Allan B. Massie

Background: The Increasing Organ Transplant Access (IOTA) model is a mandatory experimental payment model that aims to improve kidney transplant access using financial incentives and penalties for transplant centers randomized to model participation, based primarily on growth in transplant volume. Methods: We used national transplant registry data to conduct a retrospective cohort study of US kidney transplant centers. We identified centers randomized to IOTA participation based on the published list of center participants. Using a difference-in-differences approach, we compared IOTA participants with nonparticipants on changes in overall, deceased donor, and living donor kidney transplant volume per 30 days in the period before IOTA randomization status was announced versus the 9 months following IOTA implementation. Separately among IOTA participants and among nonparticipants, we compared the proportional change in transplant volume when stratifying centers by pre-IOTA transplant volume, organ offer acceptance rate, and transplant rate ratio. Results: Among 177 included centers, 97 (55%) were IOTA participants and 80 (45%) nonparticipants. Most IOTA participants (53%) and nonparticipants (55%) experienced a fall in overall transplant volume after model implementation. However, IOTA participants exhibited a 5% increase in transplant volume per 30 days, whereas nonparticipants exhibited a 3% decrease ( P = 0.01). The difference between groups was seen for deceased donor transplants (participants +5% versus nonparticipants −9%, P < 0.001), while living donor transplants rose in both groups (+7 versus +19%, P = 0.24). Among IOTA participants, there were no statistically significant differences in changes in transplant volume when comparing centers categorized by pre-IOTA transplant volume, organ offer acceptance rate, or transplant rate ratio. Conclusions: Centers randomized to IOTA participation outperformed model nonparticipants in changes in kidney transplant volume after model implementation, driven by an increase in deceased donor transplant volume among model participants but a fall among nonparticipants.

Introduction: Biological parental donations provide the best option for many pediatric recipients, yielding unique immunological benefits that may enable minimization of immunosuppression in transplanted children. However, living related maternal donation in the postpartum period may introduce an increased risk of donor complications due to the physiological changes of pregnancy and childbirth, and the optimal timing of postpartum living donation is unknown. Methods: Using US national registry data, we characterized donor and recipient outcomes for pediatric living donor liver transplants performed between 2004 and 2022 where a biological mother donated to a child ≤ 24 months old. Results: Our study population included 256 donor‐recipient pairs, with biliary atresia representing the most common indication for transplantation (68.0%). Donors had a median [IQR] age of 30 [25, 34] years, and the median [IQR] time from birth to donation was 9.0 [6.8, 13.0] months. 6.3% of donors experienced a biliary or other complication. When stratifying by donors who donated ≤ 6 vs. > 6 months postpartum, we found no significant differences in donor complications or readmission. Stratified analyses were also comparable for recipient mortality, graft survival, and rejection‐free survival. Donors ≤ 6 months postpartum ( n = 64) were more likely to experience reoperation than mothers who donated > 6 months postpartum ( n = 192) (6.2% vs. 1.0%, p = 0.04). Conclusions: While maternal living donor liver transplantation is safe for most donors, there is a higher risk of reoperation when donation is performed ≤ 6 months postpartum. Surgeons should be aware that these donors are a higher risk population, requiring discussion upon consent and warranting close post‐operative monitoring.

Introduction: Technological advances in organ preservation and reconditioning have enabled increased use of donation after circulatory death (DCD) organs. We aimed to characterize temporal trends in pediatric DCD (pDCD) in the United States. Methods: We used Organ Procurement and Transplantation Network data to identify all pediatric (age < 18 years) deceased organ donors in the US, 2000–2025. We calculated the number and proportion of pediatric donation after brain death (pDBD) and pDCD donors by year. We calculated the number and type of recovered and transplanted pDBD and pDCD organs by year. Results: The annual number of pDBD donors fell from 985 in 2000 to 530 in 2025, whereas pDCD donors increased from 21 to 244. The rise in pDCD recovery was observed for all organs: 32%, 19%, 16%, 14%, and 12% of recovered pediatric kidneys, livers, lungs, hearts, and pancreata by 2025. Among transplants with pediatric recipients in 2000, there was 1 pDCD liver transplant and no pDBD kidney, heart, lung, or pancreas transplants. By 2025, pDCD transplants accounted for 3%, 2%, and 8% of kidney, liver, and heart transplants with pediatric recipients. Conclusion: pDBD donors have fallen over the last 25 years, whereas pDCD donors have increased over 10‐fold over the same period. Given the ongoing need for pediatric organ transplantation and the ethical importance of preserving opportunities for donation, there is an urgent need to develop a parallel communication and ethical framework to support families, clinicians, and transplant teams in navigating these donation opportunities.

Key Points: In this cohort study of 720,348 adults referred for kidney transplantation from 2014 to 2025, only 48% were evaluated and 19% were waitlisted. Progression from referral to evaluation, waitlisting and kidney transplantation was limited by individual, center-level, and geographic factors. Some centers evaluated and waitlisted patients at rates far below the national average, and low-volume centers had lower rates of transplantation. Background: Kidney transplantation is a cost-effective, lifesaving treatment of kidney failure, compared with dialysis. Unfortunately, most patients with kidney failure never undergo transplantation. Methods: Using Epic Cosmos electronic health record data on all patients referred for kidney transplantation from 2014 to 2025, we assessed the stage-specific progression and attrition in the process of evaluation, waitlisting, and kidney transplantation. Center-level and individual (socioeconomic, geographic, and insurance status) factors associated with access to evaluation, waitlisting, and kidney transplantation were characterized using modified Poisson regression. Results: Among 720,348 referred candidates, the median age was 55 years (interquartile range [IQR], 42–64); 47% of patients were White, 52% were male, and 87% were English speaking. Eighty-five percent of patients lived in urban areas. Of the referred candidates, 48% initiated evaluation, 19% were waitlisted, and 10% ultimately underwent transplantation. Among the referred patients who initiated evaluation, the median (IQR) time to evaluation initiation was two (1–4) months after referral; among the patients who were waitlisted, the median (IQR) time to waitlisting was four (2–9) months after evaluation initiation. Patients who were never married (0.94; 95% confidence interval [CI], 0.93 to 0.94), had severe obesity (0.70; 95% CI, 0.69 to 0.72), or were from rural zip codes (relative risk, 0.98; 95% CI, 0.97 to 1.00) were less likely to initiate evaluation. Low-volume centers had lower relative rates of transplantation (0.92; 95% CI, 0.88 to 0.96). In centers with documentation for nonprogression to evaluation, reasons for removal included not meeting criteria/not a candidate (18%), patient decision (13%), unable to contact (12%), death (4%), and financial/insurance complications (7%). Conclusions: Our study shows substantial attrition before kidney transplant waitlisting.