ABSTRACTIntroductionDonor age is a key determinant of liver transplant (LT) outcomes, but its impact varies across recipient age groups. Specific donor age thresholds associated with excess risk remain undefined.MethodsUsing data from the Scientific Registry of Transplant Recipients (2011–2021; follow‐up through 2024), we analyzed first‐time, single‐organ LT recipients. Donors and recipients were stratified by age. Outcomes included patient, graft, and death‐censored graft survival. Multivariable Cox regression models adjusted for liver disease severity, comorbidities, graft type, and transplant year were used to identify donor age thresholds associated with increased risk in each recipient age group.ResultsAmong 70 078 recipients (median age, 57 years), mean donor age rose from 39.6 to 40.9 years (p = .004), while recipient age increased from 50.7 to 51.9 years (p = .003). Donor age ≥50 years was associated with a sixfold increase in mortality in pediatric recipients (aHR, 6.48; 95% CI, 1.92–21.83; p = .003). For adults aged 18.1–30 years, excess mortality and graft loss were observed with donors >55 years (aHRs >2.5). In recipients aged 40.1–60 years, risk increased progressively with donor age. Among recipients ≥65 years, donor age was not significantly associated with outcomes. These thresholds were consistent across outcomes and robust in sensitivity analyses.ConclusionsThis is the first national study to define recipient age‐specific donor age thresholds associated with post‐LT risk. These findings support the development of age‐informed allocation strategies and call for a reassessment of organ discard practices as donor and recipient ages continue to rise.

ABSTRACTBackgroundAntibodies to donor HLA (DSA) and non‐HLA antigens are associated with detrimental outcomes in kidney, heart, and lung transplants. Such data are scarce in liver transplants (LTx). We aim to study the roles of DSA and non‐HLA antibodies in T‐cell‐mediated rejection (TCMR) of LTx.MethodsAllograft biopsies (n = 103) from adult LTx recipients were studied. Biopsy‐paired serums were retrospectively tested for anti‐angiotensin II type 1 receptor (AT1R) and the Luminex panel of 60 non‐HLA Antibodies.ResultsTCMR was detected in 59 of 103 (57.3%) biopsies. Twenty‐six biopsies were categorized as moderate‐severe (MS‐TCMR), 77 as negative‐mild (NM‐TCMR). DSA was positive in 95/103 (92.2%) cases and wasn't associated with MS‐TCMR. Anti‐AT1R antibodies were elevated in serum paired with MS‐TCMR vs. NM‐TCMR (18.8[15.2–40.0] vs. 13.0[10.0–21.5] U/ml, p < 0.01). Positive anti‐AT1R antibodies were associated with a higher incidence of MS‐TCMR (HR = 12.4[1.5–101.6], p = 0.02). A panel of 18 non‐HLA Abs was significantly associated with MS‐TCMR. The number of panel‐18 non‐HLA antibodies was higher with MS‐TCMR vs. NM‐TCMR (3[2–5] vs. 1[0–1], p < 0.001). The incidence of MS‐TCMR was higher in cases with panel‐18 non‐HLA antibodies ≥3 vs. <3 (HR = 19.6[6.0–64.8], p < 0.001). The frequency of MS‐TCMR was the highest when DSA, anti‐AT1R, and panel‐18 non‐HLA antibodies were all present.ConclusionsNon‐HLA antibodies to AT1R or the Luminex panel are associated with MS‐TCMR in LTx biopsies. The incidence of MS‐TCMR is higher when non‐HLA antibodies are present concomitantly with DSA, indicating an additive effect. Further studies are warranted to investigate the utility of routinely monitoring DSA and non‐HLA antibodies in LTx recipients.

Urinary tract infections (UTIs) occur commonly following kidney transplant and are associated with significant morbidity. Some providers perform intra-operative antibiotic bladder irrigation at the time of ureteroneocystostomy, although practice varies widely among surgeons. As a result, this study was performed to assess outcomes following a single intravesical gentamicin injection for the prevention of UTIs. This was a retrospective cohort study of adult patients who underwent a first isolated kidney transplant between January 2018 and January 2023. Outcomes were compared between patients who received bladder irrigation with a single dose of gentamicin and controls who did not receive antibiotic irrigation. The primary end point was the incidence of culture-confirmed UTI within 3-months of transplant. Key secondary endpoints included delayed allograft function and serum creatinine at 3-months. A total of 764 patients were included in the study analysis (gentamicin=406 vs. control=358). At 3months, the incidence of UTIs was 18.2% in the gentamicin group compared to 13.1% in the control group (p=0.05). A higher incidence of BK viremia >10,000copies/mL was also observed in the gentamicin group compared with control patients (5.9% vs. 2.5%; p=0.02). After multivariable regression analysis older age, female sex, early rejection, longer dialysis vintage, and urinary catheter duration were all found to be positively correlated with the incidence of UTIs. Among kidney transplant recipients, bladder irrigation with gentamicin was not found to reduce the incidence of UTIs at 3months. Additional studies should explore a possible association between antibiotic bladder irrigation and subsequent BK viremia.

This study investigated the risk factors for both high post-void residual (PVR) and the need for urinary re-catheterization (RC) following kidney transplantation (KT). Our objectives were to develop a predictive risk model for high PVR and to outline a management strategy for patients who experience posttransplant elevated PVR. This prospective study included 110 adult patients who underwent KT. High PVR was defined as > 150mL in non-anuric patients and > 50mL in anuric patients. Logistic regression analysis was conducted to identify predictive factors for high PVR. Urinary RC was evaluated as a secondary outcome. High PVR was observed in 31 (28.2%) patients. On multivariate analysis, DM (odds ratio [OR], 3.11; 95% confidence interval [CI], 1.22-7.94; p = 0.02) and anuria before transplantation (OR, 3.80; 95% CI, 1.34-10.80; p = 0.01) were identified as significant predictors of high PVR. The area under the curve of the receiver operating characteristic for the risk model using these factors was 0.72 (95% CI, 0.61-0.82). Urinary RC was required in 14 (12.7%) patients, and among male recipients, those who required RC due to high PVR had significantly larger prostate volume (p = 0.003). The present study demonstrated that DM and anuria are predictive factors for high PVR and larger prostate volume in male recipients was associated with an increased likelihood of RC. To prevent the following complications, PVR should be routinely measured especially in patients with a history of diabetes or anuria.

Although advances in pancreas transplantation have improved patient survival, prolonged immunosuppression has increased the risk of post-transplant malignancies. This study aimed to examine the incidence, risk factors, and long-term outcomes of solid organ malignancies in pancreas transplant recipients at a single center. All adult pancreas transplants between February 1, 1983, and December 31, 2023 at the University of Minnesota were reviewed, including pancreas transplant alone (PTA), simultaneous pancreas-kidney transplants (SPK), and pancreas after kidney transplants (PAK). 1729 pancreas transplant recipients were included with a median follow-up of 23years. During this period, 152 (8.8%) developed a non-skin, non-hematologic malignancy at a median time of 12.6years after transplant, with a cumulative incidence of 13% (95% CI 11%-16%) at 30years post-transplant. The most common malignancies were colorectal (14.1%), renal cell (13.0%), breast (13.0%), and lung (9.7%) cancers. Functioning graft status (HR 0.67, 95% CI 0.47-0.95, p=0.024), maintenance corticosteroid use (HR 1.51, 95% CI 1.00-2.27, p=0.051), and transplant era (p=0.015) were risk factors for development of a solid organ malignancy. Overall survival following malignancy diagnosis was poor, with a 10-year post-diagnosis survival rate of 24% (95% CI 17%-33%). No recipient or transplant-related factors were independently associated with mortality after malignancy diagnosis. Solid organ malignancies constitute a substantial late complication in pancreas transplant recipients, with corticosteroid exposure and graft longevity as key risk factors. These findings underscore the need for long-term cancer surveillance and tailored immunosuppressive strategies in this population.

The use of donation after circulatory death (DCD) donors has significantly increased in recent years. The current study sought to risk-stratify transplants where DCD donors are utilized. We reviewed the UNOS database for adult patients who underwent lung transplantation (LT) using DCD donors between 2017 and 2022 (n = 948, 6.31% of all LT). One-year mortality was the primary dependent variable. The proportion of DCD donors is increasing (3.7% in 2017 to 7.6% in 2022, p < 0.001) and is associated with significantly higher 1-year mortality (13.9%vs. 10.7% among recipients of brain dead donors; p = 0.003). On Cox proportional hazard analysis with bootstrap validation, recipient age > 65 years (adjusted hazards ratio, 95% CI: 1.51, 1.05-2.2; p = 0.028), admission to the ICU at the time of transplant (2.11, 1.34-3.31; p = 0.001), estimated GFR < 75mL/min/1.73 m2 at the time of transplant (1.81, 1.23-2.67; p = 0.003), and organ out of body time >7 h (2.02, 1.39-2.94; p < 0.001) are associated with 1-year mortality. A composite variable, the recipient risk score, based on the number of above risk factors, is strongly associated with 1-year mortality. The utilization of DCD donors is associated with worse 1-year mortality after LT. The recipient risk score based on the four simple-to-use recipient and procedure-related variables strongly predicts outcomes.

ABSTRACTBackgroundOrgan allocation has recently changed to acuity circle (AC)‐based policies. This study aimed to quantify changes in travel distance and potential environmental impacts of AC policies.MethodsData were obtained from the Scientific Registry of Transplant Recipients for each solid organ for an equidistant window before and after AC implementation. We calculated the distance between the donor and recipient hospital for each organ. We used an interrupted time series model to calculate excess travel distance after AC along with associated carbon emissions.ResultsWe analyzed travel distance for 226 731 deceased donor organs. There was a significant increase in total excess distance traveled: 1.5 × 106 miles for lung, 3.1 × 106 for heart, 2.2 × 106 miles for liver, and 3.2 × 106 miles for kidney. This led to increased estimated carbon emissions associated with transport ranging from: 175.7 to 193.4 kg CO2e per lung, 291.7 to 312.5 kg CO2e per heart, 114.9 to 131.7 kg CO2e per liver, and 0.2 to 5.3 kg CO2e per kidney.ConclusionsOur findings quantify an increase in total distance traveled and potential carbon emissions after AC implementation. Environmental impacts of allocation policies should be considered, especially with upcoming continuous distribution.

Heart transplantation remains the main treatment for end-stage heart failure. The opioid crisis has increased donor availability, including organs from intoxicated individuals, but the impact on outcomes is uncertain. Following PRISMA 2020, we searched MEDLINE, Embase, and Web of Science for studies on adult heart transplant recipients with donors exposed to substances like cocaine, heroin, marijuana, tobacco, or opioids. Eligible studies met PICOS criteria, and meta-analyses used a random-effects model. Twelve retrospective cohorts were included, totaling 189935 recipients, 33393 of whom received organs from intoxicated donors. The most reported substances were cocaine, alcohol, and tobacco. No significant differences were found in 5-year survival (HR=1.05; CI=0.94-1.17), 10-year survival (HR=0.94; CI=0.88-1.00), or survival with overdose-related donors (HR=0.96; CI=0.84-1.09). Rates of allograft rejection (HR=0.99; CI=0.21-0.88) and cardiac allograft vasculopathy (HR=1.02; CI=0.95-1.11) were also similar. Subgroup and sensitivity analyses confirmed result consistency. Organs from intoxicated donors do not compromise long-term outcomes and may help address donor shortages.

The role of failure to rescue (FTR) in solid organ transplantation (SOT) is less clear. This scoping review aimed to evaluate the incidence, complications, and risk factors for FTR in SOT. We systematically searched PubMed, Scopus, and Web of Science for studies reporting on FTR in SOT. Data on incidence, complications, risk factors, and definitions were extracted and synthesized narratively due to heterogeneity across studies. Seven studies were identified: four in liver transplantation, two in lung transplantation, and one in heart transplantation; none addressed kidney or pancreas transplantation. Definitions of FTR varied by time window, complication set, and analytic unit. Reported FTR rates ranged from 4.6% to 39.6% in liver, 19% to 26% in lung, and 11.5% in heart transplantation. Across organs, dialysis-requiring acute kidney injury (AKI) was the most frequent proximate pathway to death. Risk signals spanned patient-level factors (age, comorbidities, frailty/sarcopenia, functional status), donor factors (age, sex, race/ethnicity), and system-level factors (center volume, mortality tertile, insurance coverage). Notably, heart transplantation data revealed higher adjusted odds of FTR among Hispanic recipients. Evidence on FTR in transplantation remains sparse and heterogeneous, but early findings suggest that both patient vulnerability and system capacity shape rescue outcomes, with AKI consistently emerging as a cross-organ target. Standardized definitions, multicenter analyses, and extension to kidney and pancreas transplantation are needed to establish FTR as a transplant-specific quality metric and to guide interventions that optimize rescue.