Significant barriers and biases within medical systems hinder equitable access to organ transplantation for patients with disabilities, whether they be intellectual, developmental, or physical. Physicians may hold implicit biases, and transplant centers typically lack disability-specific evaluation standards, which leads to inconsistencies and subjective decisions regarding care. Prior literature has shown that patients with disabilities are less likely to be evaluated for transplant, even with clinical guidelines indicating that appropriate social support should be the driving factor for waitlisting decisions in this population. Commonly cited concerns about poorer outcomes, quality of life, and non-adherence to postoperative care are largely not supported by available evidence, albeit limited. This review will examine factors affecting access to transplantation for patients with disabilities, including guidelines, systemic barriers, implicit biases, and the evidence for patient selection. Additionally, it will discuss standardized functional assessment as a possible path to more equitable evaluation.
Renal transplantation is the only curative treatment approach for children with end-stage kidney disease, ensuring the best possible growth, neurocognitive and social development. However, the field of pediatric kidney transplantation is highly heterogeneous with different indications, timing, graft types, institutional standards, and recipient anthropometrics. The availability of suitable grafts is limited, especially for small recipients. While hypothermic, normothermic machine perfusion (HMP/NMP) and normothermic regional perfusion (NRP) approaches are rapidly dominating the field of adult kidney transplantation, their role in the pediatric setting remains largely unexplored. This review discusses the current state-of-the-art of MP of the kidney focusing on the lessons learned from adult studies. Based on the synthesis of the available evidence, we give a futuristic overview on how MP might enter the pediatric arena in the upcoming years and change the way we treat children undergoing renal transplantation. Clinical studies in pediatric kidney transplantation using MP are awaited. Due to limited caseload in most centers and vulnerable patient population, strong international collaborations are needed to investigate the value and limitations of perfusion technology in the pediatric cohort, in which improved outcomes are not just associated with quantitative results, such as improved survival data, but might indeed define the entire future and psychosocial chances of the affected children in their life.
The Kidney Donor Profile Index (KDPI) summarizes the expected longevity of deceased-donor kidneys, but its relationship with long-term graft outcomes and its performance outside the United States remain uncertain. We systematically reviewed cohort evidence evaluating KDPI and long-term deceased-donor kidney transplant outcomes. MEDLINE, Embase, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov were searched from January 2014 through June 2026. Eligible studies included at least 100 adult deceased-donor kidney recipients with outcomes assessed at a minimum three-year horizon. Adjusted hazard ratios (HRs) for death-censored graft failure were standardized to a 10-point KDPI increase and pooled using a random-effects model with restricted maximum likelihood and modified Hartung-Knapp intervals. Thirteen publications were included; five studies comprising 2902 recipients contributed comparable adjusted estimates. Each 10-point increase in KDPI was associated with a higher rate of death-censored graft failure (HR 1.19, 95% CI 1.08–1.31; I2 = 43.8%; 95% prediction interval 0.97–1.46). Restriction to three studies with explicit long-term follow-up yielded HR 1.14 (95% CI 1.02–1.27; I2 = 14.2%). The exploratory KDPI >85% analysis was imprecise (HR 2.13, 95% CI 0.75–6.02). Reported KDPI discrimination was generally limited, with C-statistics around 0.54–0.62. Higher KDPI is associated with worse long-term death-censored graft outcomes, but effect magnitude varies across settings and KDPI alone has limited discriminatory ability. Local validation and periodic recalibration remain important.
Living donor liver transplantation (LDLT) should not only be evaluated as an alternative graft source in transplant oncology; it should also be evaluated as a disease-specific intervention on access and oncologic time. By removing dependence on deceased-donor availability, LDLT can convert an uncertain wait into a planned operation—but that temporal advantage is not biologically neutral, and its consequences differ sharply by tumor type. In hepatocellular carcinoma, an abbreviated wait can reduce waitlist dropout but may also shorten the interval during which aggressive biology would otherwise declare itself; contemporary biology-based selection has reduced this concern in selected cohorts. In perihilar cholangiocarcinoma, LDLT solves organ scarcity, but the neoadjuvant and staging protocol—not the graft—must remain the actual selection mechanism, and irradiated recipient anatomy adds a distinct technical burden. In intrahepatic cholangiocarcinoma, LDLT remains investigational, justified only by durable response to systemic therapy in small, prospectively protocolized cohorts. In neuroendocrine liver metastases, direct living-donor evidence is too sparse to support a confident recommendation in either direction. In colorectal liver metastases, LDLT can be framed as a timing technology: transplantation is scheduled once sustained chemotherapy response suggests a temporarily favorable biological state, on the premise that an unpredictable wait might otherwise close that window. This narrative review deliberately isolates the living-donor evidence within each of these five diseases rather than treating LDLT as one intervention, and proposes a common framework—the oncologic clock, the strength of pre-transplant biological selection, and the donor risk that expected recipient benefit can justify—for interpreting it. We further argue that transplant benefit over the best nontransplant alternative, rather than post-transplant survival, should anchor these judgments; that left-lobe and two-stage (RAPID-type) grafting strategies offer a means to reduce donor risk; and that the appropriate metrics depend on whether LDLT operates within a deceased-donor-predominant or a living-donor-predominant health-care system. Across all five diseases, graft source itself appears to matter less than who is selected and when; the central task for the next generation of studies is to report outcomes from evaluation and donor exposure forward, not from transplantation alone.
