a total of 6 mg per kilogram of body weight given over 4 days, in 69 patients). The 335 low-risk patients received alemtuzumab (one dose of 30 mg, in 164 patients) or basiliximab (a total of 40 mg over 4 days, in 171 patients). All patients received tacrolimus and mycophenolate mofetil and underwent a 5-day glucocorticoid taper in a regimen of early steroid withdrawal. The primary end point was biopsy-confirmed acute rejection at 6 months and 12 months. Patients were followed for 3 years for safety and efficacy end points. RESULTS: The rate of biopsy-confirmed acute rejection was significantly lower in the alemtuzumab group than in the conventional-therapy group at both 6 months (3% vs. 15%, P<0.001) and 12 months (5% vs. 17%, P<0.001). At 3 years, the rate of biopsy-confirmed acute rejection in low-risk patients was lower with alemtuzumab than with basiliximab (10% vs. 22%, P=0.003), but among high-risk patients, no significant difference was seen between alemtuzumab and rabbit antithymocyte globulin (18% vs. 15%, P=0.63). Adverse-event rates were similar among all four treatment groups. CONCLUSIONS: By the first year after transplantation, biopsy-confirmed acute rejection was less frequent with alemtuzumab than with conventional therapy. The apparent superiority of alemtuzumab with respect to early biopsy-confirmed acute rejection was restricted to patients at low risk for transplant rejection; among high-risk patients, alemtuzumab and rabbit antithymocyte globulin had similar efficacy. (Funded by Astellas Pharma Global Development; INTAC ClinicalTrials.gov number, NCT00113269.).

Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation.

INTRODUCTION: Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming. RESEARCH QUESTION: We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability. DESIGN: Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program. Surveys were linked at the participant-level to the Centers for Disease Control and Prevention Social Vulnerability Index and county health rankings and overall social vulnerability and subthemes, individual barriers, telehealth capabilities/ knowledge, interest, and ability to participate were assessed utilizing nonparametric Wilcoxon ranks sums tests, chi-square, and Fisher's exact tests. RESULTS: Participants indicating distance as a barrier to participation in navigator programming lived approximately 82 miles farther from our center. Disinterested participants lived in areas with the highest social vulnerability, higher physical inactivity rates, lower college education rates, and higher uninsurance (lack of insurance) and unemployment rates. Similarly, participants without a computer, who never heard of telehealth, and who were not encouraged to participate in telehealth resided in areas of highest social vulnerability. CONCLUSION: These data suggest geography combined with being from under-resourced areas with high social vulnerability was negatively associated with health care engagement. Geography and poverty may be surrogates for lower health literacy and fewer health care interactions.

Self-advocacy is associated with lower likelihood of living donor kidney transplantation.

BACKGROUND: The Living Donor Navigator (LDN) Program pairs kidney transplant candidates (TC) with a friend or family member for advocacy training to help identify donors and achieve living donor kidney transplantation (LDKT). However, some TCs participate alone as self-advocates. METHODS: In this retrospective cohort study of TCs in the LDN program (04/2017-06/2019), we evaluated the likelihood of LDKT using Cox proportional hazards regression and rate of donor screenings using ordered events conditional models by advocate type. RESULTS: Self-advocates (25/127) had lower likelihood of LDKT compared to patients with an advocate (adjusted hazard ratio (aHR): 0.22, 95% confidence interval (CI): 0.03-1.66, p = 0.14). After LDN enrollment, rate of donor screenings increased 2.5-fold for self-advocates (aHR: 2.48, 95%CI: 1.26-4.90, p = 0.009) and 3.4-fold for TCs with an advocate (aHR: 3.39, 95%CI: 2.20-5.24, p < 0.0001). CONCLUSIONS: Advocacy training was beneficial for self-advocates, but having an independent advocate may increase the likelihood of LDKT.

Obesity as an isolated contraindication to kidney transplantation in the end-stage renal disease population: A cohort study.

OBJECTIVE: The aim of this study was to characterize end-stage renal disease (ESRD) patients with obesity as their only contraindication to listing and to quantify wait-list and transplant access. METHODS: Using the US Renal Data System, a retrospective cohort study of incident dialysis cases (2012 to 2014) was performed. The primary outcomes were time to wait-listing and time to transplantation. RESULTS: Of 157,572 dialysis patients not already listed, 39,844 had BMI as their only demonstrable transplant contraindication. They tended to be younger, female, and Black. Compared with patients with BMI < 35, those with BMI 35 to 39.9, 40 to 44.9, and ≥45 were, respectively, 15% (adjusted hazard ratio [aHR] 0.85; 95% CI: 0.83-0.88; p < 0.001), 45% (aHR 0.55; 95% CI: 0.52-0.57; p < 0.001), and 71% (aHR 0.29; 95% CI: 0.27-0.31; p < 0.001) less likely to be wait-listed. Wait-listed patients with BMI 35 to 39.9 were 24% less likely to achieve transplant (aHR 0.76; 95% CI: 0.72-0.80; p < 0.0001), BMI 40 to 44.9 were 21% less likely (aHR 0.79; 95% CI: 0.72-0.86; p < 0.0001), and BMI ≥ 45 were 15% less likely (aHR 0.85; 95% CI: 0.75-0.95; p = 0.004) compared with patients with BMI < 35. CONCLUSIONS: Obesity was the sole contraindication to wait-listing for 40,000 dialysis patients. They were less likely to be wait-listed. For those who were, they had a lower likelihood of transplant. Aggressive weight-loss interventions may help this population achieve wait-listing and transplant.

Enhanced Advocacy and Health Systems Training Through Patient Navigation Increases Access to Living-donor Kidney Transplantation.

BACKGROUND: To date, no living donation program has simultaneously addressed the needs of both transplant candidates and living donors by separating the advocacy role from the candidate and improving potential donor comfort with the evaluation process. We hypothesized that the development of a novel program designed to promote both advocacy and systems training among transplant candidates and their potential living kidney donors would result in sustained increases in living-donor kidney transplantation (LDKT). To this end, we developed and implemented a Living Donor Navigator (LDN) Program at the University of Alabama at Birmingham. METHODS: We included adult patients awaiting kidney-only transplant in a retrospective cohort analysis. Using time-varying Cox proportional hazards regression, we explored likelihood of living donor screening and approval by participation in the LDN program. RESULTS: There were 56 LDN participants and 1948 nonparticipants (standard of care). LDN was associated with a 9-fold increased likelihood of living donor screenings (adjusted hazard ratio, 9.27; 95% confidence interval, 5.97-14.41, P < 0.001) and a 7-fold increased likelihood of having an approved living donor (adjusted hazard ratio, 7.74; 95% confidence interval, 3.54-16.93; P < 0.001) compared with the standard of care. Analyses by participant race demonstrated higher likelihood of screened donors and a similar likelihood of having an approved donor among African Americans compared with Caucasians. CONCLUSIONS: These data suggest that both advocacy and systems training are needed to increase actual LDKT rates, and that LDN programs may mitigate existing racial disparities in access to LDKT.

Maximizing renal artery length in right laparoscopic donor nephrectomy by retrocaval exposure of the aortorenal junction.

Laparoscopic donor nephrectomy (LDN) has become the standard of care at increasing numbers of renal transplant programs worldwide. As in open donor nephrectomy, the left kidney has remained the preferred organ for LDN because of the greater renal vessel lengths. Currently, the overwhelming majority of donor operations are performed on the left kidney. This disparity may be due to an unfamiliarity with the technique of right LDN and technical difficulties encountered in obtaining adequate arterial and venous vessel lengths. Modifications in the laparoscopic technique have increased the length of the renal vein obtained from either side; however, further techniques are needed to maximize the length of the right renal artery in LDN. Herein the authors present a technique to provide exposure of the right aortorenal junction that provides maximal length of the right renal artery. This technique has currently been used in 20 consecutive right LDN operations without vascular complications or technical graft losses.

Recurrence risk after organ transplantation in patients with a history of Hodgkin disease or non-Hodgkin lymphoma.

This study defines the incidence and recurrence risk of Hodgkin disease (HD) and non-Hodgkin lymphoma (NHL) after organ transplant. Patients from the United States with a history of HD or NHL before organ transplantation reported to the Israel Penn International Transplant Tumor Registry from 1968 to 2001 were analyzed. A total of 91 patients underwent organ transplantation with a lymphoma history: HD (38 patients) and NHL (53 patients). Median disease-free interval pretransplant was 99 (range 0-459.1) months, and median follow-up posttransplant was 25.7 (0.4-131.1) months. Ten patients were excluded from further analysis because of lack of follow-up information (n=9) or they never achieved remission (n=1). Recurrence incidence was 8 of 81 patients (10%) (HD=3/34 [9%] vs. NHL=5/47 [11%]). Gender, race, allograft type and source, age at lymphoma diagnosis, and immunosuppression did not influence recurrence. Patients with less than a 2-year period between diagnosis and transplant seem to be at increased risk of relapse. Median disease-free interval before transplant was longer for patients without recurrence (115 vs. 30.2 months, P=0.24), but was not statistically significant. Median time to recurrence posttransplant was 18.7 (range 1.9-82.2) months (HD=3.7 vs. NHL 23.6 months, P=0.10). Survival after recurrence was poor (HD [1/3] and NHL [1/5], median survival 6.8 [range 0-22.1] months). There is no difference in recurrence rates for HD and NHL. The outcome for recurrent lymphoma is poor. The low risk of recurrence (10%) indicates that preexisting HD and NHL need not be an absolute contraindication to transplantation.

Donors with central nervous system malignancies: are they truly safe?

BACKGROUND: In an era of organ shortage, the use of expanded or marginal donors has been attempted to increase transplantation rates and diminish waiting list mortality. One strategy is the use of organs from patients with a history of or active central nervous system (CNS) tumor. METHODS: Sixty-two recipients were identified as the recipients of organs from donors with a history of or active CNS malignancy. Patient demographics, donor tumor management, incidence of tumor transmission, and patient survival were examined. RESULTS: Of the organs recovered and transplanted from donors with astrocytoma, 14 were associated with at least one risk factor including high-grade tumor (n=4), prior surgery (n=5), radiation therapy (n=4), and systemic chemotherapy (n=4). One tumor transmission was identified at 20 months posttransplant with the patient expiring from metastatic disease. Twenty-six organs were transplanted from glioblastoma patients with 15 demonstrating risk factors including high-grade tumor (n=9) and prior surgery (n=10). Eight transmissions were identified with a range of 2 to 15 months posttransplant, with seven patients dying as the result of metastatic disease. Seven organs were used from donors with a medulloblastoma. Three transmissions were identified at a range of 5 to 7 months, all associated with ventriculoperitoneal shunts. Two medulloblastoma recipients died as the result of metastatic disease, whereas the third is alive with diffuse disease. The rate of donor tumor transmission, in the absence of risk factors, was 7%, whereas in the presence of one or more risk factor this rate dramatically rose to 53% (P<0.01). CONCLUSIONS: Organs from donors with CNS tumors can be used with a low risk of donor tumor transmission in the absence of the following risk factors: high-grade tumors, ventriculoperitoneal or ventriculoatrial shunts, prior craniotomy, and systemic chemotherapy.

MALToma: a Helicobacter pylori-associated malignancy in transplant patients: a report from the Israel Penn International Transplant Tumor Registry with a review of published literature.

BACKGROUND: Mucosa-associated lymphoid tissue lymphoma (MALToma) is a Helicobacter pylori-related tumor of B-cell origin, the malignant potential for which remains to be defined in immunosuppressed patients. METHODS: Review of the Israel Penn International Transplant Tumor Registry identified six cases of gastric MALToma. Patient demographics, management, and outcomes were compared and published literature was reviewed. RESULTS: MALToma developed in six transplant recipients (three kidney, two heart, one kidney-pancreas). All were treated with immunosuppression minimization and therapy for H. pylori, resulting in disease regression in five patients. One patient developed progression to high-grade MALToma despite documented H. pylori eradication, required surgery and chemotherapy, and died, with significant disease at autopsy. CONCLUSIONS: Treatment of MALToma with immunosuppression minimization and anti-H. pylori therapy results in a majority of patients becoming disease free. Observation of malignant degeneration into an aggressive, high-grade lymphoma in one patient indicates the malignant potential. Diligent follow-up of these patients with endoscopy and biopsy is therefore indicated.

Right donor nephrectomy: a comparison of hand-assisted transperitoneal and retroperitoneal laparoscopic approaches.

BACKGROUND: We compare the anatomic and functional outcomes of right live-donor nephrectomy (LDN) using either a hand-assisted approach (HALDN) or a pure retroperitoneoscopic approach (RLDN) in two institutions. PATIENTS AND METHODS: Data were recorded prospectively in 59 patients undergoing right LDN using either hand-assisted (n=31) or pure retroperitoneoscopic (n=28) approaches. All HALDN cases were performed at the University of Cincinnati, and all RLDN cases were performed at the Cleveland Clinic Foundation. RESULTS: Demographics were similar with respect to age (41.1+/-11.5 vs. 44.5+/-8.5 years) and human leukocyte antigen mismatches (2.7+/-1.8 vs. 2.6+/-1.6). Operative times were longer for HALDN (3.4+/-0.7 vs. 3.0+/-0.7 hours, P <0.04), whereas warm ischemia time was shorter (3:55+/-1:47 vs. 4:55+/-0:55 minutes, P <0.001). Length of renal vein and artery were equivalent (2.4/3.4 vs. 2.3/3.2 cm, P =0.5). Complication rates were similar (10% vs. 7%, P =0.5), including conversion to open surgery (n=1), accessory upper pole artery transection (n=1), and swollen testicle (n=1) in the HALDN group, and a small parenchymal injury (n=1) and a capsular tear (n=1) in the RLDN group. Donor length of stay and convalescence were similar in both groups (43.5+/-14.1 vs. 45.7+/-25.3 hours, P =0.1; convalescence 23.5+/-5.3 vs. 20.2+/-4.1 days, P =0.5). One-week, 1-month, and 1-year serum creatinine levels were equivalent with both approaches. No grafts were lost in either group. CONCLUSIONS: This study confirms that the HALDN and RLDN techniques can provide kidney grafts with equivalent-length vessels and excellent function.

Experience with 274 cardiac transplant recipients with posttransplant lymphoproliferative disorder: a report from the Israel Penn International Transplant Tumor Registry.

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication that occurs in a small but significant minority of solid organ transplant recipients. Published experiences with PTLD in cardiac transplant recipients are limited to relatively small single-center reports. METHODS: This report presents experience with 274 cases of PTLD in cardiac transplant recipients reported to the Israel Penn International Transplant Tumor Registry (IPITTR). RESULTS: PTLD carried an ominous prognosis: Kaplan Meier survival after PTLD diagnosis was 45%, 33%, 30%, and 13%, respectively, at 1, 3, 5, and 10 years. Common causes of death included: PTLD, cardiovascular collapse, and infection; all occurred at a median of less than 6 months. Risk of death from cardiovascular collapse secondary to immunosuppression withdrawal was substantial (28%), indicating that a fine balance exists between death from PTLD and from sudden cardiac death due to acute rejection. PTLD therapy in the majority of patients consisted of combination therapy (49%). Survival in patients receiving immunosuppression minimization (ISM) alone was 32%, with ISM plus other therapy was 27%, and with other therapies not containing ISM was 11% (P < 0.01). CONCLUSION: PTLD in cardiac transplant recipients is associated with low long-term survival rates. Analysis of PTLD therapies and outcomes suggest that immunosuppression minimization, when applied, improves survival. However, risk of sudden death may mitigate the positive effect of ISM. This observation has important implications for ISM in PTLD therapy in cardiac transplant recipients. Carefully designed prospective studies are needed to evaluate the positive and negative effects of ISM in cardiac transplant recipients with PTLD.

Incidental diagnosis of gastric cancer in transplant recipients improves patient survival.

BACKGROUND: Gastric cancer in the United States is often diagnosed at advanced stages, resulting in dismal outcomes. In the immunosuppressed transplant recipient population, little is known about the clinical staging and outcome of these compromised patients. METHODS: All US cases reported to the Israel Penn International Transplant Tumor Registry were retrospectively examined for patient demographics, immunosuppressive therapy, tumor characteristics, therapeutic modalities, and mortality. Statistical analysis was performed with Students t test, chi-square analysis, and log-rank analysis by the method of Kaplan-Meier. RESULTS: Gastric cancer was identified in 34 recipients: 28 (82%) were male; 24 (71%) were white. Mean age at diagnosis was 58 +/- 11 years. Twenty-four (71%) patients received kidney transplants, 7 (21%) received heart transplants, and 3 (9%) received liver transplants. Fifty percent received induction therapy, whereas 94% were maintained on calcineurin inhibitors and corticosteroids. Thirty-five percent of patients were diagnosed during evaluation for gastrointestinal symptoms, with the remaining cases discovered incidentally during endoscopy (53%) or during computed tomography (12%) performed for other reasons. Stage varied at presentation as follows: stage I (n = 6), stage II (n = 11), stage III (n = 13), and stage IV (n = 4). Incidental diagnoses resulted in a lower stage malignancy (P <.001) and greater 1-year and 5-year survivals (P <.05) compared with those patients whose were diagnosed after being evaluated of gastrointestinal symptoms. CONCLUSION: In the United States, because gastric cancer in the transplant recipient is frequently identified at an earlier stage (50% were stages I and II) than in the general population, survivals are equivalent despite continued administration of immunosuppression. This early identification may be attributed to more frequent presymptom diagnosis and staging, resulting from incidental detection of these malignancies during posttransplant upper endoscopy or computed tomography. Early detection has resulted in a 29% 5-year survival for the entire transplant recipient group compared with a 5% to 15% 5-year survival in the general population.

The role of immunosuppression in lymphoma.

Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized yet serious complication in solid organ transplant recipients and currently represents the second most common de novo malignancy following solid organ transplantation. PTLD has been noted in all transplant immunosuppressive eras including the pre-cyclosporine, cyclosporine, and post-cyclosporine eras. The time from organ transplantation to PTLD presentation varies widely from less than 1 month to several years. PTLD presents with a broad spectrum of clinical manifestations depending on the transplanted organ, immunosuppressive therapy and patient age. Intense immunosuppressive therapy is a major risk factor for development of PTLD. Whenever a new agent is introduced, there is a learning curve that leads to dosing modifications, which in turn result in optimization of its immunosuppressive efficacy and reduction of toxicities, including PTLD. We review the major historical and recent immunosuppression trials to assess the impact of individual immunosuppressive agents and regimens on PTLD risk.

Donor transmitted malignancies.

Early experiences in transplantation, which pre-dated brain death laws, utilized organs from donors with active malignancies. The use of organs from such donors occasionally resulted in the transmission of malignancy from the donor to an unknowing recipient. Over a period of three decades, Israel Penn, M. D. catalogued some two hundred and fifty cases of organs transplanted from donors with a history of malignancy; carefully examining each reported case for tumor histology, donor risk factors, method of tumor presentation and recipient outcome. Some recipients never developed malignancies, while others were less fortunate, developing cancers that were suspicious for donor origin. The evolution of transplantation has resulted in improved patient survival, which in turn has led to an increased demand for organ transplantation. Unfortunately, the supply of organs available for transplantation has failed to keep pace with the demand, with the worldwide deficit growing annually. In an effort to bridge the widening gap, utilization of older and more marginal donors has been suggested. However, use of older donors is accompanied by the likelihood that a significant proportion may have undiagnosed malignancies. Multiple transplant programs have considered the use of donors with tumors of non-malignant or even low-grade malignant histology, most often involving the central nervous system (CNS). According to a survey from the United Network for Organ Sharing (UNOS), central nervous system malignancies are among the most commonly identified malignancies found in potential donors. This study examines the distribution of potential donor transmitted malignancies reported to the Israel Penn International Transplant Tumor Registry. The incidence of tumor transmission is examined in the overall group as well as among individual histologies. We also seek to identify specific factors associated with the risk of malignancy transmission from donor to recipient, in an effort to minimize future transmission of donor tumors to unwitting recipients. The study is based on voluntary registry data, which some argue can be criticized for a lack of true incidence data. In reality, however, this data may provide a more accurate insight since it is based on transmissions from high-risk donors rather than from the general population.