STUDY AIM: Renal biopsies provide important and decisive information for diagnosis and therapy. Although biopsies are considered safe, bleeding complications remain a concern. We analysed the complication rate after kidney biopsies in native and transplant kidneys and their association with platelet function analyser bleeding time (PFA BT) and estimated glomerular filtration rate (eGFR). METHODS: This single-centre observational study included all patients who underwent an ultrasound-guided kidney biopsy at the University Hospital Basel from 2015 to August 2019. The main objective was to investigate the association of PFA BT with significant bleeding complications in kidney biopsies. Significant bleeding was defined as a haemoglobin decrease of >10 g/l within 48 hours or the need for transfusion after bleeding, according to the discretion of the treating physician. The pre-biopsy assessment included bleeding time using PFA BT, INR, thrombocyte count, and eGFR. RESULTS: A total of 819 kidney biopsies—285 native and 534 transplant—were analysed. Complications occurred in 32 biopsies (3.9%): 18 (6.3%) in native and 14 (2.6%) in transplant kidneys. Bleeding was the most frequent complication in both groups. Overall, low eGFR (p = 0.01) and prolonged PFA BT (p = 0.02) were associated with bleeding complications. In native kidney biopsies, inpatient biopsy was associated with bleeding complications (p = 0.005), while in transplant kidney biopsies, bleeding complications were associated with time after transplantation (p <0.001), prolonged PFA BT (p <0.001), and diagnostic biopsies (p = 0.01). In the multivariable model, low eGFR was the only significant factor associated with bleeding complications (odds ratio 3.57, 95% confidence interval 1.76-7.23, p <0.001). CONCLUSIONS: A low eGFR, especially below 30 ml/min, is associated with increased bleeding risk in native and transplant kidney biopsies.

BACKGROUND:False cardiac troponin (cTn) elevations from non-cardiac causes are a major concern. We aimed to assess terminal renal failure as a possible non-cardiac cause of elevated high-sensitivity cTnT (hs-cTnT) concentrations using renal transplantation as an in vivo model of rapid restoration of renal function. METHODS:We analysed consecutive patients with end-stage renal disease (ESRD) undergoing renal transplantation at a single centre. Patients with perioperative myocardial infarction or injury were excluded. Changes in hs-cTnT and creatinine were measured pretransplant and at four post-transplant intervals (day 1, days 2-5 and days 14-180). A decrease of ≥25% in hs-cTnT within 24 hours post-transplant was deemed evidence of renal clearance recovery. RESULTS:Among 45 patients (median age 67 years, 31% women), the median pretransplant plasma creatinine concentration was 608 μmol/L (IQR 482-830), and fell to 425 μmol/L (IQR 337-619) on day 1, 289 μmol/L (IQR 201-492) on days 2-5 and 126 μmol/L (IQR 103-191) on days 14-180 (p<0.001, p<0.001 and p=0.003, respectively). The median pretransplant hs-cTnT concentration was 48 ng/L (IQR 34-70). It fell to 26 ng/L (IQR 15-38; geometric mean of relative change 36%) on day 1 (p<0.001) and then remained constant on days 2-5 (26 ng/L (IQR 18-35)) and days 14-180 (25 ng/L (IQR 20-30), p=ns). CONCLUSION:Terminal renal failure is a non-cardiac cause of elevated circulating hs-cTnT concentrations, contributing more than one-third in this cohort, while the remaining two-thirds seem related to chronic cardiomyocyte injury.

Background: The use of small pediatric donors (age ≤ 5 years and body weight < 20kg) for adult transplant recipients is still regarded controversially in terms of early complications, long-term outcomes, and development of hyperfiltration injury due to body size mismatch. Objective: To investigate long-term outcomes of adult renal allograft recipients receiving a kidney from small pediatric donor (SPD) in terms of kidney function and early features of hyperfiltration injury such as histological changes and proteinuria. Design: Retrospective, single center study. Settings: Transplant center of the University Hospital of Basel, Switzerland. Patients: Adult renal allograft recipients receiving a kidney from a small pediatric donor at our center between 2005 and 2017. Methods: The outcome of 47 transplants from SPD were compared with 153 kidney transplants from deceased-standard criteria donors (SCD) occurring during the same time period. Incidence of clinical signs of hyperfiltration injury (eg, proteinuria) was investigated. According to our policy, surveillance biopsies were taken at 3 and 6 months post-transplant and were evaluated in terms of signs of hyperfiltration injury. Results: At a median follow-up of 2.3 years post-transplant, death-censored graft survival of SPD was comparable to transplants from SCD (94% vs 93%; P = .54). Furthermore, allograft function at last follow-up (estimated glomerular filtration rate–Modification of Diet in Renal Disease) was significantly higher in pediatric transplant (80 vs 55 ml/min/1.73 m 2 , P = .002). We found histological signs of early hyperfiltration injury in 55% of SPD. There was an equally low proteinuria in both groups during follow-up. Limitations: It is a single center and retrospective observational study with small sample size. The outcomes were investigated in a well-selected population of recipients with low body mass index, low immunological risk, and well-controlled hypertension and was not compared with equal selected group of recipients. Conclusions: Early histological and clinical signs of hyperfiltration injury in SPD is frequent. Despite the hyperfiltration injury, there is an equal allograft survival and even superior allograft function in SPD compared with SCD during follow-up. This observation supports the concept of high adaptive capacity of pediatric donor kidneys.

Background. Rather little is known about how psychosocial evaluations for living kidney donation (LKD) are performed. We aimed to explore whether Swiss transplant centers (STCs) vary regarding the rate of living kidney donors refused for psychosocial reasons, the psychosocial evaluation process, and the characteristics of the donors. Methods. We investigated 310 consecutive candidates for LKD in 4 of 6 existing STC during mandatory psychosocial evaluations. We registered (i) sociodemographic data, (ii) the type of the decision-making process regarding LKD (ie, snap decision, postponed, deliberate, other), (iii) the evaluator’s perception of the donor’s emotional bonding and his/her conflicts with the recipient, (iv) the donor’s prognosis from a psychosocial perspective, (v) time taken for the psychosocial evaluation, and (vi) its result (eligible, eligible with additional requirements, not eligible). Results. Centers had comparable proportions of noneligible donors (2.9%–6.0%) but differed significantly in the percentage of donors accepted with additional requirements (3.4%–66%, P < 0.001). Significant differences emerged between centers regarding the time needed for evaluation (75–160 min [interquartile range (IQR) 75–180 min] per single exploration, P < 0.001), the perception of the donor’s emotional bonding (visual analogue scale [VAS] 8–9 [IQR 6–10], P < 0.001), his/her conflicts with the recipient (VAS 1.5–2 [IQR 0–3], P = 0.006), the donor’s psychosocial prognosis (VAS 8–9 [IQR 7–10], P < 0.001), and the type of decision concerning LKD (59%–82% with snap decision “yes,” P = 0.008). However, despite differences in the psychosocial evaluation process, the rates of patients accepted for transplantation (eligible and eligible with additional requirements versus noneligible) were comparable across STC (P = 0.72). Conclusions. Our results emphasize that it is more important to establish clear guidelines to identify potential psychosocial risks than to stringently standardize the procedure for psychosocial evaluation of living kidney donors.

Quantitative and molecular analysis have been performed on two main polymorphs of buspirone hydrochloride (BUS-HCl). Quantitative analysis of solid-state composition of pharmaceutical powders is necessary to ensure safety and efficacy of drug substance and to validate the production processes. In this study, X-ray powder diffraction and differential scanning calorimetry have been used for the quantitative analysis of two polymorphic forms of BUS-HCl. In addition, single crystal X-ray study of Form 1 revealed its crystal structure, however, a similar study on Form 2 was not possible due to the difficulties encountered in producing it. Molecular analysis including partial charge analysis has been performed by using Gaussian simulation package to find the electro-negativity pattern in molecule. 1H and 13C solid-state NMR spectra of polymorphs were recorded and also regression equations and QM theory were developed to predict the 1H and 13C NMR spectra through the use of atomic environmental descriptors. The NMR differences between the two polymorphs were discussed by using prediction and experimental results and description of each NMR shift for carbon and hydrogen atoms.

AIMS The aim of this study was to analyse the demographics, risk factors and in-hospital mortality rates of patients admitted with coronavirus disease 2019 (COVID-19) to a tertiary care hospital in Switzerland. METHODS In this single-centre retrospective cohort study at the University Hospital Basel, we included all patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection hospitalised from 27 February 2020 to 10 May 2021. Patients’ characteristics were extracted from the electronic medical record system. The primary outcome of this study was temporal trends of COVID-19-related in-hospital mortality. Secondary outcomes were COVID-19-related mortality in patients hospitalised on the intensive care unit (ICU), admission to ICU, renal replacement therapy and length of hospital stay, as well as a descriptive analysis of risk factors for in-hospital mortality. RESULTS During the study period we included 943 hospitalisations of 930 patients. The median age was 65 years (interquartile range [IQR] 53–76) and 63% were men. The numbers of elderly patients, patients with multiple comorbidities and need for renal replacement therapy decreased from the first and second to the third wave. The median length of stay and need for ICU admission were similar in all waves. Throughout the study period 88 patients (9.3%) died during the hospital stay. Crude in-hospital mortality was similar over the course of the first two waves (9.5% and 10.2%, respectively), whereas it decreased in the third wave (5.4%). Overall mortality in patients without comorbidities was low at 1.6%, but it increased in patients with any comorbidity to 12.6%. Predictors of all-cause mortality over the whole period were age (adjusted odds ratio [aOR] per 10-year increase 1.81, 95% confidence interval [CI] 1.45–2.26; p <0.001), male sex (aOR 1.68, 95% CI 1.00–2.82; p = 0.048), immunocompromising condition (aOR 2.09, 95% CI 1.01–4.33; p = 0.048) and chronic kidney disease (aOR 2.25, 95% CI 1.35–3.76; p = 0.002). CONCLUSION In our study in-hospital mortality was 9.5%, 10.2% and 5.4% in the first, second and third waves, respectively. Age, immunocompromising condition, male sex and chronic kidney disease were factors associated with in-hospital mortality. Importantly, patients without any comorbidity had a very low in-hospital mortality regardless of age.

AIMS:In Switzerland, certain patients with disabilities and reduced working ability are entitled to a disability pension granted by the Swiss Federal Social Insurance Office (FSIO). The aim was to assess the evolution of disability pension and work capacity after kidney transplantation and thereby pilot the procedures linking FSIO data with Swiss Transplant Cohort Study (STCS) data.METHODS:The current study pilot tested the record linkage of FSIO data with data from the STCS in a single-centre, observational setting. Patients were requested to consent to the use of their Swiss social security number (SSSN) for the purpose of record linkage. A privacy preserving trust centre approach was implemented with blinded statistical analysis.RESULTS:Between May 2008 and December 2015, 282 working-age renal transplant recipients of the University Hospital of Basel transplant centre were eligible for inclusion and 136 (48%, median age 48 years) consented to the use of their social security number and record linkage. The FSIO datasets of all patients were successfully retrieved and linked to STCS data in the trust centre and were numerically analysable. Yearly FSIO allowance data were available for the entire study duration. Fifty-five patients (40%) were registered as disability insurance recipients (DIR). In the entire population, the proportion of working patients slightly decreased from 76% to 72% between the pre-transplant and the post-transplant period. This was due to the lower proportion of patients working after transplantation in DIR compared with non-recipients (non-DIR) (DIR: 60% before vs 44% after; non-DIR: 83% before vs 88% after). In the DIR group, the proportion of patients not working increased from 36% to 49%, whereas in non-DIR the proportion changed only marginally (14% to 12%). The average disability insurance allowance was CHF 1172 per month. It changed from CHF 1135 before transplantation to CHF 1209 after transplantation (p = 0.59).CONCLUSIONS:In the Swiss healthcare and social insurance system, record linkage studies combining clinical datasets with data from FSIO are feasible but associated with great efforts and resource needs. The lack of changes in disability allowances after kidney transplantation should be further investigated in the nationwide setting.

This report presents a 74-year-old renal transplant patient suffering of polymorphic-post-transplant-associated lymphoproliferative disease (P-PTLD) within an Eppstein-Barr Virus (EBV) associated mucocutaneous rectal ulcer (MCU). He was initially treated by stapled hemorrhoidopexy for a symptomatic grade III hemorrhoidal prolapse refractory to conservative treatment and rubber band ligations. This leads to severe urge, frequency and stool fragmentation. The symptoms were investigated with a number of interventions until a proctoscopy with biopsies finally revealed the diagnosis. The patient had triple therapy of tacrolimus, mycophenolate mofetil and prednisone initially after transplant several years ago with recent reduction to mycophenolate. The MCU was successfully treated with Retuximab and there was no sign of relaps after 6 months. As EBVassociated PTLD is a well known complication after renal transplant, rectum-MCU seems a rare and only recently described subform of this disease that should be excluded in case of ulcerating lesions in immunosuppressed patients.

Immunocompromised patients may be at increased risk for complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, comprehensive data of SARS-CoV-2 infection in solid organ transplant (SOT) recipients are still lacking. We performed a multicenter nationwide observational study within the Swiss Transplant Cohort Study (STCS) to describe the epidemiology, clinical presentation, treatment and outcomes of the first microbiologically documented SARS-CoV-2 infection among SOT recipients. Overall, 21 patients were included with a median age of 56 years (10 kidney, 5 liver, 1 pancreas, 1 lung, 1 heart and 3 combined transplantations). The most common presenting symptoms were fever (76%), dry cough (57%), nausea (33%), and diarrhea (33%). Ninety-five percent and 24% of patients required hospital and ICU admission, respectively, and 19% were intubated. After a median of 33 days of follow-up, 16 patients were discharged, 3 were still hospitalized and 2 patients died. These data suggest that clinical manifestations of SARS-CoV-2 infection in middle-aged SOT recipients appear to be similar to the general population without an apparent higher rate of complications. These results need to be confirmed in larger cohorts.

Background Cytomegalovirus (CMV) serostatus and CMV replication are considered as risk factors for inferior graft and patient survival after renal transplantation, but long-term outcome data are limited. The aim of this retrospective single-centre study was to investigate the impact of CMV serostatus and CMV replication/disease on long-term outcomes in a well-defined cohort managed by a standardized CMV prevention/treatment protocol. Methods We investigated 599 consecutive kidney transplantations having a CMV prevention protocol consisting of either prophylaxis (D+/R- and R+ with ATG induction) or screening/deferred therapy (R+ without ATG induction). Patients were grouped according to CMV serostatus [high risk (D+/R-): n=122; intermediate risk (R+): n=306; low risk (D-/R-): n=171] and occurrence of CMV replication/disease (no CMV replication: n=419; asymptomatic CMV replication: n=110; CMV syndrome: n=39; tissue-invasive CMV disease: n=31). The median follow-up time was 6.5years. Results Graft and patient survival were not different among the three CMV serostatus groups as well as the four CMV replication/disease groups (P >= 0.44). Eighty-seven patients died, 17 due to infections (21%), but none was attributable to CMV. The overall hospitalization incidence for CMV-related infection was 3% (17/599 patients). The incidence of clinical and (sub)clinical rejection was similar among the groups (P >= 0.17). In a multivariate Cox proportional hazard model, neither CMV serostatus, nor CMV replication, nor CMV disease were independent predictors for patient death or graft failure, respectively. Conclusions This retrospective single-centre study suggests that the negative impact of CMV infection on long-term patient and allograft survival as well as on allograft rejection can be largely eliminated with current diagnostic/therapeutic management.

Switzerland is located in central Europe, has an area of 41 285 km2, and a population of 8.5 million. Mainly due to the Alps, only about half of the country is populated, resulting into a density of approximately 400 persons/km2. Switzerland has 3 major official languages: German (spoken by 70%), French (spoken by 25%), and Italian (spoken by 5%). A public healthcare system covers all transplantation-related costs. NUMBERS OF TRANSPLANT PROGRAMS Switzerland has 6 transplant centers (Basel, Bern, Geneva, Lausanne, St. Gallen, and Zürich) (Figure 1). Each transplant center has its affiliated HLA laboratory. All transplant centers perform living and deceased donor kidney transplantations. Other organ transplantations are allocated to specialized centers: heart (Bern, Lausanne, Zürich), lung (Lausanne, Zürich), liver (Bern, Geneva, Zürich), pancreas (Geneva, Zürich), bowel/multivisceral and pancreatic islet (Geneva, Zürich), and allogeneic hematopoietic stem cells (Basel, Geneva, Zürich).FIGURE 1.: Organ transplants in Switzerland are performed in 6 centers with a selection of organs/center.GOVERNMENTAL AND REGULATORY SYSTEMS INVOLVEMENT AND OVERSIGHT All transplant centers use local and national infrastructure (Figure 2). The national infrastructure consists of 3 major parts. Swisstransplant represents the national organ procurement and allocation organization (www.swisstransplant.org). It is mandated by the Federal Office of Public Health (FOPH) and supported by several expert groups. Since 1993, all living organ donors (kidney and liver) are captured in the Swiss Organ Living Donor Health Registry (SOL-DHR; www.sol-dhr.ch), assuring lifelong follow-up.1 Expenses of the SOL-DHR are covered by the healthcare insurance of transplant recipients and the FOPH. Since 2008, the Swiss Transplant Cohort Study collects data of all transplantations performed in Switzerland. While a minimal data set is mandatorily submitted for the FOPH, additional detailed information including biobanked samples support a prolific research platform (www.stcs.ch).2FIGURE 2.: Simplified illustration of local and national infrastructure available for transplant centers in Switzerland. Dashed lines represent data flow between different information technology systems and databases. Currently, there is no electronic data transfer and many redundant data are entered several times manually.OVERALL TRANSPLANT VOLUME Detailed statistics can be found on the homepage of Swisstransplant (www.swisstransplant.org/en/information-material/statistics/). In 2017, Switzerland had 145 deceased donors (17.2 per million population) and 137 living donors (16.3 per million population). In 2017, 360 kidney, 143 liver, 40 heart, 32 lung, 19 pancreas, and 17 multiorgan transplantations have been performed. Switzerland imported 36 and exported 8 organs from/to other European countries. In addition, 262 allogeneic hematopoietic stem cell transplantations were performed in 2017. LIVING AND DECEASED DONATION RATES Living donors contribute with 30%–40% to the overall kidney transplant volume and around 5%–10% of the liver transplant volume. Living kidney donation is strongly supported by all transplant centers. Five of 6 transplant centers have a successful program for ABO-incompatible kidney transplantation. ACHIEVEMENTS Several important national advances have been established or are near completion: A registry for follow-up of all living donors since 1993 (SOL-DHR). A detailed and widely used research platform incorporating all transplantations (Swiss Transplant Cohort Study). Donation after circulatory death in Switzerland, pioneered by the Zürich group, is now performed in all centers.3 Since May 2012, the algorithm for deceased donor kidney allocation uses a calculated panel-reactive antibodies and virtual crossmatch approach, which reduces transplantation across donor-specific HLA antibodies and cold ischemia time (currently around 10 h). A nationwide kidney-paired donation program will soon be operational. Many efforts on different levels have been made to increase donation rates (eg, public awareness programs, improved potential donor detection). Overall, a 42% increase of the donor conversion index has been observed (from 1.9% in 2010 to 2.7% in 2017) (Figure 3).4 The median waiting time for a deceased donor kidney is approximately 3 years.FIGURE 3.: Evolution of the donor conversion index (DCI) from 2010 to 2017. 2010–2015 DCI data4; 2016–2017 DCI values were calculated based on 2015 mortality data. An increase of 1% DCI equals 1 additional actual deceased donor/100 deaths/selected causes of death.4 The DCI increased from 1.9% in 2010 to 2.7% in 2017 (+42%).CHALLENGES We identified 4 key challenges: a successful accomplishment will require a joined effort of all transplant professionals and institutions. First, according to a recent national evaluation, only about half of the potential deceased donors become actual donors. The main reason is a lack of documentation to donate. A national organ donor registry has been implemented on October 1, 2018 to fill this void.5 Furthermore, a national public poll will very likely be performed in the next years asking the question, whether Switzerland should change from an “opting-in”to a presumed consent system. Second, highly sensitized patients with calculated panel-reactive antibody >99%—especially patients with blood groups B and AB—start to accumulate on the waiting list. Besides a kidney-paired donation program, international collaborations providing much larger donor pools are expected to improve transplant options for those patients. Third, organ allocation becomes more challenging as age and comorbidities of recipients and deceased donors are increasing. Ideally, the functional capacity of the donor organ should last for the live expectancy of the recipients, a challenging charge under the current conditions.6,7 In addition, organs from older donors are much less resistant to unspecific injuries linked to ischemia or brain death than organs from younger donors. There is hope that ex vivo organ perfusion can help to preserve, assess, and potentially improve organ function.8 Four, a legal framework and information technology interfaces need to be implemented to enable a smooth data transfer between local and national databases/information systems.

Fig. 1.Manhattan plot visualizing genome-wide association of 61 cutaneous squamous cell carcinoma (cSCC)-organ transplant recipients (OTRs) and 908 skin cancer negative-OTRs, showing -log10 p-value of SNPtest along chromosomes.Horizontal red line represents the significant threshold p-value of 5×10 -8 .Arrow indicates single nucleotide polymorphism rs34567942 with the most prominent p-value.

SUMMARY This study was conducted to determine the effects of loading of the central part of the tympanic membrane by different weights on pure tone audiometry of healthy ears. Sixty patients with normal otoscopic view, normal pure tone audiometry and wide external auditory canal to allow direct and endoscopic visualization of TM, but without any history of ear surgeries, were selected and divided equally and randomly into two groups. Loading of the central part of the TM was carried out using weights ranging from [(1 λ) 13.6 mg] to [(40 λ) 544 mg]; (λ) is a symbol for the weight of 1 microliter of mercury. The study was carried out in two steps assisted by direct oto-endoscopy, and pure tone audiometry was used to measure the effects of loading on both air and bone conduction hearing. Air conduction hearing thresholds increased in a statistically significant pattern at low frequencies, 500 Hz, 1000 Hz and 2000 Hz, when the TM was loaded by 340 mg (25 λ). The maximal effect was recorded at 544 mg (40 λ), which affected air conduction hearing at all tested frequencies (500 Hz, 1000 Hz, 2000 Hz and 4000 Hz). However, no statistically significant effect was detected on bone conduction hearing thresholds throughout the study. In conclusion, loading of the tympanic membrane by different masses affects the air conduction hearing threshold by only 340 mg (25 λ), which is very large in comparison to the mass of ossicles, without any significant effects on bone conduction hearing.

Swiss Transplant Cohort Study (STCS). Background The management of antibody mediated rejection (AMR) remains nowadays a major challenge in kidney transplantation. Different therapeutic strategies are used but more data are needed to define the optimal treatment. This is the first report of the treatment of acute AMR in kidney transplant recipients in a real-life multicenter cohort study setting. Methods Kidney transplant recipients (May 2008 – 2014) who received a treatment for an acute AMR episode occurring in the first year posttransplantation (post-Tx) were included from the Swiss Transplant Cohort (STCS). The main objectives were to describe the treatment used and to analyze the outcomes in term of efficacy (serum creatinine at 3 months post-acute AMR) and safety (incidence of infectious complications within 6 months post-acute AMR). Results Overall, 64/1669 (3.8%) patients were treated for an acute AMR occurring in the first year post-Tx (74 episodes in total). In addition to corticosteroid boluses, the most common treatment modalities used were Plasma exchange or pheresis (55.4%) and IVIG (39.2%) followed by rituximab (25.7%) and antithymocytes globulins (23.0%), and finally eculizumab (4.1%) and bortezomid (4.1%). Most acute AMR were managed with bitherapy (43.2% of episodes), mostly corticosteroids and plasmapheresis, but as much as 5 therapies were used in combination in few patients (n=4). At 3 months post-rejection, the treatments used were overall effective with a full recovery of allograft function in 67.6% of the cases. In patients with de novo DSA (n=7), this proportion reached 85.7% compared to 56.0% in patients with preformed DSA (n=50) (not significant). The graft loss at 1-year was 9.2% (6/65), the majority related to ongoing rejection. At 12 months post-Tx, 33.3% of the patients cleared all DSA (11/33). In patients with de novo DSA (n=7), the clearance reached 71.4%, compared to 23.8% in patients with preformed DSA (n=21) (p=0.02). The treatments of acute AMR were followed by at least one infectious complication in the following 6 months in 63.6% of cases. The overall incidence of viral infections was 71.2% (47/66), with 13.6% of CMV diseases and 7.6% of BK viremia. The bacterial and fungal infectious complications reached 43.9% and 7.6% respectively. At 1-year, patient survival was 93.7%. Two patients died due to severe infectious complications (3.1%). Conclusions In this multicenter national cohort study, we found a wide variety of therapeutic strategies used to treat acute AMR, supporting the need for more controlled trials in the management of acute AMR. Despite this heterogeneity in the treatments used, the graft survival at 1-year reached 91%, with an overall good response to therapy at 3 months. However, infectious complications were common, including severe infections rarely leading to patient loss.