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Fedson S, Lavee J, Bryce K, Egan T, Olland A, Kanwar M, Courtwright A, Holm AM. Ethical considerations in xenotransplantation of thoracic organs - a call for a debate on value based decisions. J Heart Lung Transplant 2024; 43:1033-1038. [PMID: 38775760 DOI: 10.1016/j.healun.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 06/03/2024] Open
Abstract
Xenotransplant covers a broad ethical territory and there are several ethical questions that have arisen in parallel with the technological advances that have allowed the first porcine transplants to occur. This brief communication highlights ethical considerations regarding heart and lung xenotransplantation, with an emphasis on unresolved value-based concerns in the field. The aim of this text is therefore to encourage the readers to consider the vast potential of this emerging technique to do good, but also the risk of doing harm, and to participate in a discussion. The list of questions presented here is not exhaustive but hopefully represents some of the questions that appear to be most pressing as the field advances. The focus is on the value-based, or ethical questions, not the questions related to the practical medical procedures.
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Affiliation(s)
- Savitri Fedson
- Baylor College of Medicine; Michael E DeBakey VA Medical Center, Houston, Texas.
| | - Jacob Lavee
- Heart Transplantation Unit, Leviev Cardiothoracic Center, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Kelly Bryce
- Behavioral Health, Henry Ford Health System; Transplant Institute, Henry Ford Health System, Detroit, Michigan
| | - Tom Egan
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne Olland
- Department of Thoracic Surgery, University Hospital Strasbourg; Inserm UMR 1260 "Regenerative Nanomedicine", University of Strasbourg, Strasbourg, France
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Andrew Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Are Martin Holm
- Department of Respiratory Medicine, Oslo University Hospital; Institute of Clinical Medicine, University of Oslo, Norway
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Hurst DJ, Padilla L, Rodger D, Schiff T, Cooper DKC. Close contacts of xenograft recipients: Ethical considerations due to risk of xenozoonosis. Xenotransplantation 2024; 31:e12847. [PMID: 38468191 DOI: 10.1111/xen.12847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 01/05/2024] [Accepted: 02/01/2024] [Indexed: 03/13/2024]
Abstract
With decades of pre-clinical studies culminating in the recent clinical application of xenotransplantation, it would appear timely to provide recommendations for operationalizing oversight of xenotransplantation clinical trials. Ethical issues with clinical xenotransplantation have been described for decades, largely centering on animal welfare, the risks posed to the recipient, and public health risks posed by potential spread of xenozoonosis. Much less attention has been given to considerations relating to potentially elevated risks faced by those who may care for or otherwise have close contact with xenograft recipients. This paper examines the ethical and logistical issues raised by the potential exposure to xenozoonotic disease faced by close contacts of xenotransplant recipients-defined herein as including but not limited to caregivers, household contacts, and sexual partners-which warrants special attention given their increased risk of exposure to infection compared to the general public. We discuss implications of assent or consent by these close contacts to potentially undergo, along with the recipient, procedures for infection screening and possible quarantine. We then propose several options and recommendations for operationalizing oversight of xenotransplantation clinical trials that could account for and address close contacts' education on and agency regarding the risk of xenozoonosis.
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Affiliation(s)
- Daniel J Hurst
- Department of Family Medicine, Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Luz Padilla
- Department of Epidemiology and Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Daniel Rodger
- Institute of Health and Social Care, School of Allied and Community Health, London South Bank University, London, USA
- Department of Psychological Sciences, Birkbeck University of London, London, UK
| | - Tamar Schiff
- Division of Medical Ethics, Department of Population Health, New York University Grossman School of Medicine, New York, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Charlestown, Massachusetts, USA
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3
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Bayliss G. Practical ethical concerns in allocation of pig kidneys to humans. Clin Kidney J 2022; 15:2161-2168. [PMID: 36381360 PMCID: PMC9664566 DOI: 10.1093/ckj/sfac125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Indexed: 01/04/2024] Open
Abstract
The fundamental ethical question of whether pig organs should be transplanted into humans has been settled, as recent surgeries demonstrating proof of concept demonstrate. Other issues need to be considered and reconciled before xenotransplantation of pig kidneys becomes a solution to the organ shortage for people waiting for a kidney transplant or as a viable alternative to the deceased donor or living donor human kidneys. Human trials will be needed beyond brain-dead individuals to show that xenotransplantation is safe from immunologic and infectious standpoints. Transplant centers will need to show that xenotransplantation provides a long-term benefit to recipients and is financially viable. If trials are successful and receive regulatory approval, pig xenotransplants may become another option for people waiting for a kidney. Before patients are discharged with a functioning xenograft, practical issues with ethical implications remain.
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Affiliation(s)
- George Bayliss
- Alpert Medical School, Brown University, Providence, RI, USA
- Rhode Island Hospital Division Organ Transplantation, Providence, RI, USA
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Padilla LA, Hurst D, Maxwell K, Gawlowicz K, Paris W, Cleveland D, Cooper DK. Informed Consent for Potential Recipients of Pig Kidney Xenotransplantation in the United States. Transplantation 2022; 106:1754-1762. [PMID: 35475475 PMCID: PMC10124773 DOI: 10.1097/tp.0000000000004144] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Clinical trials of kidney xenotransplantation are being considered in the United States. Before this novel procedure can take place, investigators will have to obtain approval from the institutional review board. The consent form that will be used for such a trial and that will receive approval from the institutional review board will be complex. Informed consent-the process by which a research participant provides his/her permission to participate in a clinical trial-is a staple of the research process and most commonly is in the form of a physical document. In the case of a novel procedure with uncertain benefits and risks and a participant population in acute need of a transplant, the consent process is crucial. These complexities may raise several ethical considerations for the initial pig kidney xenotransplantation recipients in the United States that will require adaptations of the required elements of the informed consent process by the US Department of Human and Health Services. The ethical issues include (1) a subject's ability to withdraw from the trial, (2) restrictions on their reproductive rights, and (3) the possibility of the need for quarantine if there is a perceived risk of xenozoonosis. This article aims to discuss ethical considerations that may challenge the general required elements of the informed consent form stipulated by the 45 Code of Federal Regulations 46 of the US Department of Health and Human Services and to suggest recommendations for deliberation.
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Affiliation(s)
- Luz A. Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Daniel Hurst
- Department of Family Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ
| | - Kathryn Maxwell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kennan Gawlowicz
- Institutional Review Board, Boston Children’s Hospital, Boston, MA
| | - Wayne Paris
- Department of Social Work, Abilene Christian University, Abilene, TX
| | - David Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K.C. Cooper
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA
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Ethics and Theoretical Issues in Kidney Xenotransplantation. Semin Nephrol 2022; 42:151288. [PMID: 36587995 DOI: 10.1016/j.semnephrol.2022.151288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Xenotransplantation has seen recent global interest peak as a result of several clinical xenotransplants being performed in decedents and a live cardiac recipient. However, underpinning these latest transplants have been decades of invested scientific research programs that have been developing the ideal donor source animals to avoid the overwhelming hyperacute xenograft rejection seen using nongenetically modified animal organs, tissues, and cells. However, this also needs to be undertaken along with the development of safe and efficacious xenotransplantation technologies, immunosuppression, monitoring, disease screening, patient selection, societal education, and acceptance. Paralleling the advent of such extraordinary transplants have been several decades of establishment of world xenotransplantation authorities such as the International Xenotransplantation Association, and the development of guidance documents and regulations for the assessment of these cutting-edge technologies. Similar to all new technologies there remain outdated concerns and fears of the theoretical potential for transmission of xenozoonosis, ethical concerns, and outdated or appropriately educated societal concerns and religious views of the benefits or risks and issues for xenotransplantation use of organs, tissues, or cells from animals to human beings. Here, we discuss the development of xenotransplantation and the intricate balance in managing the various challenges with which we are faced: in the absolute benefits of xenotransplantation and the dichotomy in balancing the pros and cons of xenotransplantation with social, religious, ethical, scientific, and medical opinions. Ultimately, the benefits are to those patients suffering from the many and various diseases that drive the need for xenotransplantation. The hope is that it will be implemented as soon as possible to help the many millions of patients who can truly benefit.
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Odonkor P, Strauss E, Williams B. Ethical considerations during a pioneering surgical procedure: porcine cardiac xenotransplantation. Br J Hosp Med (Lond) 2022; 83:1-7. [DOI: 10.12968/hmed.2022.0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Preclinical advances in life-sustaining porcine cardiac xenotransplantation from donor pigs to baboons have paved the way for the performance of porcine cardiac xenotransplantation in a human. This procedure was performed with emergency use authorisation granted by the United States Food and Drug Administration under the umbrella of investigational new drug use on compassionate grounds. The patient was denied candidacy for durable mechanical circulatory support and heart transplantation as a result of non-adherence to medical advice. Successful porcine cardiac xenotransplantation in humans will significantly increase the availability of potential donor organs for long-term management of end-stage heart failure. Human porcine cardiac xenotransplantation is associated with ethical conflicts encompassing multiple ethical principles which are not mutually exclusive and are sometimes conflicting. This article focuses on some of the ethical conflicts encountered in relation to the use of mechanical circulatory support, pretransplant evaluation, shared decision making during informed consent, infectious disease risk, preclinical and clinical testing, and the role of regulatory bodies during performance of the first human porcine cardiac xenotransplantation. An increase in human trials of xenotransplantation procedures is imminent. Potential ethical conflicts associated with xenotransplantation should be addressed appropriately.
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Affiliation(s)
- Patrick Odonkor
- Division of Cardiac Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Erik Strauss
- Division of Cardiac Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Brittney Williams
- Division of Cardiac Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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Garcia LR, Brito FDS, Felicio ML, Garzesi AM, Tardivo MT, Polegato BF, Minicucci MF, Zornoff LAM. Clinical trials in cardiac xenotransplantation: Are we ready to overcome barriers? J Card Surg 2021; 36:3796-3801. [PMID: 34137071 DOI: 10.1111/jocs.15747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/25/2021] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
Heart allotransplantation has become one of the methods of choice in the treatment of severe heart failure. In the face of its difficulties, such as the unmet balance between organ supply and demand, the use of xenotransplantation (XTx) might be an attractive option shortly, even more with the ongoing progress achieved regarding the avoidance of hyperacute rejection and primary organ disfunction, maintenance of xenograft function and control of xenograft growth. To make possible this translational challenge, some points must be taken into account indeed, and they are the equipoise of human benefit and animal suffering, the risk of unknown infections, a well prepared informed consent, ethical and religious beliefs, and the role of cardiac XTx in a ventricular assistance device era.
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Affiliation(s)
- Leonardo Rufino Garcia
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Flavio de Souza Brito
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Marcello Laneza Felicio
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - André Monti Garzesi
- Department of Surgery, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Márcia Terezinha Tardivo
- Department of Internal Medicine, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Bertha Furlan Polegato
- Department of Internal Medicine, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
| | - Marcos Ferreira Minicucci
- Department of Internal Medicine, Universidade Estadual Paulista-UNESP, SP, São Paulo, São Paulo, Brazil
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Schuurman H, Hoogendoorn K. Solid organ xenotransplantation at the interface between research and clinical development: Regulatory aspects. Xenotransplantation 2020; 27:e12608. [DOI: 10.1111/xen.12608] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/20/2022]
Affiliation(s)
| | - Karin Hoogendoorn
- Interdivisional GMP Facility Hospital Pharmacy Leiden University Medical Center Leiden The Netherlands
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Li X, Burlak C. Xenotransplantation literature update, March/April 2020. Xenotransplantation 2020; 27:e12607. [PMID: 32472558 DOI: 10.1111/xen.12607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Xiaohang Li
- Department of Hepatobiliary Surgery, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Christopher Burlak
- Department of Surgery, Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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10
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Kwon I, Park C, Lee S. Regulatory aspects of xenotransplantation in Korea. Xenotransplantation 2020; 27:e12602. [DOI: 10.1111/xen.12602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Ivo Kwon
- Department of Medical Education Ewha Womans University College of Medicine Seoul Korea
- Xenotransplantation Research Center Seoul National University College of Medicine Seoul Korea
| | - Chung‐Gyu Park
- Xenotransplantation Research Center Seoul National University College of Medicine Seoul Korea
- Department of Microbiology and Immunology Seoul National University College of Medicine Seoul Korea
- Cancer Research Institute Seoul National University College of Medicine Seoul Korea
- Institute of Endemic Diseases Seoul National University College of Medicine Seoul Korea
- Department of Biomedical Science Seoul National University Graduate School Seoul Korea
| | - SeungHwan Lee
- Clinical Trials Center & Department of Clinical Pharmacology and Therapeutics Seoul National University Hospital Seoul Korea
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Gates C. Preparing IRB members for xenotransplantation clinical trials. Xenotransplantation 2020; 27:e12590. [PMID: 32223064 DOI: 10.1111/xen.12590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Cindy Gates
- Human Subject Research Office, University of California, Miami, FL, USA
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