Transplant International最新文献

There is no consensus on whether to ligate or preserve uncomplicated vascular access (VA) after kidney transplantation (KT), as International Guidelines do not address this issue. Enhanced survival rates of kidney grafts may elevate the risk of cardiac morbidity and mortality due to prolonged exposure to the hemodynamic effects of arterio-venous fistulas (AVF). Although VA ligation reduces left ventricle (LV) mass, its impact on cardiovascular (CV) morbidity or mortality is unclear. High-flow VAs can complicate KT patients, and immunosuppressive medication may increase these complications. Despite preserving VA for future hemodialysis (HD) use, central catheters are used in nearly two-thirds of patients. Detecting transplant patients who can undergo AVF ligation and reconstruction when returning to HD allows for flexible decision-making with a multidisciplinary approach, personally tailored to patients at their discretion. Therefore, an algorithm involving Doppler ultrasound and cardiac evaluation is advisable.

The expansion of eligibility criteria has led to an increase in the age at kidney transplantation (KT), with consequences on the infection risk. We performed a prospective single-center cohort study of 712 patients undergoing KT between 2014 and 2022. Recipient age (median: 56.6 years [interquartile range: 43.2-68.5]) was analyzed by 10-year strata and dichotomized by thresholds (≥60, ≥70, ≥75 and ≥80). Univariable and multivariable regression models were constructed to assess the incidence of overall, bacterial and opportunistic post-transplant infection. In unadjusted analyses, each 10-year-increase was associated with overall (subdistribution hazard ratio [SHR]: 1.18; 95% confidence interval [CI]: 1.11-1.26), bacterial (SHR: 1.17; 95% CI: 1.09-1.26) and opportunistic infection (SHR: 1.26; 96% CI: 1.13-1.40). All groups >50 had an increased risk of infection. After multivariable adjustment, this association remained significant for overall (adjusted SHR [aSHR] per 10-year-increase: 1.09; 95% CI: 1.02-1.18) and bacterial infection (aSHR per 10-year-increase: 1.09; 95% CI: 1.00-1.18). Recipients ≥60 exhibited higher risk of overall infection (aSHR: 1.25; 95% CI: 1.00-1.54), and recipients ≥70 higher risk of opportunistic infection (aSHR: 1.54; 95% CI: 1.02-2.32). The incidence of infection was not significantly higher for patients ≥80 years. In conclusion, infection risk after KT increases with age, notably beyond 60 years.

Lung transplantation has become an established life-saving treatment for selected patients with end-stage pulmonary disease. In December 2024, our center reached the milestone of 1,500 lung transplants, providing an opportunity to evaluate long-term trends, outcomes, and challenges. We analyzed donor and recipient demographics, procedural evolution, and graft survival. Contemporary guidelines and consensus recommendations were also reviewed to contextualize current practice and highlight unmet needs. Median graft survival improved markedly across eras: 3.5 years between 1991 and 2000, 9.9 years between 2001 and 2010, and 11.2 years between 2011 and 2020 (p < 0.0001). Shifts in procedure type, donor selection, and transplant indications mirrored broader developments in the field (all p < 0.0001). Donor and recipient age increased significantly over time, with older recipients experiencing poorer long-term outcomes. Despite these advances, chronic lung allograft dysfunction (CLAD) remains the most important barrier to durable success, with median CLAD-free survival of 6.7 years in the modern era (2010-2024) and a retransplantation rate of 4%. While survival now exceeds a decade in many recipients, extended longevity presents new challenges, including management of comorbidities and optimization of CLAD prevention, treatment, and retransplantation strategies. Continued translational research and evidence-based approaches remain critical to improving long-term results.

Poorly HLA matched transplants have poorer long-term outcomes, however it is unclear whether living donation or pre-emptive transplantation can counteract the effects of HLA mismatches. We reviewed the long-term outcomes of paediatric kidney transplants with different HLA matches and aimed to identify other factors which may contribute significantly to long-term outcomes. We conducted a retrospective registry analysis of all pediatric kidney transplants from 1987-2020 in the USA from the OPTN Registry. These were analysed by HLA mismatches and compared by pre-transplant dialysis status and donor type. 21,500 patients were included for analysis. Overall, patients with unfavourable HLA matches had higher rates of delayed allograft function and lower allograft survival. However, patients with unfavourable HLA matched transplants from living donors had better allograft survival than patients with favourable HLA matched transplants from deceased donors (79% at 5 years vs. 71%, p < 0⋅01). Patients with pre-emptive unfavourable HLA matched transplants had better allograft and patient survival than patients with non-pre-emptive favourable HLA matched transplants (83% at 5 years vs. 78%, p = 0⋅02% and 98% vs. 96%, p < 0⋅01 respectively). In conclusion, living donation and pre-emptive transplantation have a more significant impact on clinical outcomes and lead to better allograft and patient survival than HLA matching.

In multicenter kidney exchange programs (KEPs), either the explanted kidney must be shipped, or the donor must travel to the transplanting center. This review describes the available data on these two approaches and formulates recommendations for practice. We searched for studies addressing organ shipment or donor travel in KEPs. Data were categorized into four domains: cold ischemia time (CIT), logistics, donor/recipient perspectives and professional perspectives. From 547 articles screened, 105 were included. Kidneys are shipped in most countries. Prolonged CIT due to shipment may increase the risk of delayed graft function, but does not seem to impact graft survival. Planning the shipment requires a robust logistical framework with guaranteed operating room availability. Donor travel is reported to be both emotionally and financially distressing for donors and exposes them to inconsistencies in donor evaluation and counseling across centers. Reduced willingness to participate in KEP when travelling was reported by 36%-51% of donors. Professionals generally support offering organ shipment to donors not willing to travel. In conclusion, the decision between donor travel or organ shipment should be tailored to local circumstances. Healthcare professionals should prioritize minimizing barriers to KEP participation, either by facilitating organ shipment or reducing the burden of donor travel.

Living donor kidney transplantation (LDKT) accounts for 35% of kidney transplants in the UK. The Organ Donation and Transplantation 2030 initiative underscores the necessity to enhance LDKT rates to meet growing demand. There is limited data on national variations in live donor workup pathways from initial referral to long-term follow-up. We conducted an online survey across all 23 UK transplant centres performing LDKT, covering the entire living donor pathway. We aimed to explore and highlight practice variation and identify opportunities for improvement. Responses were received from 21 centres (91.3%). Marked variation was identified in donor acceptance criteria, including age limits, body mass index thresholds, and donor evaluation timelines (6-36 weeks). Differences were also noted in multidisciplinary team processes, kidney laterality decisions, and perioperative enhanced recovery protocols. All centres used laparoscopic techniques, with hand-assisted transperitoneal nephrectomy being most common (57.1%). Donor nephrectomy and implantation were conducted sequentially in 15 (71.4%) of centres, and in parallel in six (28.6%). Variation was also seen in follow-up duration with 47.6% of centres offering lifelong follow-up. Despite excellent national outcomes, this survey highlights significant variation. Standardising key processes could streamline donor pathways, improve experiences, and support increased LDKT activity in the UK.

Islet transplantation is a valuable therapy for selected type 1 diabetes mellitus (T1DM) patients, especially those with recurrent severe hypoglycemia, glycemic variability, or impaired hypoglycemia awareness. It improves glycemic control and protects against hypoglycemic episodes. Beyond glucose regulation, islet transplantation may mitigate diabetes-related microvascular and macrovascular complications. We conducted a systematic review to assess its impact on vascular outcomes in T1DM, focusing on islet transplantation alone (ITA) and islet-after-kidney transplantation (IAK). We included studies that quantitatively assessed vascular complications after ITA or IAK in adults with T1DM. Eligible studies compared pre-and post-transplant outcomes or posttransplant outcomes with control groups receiving standard treatment. Twenty-five studies (1,373 patients) evaluated microvascular and macrovascular outcomes using eGFR, ophthalmic e xams, and nerve conduction studies. Islet transplantation was associated with stabilization or improvement in most microvascular complications and longterm renal function preservation. While macrovascular data were less frequent, improvements in vascular health markers such as reduced procoagulant states and atherosclerosis progression were reported, suggesting possible reductions in cardiovascular events and mortality, though data remain limited. Islet transplantation shows clear benefits for microvascular complications and potential advantages for macrovascular outcomes, alongside its established role in improving glycemic stability and quality of life. Systematic Review Registration: PROSPERO Identifier CRD420251036400.

Despite recent advances, deceased donor kidney transplant allocation in the United States does not sufficiently account for the mismatch between donor and recipient age. This misalignment often leads to a suboptimal use of scarce resources. This viewpoint calls for restructuring of current kidney allocation strategies, advocating for a more intentional, age-matched approach that prioritizes better long-term quality kidneys for proportionally younger patients and encourages the use of older donor kidneys in similarly aged recipients. Drawing on the National Scientific Registry of Transplant Recipients data, clinical observations, and ethical reasoning, we argue that incorporating age in the organ allocation algorithms may improve both equity and utility in organ distribution. We also advocate for revision of the kidney donor risk calculators and placing a cap on the pre-emptive wait-time. Such realignments may reduce organ discard rates, enhance long-term graft utility, alleviate decision-making burdens on patients, and decrease the need for re-transplants on younger patients. To achieve this, recalibrations in allocation algorithms and reframing of what constitutes a "good" kidney are required. The goal is not to limit choice, but to structure a framework that maximizes benefit across populations while maintaining fairness towards a more sustainable model of transplant care.