Transplantology, Volume 6, Issue 1 (March 2025) – 7 articles

Background/Objectives: While there are several debates on en bloc renal transplants and pediatric donors regarding the efficacy and concern for renal mass, multiple studies have supported the notion that transplanting pediatric en bloc kidneys produces comparable results in contrast to single kidneys from living or deceased donors. Methods: This case series included a retrospective analysis of a university medical center, primarily focused on comparing the post-operative outcomes between recipients of pediatric and adult en bloc kidneys, which are horseshoe kidneys, from deceased donors and recipients of single adult kidneys from living or deceased donors. Results: This study demonstrated that the post-operative results in recipients of pediatric en bloc kidneys consisting of serum creatinine and estimated glomerular filtration rate (eGFR) values were lower and higher, respectively, and had a comparable improvement in kidney function at post-transplant, 1-week, 1-month, 3-months, and 1-year post-op marks. Conclusions: Our center data and outcomes indicate that en bloc kidney transplantation from pediatric donors yields comparable results to that of single kidney transplantations from living and deceased donors. Full article

Background/Objectives: Kidney transplantation (KT) is the preferred treatment for end-stage renal disease (ESRD), offering improved quality of life, superior survival rates and lower economic burden. However, improving long-term kidney allograft survival post transplantation remains a significant challenge. HLA eplet matching has emerged as a promising strategy to minimize immunological risk and enhance long-term graft survival. Still, our understanding of HLA immunogenicity remains limited. This study aims to evaluate if Electrostatic mismatch score (EMS) and eplet mismatch (EpMM) are significant for predicting KT outcomes and their optimal cut-off values associated with improved graft survival. Methods: Our study analyzed over 10,000 kidney transplant records from the Scientific Registry of Transplant Recipients (SRTR) dataset using traditional survival analysis and machine learning (ML) techniques. The immunogenicity scores EMS and EpMM were calculated based on donor-recipient HLA molecular mismatches. Kaplan–Meier plots, Cox proportional hazards (CPH), random survival forests (RSF), and survival decision trees (SDT) were utilized in assessing the significance of EpMM and EMS in improving KT outcomes and their optimal cut-offs. Results: EpMM and EMS were found to be significant predictors of kidney graft survival. The optimal cutoff values for improved outcomes for EMS and EpMM were 11 and 7 respectively, beyond which graft failure risk increased. The RSF model was the best-performing model in KT outcome prediction (C-index = 0.6945, Brier score = 0.1460). Conclusions: EMS and EpMM were significant in the prediction of kidney transplantation outcomes at cutoffs of 11 and 7, respectively. Incorporating these measures in KT organ allocation strategies could improve long-term survival outcomes. Full article

Background/Objectives: Dual kidney transplantation is a potential technique to reduce the number of discarded kidneys from expanded-criteria donors. Due to allegedly poor outcomes, some centres have abandoned this technique. We aimed to compare dual versus single kidney transplantation. Methods: This retrospective, propensity score-matched, non-inferiority study compared dual kidney transplantation and single kidney transplantation results. Matching was performed based on key donor characteristics, including age, sex, serum creatinine levels, and cause of death due to cerebrovascular accident. The primary outcome was graft survival at ten years post-transplant. Secondary outcomes included overall survival and perioperative complications. Non-inferiority of dual kidney transplantation was defined as a difference in graft survival within a 10% margin. Results: After propensity score, 39 dual kidney transplant recipients were matched with 78 single kidney transplants. Five-year graft survival was 66.1% for dual kidney transplants and 81.3% for single kidney transplants (p = 0.228), and 9-year graft survival was 54.1% dual transplant and 60.8% for single transplant (p = 0.961). There was no significant difference in terms of 10-year overall survival (p = 0.912) either. Surgical times were greater during dual kidney transplants (199.31 ± 49.12 min vs. 129.37 ± 42.11 min, p < 0.001). There were more overall complications associated with dual kidney transplants (35.9% vs. 17.9%, p < 0.05). Conclusions: Dual kidney transplantation achieved non-inferiority for ten-year graft and overall survival, despite higher incidence of complications and longer surgical times. Dual kidney transplantation can be a viable alternative to single kidney transplantation and may increase the pool of potential donors, reducing renal transplant waiting lists. Full article

Background: This study evaluated the outcomes of sutureless small incision Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK-SI) for treating corneal endothelial decompensation. Methods and Analysis: This retrospective study reviewed patients with corneal endothelial decompensation who underwent DSAEK-SI between January 2018 and June 2021 at the Vietnam National Eye Hospital. All patients were followed for at least one year postoperatively. The endothelial graft was inserted into the anterior chamber through a 2.8 mm main corneal incision using a Busin glide. The normal pressure air tamponade of the anterior chamber was applied to attach the graft to the recipient bed. The small incision required no sutures, and no need to remove part of the air from the anterior chamber. This ensured that the surgery ended immediately after the air tamponade, without having to wait for 15 min like with regular DSAEK. The patients were instructed to lie supine for at least 6 h postoperatively. Patients with cataracts underwent combined phacoemulsification and intraocular lens implantation with DSAEK-SI. Results: Sixty eyes from sixty patients were enrolled. The success rate of the surgery was 93.3%. Postoperatively, the best spectacle-corrected visual acuity (BSCVA) improved from 20/3600 to 20/400 at discharge and reached 20/100 at 12 months. Mild astigmatism (0.5D to 2D) was observed in 91.8% of patients, with a mean cylinder of 0.9 ± 0.4D at 12 months. The endothelial cell loss rate after 12 months was 34.6 ± 16%. No graft dislocations or detachments were recorded. Conclusions: The sutureless DSAEK-SI technique with a 2.8 mm incision is a modified technique that achieves high success rates and potentially reduces surgical manipulation and complications. Full article

Background/Objectives: Pneumocystis jirovecii pneumonia is a significant contributor to morbidity and mortality in patients with solid organ transplants. Sulfamethoxazole–trimethoprim prophylaxis has greatly reduced the incidence of this deadly fungal infection. Traditional prophylactic dosing includes single strength (400–80 mg) daily or double strength (800–160 mg) thrice weekly, but is limited by side effects. This study evaluates the efficacy and tolerability of a sulfamethoxazole–trimethoprim single-strength thrice-weekly prophylactic dosing strategy. Methods: This was a single-center, retrospective chart review of 421 patients with 423 total heart transplants at Cedars Sinai Medical Center between July 2016 and June 2020.A total of 361 patients (363 heart transplants) were started on single-strength sulfamethoxazole–trimethoprim thrice weekly for 1 year, based on institutional guidelines. Results: Patients were followed for a median of 3.86 years (range 0.17 to 6.57). Sulfamethoxazole–trimethoprim was started at a median of 7 days (range 0 to 132) for median duration of 11.5 months (range 0.25 to 22). There were no documented Pneumocystis jirovecii pneumonia cases during the study period. At 1 year, 36% of patients had discontinued sulfamethoxazole–trimethoprim. The most common causes for discontinuation were leucopenia (30.8%) and hyperkalemia (2.2%). Conclusions: In our experience, single-strength sulfamethoxazole–trimethoprim thrice weekly for 1 year effectively prevents Pneumocystis jirovecii pneumonia after heart transplant. Further multicenter studies with other patient populations will need to be performed to explore this well-tolerated strategy. Full article

Background: mTOR-Is positively influence the occurrence and course of certain tumors after solid organ transplantation. mTOR-inhibitor (mTOR-I) treatment, either alone or in combination with Calcineurininhibitors (CNIs), significantly reduces the incidence of malignancies after organ transplantation. However, there is no information on which mTOR-I, Sirolimus (SIR) or Everolimus (ERL), has a stronger anti-tumoral effect. Methods: The current literature was searched for prospective randomized controlled trials in renal transplantation. There were 1.164 trials screened, of which 20 could be included (7465 patients). We performed a network meta-analysis to analyze the relative risk of different types of mTOR-I compared to CNI treatment on malignancies after transplantation. A minimum follow-up of 24 months was mandatory for inclusion. Results: Four different types of mTOR-I treatment were analyzed in network meta-analyses—SIR mono, ERL mono, SIR with CNI, and ERL with CNI. The average follow-up of all trials was 43.8 months. All four different mTOR-I regimes showed a significant reduced relative risk for malignancies compared to a regular CNI-treatment with the strongest effect under SIR in combination with a CNI (RR 0.23, CI 0.09–0.55, p = 0.001). This effect remained consistent for all tumor entities except non-melanoma skin cancer (RR 0.25, CI 0.07–0.90, p = 0.033). Conclusions: It is well known that an mTOR-I based treatment in transplant patients reduces the risk of tumor manifestation in comparison to CNI treatment. A combination of SIR and CNI seems to be the most potent mTOR-I therapy against malignancies. Full article

Solid organ transplantation entails numerous complex medical and ethical decisions. Shared decision-making (SDM) has been advocated as the optimal model for navigating these decisions, providing a collaborative framework that enhances person-centered care. This approach involves patients, caregivers, and healthcare professionals in the decision-making process, ensuring that clinical decisions align with patient preferences, values, and individual circumstances alongside clinical indications. This paper reviews the implementation of SDM throughout the transplantation journey, from diagnosis and transplant referral, pre-transplant assessments, waiting lists, to the organ offer, perioperative period, and long-term follow-up. Barriers to SDM include factors at the patient, provider, and system levels, including inadequate patient–provider communication. Effective SDM requires tailored educational resources, prognostic tools, clinician training, collaborative care models, and supportive policies. Additionally, leveraging technology, such as artificial intelligence and mobile applications, can enhance patient engagement and decision quality. SDM promotes equity by involving all patients—including those from more vulnerable groups—in meaningful conversations about their treatment options, thereby mitigating disparities in access and outcomes. Future research should focus on the long-term impacts of SDM interventions, the development of comprehensive prognostic tools incorporating patient-reported outcomes, and systemic changes to integrate SDM into clinical practice, aiming to improve patient outcomes and person-centered care. Full article