Heart transplantation following donation after controlled circulatory death (DCD) could alleviate the global shortage of organs. We assessed the cost-effectiveness of this strategy and outlined the factors enabling an efficient DCD heart program. Two strategies were compared: donation after brain death (DBD) using static cold storage vs. DBD + DCD transplantation, where DCD hearts are preserved with a normothermic ex situ perfusion system. Costs (€; 2024 value) and outcomes (quality-adjusted life years (QALYs)) were modelled through a 15-year time horizon. Our main assumption was that DCD would increase transplant access without affecting waitlist mortality, with equivalent post-transplant outcomes. With a 20% annual increase in transplant activity, the DBD + DCD strategy resulted in a mean incremental gain of 0.14 QALYs at an additional cost of €20,618 compared with DBD alone. The incremental cost-effectiveness ratio was €146,373 per QALY gained. An 8% relative reduction in waitlist mortality (i.e., four additional lives saved annually among 500 new waitlisted patients) would make the DCD heart program cost-effective at €100,000 per QALY. Lower consumable costs would further improve cost-effectiveness. Decision-makers should consider these findings in light of the disease severity and the persistent shortage of heart donors that could be alleviated with DCD.
Sequential dual-organ living donation, defined as donation of a kidney and a partial liver graft by the same individual in separate operations, represents a rare extension of living donor transplantation. A donor-focused analysis was performed to characterize the donor population, the operative considerations posed by a second donor operation, and early donor outcomes at a single high-volume center. A retrospective review of all dual-organ living donors at our institute was performed. Twenty-four donors were identified (n = 10 liver-first and n = 14 kidney-first). The median interval between donations was 2 years (IQR 1.1–4.2). Twelve donors donated both organs anonymously, nine donated one organ anonymously and directed the other, and three directed both donations. Anonymous donation is a strong motivator in this unique population. Ten donors (42%) participated in kidney paired donation. Liver donations (left lateral segment (42%), left lobe (25%), and right lobe (33%)) were performed by an open approach. Laparoscopic nephrectomy was performed in all cases except two prior liver donors. Liver-after-kidney donors (n = 14) did not develop renal dysfunction after donation. Prior organ donation does not usually require modification of surgical technique for the second procedure. Dual-organ living donation is rare but can be safely performed independent of sequence.
Lungs are highly affected by brain death, with females showing a higher inflammatory response, linked sex hormones acute reduction. With the aging of world population, the number of older donors is increasing. So, the study of menopause associated changes gain importance. Here we investigated menopause’s effects in female brain death rats, previously subjected to transitional follicular depletion and aging. Female Wistar rats were divided in young and menopause groups. After follicular depletion, rats aged for 10 weeks. The animals were submitted to brain death and Sham operated rats served as controls. White blood cell counts, bronchoalveolar lavage were analyzed and inflammatory mediators were quantified. Lung tissue was evaluated for myeloperoxidase, intercellular adhesion molecules, miRNA expression, and protein and gene expression of estradiol receptors. In menopause group, there was increase in systemic and tissue leukocyte infiltration, myeloperoxidase expression, inducible nitric oxide synthase, intercellular adhesion molecule-1, lung edema, and loss of IL-10 regulation. Additionally, we found alterations in estradiol receptors along with changes in the expression of miRNAs associated to inflammation, vascular function and senescence. Menopause increases lung inflammation after brain death, by higher leukocyte infiltration and reduction of IL-10 and may impact the outcome of lung transplantation.
Artificial intelligence (AI) is increasingly entering clinical medicine, and organ transplantation is no exception. While a growing body of literature addresses the ethical challenges of AI in healthcare, systematic analysis of the specific ethical dimensions of AI use in organ transplantation is missing. This gap reflects a genuine analytical challenge: the transplantation process is ethically complex in ways that general AI ethics frameworks do not adequately capture. Transplantation medicine simultaneously bears ethical obligations to deceased donors, living donors, donor families, organ recipients, and the public at large. These obligations shift substantially across the stages of the transplantation process, from the patient-centred ethics of donor identification and listing decisions, through the distributive justice logic governing organ allocation, to the professional responsibility questions of the peri- and post-transplant phases. A rigorous ethical analysis of AI in organ transplantation therefore requires, first, a systematic mapping of AI use cases and models onto the transplantation process; second, an identification of the stakeholder-specific ethical obligations pertinent at each stage; and third, an in-depth analysis of how those obligations are specifically affected by the properties of the AI system in question. This paper proposes this framework and illustrates it using the example of AI-assisted organ allocation.
The field of xenotransplantation is advances rapidly. Its cross-species nature creates regulatory challenges different from those in allotransplantation. Public opinion is promoted as an essential element in developing responsible governance for this technology. This study takes a qualitative thematic approach to analyze data collected through a questionnaire (n = 136) to the Swedish public. The aim is, first, to analyze how respondents articulate concerns, hopes, and moral evaluations regarding XT, and second, to reflect on what these responses reveal about the methodological conditions required for meaningful public engagement in the development of regulatory frameworks for emerging biomedical technologies. The findings demonstrate that public views are not directly associated with the technical assessment of risk and benefit but are anchored in shifting sociocultural perceptions regarding human survival, animal welfare, and vulnerability as individuals move between different scenarios. We conclude that developing policy and regulations for XT require continuous engagement with the underlying public opinions. We learned that meaningful public engagement with emerging biomedical technologies involves sustained processes of familiarization, communication, and dialogue between science, society, and policy.
While living kidney donation is considered safe and beneficial, long-term psychosocial donor outcomes remain under-explored, particularly regarding donor-recipient relationships and caregiving dimensions. This study examined quality of life (QoL) and psychological outcomes among 713 living kidney donors from two major European transplant centers, assessing QoL, anxiety, depression and somatization alongside donor-recipient relationship types, caregiver role, caregiving burden and perceived responsibility for the recipient’s health. After adjusting for gender, age, center and time since donation, relationship type was not associated with physical wellbeing, but was linked to lower mental wellbeing in spouse donors compared to child-to parent and other genetically related donors. Caregiver role was linked to lower mental wellbeing and increased anxiety, caregiving burden with higher somatization, and perceived responsibility for recipient’s health with higher depression. Identified differences in mental health between centers likely reflect cultural and organisational characteristics, while differences in wellbeing linked to older age and time since donation are eventually understood within ageing processes. Conclusively, caregiving burden and perceived responsibility for the recipient’s health emerged as key predictors of psychological distress, while the effect of relationship type on wellbeing remains inconclusive. While most donors demonstrate good psychosocial outcomes, at-risk subgroups warrant appropriate attention prior and after donation.
Habit impacts healthy behaviors. The SystemCHANGE™ intervention supports associating medication taking with existing habits or creating new habits to improve medication adherence. This secondary analysis of United States and Türkiye MAGIC study data examines differences in habit between SystemCHANGE™ and attention control groups, differences in habit between countries, and habit as a relationship mediator between the SystemCHANGE™ intervention and immunosuppressive medication adherence in adult kidney transplant recipients. The Medication Event Monitoring System measured medication adherence. Objective habit index was computed during screening, intervention, and maintenance. During the SystemCHANGE™ intervention, habit strength was higher than during the screening and maintenance periods in both groups (mean difference 0.042, 95% confidence interval (CI): 0.004 to 0.080, p = 0.030). Habit index was lower for US participants compared to Turkish participants (mean difference −0.195, 95% CI: −0.300 to −0.089, p < 0.001). Habit was a mediator of the SystemCHANGE™ intervention on medication adherence (indirect effect was 0.094, 95% CI: 0.080 to 0.114, p < 0.001). The SystemCHANGE™ intervention exerted an impact on habit in two different populations which then had a positive impact on medication adherence.
As part of the ESOT International Consensus on Controlled Donation After Circulatory Determination of Death (cDCDD) Project, a dedicated working group addressed considerations relating to the determination of death in the context of cDCDD. Delphi methodology was used to explore international perspectives on the definition of death, and clinical and ethical standards for the determination of death in the setting of cDCDD. The results indicated consensus that establishing a “single unified definition of death worldwide” and specifically the “unifying brain-based concept of death” would be beneficial. There was consensus on the proposed definition of this concept and several principles relating to the determination of death in the context of cDCDD, such as the “dead donor rule.” However, limited agreement was reached on the more practical aspects of death determination. The results nevertheless provide a foundation for current policy and practice and should guide further efforts to establish minimum clinical standards for the determination of death in the context of cDCDD.
Acute-on-chronic liver failure (ACLF) carries high short-term mortality, and liver transplantation (LT) remains the curative treatment. Donation after circulatory death (DCD) grafts expand the donor pool but carry higher risks of dysfunction compared to donation after brain death (DBD) grafts, and data directly comparing their outcomes in ACLF are limited. Using the Scientific Registry of Transplant Recipients (SRTR), we conducted a retrospective cohort study of 67,201 adult LT recipients from 2004 to 2023, stratified into three eras (Era 1: 2004–2012, Era 2: 2013–2018, Era 3: 2019–2023). Patients with prior LT, fulminant liver failure (status 1A), active hepatocellular carcinoma, or multivisceral transplants (excluding liver-kidney) were excluded. Estimated ACLF (EST-ACLF) severity was defined using EASL-CLIF criteria. One-year graft failure and survival were assessed using multivariable Cox regression and Kaplan-Meier analyses. Of 67,201 recipients, 62,510 received DBD and 4,691 DCD grafts. DCD grafts did not show clinically meaningful differences in 1-year hazards of graft failure compared to DBD grafts. One-year graft survival in EST-ACLF-2/3 improved over time from 87.2% in Era 1%–96.0% in Era 3, approaching the 97.5% observed with DBD grafts. DCD grafts may represent a viable and increasingly safe strategy for expanding LT access in ACLF.
Many countries have established donation after circulatory death (DCD) in addition to donation after brain death (DBD). In Germany, DCD is not permitted, and its potential to increase organ donation rates has not yet been quantified. We retrospectively identified all deceased with brain injury between 2023–2024 at seven German university hospitals. Eligible DCD donors were defined as patients with preserved brainstem reflexes precluding DBD donation, documented consent or an unknown donation preference, and death occurring within 120 min after withdrawal of life-sustaining measures. For patients with unknown preference, a consent rate of 40% was assumed. Among 4,587 deceased, 1,509 had preserved brainstem reflexes as the main reason against DBD. Of these, 58 patients with documented consent and 212 patients with an unknown donation preference died within 120 min after treatment withdrawal. Compared with 128 utilized DBD donors, this corresponds to an additional theoretical DCD potential of 45% based solely on documented consent. When applying the assumed consent rate to patients with an unknown preference, the hypothetical increase reaches 112%. The introduction of a DCD program could substantially increase organ donation rates at German university hospitals. However, its actual impact would depend on establishing appropriate legal, organizational, and ethical frameworks.
This study is a retrospective analysis of a cohort of patients presenting with transplant renal dysfunction related to proximal aorto-iliac occlusive disease and treated with angioplasty and stenting. Primary outcomes included changes in intrarenal resistive index (RI) and laboratory and clinical data including serum creatinine level, systolic and diastolic blood pressure, and number of anti-hypertensive drugs before and after endovascular intervention. Secondary outcomes included overall patient and transplant kidney survival. Endovascular intervention was successful in all 26 included patients and associated with a significant increase in intrarenal RI in the upper pole (0.65 before vs. 0.74 after stent; P = 0.0009), in the interpolar region (0.64 before vs. 0.74 after stent; P = 0.0028), and in the lower pole (0.63 before vs. 0.76 after stent; P = 0.0002). In addition, there was a significant improvement in serum creatinine (2.29 mg/dL before vs. 1.49 mg/dL 6 weeks after stent; P < 0.0001) and systolic blood pressure (149.6 mmHg before vs. 139.8 mmHg 1 week after stent; P = 0.0233). Overall estimated transplant kidney survival was 95% at 5 and 10 years of follow-up. Endovascular intervention is a very effective and durable treatment option for the management of transplant renal dysfunction related to proximal aorto-iliac occlusive disease.
ABOi transplantation is a growing practice with excellent clinical outcomes. Some paediatric transplant programmes are reluctant to offer ABOi transplantation and list children on a DD waiting list. However, there are no studies directly comparing the outcomes between pediatric ABOi LD kidney transplants (LDKTx) and ABOc DD transplants (DDKTx). Data were retrieved on all pediatric kidney transplants from 1987–2020, from the United Network for Organ Sharing. Propensity score matching was used to select a control group of ABOc transplant recipients. Long term outcomes were compared between ABOi and ABOc kidney transplants and between ABOi LDKTx and ABOc DDKTx. Data were compared using chi-square test, t-test and Kaplan-Meier survival analysis. Overall, there were 70 pediatric ABOi kidney transplants meeting the study criteria. There was no significant difference in allograft (p = 0.42) and patient survival (p = 0.58) between ABOi and ABOc transplants. ABOi LDKTx had significantly lower incidence of delayed allograft function and better long-term allograft survival than ABOc DDKTx (p < 0.01, p = 0.01). ABOi transplantation has excellent long-term outcomes. ABOi LDKTx lead to better long-term outcomes than ABOc DDKTx. We recommend that ABOi transplantation from a LD should be considered prior to listing children for transplantation from a DD.
Low tacrolimus (Tac) trough concentration-to-dose ratio (C0/D ratio) identifies kidney transplant patients with high level of Tac metabolization and is associated with poorer outcomes. We hypothesized that fast metabolization is associated with higher maximal Tac blood concentration (Cmax) and that Tac Cmax has a detrimental effect by itself. We retrospectively selected consecutive kidney transplant patients who (i) were treated by Tac, (ii) had systematic pharmacokinetic evaluation at 3- and 12-month posttransplant, and (iii) with a minimal follow-up of 5 years. Association between Tac Cmax/C0 with traditional transplant outcomes was analysed. 519 patients with a median follow-up of 8 years were included. Fast metabolizers displayed significantly higher median Cmax (20 vs. 17 ng/mL p < 0.001). Death-censored graft survival (DCGS) was significantly lower for patients with the highest Cmax/C0 values (Log rank, p = 0.05). In multivariate cox analysis, higher Cmax/C0 was independently associated with DCGS (HR = 1.37 [1.01; 1.87], p = 0.043). Our data support the hypothesis that exposure to high Cmax is detrimental and that fast metabolizers exhibit higher Tac Cmax even in situations where Tac C0 is not elevated. Tac formulations prone to mitigate pharmacokinetic peak could thus be particularly beneficial to fast metabolizers and should be evaluated in this indication.
Infectious complications remain a leading cause of morbidity and mortality after solid organ transplantation, driven by profound immunosuppression, emerging pathogens, and increasing antiviral resistance. The 2025 Spring Highlights in Transplantation Sciences (HITS) meeting, held in Paris under the auspices of the Société Francophone de Transplantation and endorsed by the European Society of Organ Transplantation, brought together international experts to discuss recent advances in the diagnosis, pathogenesis, prevention, and treatment of infections in transplant recipients. This report summarizes the key scientific presentations covering innovative approaches to viral hepatitis, cytomegalovirus (CMV), Epstein–Barr virus, human herpesvirus-8, BK polyomavirus, infectious encephalitis, and vaccination strategies. Particular emphasis was placed on the growing role of metagenomic next-generation sequencing for diagnosing unexplained infections, the integration of immune monitoring into clinical decision-making, and the development of adoptive cellular therapies, including virus-specific αβ T cells and γδ T-cell–based immunotherapies for refractory CMV infection. The meeting also highlighted emerging concepts in donor-recipient immunogenetics, novel diagnostic technologies, and personalized preventive strategies. Collectively, these advances illustrate the transition toward precision medicine in transplant infectious diseases, combining cutting-edge diagnostics, immune profiling, and innovative immunotherapeutic approaches to improve the management and outcomes of solid organ transplant recipients.
