The functional adaptability of hyporesponsive T cells in precluding transplant acceptance is not well recognized. This review aims to highlight the impact of this mechanism on transplant outcomes and explore potential strategies to overcome this challenge. Hyporesponsive T cells exist in two major distinct states: anergy and exhaustion. In response to infection, alloreactive anergic T cells can differentiate into IFN-γ producing effector cells, leading to the abrogation of transplant acceptance. Depleting anergic T cells has been shown to promote transplant acceptance under infection. In addition, "precursor exhausted" T (TPEX) cells can differentiate into effector cells during checkpoint inhibitor immunotherapy. This helps explain why using checkpoint inhibitors in transplant recipients heightens the risk of graft rejection. This review focuses on the functional adaptability of hyporesponsive T cells and highlights the importance of further investigations into strategies to disarm these cells. Such research could have significant clinical implications for transplant patients.

Purpose of ReviewWe explore how to develop Maastricht category I and II donation in the UK. We discuss lessons learned from previous UK pilots and define future steps in the journey to establishing a sustainable uDCD programme in the UK.Recent FindingsThe emergence of normothermic regional perfusion (NRP) as a successful strategy in cDCD donation with excellent clinical results creates the optimal platform for the development of a uDCD programme. Coordinated logistics with ambulance services and ED departments, embedded donor coordination in ED, public acceptance and wider discussion on acceptable peri-mortem interventions are key for future developments.SummaryA uDCD programme in the UK is feasible. Despite an increase in public awareness and recent changes in legislation, there remain several challenges. Recent advances in perfusion and preservation and an established national retrieval infrastructure, create the premises for future sustainable developments.

Purpose of ReviewSolid organ transplant recipients (SOTRs) are ideal candidates for early treatment or prevention of coronavirus disease 2019 (COVID-19) using anti-SARS-CoV-2 monoclonal antibodies because of multiple underlying medical conditions, chronic immune-suppression, sub-optimal immunogenic response to vaccination, and evolving epidemiological risks. In this article, we review pertinent challenges regarding the management of COVID-19 in SOTRs, describe the role of active and passive immunity in the treatment and prevention of COVID-19, and review real-world data regarding the use of anti-SARS-CoV-2 monoclonal antibodies in SOTRs.Recent FindingsThe use of an anti-SARS-CoV-2 monoclonal antibody in high-risk solid organ transplant recipients is associated with a reduction in the risk of hospitalization, need for intensive care, and death related to COVID-19. Overall, the early experiences from a diverse population of solid organ transplant recipients who were treated with anti-spike monoclonal antibodies are encouraging with no reported acute graft injury, severe adverse events, or deaths related to COVID-19.SummaryAnti-SARS-CoV-2 antibodies are currently authorized for treatment of mild-moderate COVID-19 and post-exposure prophylaxis, including in SOTRs. Potential future uses include pre-exposure prophylaxis in certain high-risk persons and synergistic use along with emerging oral treatment options. Successful timely administration of anti-SARS-CoV-2 monoclonal antibodies requires a multidisciplinary team approach, effective communication between patients and providers, awareness of circulating viral variants, acknowledgement of various biases affecting treatment, and close monitoring for efficacy and tolerability.

Purpose of ReviewWhile solid organ transplant (SOT) recipients are at the highest risk for severe complications and increased mortality from COVID19 disease, their vaccination against SARS-CoV-2 remains challenging due to fear of immune-mediated adverse events and suboptimal immune response. Our current review is aimed to summarize current knowledge about the safety and efficacy of SARS-CoV-2 vaccines, describe factors that are correlated with immune response, and discuss strategies to improve vaccine immunogenicity in SOT recipients.Recent FindingsSARS-CoV-2 vaccines are safe in SOT recipients and not related to rejection or other major adverse events. The immune response to two doses of vaccine is suboptimal and correlated to age and magnitude of immunosuppression. Administration of a third vaccine dose brings to significant amplification of immune response.SummaryThis review strengthens the existing recommendation of vaccination by three doses of vaccine in all SOT recipients and completion of vaccination before transplantation if possible.

The purpose of this review is to describe the Southeastern Kidney Transplant Coalition's mission, vision, goals, and Early Transplant Access registry as an example of a community/academic collaboration dedicated to improving access to transplantation and reducing inequities in transplant access. The barriers and facilitators to referral and evaluation for kidney transplantation are not necessarily the same as for waitlisting and transplantation. Recent findings suggest that inequities in transplant access are multilevel and multifactorial and require continued community engagement to improve access to kidney transplantation across patients, health systems, and populations. Community-engaged approaches are critical to ensuring that inequities in transplant access - which may vary across regions -- are not only described but are addressed in practice in a sustainable manner.