Background:. Adults with a modified lower urinary tract (MLUT) represent a growing but understudied population in renal transplantation. Concerns regarding long-term graft survival, infection, and urological morbidity persist, yet adult-specific outcome synthesis and clinically useful guidance are lacking. Methods:. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of studies reporting posttransplant outcomes in adults with abnormal or surgically MLUT anatomy. Primary outcomes were 1- and 5-y graft and patient survival. Secondary outcomes included urological complications. Given substantial heterogeneity, data were synthesized narratively. Results:. Twenty-four studies, including 511 MLUT recipients, were identified. Most were retrospective single-center series, and only a minority included comparator cohorts. Several studies included mixed adult-pediatric cohorts where adult-only outcomes could not be separated. Across comparative studies, 1-y graft survival appeared broadly similar between MLUT and control recipients, whereas 5-y graft survival was more often lower in MLUT cohorts. Patient survival was comparable, although long-term comparative data were limited. Urological morbidity was consistently greater in MLUT recipients, particularly recurrent urinary tract infection and the need for further urological intervention. Conclusions:. Renal transplantation in selected adults with MLUT is achievable with acceptable early outcomes, but the burden of urological morbidity is substantial, and longer-term graft outcomes are less favorable. These findings support careful pretransplant lower urinary tract assessment and highlight the need for pragmatic optimization pathways, although higher-quality prospective data remain necessary.
Background. Split liver transplantation (SLT) maximizes donor organ utilization but faces challenges with ischemia-reperfusion injury (IRI). Machine perfusion techniques, including hypothermic oxygenated perfusion (HOPE), dual HOPE (DHOPE), and normothermic machine perfusion (NMP), may enhance graft viability and expand the donor pool. This scoping review maps existing clinical and experimental evidence on machine perfusion in SLT, examining benefits, feasibility, outcomes, and knowledge gaps. Methods. Following Joanna Briggs Institute manual guidelines, we searched PubMed, Embase, Scopus, and Web of Science through September 3, 2025, plus gray literature (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Google Scholar). Studies exploring machine perfusion techniques in liver splitting of human or animal grafts, with or without transplantation, were included. Results. After screening 958 records, 38 studies were included (29 primary studies, 9 reviews). Among primary studies, 84 clinical transplant cases using machine perfusion were identified (including 2 cases with unspecified perfusion modality); however, this number may not represent unique patients because of possible overlap between same-center cohorts. HOPE (7 studies, 40 cases) was supported by preliminary comparative data suggesting reduced IRI versus static cold storage, with 1 cohort study showing lower postreperfusion syndrome rates (13.3% versus 47.1%, P = 0.04) and reduced IRI scores (3 versus 4, P = 0.03). NMP (16 studies, 34 cases) enabled extended preservation up to 25 h with 100% short-term graft survival in case series. DHOPE (4 studies, 8 cases) reported feasibility for complex full-left/full-right splitting. Evidence was limited by small sample sizes (median n = 2, range 1–26), short follow-up (maximum 18 mo, median 6 mo), absence of randomized trials, and potential publication bias. Conclusions. Machine perfusion remains an investigational strategy in SLT. Preliminary evidence suggests HOPE may reduce IRI and NMP may provide logistical advantages through extended preservation. However, evidence derives entirely from small observational studies without randomization. Multicenter prospective studies with standardized protocols, longer follow-ups, and cost-effectiveness analyses are needed.
Background. Uterus procurement from brain-dead donors during multiorgan procurement for uterus transplantation (UTx) presents a technical challenge because the uterus is not a vital organ and also because of the need to harvest uterine and ovarian veins for transplantation. The aim of this article is to describe the technical refinements in uterus procurement from brain-dead donors during multiorgan procurement and evaluate their impact on graft viability in UTx. Methods. According to a prospective interventional study within a national multiorgan procurement network, we described uterus procurement during multiorgan retrieval with protocol modifications between the first and second procedures, including bilateral femoral artery cannulation for pelvic perfusion and in situ identification of uterine and pelvic vessels before cold flushing. The main outcomes were the feasibility of procurement, graft viability, surgical parameters (ischemia times, operative duration), and short-term graft outcomes. Results. Among 8 evaluated recipients, 3 UTx procedures from brain-dead donors were performed. The first transplantation resulted in early graft loss because of bilateral arterial thrombosis requiring graft explantation on postoperative day 1. The second and third transplantations demonstrated sustained graft viability with normal perfusion on Doppler imaging up to 2 and 7 mo, resumption of menstruation, and only 1 episode of mild rejection responsive to corticosteroids. Technical refinements reduced back-table complexity and operative time (5 h 40 min versus 4 h 15 min) and enabled improved venous outflow through additional anastomoses. Bilateral femoral artery cannulation allowed effective pelvic perfusion without interfering with standard multiorgan procurement. Conclusions. UTx from brain-dead donors is feasible within a multiorgan procurement setting. Bilateral femoral cannulation combined with in situ vascular identification improves graft preparation and may enhance reproducibility without compromising retrieval of vital organs. These refinements represent important steps toward standardization of deceased donor UTx.
Background. Kidneys from pediatric donors are underutilized, in part because of concern about acute rejection. This study evaluated the association between donor age and 1-y acute rejection after deceased-donor kidney transplantation. Methods. We retrospectively analyzed Scientific Registry Of Transplant Recipients data from 2014 to 2025 for first-time, deceased-donor, adult kidney recipients. The primary outcome was any reported acute rejection episode within 12-mo posttransplant, modeled by multivariable generalized estimating equations logistic regression clustered by transplant center and restricted to pretransplant covariates. Donor age was a 5-level categorical variable with post hoc, data-derived cut-points at 3.5, 18.3, 34.3, and 61.3 y from locally estimated scatterplot smoothing inflection points. A secondary model split the reference group by en bloc versus non–en bloc procedures. Results. Among 136 182 recipients, 8803 had rejection events (6.5%). Donors <3.5 y (n = 2061) had an unadjusted rejection rate of 4.8% versus 6.5% for donors ≥3.5 y (P = 0.002). Adjusted odds were higher in every older stratum: 3.5–18.3 y (adjusted odds ratio 1.59; 95% CI 1.25-2.04), 18.3–34.3 y (1.61; 1.24-2.10), 34.3–61.3 y (1.97; 1.51-2.56), and >61.3 y (2.49; 1.88-3.28); all P < 0.001. Population-standardized adjusted probabilities increased from 3.9% (2.9–5.0) to 9.1% (8.2–10.0). En bloc allografts differed significantly from all four older strata; non–en bloc allografts from the 2 oldest only. Conclusions. Younger ages of deceased-donors are associated with up to 60% lower adjusted odds of 1-y rejection. Donor age appears to have an independent association with early acute rejection.
