The deceased donor kidney allocation system in the United States has undergone several rounds of iterative changes, but these changes were not explicitly designed to address the geographic variation ...in access to transplantation. The new allocation system, expected to start in December 2020, changes the definition of “local allocation” from the Donation Service Area to 250 nautical mile circles originating from the donor hospital. While other solid organs have adopted a similar approach, the larger number of both kidney transplant centers and transplant candidates is likely to have different consequences. Here, we discuss the incredible increase in complexity in allocation, discuss some of the likely intended and unintended consequences, and propose metrics to monitor the new system.
With implementation of the new US kidney allocation system, the authors discuss the incredible increase in allocation complexity, likely consequences, both intended and unintended, and possible metrics to best monitor impact. See Formica's editorial on page 1996.
Background Hashimoto's thyroiditis (HT) is the most common cause of hypothyroidism and is characterized by gradual autoimmune mediated thyroid failure with occasional goiter development. HT is seven ...times more likely to occur in women than in men. Papillary thyroid cancer (PTC), the most prevalent form of cancer in the thyroid, is 2.5 times more likely to develop in women than men. Given the relatively high prevalence of these diseases and the increased occurrence in women, we analyzed data from our institution to determine if there is a correlation between Hashimoto's thyroiditis and PTC in women. Methods From May 1994 to January 2007, 1198 patients underwent thyroid surgery at our institution. Of these, 217 patients were diagnosed with HT (196 women, 21 men). The data from these patients were statistically analyzed using SPSS. Results PTC occurred in 63 of 217 (29%) HT patients and 230 of 981 (23%) patients without HT ( P = 0.051). Of these groups, 41 (65%) and 158 (69%) patients, respectively, had tumor sizes ≥1.0 cm; 56/196 women (29%) with HT had coexistent PTC compared with 160/730 women (22%) without HT ( P = 0.03). Among women with any type of thyroid malignancy, 56/59 cases (95%) with HT had PTC compared with 159/196 cases (81%) in women without HT ( P = 0.006). Additionally, female HT patients with goiters had a significantly lower rate of PTC (9% versus 36%, P < 0.001) compared with women without goiters. These differences were not observed in men with HT. Conclusions These data demonstrate that HT is associated with an increased risk of developing PTC. Female patients with HT undergoing thyroidectomy are 30% more likely to have PTC. Thus, more aggressive surveillance for PTC may be indicated in patients with HT, especially in women.
The authors comment on Reddy et al's insights (page 2661) into a single center's experience with the increased number of organ offers after kidney and liver allocation system changes, emphasizing the ...increased workload, potential outcomes and possible solutions.
Deceased donor kidney allocation follows a ranked match‐run of potential recipients. Organ procurement organizations (OPOs) are permitted to deviate from the mandated match‐run in exceptional ...circumstances. Using match‐run data for all deceased donor kidney transplants (Ktx) in the US between 2015 and 2019, we identified 1544 kidneys transplanted from 933 donors with an OPO‐initiated allocation exception. Most OPOs (55/58) used this process at least once, but 3 OPOs performed 64% of the exceptions and just 2 transplant centers received 25% of allocation exception Ktx. At 2 of 3 outlier OPOs these transplants increased 136% and 141% between 2015 and 2019 compared to only a 35% increase in all Ktx. Allocation exception donors had less favorable characteristics (median KDPI 70, 41% with history of hypertension), but only 29% had KDPI ≥ 85% and the majority did not meet the traditional threshold for marginal kidneys. Allocation exception kidneys went to larger centers with higher offer acceptance ratios and to recipients with 2 fewer priority points—equivalent to 2 less years of waiting time. OPO‐initiated exceptions for kidney allocation are growing increasingly frequent and more concentrated at a few outlier centers. Increasing pressure to improve organ utilization risks increasing out‐of‐sequence allocations, potentially exacerbating disparities in access to transplantation.
A retrospective cohort study of deceased donor kidney allocation in the United States shows an increase in discretionary allocation exceptions over time with 3 outlier organ procurement organizations and 2 outlier transplant centers disproportionately involved in initiating and receiving offers using these exemptions.
IMPORTANCE: Large-scale motorcycle rallies attract thousands of attendees and are associated with increased trauma-related morbidity and mortality. OBJECTIVE: To examine the association of major US ...motorcycle rallies with the incidence of organ donation and transplants. DESIGN, SETTING, AND PARTICIPANTS: This population-based, retrospective cross-sectional study used data from the Scientific Registry of Transplant Recipients for deceased organ donors aged 16 years or older involved in a motor vehicle crash and recipients of organs from these donors from March 2005 to September 2021. EXPOSURE: Dates of 7 large US motorcycle rallies and regions near these events. MAIN OUTCOMES AND MEASURES: The main outcomes were incidence of motor vehicle crash–related organ donation and number of patients receiving a solid organ transplant from these donors. An event study design was used to estimate adjusted rates of organ donation during the dates of 7 major US motorcycle rallies compared with the 4 weeks before and after the rallies in rally-affected and rally-unaffected (control) regions. Donor and recipient characteristics and metrics of organ quality were compared between rally and nonrally dates. RESULTS: The study included 10 798 organ donors (70.9% male; mean SD age, 32.5 13.7 years) and 35 329 recipients of these organs (64.0% male; 49.3 15.5 years). During the rally dates, there were 406 organ donors and 1400 transplant recipients. During the 4 weeks before and after the rallies, there were 2332 organ donors and 7714 transplant recipients. Donors and recipients during rally and nonrally dates were similar in demographic and clinical characteristics, measures of organ quality, measures of recipient disease severity, and recipient waiting time. During rallies, there were 21% more organ donors per day (incidence rate ratio IRR, 1.21; 95% CI, 1.09-1.35; P = .001) and 26% more transplant recipients per day (IRR, 1.26; 95% CI, 1.12-1.42; P < .001) compared with the 4 weeks before and after the rallies in the regions where they were held. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, major motorcycle rallies in the US were associated with increased incidence of organ donation and transplants. While safety measures to minimize morbidity and mortality during motorcycle rallies should be prioritized, this study showed the downstream association of these events with organ donation and transplants.
IMPORTANCE: Women on the liver transplant waiting list are less likely to undergo a transplant than men. Recent approaches to resolving this disparity have involved adjustments to Model for End-Stage ...Liver Disease (MELD) scoring, but this will not affect candidates who rely on exception scores rather than calculated MELD score, the majority of whom have hepatocellular carcinoma (HCC). OBJECTIVE: To evaluate the association between female sex, candidate size, and access to liver transplant among wait-listed patients with HCC. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used US transplant registry data of all adult (aged ≥18 years) wait-listed liver transplant candidates receiving an HCC exception score between January 1, 2010, and March 2, 2023. EXPOSURE: Wait-listed liver transplant candidate sex. MAIN OUTCOMES AND MEASURES: The association of female sex with (1) deceased-donor liver transplant (DDLT) and (2) death or waiting list removal for health deterioration were estimated using multivariable competing-risks regression. Results with and without adjustment for candidate height and weight (mediators of the sex disparity) were compared. RESULTS: The cohort included 31 725 candidates with HCC (mean SD age at receipt of exception, 61.2 7.1 years; 76.3% men). Compared with men, women had a lower 1-year cumulative incidence of DDLT (50.8% vs 54.0%; P < .001) and a higher 1-year cumulative incidence of death or delisting for health deterioration (16.2% vs 15.0%; P = .002). After adjustment, without accounting for size, women had a lower incidence of DDLT (subdistribution hazard ratio SHR, 0.92; 95% CI, 0.89-0.95) and higher incidence of death or delisting (SHR, 1.06; 95% CI, 1.00-1.13) compared with men. When adjusting for candidate height and weight, there was no association of female sex with incidence of DDLT or death or delisting. However, at a height cutoff of 166 cm, short women compared with short men were still less likely to undergo a transplant (SHR, 0.93; 95% CI, 0.88-0.99). CONCLUSIONS AND RELEVANCE: In this study, women with HCC were less likely to receive a DDLT and more likely to die while wait-listed than men with HCC; these differences were largely (but not entirely) explained by sex-based differences in candidate size. For candidates listed with exception scores, additional changes to allocation policy are needed to resolve the sex disparity, including solutions to improve access to size-matched donor livers for smaller candidates.
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