Hepatic arterial occlusion after living donor liver transplantation (LDLT) can be catastrophic, yet outcomes when revascularization fails are incompletely defined. We conducted a retrospective multicenter cohort study across 10 International Living Donor Liver Transplantation Group institutions (2008-2022), including LDLT recipients in whom durable hepatic arterial inflow could not be achieved-either intraoperatively or after postoperative occlusion despite surgical or endovascular attempts. Twenty-five patients met criteria. Median time to occlusion was 8 days (IQR 2-46). Etiologies were hepatic artery thrombosis (72%), occlusion after transarterial embolization (12%), intimal dissection (12%), and severe anastomotic stricture (4%). Diagnosis was imaging-based in 84%. Revascularization was attempted in 16 patients, restoring temporary flow in 6. Portal vein arterialization was used in 3 intraoperative failures. Biliary complications occurred in 56%, and infectious complications in 76%. Collateral-driven restoration of arterial flow occurred in 3 patients, and all three remain alive without graft failure. Using the date of failed revascularization as time zero, graft survival at 1/3/5 years was 48%/31%/23% (median 306 days, IQR 21-604), and overall survival 60%/50%/50% (median 574 days, IQR 65-1926); seven patients underwent retransplantation (median 430 days). Failure to revascularize within 30 days was associated with worse overall survival, while graft survival was similar. Unsuccessful revascularization after LDLT predicts poor graft outcomes with substantial biliary and infectious morbidity; collateral reperfusion, though uncommon, may enable long-term graft survival.

Abstract. The shortage of suitable donor kidneys remains a major challenge in transplantation. To address this shortage, kidneys from circulatory death donors and donors who do not meet the standard criteria are increasingly used. However, such kidneys are associated with poorer posttransplant outcomes and would therefore benefit from robust pretransplant evaluation. Machine perfusion technology enables noninvasive, real-time evaluation of kidney grafts through functional measurements and biomarker analysis in the circulating perfusate and urine. These measurements have the potential to determine kidney graft quality before transplantation and potentially predict posttransplant outcomes. However, reliable evaluation tools are not yet well-established and approximately 18% of donor kidneys are still ultimately discarded based on subjective assessments. Evidence indicates that physiological and biochemical parameters, such as renal blood flow and endocrine function, can be used to assess graft quality objectively. Additional perfusate biomarkers identified include immune mediators, markers of cellular stress, injury and death, metabolic biomarkers, and imaging-based assessments. This review highlights a diverse range of perfusion parameters, as well as urinary and perfusate biomarkers that may give valuable information about donor kidney quality and possibly associate with posttransplant outcomes. Nonetheless, most markers have not yet been clinically validated, and their predictive value for posttransplant outcomes remains uncertain. Standardized study designs and integration of multiple quality assessment parameters are essential to advance donor kidney assessment.

BACKGROUND:Simultaneous liver-kidney transplantation (SLKT) has increased substantially in the United States since adoption of the Model for End-stage Liver Disease-based allocation, now comprising 9%-10% of liver transplants. The survival benefit of SLKT compared with liver transplantation alone (LTA) remains uncertain. METHODS:Using the Organ Procurement and Transplant Network (OPTN)/United Network for Organ Sharing registry, we analyzed 63 407 adult liver transplants (57 780 LTA; 5627 SLKT) performed between 2010 and 2019. Patient survival was evaluated across pretransplant estimated glomerular filtration rate (eGFR) categories and according to transplant era before and after implementation of the 2017 OPTN policy. RESULTS:Among patients with pretransplant eGFR ≥30 mL/min/1.73 m2, SLKT conferred no survival benefits, and LTA recipients achieved comparable or better long-term outcomes. In contrast, SLKT significantly reduced mortality in patients with advanced renal dysfunction. For eGFR 15-29 mL/min/1.73 m2, SLKT reduced 1-, 3-, and 5-y mortality by 25%, 15%, and 13%, respectively. For eGFR <15 mL/min/1.73 m2, SLKT reduced 1-, 3-, 5-, and 10-y mortality by 32%, 24%, 22%, and 17%, respectively. Following implementation of the 2017 OPTN policy and "Safety Net" policies, SLKT procedures declined. The survival advantage of SLKT observed in the pre-policy era was no longer evident post-policy, with 1.4% of LTA recipients undergoing kidney after liver transplantation under "Safety Net" allocation priority. CONCLUSIONS:SLKT is associated with survival benefit in patients with severe renal dysfunction (eGFR <30 mL/min/1.73 m2). Following implementation of the 2017 OPTN policy, this survival difference was no longer evident, and SLKT procedures were reduced without compromising survival. These findings support a stage-specific allocation strategy incorporating the "Safety Net" framework.

Living donor kidney transplantation (LDKT) offers superior graft survival and cost-effectiveness compared with deceased donor transplantation (DDKT), yet the availability of immunologically compatible living donors limits its reach. Kidney exchange programs (KEPs) can overcome these barriers by matching incompatible pairs through paired exchanges, domino chains, and nonsimultaneous extended altruistic donor (NEAD) chains. This review summarizes the evolution and current landscape of national and international KEPs. We examine operational challenges (cold ischemia time [CIT], logistical coordination, algorithmic fairness, and ethical and regulatory heterogeneity) and explore innovations in matching algorithms, international kidney exchange debates, and machine perfusion technologies. We conclude by proposing strategic priorities to optimize capacity, equity, and outcomes in future kidney exchange efforts.

Background:With growing transplant waiting lists, more extended criteria donor organs are being accepted, requiring optimization of the organs to increase utilization. Abdominal normothermic regional perfusion (aNRP) benefits the outcomes of transplanted livers and pancreatic islets, but its effects on donor kidneys subsequently preserved with (oxygenated) hypothermic machine perfusion (HMPO2) remain to be determined. This study examines the function and survival of an aNRP-preserved controlled donation after circulatory death (cDCD) kidneys followed by HMPO2. Methods:From October 2018 until June 2023, we evaluated all ≥50 y cDCD kidneys retrieved using aNRP during a pilot implementation project and compared posttransplant outcomes of these donor kidneys to those of cDCD kidneys retrieved by standard rapid retrieval during the same period. All kidneys received HMPO2 as standard preservation. This study primarily compared estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration), 1 y graft and recipient survival. Results:Data of 70 aNRP-preserved kidneys were compared with a control group of 124 kidneys. One year estimated glomerular filtration rate was comparable between groups (40.4 mL/min/1.73 m2 [29.3-52.3] versus 40.0 mL/min/1.73 m2 [28.1-48.1]; P = 0.5) as well as graft and recipient survival at 1 y (81.4% versus 83.1%; hazard ratio, 1.1; 95% confidence interval [CI], 0.6-2.3; P = 0.63; 88.6% versus 88.7%, hazard ratio, 1.0; 95% CI, 0.4-2.4; P = 0.99, respectively). Primary nonfunction and delayed graft function were not significantly different (odds ratio, 1.3; 95% CI, 0.4-4.2; P = 0.68; odds ratio, 1.3; 95% CI, 0.7-2.5; P = 0.39). Conclusions:This study demonstrates that aNRP-preserved kidneys from cDCD donors aged 50 y and older had comparable outcomes to kidneys retrieved with standard rapid retrieval, in the context of HMPO2 as a standard ex situ preservation technique. This differs from earlier studies showing improved results of aNRP in the context of cold storage without standard machine perfusion. With aNRP gaining interest because of its value for liver and pancreatic islet transplantation, a prospective randomized study should be performed to further analyze the benefit of continuous kidney HMP(O2) after aNRP.

INTRODUCTION:After graft failure, kidney transplant recipients may develop immunological intolerance to the allograft left in situ. In such cases, surgical removal of the allograft is usually performed, but is associated with substantial morbidity and mortality. A less invasive option is percutaneous embolization of the renal artery. Here, we describe our clinical experience with embolization and report observed differences with graft nephrectomy. METHODS:In this retrospective, single-center study, we included kidney transplant recipients who underwent either graft nephrectomy or embolization between 2018 and 2024. Patients with indication "gain of space" were excluded. We reported on major post-procedural complications within three months (Clavien Dindo score 3-4), post-embolization syndrome, blood transfusions, length of hospitalization and readmissions, and mortality. RESULTS:We included 13 embolizations and 32 graft nephrectomies. Major post-procedural complications occurred in 23% after embolization versus 41% after nephrectomy (p = 0.32). Length of hospitalization was shorter after embolization compared to nephrectomy (median 1 vs. 5 days, p = 0.001). Post-embolization syndrome occurred in 9 of 13 patients (69%) and was managed conservatively. One patient with recent graft infections required a subsequent nephrectomy for infected necrosis after embolization. Another patient with residual blood flow after embolization required a nephrectomy for persisting hematuria. Two patients with pre-existing sepsis and bacteriemia died after embolization. CONCLUSIONS:Embolization results in shorter length of hospitalization and is likely associated with a reduced incidence of procedure-related major complications as compared to nephrectomy. Pre-existing sepsis is a risk factor for adverse outcomes after embolization, and recent graft infections should be considered a contra-indication.

RATIONALE & OBJECTIVE:Living donor kidney transplantation is considered the most effective treatment for end-stage kidney disease, but healthy individuals who donate may experience potential threats to their long-term well-being. This meta-analysis assessed the impact of living kidney donation on health-related quality of life (HRQoL) among donors overall and among those at higher risk for negative health impacts. STUDY DESIGN:Systematic review and meta-analysis. SETTING & PARTICIPANTS:Living donors of kidney allografts included in studies of postdonation HRQoL with predefined inclusion and exclusion criteria. Studies were identified through a comprehensive search of Embase, MEDLINE OvidSP, CENTRAL, Web of Science, PsycINFO, and the top 100 rankings in Google Scholar. DATA EXTRACTION:Data were extracted in accordance with PRISMA guidelines, with independent extraction by multiple observers to ensure accuracy. ANALYTICAL APPROACH:Primary outcomes included the 36-item Short-Form Health Survey (SF-36) and its composite mental component summary (MCS) and physical component summary (PCS). These measures were used to compare postdonation HRQoL with predonation levels and to the HRQoL of the general population. Study-level effects were calculated as standardized mean differences for continuous variables. Pooled effects were estimated with a random-effects model using restricted maximum likelihood. RESULTS:The meta-analysis included 73 studies with 14,474 donors. The MCS did not show significant changes at 3, 6, or 12 or more months after donation compared with baseline. However, the PCS was significantly lower at 3 months after donation compared with before donation (standardized mean difference, -0.38 [95% CI, -0.72 to -0.05], P = 0.02), which did not persist at 6 or 12 months. Both PCS and MCS scores were significantly higher in donors than in the general population. Donors' HRQoL scores were comparable to or better than those of healthy controls, recipients, patients who underwent a nephrectomy, and patients receiving maintenance dialysis. LIMITATIONS:Heterogeneity in study populations and outcomes, a limited number of studies for certain comparisons, methodological weaknesses of especially older studies, variability across geographies studied, and unaccounted for temporal changes. CONCLUSIONS:Kidney donors reported physical HRQoL to be decreased after living donor nephrectomy, which returned to predonation levels by 6 months. The HRQoL reported by living donors was significantly better than that of the general population and healthy controls. These findings suggest that concerns about postdonation HRQoL need not be a deterrent to potential living kidney donors. TRIAL REGISTRATION:Registered at PROSPERO with study number CRD42024540202. PLAIN-LANGUAGE SUMMARY:This study examined the well-being of living kidney donors after donation by summarizing the findings of 73 studies, which included more than 14,000 donors. Overall, the donors' quality of life remained high. Their physical health was slightly lower 3 months after donation but returned to predonation levels shortly afterward. Their quality of life related to mental health remained unchanged after donation. Donors generally experienced health comparable to or better than that of the general population and other patient groups. Certain factors, such as complications or stress related to the recipient's condition, may temporarily have affected donors' well-being, but most recovered fully within a year. These findings may reassure potential donors that kidney donation does not typically have long-term negative effects on their health.

Living liver donation is a critical component for addressing organ shortage and improving outcomes for patients with end-stage liver disease. As the prevalence of living donor liver transplantation (LDLT) increases worldwide, understanding and optimizing long-term donor health is paramount. The 2025 International Liver Transplantation Society and International Living Donor Liver Transplantation Society (ILTS-iLDLT) Consensus Conference convened experts in the field of liver transplantation to establish evidence-based guidelines focused on the long-term medical, psychological, and social considerations following living liver donation. The aim of this working group was to integrate current evidence and expert consensus on donor follow-up protocols, risk assessment, and management strategies to promote long-term donor health, quality of life, and living liver donor programs globally to safeguard the welfare of this unique population.

Introduction: The shortage of donor grafts for kidney transplantation remains a critical challenge. En bloc kidney transplantation (EBKT) from small deceased pediatric donors can potentially expand the donor pool. This study aimed to investigate the safety of pediatric-donor EBKT in adults compared with the standard deceased kidney transplantation (SDKT). Methods: This retrospective study was performed to compare outcomes after pediatric-donor EBKT (n = 17; donor weight, 9.8 ± 4.0 kg) and SDKT (n = 72; donor weight, 79.6 ± 18.4 kg) in adult recipients at our center. Outcomes of EBKT from donors weighing <10 kg were compared with those from donors weighing ≥10 kg. The primary outcome was death-censored graft survival. Secondary outcomes included patient survival, serum creatinine, and the incidence of postoperative complications. Results: The death-censored graft survival rates at 1, 5, and 10 years were 0.86 ± 0.09, 0.86 ± 0.09, and 0.86 ± 0.09, respectively, for pediatric-donor EBKTs and 0.84 ± 0.05, 0.76 ± 0.07, and 0.64 ± 0.13, respectively, for SDKTs (p > 0.05). The patient survival rates at 1, 5, and 10 years were 0.93 ± 0.06, 0.67 ± 0.16, and 0.24 ± 0.20, respectively, for pediatric-donor EBKTs and 0.86 ± 0.04, 0.60 ± 0.08, and 0.42 ± 0.10, respectively, for SDKTs (p > 0.05). No significant differences were observed between pediatric-donor EBKT and SDKT groups in postoperative complications (p > 0.05). Subgroup analysis of pediatric-donor EBKT by donor body weight revealed no significant differences (p > 0.05) in long-term graft and patient survival. Conclusion: Pediatric-donor EBKT in adults is a safe approach, with outcomes comparable to those of SDKT in our study. Moreover, EBKT from donors weighing <10 kg demonstrated comparable long-term graft and patient survival to that from donors weighing ≥10 kg. Considering the small sample size and the increased mortality observed over time, further research involving larger cohorts is necessary to validate these findings and to refine criteria for optimal recipient selection.

BACKGROUND:The shortage of donor grafts for kidney transplantation remains a critical challenge. En bloc kidney transplantation (EBKT) using small deceased pediatric donors has the potential to expand the donor pool. This review aimed to investigate the outcomes of pediatric-donor EBKT in adults compared with standard single kidney transplantation (SKT). METHODS:Relevant databases, including Ovid, Web of Knowledge, Google Scholar, Wiley, and Embase, were searched for eligible studies. Demographic data and transplant outcomes were extracted from the included studies. The primary outcome was graft survival. A random-effects model was used for the meta-analysis. RESULTS:Thirteen studies were included. The median 1-year graft survival rates were 83.8 % and 89.2 % for EBKT and SKT, respectively (risk ratio [RR], 0.97; 95 % confidence interval [CI], 0.93-1.01). The median 5-year graft survival rates were 78.7 % and 72.7 % for EBKT and SKT, respectively (RR, 1.05; 95 % CI, 0.93-1.19). For donors with a body weight > 10 kg (EBKT >10 kg) and ≤ 10 kg (EBKT ≤10 kg), the median 1-year graft survival rates were 100.0 % and 90.0 %, respectively (RR, 1.08; 95 % CI, 1.05-1.12). Vascular complications were identified as the primary cause of graft loss. CONCLUSIONS:Pediatric-donor EBKT in adults is a safe approach with excellent long-term functional outcomes comparable to those of SKT. EBKT represents an effective option to further utilizing pediatric donor kidneys. Outcomes of EBKT vary based on donor body weight. EBKT ≤10 kg was associated with higher short-term graft failure rates despite long-term performance being comparable to EBKT >10 kg.

BACKGROUND:New diagnostic criteria have recently been established to classify small-for-size syndrome (SFSS) after living donor liver transplantation into 3 groups based on severity. This study aimed to evaluate the clinical impact of grade A SFSS and identify the mortality risk. METHODS:We collected data from 406 patients diagnosed with grade A SFSS after living donor liver transplantation. Grade A SFSS is characterized by total bilirubin >5 mg/dL on postoperative day (POD) 7 or total bilirubin >5 mg/dL or ascites >1 L/d on POD 14. After propensity score matching, 193 patients were categorized into the up-trend group, down-trend group, and ascites group, with 43 patients (22.3%) in the up-trend group (total bilirubin on POD 7 < POD 14), 107 patients (55.4%) in the down-trend group (total bilirubin on POD 7 > POD 14), and 43 patients (22.3%) in the ascites group (only satisfying ascites criteria). RESULTS:There was no significant difference in survival between patients with grade A SFSS and those without SFSS ( P = 0.152). The up-trend group showed a higher 90-d mortality rate than the down-trend and ascites groups ( P = 0.025). The 1-y survival rate differed significantly between the groups (87.6%, 91.9%, and 97.7%, respectively; P = 0.044). The independent risk factors for survival were up-trend of total bilirubin, recipient age (65 y and older), model for end-stage liver disease score (≥30), and ABO incompatibility. Patients with ≥2 risk factors had worse survival rates than those with none and only 1 risk factor ( P < 0.001). CONCLUSIONS:Although the survival rate was comparable between the grade A SFSS and non-SFSS cohorts, the up-trend group showed worse survival. Aggressive interventions should be considered for up-trend patients with risk factors.

With an increasingly aging population, both end-stage renal disease and peripheral artery disease become more prevalent. Peripheral artery disease is increasingly treated with endovascular procedures. Endovascular stenting of the external iliac artery is often considered a contraindication for kidney transplantation, as clamping of the artery could result in possible injury to the stent. In this study, we describe our first 2 cases of kidney transplantation with a graft placed on a self-expandable metal stent and a covered stent as part of an endovascular repair of the aortic bifurcation, using endovascular balloon occlusion to occlude the proximal side of the external iliac artery. Six months after transplantation, both recipients have good kidney function without any signs of ischemia of the ipsilateral limb. This study shows that it is feasible to place a kidney graft on an endovascular stent.

BACKGROUND:The impact of donor and recipient sex on living donor kidney transplantation (LDKT) remains debated. This study investigates the impact of donor-recipient sex combinations on long-term transplant outcomes. METHODS:A dual-center retrospective study was conducted at Erasmus Medical Center (EMC) and University Medical Center Groningen (UMCG), including all LDKT patients between 2010 and 2020. Transplantations were categorized into male donor-male recipient (MDMR, n = 476), female donor-male recipient (FDMR, n = 765), male donor-female recipient (MDFR, n = 463), and female donor-female recipient pairs (FDFR, n = 372). The primary outcome was graft survival. Secondary outcomes included patient survival, delayed graft function (DGF), acute rejection, and graft function. RESULTS:The 10-year death-censored graft survival rates were 85.5% (MDMR), 85.4% (FDMR), 82.8% (MDFR), and 81.8% (FDFR) (p = 0.38), while corresponding 10-year patient survival rates were 73.3%, 70.7%, 74.8%, and 73.6%, respectively (p = 0.28). Male recipients had a slightly higher DGF rate compared to females (6.9% vs. 5.6%, p = 0.29). The incidence of acute rejection ranged from 15.5% to 18.3% across all combinations (p = 0.76). FDFR pairs in recipients ≥ 60 years had significantly better graft survival (95.9% vs. 86.6% vs. 87.0% vs. 80.7%, p = 0.048). Cox regression model confirmed this protective effect of female donor kidneys in aged female recipients (adjusted HR 0.24, 95% CI: 0.06-0.91, p = 0.036). MDMR pairs consistently showed superior long-term graft function but this advantage did not translate into better graft survival. CONCLUSIONS:Female recipients aged 60 or older benefit from improved graft survival when receiving female donor kidneys. While MDMR pairs consistently exhibited superior eGFR, this advantage did not translate into better graft survival.