Transplantology, Volume 7, Issue 1 (March 2026) – 5 articles

Background: Alemtuzumab is a recombinant DNA-derived humanized monoclonal antibody directed against the 21–28 kd cell surface glycoprotein, CD52. Alemtuzumab is used as an organ anti-rejection therapy in transplant recipients. Neuro-ophthalmic adverse effects are rarely described, and, to our knowledge, accommodative spasm has not previously been reported in a transplant recipient. Case Description: A thirty-nine-year-old woman with genetically confirmed NPHP1-associated nephronophthisis, with stage F3 fibrosis, developed persistent bilateral blurred vision 72 h following alemtuzumab administration for a biopsy-proven acute cellular rejection, approximately six to seven weeks post-transplant. Initial attribution to hyperglycaemia and tacrolimus toxicity delayed recognition. Cycloplegic refraction confirmed a marked hyperopic shift (+2.75 D right eye, +2.50 D left eye) with significant improvement in visual acuity, consistent with accommodative spasm. Systemic evaluations excluded hyperglycaemia-related lens changes, calcineurin inhibitor neurotoxicity, and cytomegalovirus retinitis. MRI was not pursued in the absence of red flag neurological features, and because a definitive ophthalmic diagnosis had been made. Management and Outcome: The patient was managed expectantly, as cycloplegic refraction had already confirmed the diagnosis, and symptoms were improving. Therapeutic cycloplegia (e.g., atropine) was withheld to avoid impairing near vision and driving ability. Full resolution occurred within 4 to 6 weeks without intervention. Drug exposure to onset of symptoms was 72 h; onset of symptoms to diagnostic confirmation was 22 days; total symptom duration was 5.5 weeks, and recovery was 2 weeks after diagnosis. Conclusions: This case represents the first reported transplant case of alemtuzumab-associated accommodative spasm. Causality assessment supports a WHO-UMC classification of “Probable”, aligning with five Bradford–Hill considerations (temporality, biological plausibility, consistency, specificity, and analogy), but without statistical “strength of association” given that this is a single case report. Early cycloplegic refraction should be incorporated into the evaluation of post-alemtuzumab visual complaints, and clinicians should contribute to pharmacovigilance through structured reporting to capture these rare but important events. Full article

Background/Objectives: Incisional hernia (IH) is a frequent complication after kidney transplantation, with its risk influenced by both patient-related factors such as obesity, diabetes mellitus, and smoking, and procedure-related factors including surgical technique and immunosuppressive therapy. This study aimed to identify risk factors associated with IH and to evaluate the impact of suture type used for fascial closure in kidney transplant recipients. Methods: We performed a single-center retrospective case–control study including adult kidney transplant recipients who underwent transplantation between January 2014 and January 2024. Patients who developed an IH were identified and matched 1:6 with controls according to year of transplantation. Demographic variables, patient comorbidities, dialysis modality, and type of fascial closure suture were analyzed. Patients were subsequently compared according to the type of fascial closure used, either absorbable barbed polydioxanone sutures or absorbable monofilament polyglyconate loop sutures. Multivariable logistic regression analysis was conducted to identify independent predictors of IH. Results: Among 1586 kidney transplant recipients, 39 patients developed an IH, corresponding to an incidence of 2.5% after a median follow-up of 36 months. On multivariable analysis, age was independently associated with IH development (OR 1.04; p = 0.01), as was obesity (body mass index > 30 kg/m²; OR 2.55; p = 0.01). The overall incidence of IH did not differ significantly between suture types, with rates of 11.4% (10/88) for absorbable barbed polydioxanone sutures versus 15.6% (29/186) for absorbable monofilament polyglyconate loop sutures (p = 0.35). In obese recipients, however, fascial closure with barbed polydioxanone sutures was associated with a significantly lower incidence of IH, at 9.1% (2/22) versus 36.4% (12/33) for loop sutures (p = 0.02). Conclusions: Obesity and older age were the main independent predictors of IH after kidney transplantation in this cohort. In obese recipients, fascial closure using absorbable barbed polydioxanone sutures was associated with a substantially lower IH rate. These findings warrant confirmation in prospective, randomized studies. Full article

Introduction: While extensive research has been conducted on specific factors affecting transplant outcomes in simultaneous pancreas-kidney recipients, less is known about outcomes following single pancreas transplantation (PTx). This study focuses on identifying factors related to early graft loss after PTx. Patients and Methods: A retrospective analysis was performed on a Eurotransplant (ET) registry database encompassing all consecutive solitary pancreas transplantations from 2000 to 2018. To address any missing values, multiple imputation techniques were employed. Uni and multivariable statistical analyses were performed. Results: The primary causes of early graft loss (<90 days) were thrombosis, bleeding, rejection, and infection. Using multivariable analysis, donor male gender (Hazard Ratio (HR) 0.62) was significantly associated with early graft survival. Of all recipient variables, recipient age (HR 0.96) and recipient cardiovascular history (HR 2.10) were associated with graft loss. A subgroup analysis PTx of female donors into female recipients showed an increased risk for early graft loss compared to male-to-male transplants (HR 2.14). The graft survival rates were 62.9% and 79.0%, respectively (p = 0.017). Discussion: This Eurotransplant registry analysis identifies various donor- and recipient-related risk factors after PTx, partly mirroring the SPK population but also identifying new factors. These findings identify PTx patients as a separate entity in pancreas transplantation and emphasize the need for tailor-made matching of donors and recipients. Full article

Liver graft shortage remains a major limiting factor in contemporary liver transplantation, particularly in the setting of increasing waiting list pressure and constrained donor availability. While the biological quality of donor organs cannot be modified surgically, several operative strategies have been developed to optimize liver utilization and compensate for insufficient graft volume. These include split liver transplantation (SLT), dual-graft living donor liver transplantation (DGLT), auxiliary procedures, and selected multi-graft or hybrid configurations. This review provides an updated and structured overview of surgical concepts aimed at maximizing effective liver mass for transplantation. We discuss indications, technical considerations, and reported outcomes of split, dual, and combined graft approaches, with particular emphasis on graft-to-recipient weight ratio (GRWR), portal inflow modulation, and prevention of small-for-size syndrome. The role of machine perfusion technologies—including normothermic and hypothermic approaches—as enabling tools for graft assessment and safer utilization of partial grafts is also examined. Finally, we address ethical and logistical challenges associated with complex graft strategies and outline future directions in which advances in perfusion, graft assessment, and staged transplantation concepts may further refine patient selection and procedural safety. Collectively, these strategies represent complementary solutions for extending liver transplantation beyond conventional single-graft paradigms in highly selected settings. Full article

Background: Chyle leakage is known to be a rare postoperative complication following liver transplantation (LT), and continuous leakage of large volumes of chyle can worsen prognosis. However, its mechanism is not fully understood, and no existing reports show the influence of chyle leakage after LT on blood concentration of the drug tacrolimus. Case presentation: A 43-year-old male with primary hepatocellular carcinoma (HCC), decompensated cirrhosis, and massive ascites underwent orthotopic liver transplantation (OLT). During active chyle leakage, his daily tacrolimus dose was escalated to 4.0 mg with concurrent administration of a CYP3A5 inhibitor, but blood concentrations remained subtherapeutic (1.7–2.5 ng/mL). Conservative treatments failed, so intraperitoneal injection of erythromycin (0.75 g) dissolved in 25% glucose solution (40 mL) was initiated on postoperative day (POD) 11, then administered every other day. After three treatments, chylous drainage reduced significantly, and tacrolimus concentrations abruptly increased to 14.7 ng/mL following a marked reduction in chylous drainage (to 800 mL/d on POD 13). Subsequent dose adjustments stabilized tacrolimus levels at 4.6–6.2 ng/mL with a daily dose of 2.0 mg. Conclusions: Intraperitoneal injection of erythromycin hypertonic solution may promote lymphatic fistula closure via chemical stimulation, though its efficacy requires further validation. Chyle leakage likely reduces tacrolimus blood concentration through multiple potential mechanisms. This case highlights the need for clinical attention to the association between chyle leakage and immunosuppressant concentrations, though further studies are required for validation. Full article