Background Delirium is an increasingly recognized post-surgical complication but remains poorly understood among liver transplant (LT) recipients. Objective We sought to characterize the course, risk factors, and postoperative outcomes of post-LT delirium. Methods Among LT recipients enrolled in a prospective cohort study, we evaluated delirium using clinical care CAM-ICU assessments. We characterized delirium course using descriptive statistics and risk of delirium using multivariable logistic regression. Results Among 261 recipients, 42.5% experienced post-LT delirium. Risk factors included higher MELD, hepatic encephalopathy, alcohol-related liver disease, and pre-transplant ICU admission. On multivariable analysis, MELD at transplant (aOR 1.06 [95% CI 1.02-1.10], p=0.001) and pre-transplant ICU admission (aOR 2.35 [95% CI 1.02-5.38], p=0.04) remained associated with post-transplant delirium. Delirium began on post-transplant day 0-1, median (IQR) duration was 2 (1-3) days, and 30% screened positive on day of transfer out of the ICU. Delirium was associated with longer median ICU (2 vs. 1 days, p<0.001) and hospital (26 vs. 11 days, p<0.001) lengths of stay and higher likelihood of ICU readmission (12% vs. 4%,p=0.02), neurology consult (18% vs. 6%, p=0.002), and non-home discharge (33% vs. 7%, p<0.001). Conclusions The high prevalence of post-LT delirium and association with inferior post-transplant outcomes underscore the importance of recognizing post-LT delirium and implementing prevention strategies.

Importance:Neighborhood segregation, a mechanism of structural racism, is associated with racial and ethnic disparities in health care access and outcomes. Live donor liver transplant (LDLT) is the ideal treatment for cirrhosis, improving survival and quality of life. Understanding the role of segregation in LDLT access is important to address disparities. Objective:To assess the associations between residential and transplant center neighborhood segregation and LDLT access. Design, Setting, and Participants:This cohort study used data from a US national transplant registry on adult candidates (age ≥18 years) for first-time liver transplant between February 1, 2016, and June 30, 2025, at centers that performed 1 or more LDLT annually during that time. Exposure:Residential and transplant center neighborhood segregation, measured using the Thiel H method at the zip code tabulation area level and dichotomized at the respective median values. Main Outcomes and Measures:A Cox proportional hazards regression model quantified the adjusted hazard ratio (AHR) of LDLT and included interactions with race and ethnicity and insurance. LDLT access within high-segregation residential neighborhoods by racial and ethnic composition (predominantly White or predominantly racial and ethnic minoritized population) was also quantified. Results:Among 22 223 adult liver transplant candidates, mean (SD) age was 55.3 (11.2) years, 13 518 (60.8%) were male, 1476 (6.6%) were Black, 5097 (22.9%) were Hispanic or Latino, and 15 650 (70.4%) were White. Most (11 669 [52.5%]) had private insurance. After adjustment, candidates residing in high-segregation neighborhoods had lower likelihood of LDLT access (AHR, 0.81; 95% CI, 0.74-0.88). Hispanic or Latino candidates in high-segregation neighborhoods had lower likelihood of LDLT access than their counterparts in low-segregation neighborhoods (AHR, 0.59; 95% CI, 0.49-0.72; P < .001 for interaction), but associations between neighborhood segregation and LDLT did not vary significantly by insurance type (P = .52 for interaction). Candidates wait-listed at transplant centers in high-segregation neighborhoods had lower likelihood of LDLT access (AHR, 0.64; 95% CI, 0.59-0.70). Candidates with Medicare or Medicaid wait-listed at centers in high-segregation neighborhoods had lower likelihood of LDLT access than their counterparts in low-segregation neighborhoods (AHR, 0.53; 95% CI, 0.45-0.51; P < .001 for interaction). Within high-segregation residential neighborhoods, candidates in neighborhoods with a larger racial and ethnic population had lower likelihood of LDLT access than those living in neighborhoods with a larger White population (AHR, 0.68; 95% CI, 0.59-0.78). Conclusion and Relevance:In this national cohort study, living in or being wait-listed at centers in high-segregation neighborhoods was associated with lower likelihood of LDLT access and candidates living in high-segregation neighborhoods with a larger racial and ethnic minority population compared with a larger White population had lower likelihood of LDLT. Investing in high-segregation neighborhoods to address these structural disadvantages may help improve equity in LDLT access.

INTRODUCTION:Following implementation of the U.S. Kidney Allocation System (KAS) in 2014, deceased donor kidneys with a kidney donor profile index (KDPI) < 35% are prioritized for allocation to pediatric candidates. Early post-KAS data suggested this prioritization may have led to more frequent delayed graft function compared to pre-KAS, when pediatric allocation priority was based on donor age < 35 years. We sought to understand the impact of this allocation change on longer-term pediatric kidney transplant outcomes. METHODS:We used SRTR data to identify all deceased donor kidney transplants with pediatric recipients during two eras: "Pre-KAS" (12/1/2009-11/30/2014) and "KAS" (12/1/2015-11/30/2020). We used Cox proportional hazards models to calculate the association between study era and all-cause graft failure (graft failure or death) after adjusting for recipient characteristics. RESULTS:Among 4502 included transplants, 2175 (48%) were in the pre-KAS era and 2327 (52%) in the KAS era. KAS-era donors were older (median age 23 years, 13% age ≥ 35 years vs. median age 21, 1% age ≥ 35 years), less likely to have diabetes and hypertension, and had lower serum creatinine. Transplantation during the KAS era was associated with a lower hazard of graft failure after adjusting for recipient characteristics (adjusted HR 0.690.790.91, p = 0.001). Results were similar in sensitivity analyses limited to recipients < 10 years old and recipients alive with a functioning graft 90 days post-transplant. CONCLUSIONS:KDPI-based prioritization of kidneys for pediatric allocation was associated with a lower risk of graft failure compared to donor age-based prioritization. Further refining donor risk scores may enable additional improvements in graft survival.

Background:Kidney and liver transplantation have become standard of care for medically eligible people with HIV (PWH) with end-organ disease in the US, but data on heart transplantation (HT) in PWH remains limited. Methods:We used US national registry data 2014-2024 to identify 197 recipients with HIV (HIV R+) vs 34,213 without HIV (HIV R-) and used nonparametric tests of trend and Gini coefficients to quantify changes over time. Adjusted Cox regression, stratified by transplant centers, and modified Poisson regression were used to compare transplant outcomes in HIV R+ vs HIV R-. Results:Annual HIV R+ HT increased from 0.3% in 2014 to 0.9% of HTs in 2024 (p<0.001). Center clustering decreased slightly over time: 14/135 HT centers performed 80% of HIV R+ HT in 2014-2019 (Gini 0.80) and 35/143 performed 80% in 2020-2024 (Gini 0.72). Compared to HIV R-, HIV R+ were younger, more often Black. Prior to 2020, 1-year patient survival was 85% HIV R+ vs 91% HIV R- (adjusted hazard ratio for mortality [aHR] 1.30, 95% CI: [0.84-2.01]), and 1-year rejection was 27% vs 20% (adjusted relative risk [aRR] 1.35 [0.86-2.14]). After 2020, 1-year patient survival was 90% HIV R+ vs 92% HIV R-, (aHR 1.05 [0.66-1.65]), and 1-year rejection was 15% vs 15% (aRR 1.04 [0.67-1.61]). Conclusions:The practice of HT in PWH has expanded over time, though it is still clustered, occurring at 72 limited number of programs. Patient survival and rejection among HIV R+ are comparable to HIV R-.

This cross-sectional study examines trends in US patient portal messaging, telehealth and telephone encounters, and office visits, assessing differences in messaging by various patient sociodemographic characteristics.

BACKGROUND:In out-of-sequence (OOS) allocation of deceased donor kidney transplants (DDKTs), providers are allowed to choose recipients irrespective of waitlist priority. Whether candidate obesity affects OOS recipient selection is unknown. METHODS:We examined access to OOS-DDKT by candidate body mass index (BMI) using kidney offers from Organ Procurement and Transplantation Network data (1/2022-12/2023). We compared characteristics of OOS-DDKT versus being last-skipped candidate at the same center using donor-level conditional logistic regression and multilevel modeling among the top-20 OOS-performing centers. RESULTS:We identified 4970 OOS-placements and 4588 list-skipped candidates. OOS candidates were older and less likely to be Black. We found a dose-response relationship between weight class and odds of OOS-DDKT. Compared to normal weight candidates, candidates with Class 1, 2, and 3 obesity had 32%, 50%, and 69% lower odds of receiving OOS-DDKT. Mediation analysis suggested candidate BMI partially explained higher access among Asian and Hispanic candidates. There was substantial center-level variation; a 10-unit increase in BMI was associated with >50% lower odds of OOS-DDKT at 3/20 centers, 20%-50% lower odds at 12/20 centers, and comparable odds at 5/20 centers. CONCLUSIONS:DDKT candidates with obesity have lower access to OOS kidney allocation. However, equitable distribution irrespective of candidate obesity was observed at a small number of top-performing centers.

BACKGROUND:Multiorgan heart and kidney transplants (HKTx) performed for patients with end-stage heart failure and chronic kidney disease have increased in recent years. However, no established protocols exist on whether a heart and kidney from the same donor should be transplanted in the same operation versus 1-2 days apart. METHODS:Using SRTR data 1993-2023, we compared same-donor HKTx recipients with both transplants performed on the same day ("simultaneous") to recipients with kidney transplants performed within 1 day of the heart transplant ("staged"). We examined differences in weighted post-transplant clinical characteristics using average treatment effect. Post-transplant mortality and graft failure was also assessed using Kaplan-Meier curves and instrumental variable analysis adjusted for recipient characteristics and year of transplant. RESULTS:The proportion of staged HKTx increased from 20.7% in 2015 to 58.8% in 2023. Recipients of simultaneous versus staged HKTx had similar rates of stroke (3.4% vs. 4.1%, p = 0.3), permanent pacemaker prior to discharge (2.0% vs. 1.8%, p = 0.7), and kidney primary non-function (2.7% vs. 2.6%, p = 0.8). However, simultaneous HKTx recipients had shorter kidney cold ischemic time (median (IQR) (h) 10.0 (7.5 vs. 14.6) versus 20.3 (15.9, 24.8), p < 0.001) and a lower weighted hospital stay compared to staged HKTx recipients (1.08 1.09 1.11, p < 0.001). Weighted patient mortality, all cause heart failure (ACHF), and all cause kidney failure (ACKF) 4 years post-transplant were slightly lower for simultaneous versus staged HKTx recipients (17.1% vs. 19.9%, 17.2% vs. 20.1%, 20.8% vs. 24.7%). However, instrumental variable analysis found no meaningful differences in adjusted patient survival, ACHF, or ACKF by HKTx type. CONCLUSION:Simultaneous HKTx recipients have shorter hospital stays, decreased mortality, and higher rates of graft survival post-transplant compared to staged HKTx recipients, which may reflect favorable patient factors that enable both operations to be performed on the same day rather than an inherent benefit of simultaneous HKTx, given equivalent adjusted patient mortality, ACHF, and ACKF.

Purpose: Simultaneous liver–kidney transplantation (SLK) eligible candidates may receive SLK or liver-alone transplant (LA) with access to kidney transplant after initial LA (KAL). We aimed to characterize SLK-eligible recipient outcomes according to treatment approach. Methods: This study utilized 2017–2023 SRTR data to identify SLK-eligible deceased donor liver transplants. Recipients were placed into two groups based on whether SLK was performed; non-SLK patients were sub-stratified into LA and KAL cohorts. After baseline comparisons, 2-year patient and graft survival outcomes were characterized by univariable and multivariable Cox proportional hazard regression and Kaplan–Meier analysis. Results: Among 4879 candidates identified, 3746 (76.8%) underwent SLK, 1023 (21.0%) LA, and 110 (2.3%) KAL. SLK recipients maintained the highest eGFRs at 6 months, 1 year, and 2 years post-transplant (p < 0.01). Compared to SLK recipients, non-SLK recipients had a higher 2-year risk of mortality (aHR 2.46, p < 0.01), all-cause events (aHR 1.91, p < 0.01), and liver graft failure (HR 1.55, p = 0.02). LA conferred a higher 2-year mortality risk (aHR 2.98, p < 0.01) and all-cause event risk (aHR 2.25, p < 0.01), while KAL had comparable mortality risk to SLK (aHR 0.43, p = 0.40). Conclusions: When SLK-eligible candidates undergo transplants, SLK remains the optimal path forward, even when a safety net kidney can be performed.

INTRODUCTION:Biological parental donations provide the best option for many pediatric recipients, yielding unique immunological benefits that may enable minimization of immunosuppression in transplanted children. However, living related maternal donation in the postpartum period may introduce an increased risk of donor complications due to the physiological changes of pregnancy and childbirth, and the optimal timing of postpartum living donation is unknown. METHODS:Using US national registry data, we characterized donor and recipient outcomes for pediatric living donor liver transplants performed between 2004 and 2022 where a biological mother donated to a child ≤ 24 months old. RESULTS:Our study population included 256 donor-recipient pairs, with biliary atresia representing the most common indication for transplantation (68.0%). Donors had a median [IQR] age of 30 [25, 34] years, and the median [IQR] time from birth to donation was 9.0 [6.8, 13.0] months. 6.3% of donors experienced a biliary or other complication. When stratifying by donors who donated ≤ 6 vs. > 6 months postpartum, we found no significant differences in donor complications or readmission. Stratified analyses were also comparable for recipient mortality, graft survival, and rejection-free survival. Donors ≤ 6 months postpartum (n = 64) were more likely to experience reoperation than mothers who donated > 6 months postpartum (n = 192) (6.2% vs. 1.0%, p = 0.04). CONCLUSIONS:While maternal living donor liver transplantation is safe for most donors, there is a higher risk of reoperation when donation is performed ≤ 6 months postpartum. Surgeons should be aware that these donors are a higher risk population, requiring discussion upon consent and warranting close post-operative monitoring.

People with HIV-1 have higher risk for rejection after kidney transplantation but the mechanism is poorly understood. As HIV latency promotes immune dysregulation and chronic inflammation, we evaluated whether the size of the HIV latent viral reservoir (LVR) at baseline and through 52-weeks is associated with rejection in kidney transplant recipients with HIV from donors with and without HIV. Using the intact proviral DNA assay, we found no differences in the LVR between those who experienced rejection (n = 14) versus those who did not (N = 55) regardless of donor HIV status. These data support the feasibility of HIV+ to HIV+ organ transplantation. Clinical Trials Registration. NCT03500315.

Objective To perform comprehensive validations of the integrative Box (iBox) system, a prediction model for long term risk of kidney allograft failure, for extension of its context of use in clinical trials as well as for its wider implementation in clinical practice.Design Extended validation study.Setting Paris Transplant Group database (comprising kidney recipients with transplantations between 1 January 2005 and 1 January 2014) and European, North American, and South American hospitals (comprising recipients of kidneys transplanted beween 1 January 2000 and 1 January 2022). Patients were followed until 1 November 2024.Participants 12 683 kidney tranplant recipients from 21 academic centres in Europe, North America, and South America; 4000 patients in the derivation cohort and 8683 in the validation cohorts.Main outcome measures Performance of the iBox, including flexible iBox versions in specific clinical contexts (race-free estimated glomerular filtration rate (eGFR) equations (ie, without including race as a factor in the calculation), in specific clinical contexts (initial nephropathy recurrence, BK virus associated nephropathy, and different immunosuppressive strategies), and over-extended follow-up periods. Predictive performance was assessed by discrimination, calibration, overall fit, and clinical utility.Results 12 683 kidney transplant recipients were included in the study (n=4000 in the derivation cohort and n=8683 in the validation cohorts). Median follow-up time after risk evaluation was 5.78 years (interquartile range (IQR) 3.51-7.00) in the derivation cohort and 4.68 years (2.48-7.00) in the validation cohorts. 549 (13.7%) and 991 (11.4%) patients had graft loss in the derivation and validation cohorts, respectively. All versions of the iBox algorithm maintained good discrimination and overall fit performance in the derivation and validation cohorts (C index range 0.79-0.87, Brier scores 0.08-0.11). Calibration was adequate in some but not all external validation cohorts, with trends toward overestimation or underestimation of predicted risks. Decision curve analysis showed positive and comparable net benefit for all iBox algorithms across decision thresholds up to 40% in the derivation cohort (net benefit 0.07-0.08 at 20% threshold) and validation cohorts (net benefit 0.03-0.11 at 20% threshold). Accounting for the competing risk of death with a functioning graft resulted in similar performance, except for calibration which varied across cohorts, without any model consistently outperforming any other model. The model performed well with different race-free eGFR equations (C index 0.81), in various clinical scenarios, including disease recurrence and BK virus nephropathy, with different immunosuppressive strategies, such as calcineurin inhibitors and mTOR (mechanistic target of rapamycin) inhibitors (C index range 0.74-0.87), and when extending the prediction period to 10 years after risk evaluation (C index 0.79). The iBox predictive performance was not modified when various histological indices were used. The iBox was also superior to eGFR slope (C index 0.81 v 0.62) and circulating anti-HLA donor specific antibodies (C index 0.81 v 0.57) in its predictive ability.Conclusions In this study, the robust predictive performance of the iBox system across diverse real world settings and clinical scenarios was shown. These results highlight the versatility and reliability of the iBox system, and support its use for risk stratification in routine clinical practice and as a surrogate endpoint for clinical trials.

BACKGROUND:Before KAS250 (circles-based allocation), donor service area (DSA) of listing was the largest contributor to deceased donor kidney transplantation (DDKT) rate disparities. Both before and after KAS250, it is unclear to what extent DSA-level disparities are attributable to center-level practice variation. We aimed to disentangle contributions to DDKT rate variation from: (1) center practices, (2) kidney distribution within sharp policy boundaries (DSAs, OPTN Regions), and (3) other geographic variation in kidney scarcity. METHODS:With national transplant registry data, we studied transplant rate variation in the pre-KAS250 era, which prioritized patients based on DSAs and Regions, and under KAS250, which prioritizes patients within 250 nautical mile circles. We modeled candidate DDKT rates with multilevel Poisson regression, adjusting for candidate factors, and calculated median incidence rate ratios (MIRR) to summarize variation attributable to DSAs, OPTN regions, states, census divisions, and to centers within those units. RESULTS:DSA-level MIRR declined sharply from 1.311.351.39 to 1.131.171.21 after KAS250 implementation. Under KAS250, 93.4% of geographic variability in transplant rates was attributable to center-level (within-DSA) variation (MIRR: centers 1.761.821.86, DSAs 1.131.171.21), while before KAS250, only 81.7% of geographic variability in transplant rates was attributable to center-level (within-DSA) variation (MIRR: centers 1.831.891.95, DSAs 1.311.351.39). Adjusted center-level DDKT rates under KAS250 were highly associated with offer acceptance rates (ρ = 0.60, p < 0.001). CONCLUSIONS:Though geographic disparities are driven primarily by center-level practice differences including offer acceptance, KAS250 did reduce DSA-level disparities. Further allocation policy changes are unlikely to substantially reduce geographic variation in DDKT rates.

INTRODUCTION:Hyperparathyroidism (HPT) commonly persists following kidney transplant (KT) and can result in bone alterations. However, the association between persistent HPT post-KT and fracture risk is not well-understood. We sought to quantify the association between persistent HPT at 1-year post-KT and fracture risk among KT recipients. METHODS:We leveraged a longitudinal prospective cohort of 344 adult KT recipients who underwent KT at a single institution (12/2008-07/2019). PTH levels were retroactively abstracted, and fractures after 1-year-post-KT were ascertained using ICD-9/ICD-10 codes. Competing risk models were used to estimate the association between persistent HPT (PTH ≥ 70 pg/mL) at 1-year post-KT and the risk of fracture, with death treated as a competing event. RESULTS:Among 344 KT recipients, 227 (66.0%) had persistent HPT at 1-year post-KT. After adjusting for confounders, HPT 1-year after KT was associated with a 3.11-fold increased risk of fractures (95% CI: 1.08-8.91). There were no differences in this association by age, sex, race, eGFR at 1-year-post-KT, osteoporosis at KT, or dialysis vintage. CONCLUSION:Recipients with HPT 1-year after KT had a significantly higher risk of fractures than those without persistent HPT. Future studies should establish standardized practice guidelines for the treatment of persistent HPT to mitigate fracture-related morbidity and mortality.

Introduction:Older adults with chronic kidney disease (CKD) likely face higher dementia risk because of vascular injury and chronic inflammation, potentially intensified among racially minoritized groups and those in rural or deprived neighborhoods. We quantified this association and examined variation by race and ethnicity, urbanicity, and neighborhood deprivation. Methods:We identified 211,321 older adults with CKD stages 3 to 5 from the Medicare 5% sample (2010-2022) using International Classification of Diseases (ICD)-9 and/or ICD-10 codes. Zone Improvement Plan (ZIP)-code level urbanicity was defined using Rural-Urban Commuting Area Codes, and neighborhood deprivation was derived from the American Community Survey. We used cause-specific hazard models with time-varying CKD stage (reference = stage 3) to quantify the adjusted hazard ratio (aHR) of dementia and included interaction terms to test the differential effect of these associations by race and/or ethnicity, urbanicity, and neighborhood deprivation. Results:After adjustment, older adults with CKD stages 4 and 5 had a higher risk of dementia (stage 4 aHR: 1.28, 95% CI: 1.25-1.32; stage 5 aHR: 1.82, 95% CI: 1.76-1.88). These associations differed by race/ethnicity (stage 4 and 5: P interactions < 0.001) and neighborhood deprivation (stage 5: P interaction = 0.04). Among older Black (stage 4 aHR: 1.38, 95% CI: 1.28-1.48; stage 5 aHR: 2.01, 95% CI: 1.88-2.15) and Hispanic adults (stage 4 aHR: 1.33, 95% CI: 1.10-1.62; stage 5 aHR: 1.98, 95% CI: 1.67-2.34), stages 4 and 5 were associated with a higher risk of dementia. Among older adults in high-deprivation neighborhoods, stage 5 was associated with a higher risk of dementia (aHR: 1.89, 95% CI: 1.80-1.99). Conclusion:CKD stages 4 and 5 were associated with a higher dementia risk, particularly among older Black adults and those in high-deprivation neighborhoods. These findings may inform targeted interventions for early detection and management of cognitive decline in advanced CKD.

Rationale & Objective Among older patients with kidney failure, those who are minoritized or residing in rural areas experience a disproportionate burden of Alzheimer’s disease and related dementias (ADRD). Neighborhood disadvantage drives health disparities, but few studies have directly examined its association with ADRD and whether this association varies by race/ethnicity and by urbanicity. Study Design Cohort study. Setting & Participants United States Renal Data System data; older patients (age ≥55 years) initiating dialysis in 2003-2021. Exposures Residential neighborhood disadvantage was measured using a ZIP-code level index across nine domains (built environment, criminal justice, education, employment, housing, poverty, social fragmentation, transportation, and wealth). Outcome ADRD using diagnosis codes. Analytical Approach We used cause-specific hazards models to quantify the adjusted hazard ratios (aHR) of ADRD diagnoses. We then used interaction terms to quantify whether these associations differed by race/ethnicity and urbanicity. Results After adjustments, older patients in high-disadvantage neighborhoods had a higher risk of ADRD diagnoses (dementia: aHR=1.09, 95%CI:1.08-1.10; AD: aHR=1.25, 95%CI:1.22-1.27) compared to older patients in low-disadvantage neighborhoods; these associations differed by race/ethnicity (dementia: Pinteraction=0.03; AD: Pinteraction=0.002) and by urbanicity (Pinteractions<0.001 for both). Specifically, older Black patients in high-disadvantage neighborhoods had a higher risk of ADRD (dementia: aHR=1.19, 95%CI:1.17-1.21; AD: aHR=1.31, 95%CI:1.28-1.35) compared to older Black patients in low-disadvantage neighborhoods. Within suburban, rural, and small-town areas, older patients residing in high-disadvantage neighborhoods had a higher risk of ADRD compared with those in low-disadvantage neighborhoods. Limitations ZIP codes as a proxy for neighborhoods. Conclusions Older patients with kidney failure residing in high-disadvantage neighborhoods, particularly Black patients and those in suburban, rural, or small-town areas, had a higher risk of ADRD compared with those in low-disadvantage neighborhoods. Multifaceted interventions (e.g., cognitive screening, collaborative care) are needed to mitigate structural barriers associated with neighborhood disadvantage and preserve cognitive function in this population.

BACKGROUND Transplanting kidneys from donors with HIV to recipients with HIV has become standard clinical practice. However, donors with HIV may have higher prevalence of viral and bacterial infections and autoimmunity that could increase allograft rejection in recipients. METHODS We included deceased kidney donors (60 with HIV and 41 without HIV) who participated in a multicenter prospective study of HIV kidney transplantation between April 2018 and September 2021. Using phage immunoprecipitation sequencing, we compared the human antibody repertoire (allergens, autoantibodies, viruses, and bacterial toxins) between donors with and without HIV and evaluated their association with recipient allograft rejection. Moderated t tests were used to assess reactivity and a multivariate logistic regression model adjusted for donor sex and kidney donor profile index assessed the association between donor adenovirus reactivity and recipient allograft rejection. RESULTS Compared with donors without HIV, donors with HIV had lower BMI and were more likely to be African American. The median number of positive autoantibodies was marginally higher among donors with HIV (499 [IQR, 357, 579]) compared with that of donors without HIV (395 [IQR, 256, 538], P = 0.058). Donors with HIV additionally had significantly higher antibody reactivity to Epstein-Barr virus and cytomegalovirus ( q < 0.05). Among all donors with and without HIV, antibodies against adenovirus were significantly associated with increased rejection among recipients, including after adjusting for false discovery ( q < 0.05) and also adjusting for demographic factors using multivariable logistic regression (odds ratio = 4.97; 95% CI = 1.89–13.61). CONCLUSION The presence of antibodies against adenovirus infection in kidney donors with HIV may be associated with allograft rejection. TRIAL REGISTRATION ClinicalTrials.gov NCT03500315. FUNDING US NIH.