Life-Threatening Hematuria as Initial Presentation of a Complicated Transplant Renal Artery Pseudoaneurysm.

In this case report, we describe the clinical course of a complicated transplant renal artery (TRA) pseudoaneurysm, clinically featured by gross and massive hematuria one month after a kidney transplant was performed on a 50 year-old male patient. TRA pseudoaneurysm is a rare but potentially life-threatening complication that may result in bleeding, infection, graft dysfunction/loss, lower limb ischemia/loss, hemorrhagic shock, and death. TRA pseudoaneurysm treatment remains challenging as it needs to be tailored to the patient characteristics including hemodynamic stability, graft function, anatomy, presentation, and pseudoaneurysm features. This publication discusses the clinical scenario of massive gross hematuria that derived from a retroperitoneal hematoma which originated from an actively bleeding TRA pseudoaneurysm. This case highlights the combined approach of endovascular stent placement and subsequent transplant nephrectomy as a last resort in the management of intractable bleeding from a complicated TRA pseudoaneurysm. To the best of our knowledge, this is the first published case report of an actively bleeding TRA anastomotic pseudoaneurysm that caused a massive retroperitoneal bleed that in turn evacuated via the bladder after disrupting the ureter-to-bladder anastomosis. A temporizing hemostatic arterial stent placed percutaneously allowed for a safer and controlled emergency transplant nephrectomy.

A randomized trial of continuous glucose monitoring to improve post-transplant glycemic control.

INTRODUCTION: This study examines whether the use of inpatient Continuous Glucose Monitors provides improved glycemic control over finger-stick glucose monitoring post-transplant. METHODS: This is a single-site, prospective randomized controlled trial of 40 patients receiving conventional finger-stick glucose monitoring or continuous monitoring using the Medtronic Guardian Sensor 3 during the first 5 days post-transplant. Included patients were adult renal transplant recipients with a diagnosis of diabetes. Assessed endpoints included post-transplant daily median glucose level, hyperglycemic (≥180 mg/dL) and hypoglycemic (≤80 mg/dL) episodes, number of post-transplant bacterial infections and length of stay. RESULTS: Groups were well matched in demographic variables. Median daily glucose was significantly lower in the intervention group. There were also significantly less episodes of hyperglycemia on postoperative days 2, 3, 4, and 5. There were no differences in the incidences of hypoglycemia, postoperative bacterial infections, or length of stay. CONCLUSION: In this randomized study, the use of a continuous glucose monitor to guide post-transplant glucose management significantly lowered the incidence of hyperglycemic episodes and median glucose levels through the first 5 days post-transplant without increasing the number of hypoglycemic episodes. The use of these devices can be considered in the immediate post-renal transplant setting.

Transplant Onconephrology in Patients With Kidney Transplants.

Cancer is a leading cause of death in patients with kidney transplantation. Patients with kidney transplants are 10- to 200-times more likely to develop cancers after transplant than the general population, depending on the cancer type. Recent advances in cancer therapies have dramatically improved survival outcomes; however, patients with kidney transplants face unique challenges of immunosuppression management, cancer screening, and recurrence of cancer after transplant. Patients with a history of cancer tend to be excluded from transplant candidacy or are required to have long cancer-free wait time before wait-listing. The strategy of pretransplant wait time management may need to be revisited as cancer therapies improve, which is most applicable to patients with a history of multiple myeloma. In this review, we discuss several important topics in transplant onconephrology: the current recommendations for pretransplant wait times for transplant candidates with cancer histories, cancer screening post-transplant, post-transplant lymphoproliferative disorder, strategies for transplant patients with a history of multiple myeloma, and novel therapies for patients with post-transplant malignancies. With emerging novel cancer treatments, it is critical to have multidisciplinary discussions involving patients, caregivers, transplant nephrologists, and oncologists to achieve patient-oriented goals.

Outcomes of kidney transplantation in patients with myeloma and amyloidosis in the USA.

BACKGROUND: Recent improvement in treatment and patient survival has opened the eligibility of kidney transplantation to patients who developed end-stage kidney disease (ESKD) from plasma cell dyscrasias (PCDs). Data on clinical outcomes in this population are lacking. METHODS: We conducted a retrospective study of United Network for Organ Sharing/Organ Procurement and Transplantation Network dataset (2006-2018) to compare patient and graft outcomes of kidney transplant recipients with ESKD due to PCD versus other causes. RESULTS: Among 168 369 adult first kidney transplant recipients, 0.22-0.43% per year had PCD as the cause of ESKD. The PCD group had worse survival than the non-PCD group for both living and deceased donor types {adjusted hazard ratio [aHR] 2.24 [95% confidence interval (CI) 1.67-2.99] and aHR 1.40 [95% CI 1.08-1.83], respectively}. The PCD group had worse survival than the diabetes group, but only among living donors [aHR 1.87 (95% CI 1.37-2.53) versus aHR 1.16 (95% CI 0.89-1.2)]. Graft survival in patients with PCD were worse than non-PCD in both living and deceased donors [aHR 1.72 (95% CI 1.91-2.56) and aHR 1.30 (95% CI 1.03-1.66)]. Patient and graft survival were worse in amyloidosis but not statistically different in multiple myeloma compared with the non-PCD group. CONCLUSION: The study data are crucial when determining kidney transplant eligibility and when discussing transplant risks in patients with PCD.

The effect of race coefficients on preemptive listing for kidney transplantation.

Background: Race coefficients of estimated glomerular filtration rate (eGFR) formulas may be partially responsible for racial inequality in preemptive listing for kidney transplantation. Methods: We used the Scientific Registry of Transplant Recipients database to evaluate differences in racial distribution of preemptive listing before and after application of the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) race coefficients to all preemptively listed non-Black kidney transplant candidates (eGFR modulation). Odds of preemptive listing were calculated by race, with Black as the reference before and after eGFR modulation. Variables known to influence preemptive listing were included in the model. Results: Among 385 087 kidney-alone transplant candidates from 1 January 2010 to 2 December 2020, 118 329 (30.7%) candidates were identified as preemptively listed (71.7% White, 19% Black, 7.8% Asian, 0.6% multi-racial, 0.6% Native American and 0.3% Pacific Islander). After eGFR modulation, non-Black patients with an eGFR ≥20 mL/min/1.73 m2 were removed. Compared with Black candidates, the adjusted odds of preemptive listing for White candidates decreased from 2.01 [95% confidence interval (95% CI) 1.78-2.26] before eGFR modulation to 1.18 (95% CI 1.0-1.39; P = 0.046) with the MDRD and 1.37 (95% CI 1.18-1.58) with the CKD-EPI equations after adjusting for race coefficients. Conclusions: Removing race coefficients in GFR estimation formulas may result in a more equitable distribution of Black candidates listed earlier on a preemptive basis.

Simultaneous Liver-Kidney Transplantation.

End-stage kidney disease (ESKD) after liver transplantation is associated with high morbidity and mortality. This increase in mortality can be offset by performing a kidney transplant at the time of the liver transplant in select cases. Accordingly, Margreiter and colleague; s performed the first simultaneous liver-kidney (SLK) transplant in 1983. The number of SLK transplants has increased by more than 300% since then. In 1990%, 1.7% of all liver transplants in the United States were SLK transplants which increased to 9.9% by 2016. This steep increase was likely due to the implementation of the model of end-stage liver disease (MELD) scoring system in 2002, which is heavily weighted by serum creatinine.

Kidney transplantation in patients with multiple myeloma: narrative analysis and review of the last two decades.

There have been significant advances in the treatment of multiple myeloma in the last two decades. Approximately 25% of patients with newly diagnosed myeloma have some degree of kidney impairment. During the course of illness, nearly 50% of myeloma patients will develop kidney disease. Moreover, ∼10% of myeloma patients have advanced kidney disease requiring dialysis at presentation. Hemodialysis is associated with a significantly reduced overall survival (OS). In the setting of prolonged long-term OS due to the use of newer immunotherapeutic agents in the treatment of myeloma, patients with myeloma and advanced kidney disease may benefit from more aggressive management with kidney transplantation (KTx). Unfortunately, most data regarding outcomes of KTx in patients with myeloma come from single-center case series. With the advent of novel treatment choices, it remains unclear if outcomes of kidney transplant recipients with myeloma have improved in recent years. In this descriptive systematic review, we coalesced published patient data over the last 20 years to help inform clinicians and patients on expected hematologic and KTx outcomes in this complex population. We further discuss the future of KTx in patients with paraproteinemia.

Molecular dynamics of hERG channel: insights into understanding the binding of small molecules for detuning cardiotoxicity.

Evaluation of cardiotoxicity potential of new chemical entities (NCEs) has lately become one of the stringent filters in the drug discovery and development process. Cardiotoxicity is caused mainly by the inhibition of human ether-a-go-go related gene (hERG) channel protein. Inhibition of the hERG channel leads to a life-threatening condition known as cardiac arrhythmia. Knowledge of the structural behaviour of the hERG would aid greatly in the design of new drug molecules that do not interact with the protein and add to the safety index. In this study, a computational model for the active-state of hERG was developed. This model was equilibrated by performing the molecular dynamics simulations for 100 ns followed by clustering and selection of a representative structure based on the largest populated cluster. To study the changes in the protein structure on inhibition, three inhibitory ligands, namely, dofetilide, cisapride and terfenadine were docked, followed by molecular dynamics simulations of 200 ns for the apo and each ligand-bound structure. It was observed that docking and simulation studies of the hERG model exhibited noticeable conformational changes in the protein upon ligand-binding. A significant change in the kink of the S6-transmembrane helix was observed. Inter-chain distances between the crucial residues Y652 and F656 (present below the ion-selectivity filter), their side-chain orientation and hydrogen bonding indicated a probable collapse of the pore. These changes may infer the initiation in transition of hERG from an open to an inactive state. Hence, these findings would help in designing compounds devoid of hERG inhibition with reduced cardiotoxicity.Communicated by Ramaswamy H. Sarma.

Molecular Dynamics Simulation of Lipid-Modified Signaling Proteins.

In this chapter, we provide a practical guide on how to plan, execute, and interpret atomistic and coarse-grained molecular dynamics (MD) simulations of lipid-modified proteins in model membranes. After outlining some key practical considerations when planning such simulations, we survey resources and techniques to obtain force field parameters for nonconventional amino acids, such as posttranslationally lipid-modified amino acids that are unique to this class of proteins. We then describe the protocols to build, setup, and run the simulations, followed by a brief comment on the analysis and interpretation of the simulations. Finally, examples of insights that could be gained from atomistic and coarse-grained MD simulations of lipidated proteins will be provided, using RAS proteins as illustrative examples. Throughout the chapter, we highlight the main advantages and limitations of simulating RAS and related lipid-modified G-proteins in biomimetic membranes.

Pneumatosis Intestinalis in the Setting of COVID-19: A Single Center Case Series From New York.

This case series reviews four critically ill patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [coronavirus disease 2019 (COVID-19)] suffering from pneumatosis intestinalis (PI) during their hospital admission. All patients received the biological agent tocilizumab (TCZ), an interleukin (IL)-6 antagonist, as an experimental treatment for COVID-19 before developing PI. COVID-19 and TCZ have been independently linked to PI risk, yet the cause of this relationship is unknown and under speculation. PI is a rare condition, defined as the presence of gas in the intestinal wall, and although its pathogenesis is poorly understood, intestinal ischemia is one of its causative agents. Based on COVID-19's association with vasculopathic and ischemic insults, and IL-6's protective role in intestinal epithelial ischemia-reperfusion injury, an adverse synergistic association of COVID-19 and TCZ can be proposed in the setting of PI. To our knowledge, this is the first published, single center, case series of pneumatosis intestinalis in COVID-19 patients who received tocilizumab therapy.

Monoubiquitination of KRAS at Lysine104 and Lysine147 Modulates Its Dynamics and Interaction with Partner Proteins.

KRAS, a 21 kDa guanine nucleotide-binding protein that functions as a molecular switch, plays a key role in regulating cellular growth. Dysregulation of this key signaling node leads to uncontrolled cell growth, a hallmark of cancer cells. KRAS undergoes post-translational modification by monoubiquitination at various locations, including at lysine104 (K104) and lysine147 (K147). Previous studies have suggested that K104 stabilizes helix-2/helix-3 interactions and K147 is involved in nucleotide binding. However, the impact of monoubiquitination at these residues on the overall structure, dynamics, or function of KRAS is not fully understood. In this study, we examined KRAS monoubiquitination at these sites using data from extensive (12 µs aggregate time) molecular dynamics simulations complemented by nuclear magnetic resonance spectroscopy data. We found that ubiquitin forms dynamic nonspecific interactions with various regions of KRAS and that ubiquitination at both sites modulates conformational fluctuations. In both cases, ubiquitin samples a broad range of conformational space and does not form long-lasting noncovalent contacts with KRAS but it adopts several preferred orientations relative to KRAS. To examine the functional impact of these preferred orientations, we performed a systematic comparison of the dominant configurations of the ubiquitin/KRAS simulated complex with experimental structures of KRAS bound to regulatory and effector proteins as well as a model membrane. Results from these analyses suggest that conformational selection and population shift may minimize the deleterious effects of KRAS ubiquitination at K104 and K147 on binding to some but not all interaction partners. Our findings thus provide new insights into the steric effects of ubiquitin and suggest a potential avenue for therapeutic targeting.

An early experience on the effect of solid organ transplant status on hospitalized COVID-19 patients.

We compared the outcome of COVID-19 in immunosuppressed solid organ transplant (SOT) patients to a transplant naïve population. In total, 10 356 adult hospital admissions for COVID-19 from March 1, 2020 to April 27, 2020 were analyzed. Data were collected on demographics, baseline clinical conditions, medications, immunosuppression, and COVID-19 course. Primary outcome was combined death or mechanical ventilation. We assessed the association between primary outcome and prognostic variables using bivariate and multivariate regression models. We also compared the primary endpoint in SOT patients to an age, gender, and comorbidity-matched control group. Bivariate analysis found transplant status, age, gender, race/ethnicity, body mass index, diabetes, hypertension, cardiovascular disease, COPD, and GFR <60 mL/min/1.73 m2 to be significant predictors of combined death or mechanical ventilation. After multivariate logistic regression analysis, SOT status had a trend toward significance (odds ratio [OR] 1.29; 95% CI 0.99-1.69, p = .06). Compared to an age, gender, and comorbidity-matched control group, SOT patients had a higher combined risk of death or mechanical ventilation (OR 1.34; 95% CI 1.03-1.74, p = .027).

DCD Renal Transplantation From Donors With Acute Kidney Injury.

BACKGROUND: Deceased donor kidneys with acute kidney injury (AKI) and donation after circulatory death (DCD) kidneys are viable sources of organs. The outcomes of renal transplantation from DCD donors with AKI are not known. METHODS: A retrospective review of deceased donor renal transplants performed from 2006 to 2016 was conducted using the United Network for Organ Sharing dataset. Donors were stratified by DCD or brain dead status and by AKI stage. Recipients were followed until graft failure or the end of study. Cox regression was used to adjust for donor, recipient, and transplant covariates known to affect the incidence of delayed graft function and graft survival. RESULTS: A total of 135 644 patients were included in the study. The odds of delayed graft function among DCD recipients were significantly higher across all donor AKI stages. The unadjusted risk of overall and death-censored graft failure were similar between the 2 groups. After adjusting for covariates, there was a significant increase in the risk of overall graft failure in recipients of DCD allografts from donors with stage 2 AKI. There was also a higher risk of death-censored graft failure among stage 1 and 2 AKI DCD recipients. CONCLUSIONS: DCD renal allografts from donors experiencing stage 1 and 2 AKI have a higher adjusted risk of death-censored graft failure than AKI stage-matched donation after brain death renal allografts. Their use, however, is still associated with improved outcomes compared with waitlist mortality.

Hepatitis C-positive donor to negative recipient kidney transplantation: A real-world experience.

BACKGROUND: Several studies have shown that transplanting a hepatitis C virus (HCV)-negative recipients with a HCV-positive donor is feasible in a research setting. In February 2018, we began transplanting HCV-negative recipients with HCV-positive donors as standard of care. METHODS: All patients, except those with previously cured HCV and those with cirrhosis, were consented for HCV NAT-positive donor kidneys. After transplantation, patients were tested for HCV RNA until viremic. A direct-acting antiviral (DAA) agent was prescribed based on genotype and insurance approval. Sustained virologic response (SVR) at weeks 4 and 12 was recorded. Renal function and death censored graft survival at 1 year were evaluated and compared to recipients of HCV NAT-negative kidneys. RESULTS: A total of 25 HCV NAT-positive donor kidney transplants from February to October 2018 were performed. All patients received basiliximab and maintained with tacrolimus, mycophenolate mofetil, and prednisone. Median time from viremia to start of DAA was 13 (8-22) days. The most common genotype was 1a (60%), followed by 3a (28%). The most commonly prescribed DAA was ledipasvir/sofosbuvir (56%), followed by velpatasvir/sofosbuvir (32%), and then glecaprevir/pibrentasvir (12%). All patients achieved initial SVR12, except one. One patient had a mixed-genotype infection requiring retreatment to achieve SVR12. Death censored graft survival was 96%. Recipients of HCV NAT-positive organs compared to HCV NAT-negative organs received younger donors (mean 35 ± 8.9 vs 45.1 ± 15.7 years; P < .01) and spent less time on the waitlist (median 479 (93-582) vs 1808 (567-2263) days; P = .02). CONCLUSION: HCV NAT-negative recipients can be safely and successfully transplanted with HCV NAT-positive donor kidneys outside of a research protocol. Access to DAA and timely administration of therapy is important and an insurance approval process within the transplant center can be beneficial to patients. A case of mixed-genotype infection was presented, and although not as common, can be successfully treated. HCV organs can expand the organ pool and should no longer be considered experimental. The use of these organs in HCV-negative recipient's decreases waiting time, have excellent outcomes, and should be considered standard of care.

A multi-center study on safety and efficacy of immune checkpoint inhibitors in cancer patients with kidney transplant.

Immune checkpoint inhibitors (ICIs) are widely used for various malignancies. However, their safety and efficacy in patients with a kidney transplant have not been defined. To delineate this, we conducted a multicenter retrospective study of 69 patients with a kidney transplant receiving ICIs between January 2010 and May 2020. For safety, we assessed the incidence, timing, and risk factors of acute graft rejection. For efficacy, objective response rate and overall survival were assessed in cutaneous squamous cell carcinoma and melanoma, the most common cancers in our cohort, and compared with stage-matched 23 patients with squamous cell carcinoma and 14 with melanoma with a kidney transplant not receiving ICIs. Following ICI treatment, 29 out of 69 (42%) patients developed acute rejection, 19 of whom lost their allograft, compared with an acute rejection rate of 5.4% in the non-ICI cohort. Median time from ICI initiation to rejection was 24 days. Factors associated with a lower risk of rejection were mTOR inhibitor use (odds ratio 0.26; 95% confidence interval, 0.09-0.72) and triple-agent immunosuppression (0.67, 0.48-0.92). The objective response ratio was 36.4% and 40% in the squamous cell carcinoma and melanoma subgroups, respectively. In the squamous cell carcinoma subgroup, overall survival was significantly longer in patients treated with ICIs (median overall survival 19.8 months vs. 10.6 months), whereas in the melanoma subgroup, overall survival did not differ between groups. Thus, ICIs were associated with a high risk of rejection in patients with kidney transplants but may lead to improved cancer outcomes. Prospective studies are needed to determine optimal immunosuppression strategies to improve patient outcomes.

Long-Range Coupled Motions Underlie Ligand Recognition by a Chemokine Receptor.

Chemokines are unusual class-A G protein-coupled receptor agonists because of their large size (∼10 kDa) and binding at two distinct receptor sites: N-terminal domain (Site-I, unique to chemokines) and a groove defined by extracellular loop/transmembrane helices (Site-II, shared with all small molecule class-A ligands). Structures and sequence analysis reveal that the receptor N-terminal domains (N-domains) are flexible and contain intrinsic disorder. Using a hybrid NMR-MD approach, we characterized the role of Site-I interactions for the CXCL8-CXCR1 pair. NMR data indicate that the CXCR1 N-domain becomes structured on binding and that the binding interface is extensive with 30% CXCL8 residues participating in this initial interaction. MD simulations indicate that CXCL8 bound at Site-I undergoes extensive reorganization on engaging Site-II with several residues initially engaged at Site-I also engaging at Site-II. We conclude that structural plasticity of Site-I interactions plays an active role in driving ligand recognition by a chemokine receptor.

Taxes, institutions, and innovation: Theory and international evidence.

We develop an international model of the design of institutions for regulating innovative activities of private corporations. Informational limitations faced by the social planner preclude complete contracting with private firms. Corporate innovation creates positive and negative externalities. The social planner in each country takes into account the legal system in place, and designs an umbrella of institutions that include a menu of organizational forms, liability structures, corporate taxes, and subsidies. We show that limited liability may be accompanied by excessive innovation. However, when the nonmonetized benefits are very high, private firms may be too conservative in innovation policies. Firms choose their organizational form and level of innovation consistent with private optimality. With the optimal institutional design for each country, we demonstrate that private innovation choices are aligned with social optimality. In particular, we show that the optimally designed corporate tax rate in each country is a decreasing function of its legal effectiveness. Using data from 63 countries over 2003-2018, we document supporting evidence. MNCs can take advantage of differential liability and corporate tax structures across national boundaries to circumvent institutional design constraints. However, when MNCs generate positive externalities to host countries, their governments may provide subsidies and incentives.

Nous développons un modèle international de conception d'institutions de régulation des activités innovantes des entreprises privées. Les limitations informationnelles auxquelles est confronté le planificateur social empêchent la conclusion de contrats complets avec des entreprises privées. L'innovation d'entreprise crée des externalités positives et négatives. Le planificateur social de chaque pays prend en compte le système juridique en place et conçoit un ensemble d'institutions comprenant un menu de formes organisationnelles, de structures de responsabilité, d'impôts sur les sociétés et de subventions. Nous montrons que la responsabilité limitée peut s'accompagner d'une innovation excessive. Cependant, lorsque les avantages non monétisés sont très élevés, les entreprises privées peuvent être trop conservatrices dans les politiques d'innovation. Les entreprises choisissent leur forme organisationnelle et leur niveau d'innovation compatibles avec l'optimalité privée. Avec la conception institutionnelle optimale pour chaque pays, nous démontrons que les choix d'innovation privée sont alignés sur l'optimalité sociale. En particulier, nous montrons que le taux d'imposition des sociétés conçu de manière optimale dans chaque pays est une fonction décroissante de son efficacité juridique. En utilisant les données de 63 pays sur la période 2003­2018, nous donnons des preuves à l'appui. Les EMN peuvent tirer parti des structures de responsabilité et d'imposition des sociétés différentielles à travers les frontières nationales pour contourner les contraintes de conception institutionnelle. Cependant, lorsque les EMN génèrent des externalités positives pour les pays d'accueil, leurs gouvernements peuvent fournir des subventions et des incitations.

Desarrollamos un modelo internacional de diseño de instituciones para regular las actividades innovadoras de las corporaciones privadas. Las limitaciones informativas enfrentadas por la planificación social descartan la contratación completa con firmas privadas. La innovación corporativa crea externalidades positivas y negativas. La planificación social en cada país toma en consideración el sistema legal establecido, y diseña una sombrilla de instituciones que incluye formas organizacionales, estructuras de responsabilidad, impuestos corporativos y subsidios. Mostramos que responsabilidad limitada puede estar acompañada de innovación excesiva. Sin embargo, cuando los beneficios no monetizados son altos, las empresas privadas pueden ser demasiado conservadoras en las políticas de innovación. Las empresas eligen su forma organizacional y el nivel de innovación en concordancia con la optimalidad privada. Con el diseño organizacional óptimo para cada país, demostramos que las elecciones de innovación privada están alineadas con la optimalidad social. En particular, mostramos que la tasa impositiva corporativa en cada país es una función descendente de su efectividad legal. Usando datos de 63 países durante 2003­2018, documentamos pruebas de apoyo. Las empresas multinacionales pueden tomar ventaja de los diferenciales de responsabilidad y las estructuras tributarias corporativas entre las fronteras nacionales para eludir limitaciones de diseño institucional. Sin embargo, cuando las empresas multinacionales generan externalidades positivas a los países anfitriones, sus gobiernos pueden proporcionar subsidios e incentivos.

Desenvolvemos um modelo internacional de design de instituições para regular atividades inovadoras de empresas privadas. Limitações informacionais enfrentadas pelo planejador social impedem a contratação completa com empresas privadas. Inovação corporativa cria externalidades positivas e negativas. O planejador social em cada país leva em consideração o sistema legal em vigor e projeta um conjunto de instituições que inclui um menu de formas organizacionais, estruturas de responsabilidade, impostos corporativos e subsídios. Mostramos que a responsabilidade limitada pode ser acompanhada por excessiva inovação. No entanto, quando os benefícios não monetizados são muito altos, empresas privadas podem ser muito conservadoras em relação às políticas de inovação. Empresas escolhem sua forma organizacional e nível de inovação consistente com a otimização privada. Com o desenho institucional ótimo para cada país, demonstramos que escolhas privadas de inovação estão alinhadas com a otimização social. Em particular, mostramos que a alíquota de imposto corporativo idealizada em cada país é uma função decrescente de sua eficácia legal. Usando dados de 63 países durante 2003­2018, documentamos evidências de apoio. MNCs podem tirar proveito de diferenciada responsabilidade e de estruturas tributárias corporativas além de fronteiras nacionais para contornar restrições de design institucional. Entretanto, quando MNCs geram externalidades positivas para os países anfitriões, seus governos podem fornecer subsídios e incentivos.