Background:Procurement-related injury to the right renal vein (RRV) or renal-caval vein complex (RCVC) may preclude transplantation of an otherwise usable right kidney. We report an expanded single-center experience with the previously described York Plastic technique, focusing on technical feasibility and short-term outcomes. Methods:We retrospectively reviewed deceased-donor right kidneys assessed at our center between January 2018 and January 2025. Of 334 kidneys, 17 (5.1%) sustained procurement-related RCVC injury; 15 underwent York Plastic reconstruction and transplantation, whereas 2 were not used because of severe associated graft damage. Of the 15 transplanted cases, 10 were included in our preliminary 2023 technical report and 5 are newly reported. Results:All 15 reconstructed grafts were transplanted successfully. No intraoperative bleeding, renal vein thrombosis, or Doppler evidence of venous stenosis occurred. Mean bench reconstruction time was 35 minutes (range, 20-51), and mean cold ischemia time was 16.4 ± 2.5 h. Median serum creatinine among functioning grafts was 1.58 mg/dL at 1 month, 1.49 mg/dL at 3 months, and 1.36 mg/dL at 12 months. At 12 months, 13 of the 14 surviving recipients had functioning grafts. One recipient died at 3 months with a functioning graft; one surviving recipient returned to dialysis before 12 months because of antibody-mediated rejection associated with severe cytomegalovirus infection. Conclusions:The York Plastic technique appears to be a feasible bench-salvage option for selected procurement-related RCVC injuries and may support organ preservation in carefully chosen cases.
Background:Cardiovascular disease (CVD) is thought to evolve faster after liver transplantation (LT) due to an increased prevalence of cardiovascular risk (CVR) factors and the use of immunosuppression. The progression of coronary artery calcium score (CACS) in computed tomography is a prognostic biomarker of CVD. There is scarce information about CACS changes after LT or in patients with cirrhosis. Methods:We compared the 5-year progression of CACS in two populations: 75 LT recipients and 20 patients with cirrhosis assessed for LT but who eventually did not undergo LT (non-LT). In both populations, CACS was measured at LT evaluation and 5 years thereafter. Additionally, we studied 1-year post-LT CVR factors and immunosuppression parameters, including cumulative exposure to tacrolimus (CET) as potential predictors of 5-year CACS progression after LT. Results:Both groups were comparable regarding CVR factors, time between CACS, or baseline CACS. CACS increased in both groups, with an annualized progression of 23 Agatston units (AU)/year in LT and 30 AU/year in non-LT (p = 0.833). CVR factors control after LT was optimal, and 80% received standard/minimized CET. Higher pre-LT CACS (p < 0.001) and worse kidney function 12 months after transplantation (p = 0.003) independently predicted progression after LT. No immunosuppression-related variables were associated with CACS progression. Conclusion:In LT recipients with optimized control of CVR factors and standard/minimized CET, CACS progression was not faster than in patients with cirrhosis. The association between posttransplant renal function and CACS progression warrants further investigation.
Background:Kidney transplant recipients with high clinical complexity often face persistent symptom burden, emotional distress, and reduced quality of life despite stable graft function. Evidence for structured multidisciplinary programs tailored to this population remains scarce. Methods:We conducted a 12-month, single-center implementation cohort study including 73 kidney transplant recipients classified as complex using NECPAL criteria or presenting significant emotional distress. Participants were enrolled in a coordinated, person-centered multidisciplinary program integrating nephrology, psychology, palliative care, nutrition, rehabilitation, nursing, and social work. Outcomes were assessed at baseline and Months 1, 3, 6, 9, and 12 using validated instruments: ESAS-r (symptom burden), DME (emotional distress), GES (spiritual well-being), and SF-12 (health-related quality of life). Global adaptation was defined as improvement in ≥ 2 of 3 domains (symptom burden, emotional distress, and spirituality). Qualitative data from open-ended responses were thematically analyzed. Results:Over follow-up, participants showed reductions in symptom burden (ESAS-r: 35.27 to 18.60), emotional distress (DME: 12.53 to 6.57), and increases in spiritual well-being (GES: 17.21-20.12), with improvements in SF-12 general health, emotional health, and social functioning. Global adaptation was achieved by 43.9% of patients, most within 3 months. Patients with ≥ 4 NECPAL criteria exhibited the most pronounced multidimensional gains. Emotional coping emerged as the strongest predictor of improvement. Qualitative analysis revealed unreported symptoms, resilience strategies, and existential reframing. Conclusions:Implementation of a structured multidisciplinary model, combined with early complexity screening, was feasible and associated with longitudinal improvements across physical, emotional, spiritual, and functional domains in complex kidney transplant recipients. These preliminary findings suggest potential benefit-particularly for those with highest baseline vulnerability-and support the need for validation in multicenter, controlled studies.
Background The use of livers from donors with expanded criteria, where monitoring the degree of hepatic steatosis (HS) is crucial, has increased in recent years to address the shortage of available grafts. The aim of this study is to evaluate the utility of monitoring regional hepatic oxygen saturation (rSO2) using the INVOS somatic oximeter in the assessment of liver donors. Methods An observational, longitudinal, and prospective study was conducted of adult patients undergoing liver transplantation at our center between 08/01/2020 and 06/01/2022. We measured rSO2 by placing the sensor on the donor skin and on the liver surface. Results The rSO2 measurements on the donor skin were obtained in 27 patients (93.1%), while the measurements on the donor liver were taken in 18 patients (62.1%). We found a statistically significant relationship between the rSO2 values measured on the donor liver and the degree of steatosis ( p = 0.001). rSO2 values > 57% measured on the donor liver were associated with HS < 30% (S: 92%; E: 75%). Donors with lower preoperative GOT values had statistically significantly higher rSO2 values measured on the skin ( p = 0.046). Conclusions Hepatic rSO2 measurements obtained with the NIRS device in liver donors were associated with relevant donor graft characteristics, particularly the degree of HS.
ObjectiveInfectious arteritis involving the iliac arteries is a rare but severe complication after kidney transplantation, frequently leading to graft loss and mortality. Direct repair within infected fields is often unsuccessful. We report outcomes of femoral-femoral artery artificial vascular bypass (Fem-Fem bypass) as a strategy to exclude infected arterial segments and preserve limb perfusion in five such cases.MethodRetrospective analysis of four kidney transplant recipients who developed infectious arteritis (external iliac artery) with rupture or aneurysm between January 2015 and January 2023. All underwent resection of the infected arterial segment with proximal/distal ligation and extra-anatomic Fem-Fem bypass using a synthetic graft.ResultsAmong the four patients, two were infected with carbapenem-resistant Pseudomonas aeruginosa (CRPA), one with carbapenem-resistant Enterobacteriaceae (CRE), and one with mucormycosis. All underwent Fem-Fem bypass following resection of the infected arterial segment. One patient with CRPA infection died 5 months postoperatively due to septicemia and multiorgan failure. The remaining three patients survived with functional grafts and patent bypasses at follow-up, without recurrence of infection or vascular complications.ConclusionsFem-Fem bypass effectively controls hemorrhage or aneurysm expansion and maintains limb perfusion by excluding the infected iliac arterial segment in kidney transplant recipients with infectious arteritis. It represents a viable salvage option when endovascular repair fails or is contraindicated. Long-term success depends on effective infection control, appropriate antimicrobial therapy, and patient-specific factors. Mortality remains significant in cases with systemic sepsis or highly resistant pathogens.
Background:Living donor intestinal transplantation (LDITx) is an alternative option to cadaveric transplants as a last resort in treating intestinal failure. There are limited data on LDITx outcomes. This systematic review evaluates LDITx in terms of indications, contraindications, surgical complications, and patient outcomes. Methods:A comprehensive search was conducted across PubMed, Cochrane Library, Virtual Health Library, and Web of Science databases following the PRISMA guidelines. After filtration, data were systematically extracted from all relevant observational studies, case series, and case reports. Quality assessments were performed using the CARE guideline for case reports and case series, while STROBE was used for observational studies. Results:Fifty-four studies were included, comprising 11 observational studies, 9 case series, and 34 case reports. The main indications of LDITx were the availability of a compatible donor and the urgency of the recipient's clinical condition. The standard surgical technique involves segmental ileal resection and transplantation. Postoperative complications included infections, ischemic events, and vascular complications. Recipients had either manageable complications or no complications. About 21.2% of the population experienced at least one episode of rejection, with an overall mortality rate of 23%. Many cases reported successful TPN weaning and good outcomes for the recipients and donors. Conclusion:In patients with chronic IF complicated by severe TPN-related morbidity or underlying pathologies causing SBS, LDITx represents an effective treatment option and an alternative to the more conventional cadaveric intestinal transplantation, bypassing problematic time sensitivity and donor availability.
Pediatric liver transplantation (LT) with large-for-size (LFS) grafts frequently necessitates open abdomen (OA) management due to donor-recipient graft size mismatch, increasing the risk of delayed closure and frequently requires the use of permanent prosthetic materials, together compounding the risk of postoperative infection. This study evaluates the safety and effectiveness of the Topaz-Gurevich Doppler-guided controlled-closure technique (DGCT) in facilitating early primary abdominal closure without graft size reduction or the use of permanent prosthetic implants. A retrospective review was conducted at Schneider Children's Medical Center (2016-2024), including 21 pediatric LT recipients requiring OA management, primarily due to LFS grafts. DGCT integrates a tension relief system (TRS) for gradual abdominal wall approximation, guided by real-time Doppler ultrasound to monitor perfusion and modulate closure tension, and is complemented by regulated, oxygen-enriched irrigation and negative pressure-assisted wound therapy to optimize the local wound environment. All patients achieved primary abdominal closure within a median of 8 days (range, 2-23); only the first three cases required the temporary use of prosthetic materials. The median PICU and hospital stays were 17 and 35 days, respectively. No cases of graft failure, retransplantation, or mortality occurred. One patient developed sepsis related to a bowel leak and fully recovered. DGCT proved safe and effective in managing OA in pediatric LT, avoiding permanent prosthetic implantation, and enabling early closure while maintaining graft perfusion. Its combined approach of mechanical tension control and enhanced local wound conditions reduces the need for graft size reduction, minimizes infection risk, and may broaden the donor pool. Based on high-risk cases involving immunosuppressed children with significant graft-recipient mismatch, these findings support DGCT as a valuable strategy for pediatric transplantation. Moreover, the principles demonstrated here may be extrapolated to the closure of complex OA scenarios across broader pediatric and adult surgical populations.
Background:Liver transplantation is the definitive therapy for end-stage liver disease. The severe organ shortage necessitates exploring grafts from extended-criteria donors, including those who become brain dead due to toxicological causes. This study evaluated the outcomes of liver transplantation using grafts from brain-dead donors with confirmed warfarin-associated coagulopathy (WAC). Methods:This retrospective observational cohort study was conducted at a high-volume transplant center (1994-2024). Ten recipients who received liver grafts from brain-dead donors with WAC were included. Clinical data were reviewed to assess liver function recovery, complications, and survival. Results:The cohort included 10 recipients (8 males, 2 females; mean age: 49.8 ± 13.2 years). Liver function tests and international normalized ratio (INR) levels showed significant improvement by Postoperative day 7. Acute rejection occurred in two recipients (20%), successfully treated with corticosteroids. One patient (10%) developed primary nonfunction, leading to death. Patient survival was 100% at 30 days and 70% at 1 year; corresponding graft survival was 90% and 70%. Conclusion:In this small, highly selected cohort, liver grafts from brain-dead donors with WAC may be used with acceptable short-term safety. These preliminary findings demonstrate feasibility and highlight the need for larger, controlled studies to further evaluate outcomes and donor selection criteria.
Background:At our institution, 99mTc-MAG3 renal scintigraphy is routinely performed preoperatively in living kidney donors and on postoperative Day 1 in recipients. Given the interindividual variability in MAG3 clearance, we hypothesized that postoperative MAG3 clearance could serve as an early indicator of renal graft function. In addition, we explored whether the donor-to-recipient clearance ratio (M-ratio) provides supplemental clinical value. Early identification of such indicators of graft function is essential for optimizing postoperative management and improving outcomes. Methods:This retrospective study analyzed 52 living donor kidney transplants performed between October 2009 and May 2024. Associations were examined between donor and recipient MAG3 clearance values, the M-ratio (elevated ≥ 1.5 vs decreased/stable < 1.5), donor/recipient age and sex, T1/2 pattern (good excretion ≤ 20 min vs delayed > 20 min or unmeasurable), total ischemic time, graft weight, dialysis duration, and estimated glomerular filtration rate (eGFR) at 1 week and 1-12 months postoperatively. Variables with p < 0.05 in univariate analysis entered multivariate regression. Results:Univariate analysis showed that recipient MAG3 clearance, the M-ratio, donor and recipient age, T1/2 (up to 1 month), and graft weight (at 1 week) were significantly associated with graft function. In contrast, donor MAG3 clearance was not correlated with postoperative renal function. In multivariate analysis, recipient MAG3 clearance, recipient age, and graft weight remained independently associated with early graft function, whereas the M-ratio lost significance. Conclusions:Recipient MAG3 clearance on postoperative Day 1 is a practical, noninvasive indicator of renal graft function, while donor clearance and the M-ratio are not independently associated with postoperative outcomes.
Background:The effectiveness of training organ donation teams in improving organ donation rates has been well established. However, studies have shown that this impact is often temporary and diminishes without ongoing support and quality control programs. This study aimed to evaluate the effects of initial training and the role of a structured quality control program in sustaining these improvements in Iran's organ procurement units (OPUs). Method:A comprehensive training program, the Iranian OPUs Supporting System (IrOSS), was developed and implemented with the participation of 25 OPUs. Their organ donation (PMP) rates were recorded at baseline and monitored every 3 months for 6 months posttraining. Later, a quality control initiative, the Iranian OPUs Quality Control System (IrOQS), was introduced in 15 of these units. Through periodic assessments, weaknesses were identified and addressed via targeted interventions such as strategy improvements and retraining. The remaining 10 units served as a control group. PMP was reevaluated 3 and 6 months after the initial IrOQS implementation, with a final assessment 3 months after the second round. Longitudinal data were analyzed using advanced statistical techniques, including repeated-measures ANOVA, difference-in-differences (DiD), linear mixed-effects models (LMMs), trajectory analysis, and change point detection. Results:The mean PMP across all 25 OPUs increased from 5.31 before training to 8.05 six months after training. In the intervention group, the mean PMP increased to 13.06 after the first IrOQS phase, decreased to 9.84 over the next 6 months, and increased again to 15.6 after the second IrOQS phase. In contrast, while the control group showed an initial increase after training, their PMP gradually decreased over time. Statistical analyses showed that the initial training had a significant positive effect on performance, but these improvements were not sustained without repeated interventions. Path analyses also showed that units with lower initial performance responded most positively to training but tended to regress if retrained. Conclusion:The findings of this study suggest that initial training programs can lead to significant improvements in PMP. However, to maintain these gains, regular implementation of ongoing training programs is essential. Data science approaches and longitudinal data analysis can play a critical role in identifying performance patterns in the quality management of OPUs.
Introduction and Objectives:The use of apheresis-based desensitization has enabled a safe ABO-incompatible kidney transplantation (ABOi-KT) by reducing ABO allo-isoagglutinin IgG and/or IgM (anti-A and/or anti-B) titers. However, the rate of titer reduction and the number of apheresis sessions required for apheresis-based desensitization remain unclear. We conducted this study to summarize the effectiveness of apheresis-based desensitization for ABOi-KT, as reflected in IgG and IgM titer reduction rate (TRR) and the number of apheresis sessions required. Materials and Methods:A systematic literature search was performed on PubMed, Cochrane Library, ProQuest, Scopus, ScienceDirect, and MEDLINE according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement up to May 2025. Twenty-five cohort studies and twenty-three case series studies. Risk of bias assessment was performed using the Joanna Briggs Institute (JBI) critical appraisal tools. Results:The IgG and IgM TRR based on thirty-one and fifteen included studies involving 1105 and 642 patients, respectively, showed a statistically significant reduction in both IgG and IgM titers with pooled TRR MD of 3.73 and 3.82 Log2 units, respectively (95% CI 3.23 to 4.23, I 2 96.05%, p < 0.001; 95% CI 3.29 to 4.35, I 2 95.74%, p < 0.001). Twenty two included studies involving 934 patients showed an average of 4.97x apheresis sessions required per patient (95% CI 4.32 to 5.61, I 2 96.44%, p < 0.001). Subgroup meta-analyses based on apheresis types, publication decade, and study type were also reported with statistically significant results. Conclusion:The reported IgG and IgM TRR and apheresis sessions required per patient in apheresis-based desensitization for ABOi-KT showed significant results. Similar outcomes were observed among plasmapheresis (PE), immunoadsorption (IA), and the combination of both, indicating that any of these techniques may be effective. This may reflect the effectiveness of apheresis-based desensitization for ABOi-KT, regardless of the apheresis technique. These findings can be a consideration in developing apheresis-based desensitization guidelines for ABOi-KT.
Background:Frailty and perioperative management critically influence outcomes following liver transplantation (LT). The liver frailty index (LFI) objectively assesses frailty, while early extubation (EE) has been linked to enhanced recovery in surgical patients. However, the associations of frailty and EE with postoperative outcomes in LT remain unclear. Methods:This retrospective cohort study included adult LT recipients at a tertiary care center between 1/2019 and 7/2023. Patients were classified as frail (LFI ≥ 4.5) or nonfrail (LFI < 4.5) and stratified by EE versus delayed extubation (DE). Primary outcomes were EE rate, ICU length of stay (LOS), and hospital LOS. Linear regression models adjusted for age, gender, BMI, MELD, transplant type, and liver disease etiology. Results:Of 158 postliver transplant patients, 38 (24.1%) were frail. Frail patients had longer ICU LOS (33.2 vs. 4.2 days, p < 0.001) and hospital LOS (59.5 vs. 10.1 days, p < 0.001) compared to nonfrail patients. EE occurred in 78.5% of all postliver transplant patients, with no significant difference by frailty (p = 0.821). Multivariable regression showed frailty was associated with increased hospital LOS (β = +48 days, 95% CI: 43-54, p < 0.001) and ICU LOS (β = +28 days, 95% CI: 25-32, p < 0.001), while EE was associated with decreased hospital LOS (β = -12 days, 95% CI: -17 to -6.7, p < 0.001) and ICU LOS (β = -12 days, 95% CI: -15 to -8.4, p < 0.001), irrespective of frailty status. Conclusions:Our study demonstrated that EE significantly shortens ICU and hospital stays in postliver transplant patients with pretransplant frailty. These findings underscore the importance of incorporating EE protocols in this high-risk population and warrant further investigation into strategies that facilitate implementation to optimize clinical outcomes.
Background:Dual liver-lung transplantation (DLLT) is an uncommon but definitive therapy for carefully selected patients with concurrent end-stage hepatic and pulmonary disease. The combined operative complexity and dual-organ immunosuppressive burden may predispose recipients to early morbidity and graft-threatening complications [1-4]. Objective:To characterize early and late postoperative events (including acute cellular rejection (ACR), infectious complications, malignancy, and hospital readmissions) after DLLT and to describe associated clinical patterns. Methods:We performed a retrospective cohort study of adult DLLT recipients at a single tertiary center (2013-2024). Variables included demographics, transplant indications, ischemia times, readmissions (0-3 months; 3-12 months), infections (timing/etiology/site), biopsy-proven rejection, malignancy, and survival. ACR was biopsy-confirmed in cases of unexplained transaminitis beyond 30 days posttransplant. Analyses were descriptive, consistent with STROBE recommendations for small cohorts. Results:Ten patients (mean age 53.7 years; 50% female) underwent DLLT. Liver etiologies included alcohol-related cirrhosis (n = 2), HCV (n = 1), cryptogenic (n = 1), autoimmune (n = 1), cystic fibrosis (n = 1), and unspecified (n = 4). Lung indications were IPF (n = 5), pulmonary hypertension (n = 2), ILD (n = 2), and CF (n = 1). All patients were readmitted within 90 days, most commonly for infection (40%), diarrhea (20%), critical illness myopathy (20%), rejection (10%), and biliary stricture (10%). Biopsy-proven ACR occurred in 4/10 patients (40%) after the first month, uniformly presenting with hepatocellular transaminemia; 3/4 received pulse-dose IV corticosteroids and 2/3 subsequently developed invasive fungal disease (Aspergillus and Candida). Overall, 9/10 experienced infection within 6 months, predominantly pulmonary (fungal/bacterial pneumonias). Three patients developed malignancy (basal cell carcinoma, prostate carcinoma, and angiosarcoma [fatal]). Survival was 90% at 1 year, 70% at 3 years, and 60% at 5 years; no 10 year survivors were observed. Conclusions:DLLT is associated with early readmission and a high infectious burden, particularly invasive fungal disease after steroid-treated ACR. Despite significant early morbidity, short-term survival is favorable. Multicenter studies are needed to refine candidate selection, balance rejection prophylaxis with antifungal strategies, and standardize long-term oncologic and dermatologic surveillance in DLLT.
Background:Urinary tract infections (UTIs) are common complications following simultaneous pancreas and kidney transplantation (SPK). The role of specific immunosuppressive agents in modulating UTI incidence and recurrence remains poorly understood. Methods:In this retrospective, single-center study, we analyzed 164 SPK recipients randomized to receive either sirolimus or mycophenolate mofetil (MMF) in combination with tacrolimus. The incidence of UTIs, relapses, recurrences, and UTI-related hospitalizations was assessed over a 10-year follow-up. Univariable and multivariable negative binomial regression models were used to evaluate associations with immunosuppressive regimens and clinical outcomes in both intention-to-treat (ITT) and per-protocol analyses. Results:A total of 572 UTI episodes were recorded during follow-up (0.102 per 100 recipient-transplant days). No significant differences in overall UTI incidence or UTI-related hospitalizations were observed between the sirolimus and MMF groups. However, in the multivariable per-protocol analysis, the sirolimus group experienced significantly fewer UTI-related hospitalizations (IRR 0.46; 95% CI, 0.23-0.94; p = 0.034) and relapses (IRR 0.54; 95% CI, 0.30-0.97; p = 0.039). Significant risk factors for UTIs included female sex, JJ stent placement, and pretransplant urological abnormalities. Recurrent UTIs were associated with lower 10-year kidney graft survival (52% vs. 75%; p = 0.01) but had no impact on pancreas graft or patient survival. Conclusions:While overall UTI incidence did not differ between immunosuppressive regimens, sirolimus use was associated with fewer hospitalizations and relapses. These findings indicate a potential clinical benefit of sirolimus in selected high-risk SPK recipients, highlighting the need for further prospective investigation. Trial Registration: ClinicalTrials.gov identifier: NCT00140543.
BackgroundThis study compares the incidence of posttransplant major adverse cardiovascular events (MACE) between patients with and without prekidney transplant (KT) revascularization.MethodsA retrospective cohort of 518 patients who underwent KT was divided into groups based on whether they underwent pre-KT revascularization. The primary outcome, MACE, was defined as a composite endpoint including cardiovascular death, nonfatal MI, stroke, need for revascularization, and hospitalization for heart failure. All patients with obstructive CAD received pre-KT revascularization. Cox proportional hazards models were used to estimate the risk for MACE over a period capped at 5 years in the cohort using the propensity score method of stabilized inverse probability of treatment weighting (IPTW) to address confounders (diabetes status, age, gender, and a past medical history of CAD). Kaplan-Meier curve was constructed to visualize the development of MACE over time (Figure 1).ResultsMedian age of the entire cohort was 56.0 (44, 63) years, 56.9% men, 46.9% White, and 47.6% African Americans. Mean follow-up was 41.3 +/- 29.7 months. Multivariate analysis showed that obtaining pretransplant revascularization was not significantly associated with MACE (hazard ratio [HR] = 0.98, 95% confidence interval 0.45-2.13, p = 0.96).ConclusionThis study found that patients with obstructive CAD undergoing revascularization prior to KT had a similar risk of developing MACE compared to patients without obstructive CAD.
Background:Invasive fungal infections (IFIs) are associated with a high mortality in lung transplant recipients, with no consensus on optimal antifungal prophylaxis. We aimed to assess the efficacy of long-term itraconazole compared to short-term inhaled amphotericin to prevent IFIs post-transplant. Methods:A retrospective review of adult lung transplant recipients from January 2016 to September 2022 was conducted. The cohort was divided into two groups based on initial mold prophylaxis: long-term itraconazole and short-term inhaled amphotericin. The primary outcome was the incidence of IFIs. The secondary outcomes included the time to IFI, incidence of fungal species found on cultures, and safety/tolerability. Results:A total of 203 patients met the inclusion criteria (amphotericin group n = 108, itraconazole group n = 95). The overall incidence of IFIs was significantly higher in the amphotericin group than the itraconazole group (76.9% vs. 56.8%, p = 0.002). The Kaplan-Meier curve for the risk of IFI within 1 year of transplant showed a shorter time to IFI in the amphotericin group (p = 0.009). In the amphotericin group, there was an increased incidence of positive fungal cultures compared to the itraconazole group with Aspergillus spp. (25% vs. 8.4%, p = 0.002), Penicillium spp. (25.9% vs. 9.5%, p = 0.002), yeast (70.4% vs. 36.8%, p ≤ 0.001), and other positive fungal cultures (28.7% vs. 12.6%, respectively, p = 0.005). The amphotericin group had more discontinuations due to intolerance than the itraconazole group (12% vs. 3.2%, p = 0.019). Conclusion:In adult lung transplant recipients, long-term prophylaxis with itraconazole was more effective at preventing overall IFIs, positive cultures with Aspergillus spp., and was better tolerated than short-term inhaled amphotericin.
Background The composition of the U.S. deceased kidney donor pool is undergoing a major shift. While the past decade saw an increase in younger, overdose-death donors associated with favorable transplant outcomes, recent years have marked a decline in these donors. Concurrently, there has been a rise in higher-risk donor characteristics-namely, older age, more comorbidities, such as hypertension and diabetes, and increased reliance on donation after circulatory death (DCD). These trends may significantly affect transplant outcomes. Methods We analyzed data from the Organ Procurement and Transplantation Network (OPTN) on 101,550 deceased kidney donors (2018-Q1 2025) and 108,611 single kidney transplants (2018-mid-2024). Donor trends were assessed using segmented regression analysis. Graft survival was evaluated using Kaplan-Meier survival curves and multivariable Cox proportional hazards models, adjusting for donor, recipient, and transplant characteristics. Results Overdose-death donors declined from 16.7% in 2022 to 10.5% by Q1 2025. Simultaneously, DCD donors rose to nearly 50% of all deceased donors. The proportion of older donors and high-KDPI kidneys also increased. Kaplan-Meier analysis showed a decrease in unadjusted death-censored graft survival in 2024 compared to 2018-2022 (97.0% vs. 97.6%, p < 0.001). In adjusted Cox models, donor factors-DCD status, older age, hypertension, diabetes, and prolonged cold ischemia-were independently associated with graft loss. Conclusions The U.S. kidney donor pool is shifting toward higher-risk profiles, with early signs of declining graft survival. Strategies to optimize organ preservation and allocation will be essential to maintain transplant outcomes amid these changing donor trends.
Introduction:The integration of artificial intelligence (AI) in liver and kidney transplantation (LKT) research has surged in recent years, promising novel approaches to address traditional statistical challenges and enhance result robustness and generalizability. This study aims to explore the extent of international collaboration and the evolution of research trends in AI applications for LKT. Methods:On August 12, 2025, a systematic search was conducted using the Web of Science database to identify relevant literature. Bibliometric tools, including the "bibliometrix" package in R, VOSviewer, and Microsoft Excel were used. Key indicators such as country contributions, multiple-country publications, single-country publications, co-authorship, and keyword co-occurrence were examined to assess collaboration patterns and research hotspots. Inclusion criteria involved all published peer-reviewed articles related to AI in LKT. Editorials, corrections, and irrelevant documents were excluded. Results:A total of 633 articles published between 1994 and 2025 were included in the analysis. These collectively received 8959 citations. The United States of America emerged as the leading contributor, accounting for 37.12% of the publications, followed by China and South Korea. Notably, international co-authorship was evident in 30.02% of the publications. Keyword analysis revealed that "survival," "outcomes," "risk," "mortality," and "prediction" were the most frequent terms, highlighting them as hotspots in transplantation research. Conclusion:The field of AI in LKT research is characterized by a growing international collaboration, despite the fact that participation is still uneven and concentrated in high-income countries. In order to advance the field and enhance outcomes across diverse patient populations, it will be crucial to strengthen global data-sharing and cultivate equity-focused, culturally adaptable AI models.
Background:Liver transplantation (LT) is offered as a life-saving treatment to those with end-stage liver disease. There has recently been much interest in considering the survival benefit of transplant when prioritizing patients for transplant. In this study, we aimed to measure the survival benefit of LT across various patient demographics by measuring the number of life-years gained after LT. Method:In this study, 101,770 patients were included from the Scientific Registry of Transplant Recipients (SRTR) transplanted between 2003 and 2021. The survival benefit of LT was calculated using restricted mean survival time (RMST) in the next 16 years post-transplant. Cox proportional hazard models and Weibull models were employed to quantify the impact of various predictors on survival benefit. Results:LT was found to provide survival gains of 4.93, 6.43, 6.30, and 3.67 years for the 18-29, 30-49, 50-69, and 70+ age groups, respectively. Survival benefit was highest at 6.62 years for patients with model for end-stage liver disease (MELD) scores of 15-19, with survival benefits of 5.7, 5.4, and 5.85 years for the 6-14, 20-29, and 30-40 MELD score cohorts, respectively. Older age (HR: 1.13), male sex (HR: 1.32), diabetes (HR: 1.32), and higher MELD scores were predictors of lesser survival benefit. Protective factors included higher education levels (HR: 0.70) as well as diagnoses of fulminant liver failure and autoimmune biliary disease (HR: 0.65). Conclusion:This study underscores how survival benefit varies across patients with different demographic and clinical characteristics, highlighting the nuanced interplay of these characteristics with survival and emphasizing the need for tailored post-transplant management strategies to optimize outcomes.
Background:Predicting whether an organ offer will be accepted for transplantation remains challenging for several reasons, including large offer volumes, highly imbalanced observations (more declines than acceptances), and lack of information about the human decision-making process. Offer acceptance models are used for risk-adjusted program evaluations and policy development, but there is a lack of literature on baselines and best practices for predictive applications. We compared a suite of machine learning models, feature sets, and sampling procedures to identify performance impacts when training offer acceptance prediction models. Methods:We evaluated several kidney offer acceptance models from logistic regression to gradient boosted trees that were trained on donor and candidate characteristics. We then selected the best-performing model and augmented training data with additional features (e.g., distance from the closest airport to the transplant hospital) or additional sampling procedures (e.g., undersampling). Results:Compared to the baseline logistic regression model (average precision: 0.0645), the XGBoost model offered the best performance improvement over the baseline (average precision: 0.0907). Including transportation-related features in the model further improved model performance (average precision: 0.0940); however, we did not observe substantial model performance differences based on the sampling procedure used. Conclusions:Leveraging advanced machine learning models and incorporating nonclinical datapoints (like transportation distances) can improve transplant organ offer acceptance prediction models. However, we observed steep tradeoffs between precision and recall as captured in the low average precision scores despite deceptively high AUROCs (baseline AUROC 0.832). Our findings suggest that even the best-performing models would not provide clear, equitable benefits over existing allocation policies. More research is needed before these models are practical for clinical implementation.
