Medicine and Pharmacology

Abstract: Background: Calcineurin inhibitor (CNI)-based immunosuppression after solid organ transplantation increases the risk of severe COVID-19. Nirmatrelvir/ritonavir, the guideline-preferred oral antiviral in the general population, causes a well-documented, potentially dangerous drug-drug interaction (DDI) with tacrolimus via ritonavir-mediated inhibition of cytochrome P450 3A4 (CYP3A4). Molnupiravir lacks this interaction but remains underused, partly because non-transplant clinicians may not recognize the risk posed by nirmatrelvir/ritonavir or the safety of molnupiravir as an alternative. Methods: We conducted a single-center retrospective analysis evaluating kidney and simultaneous pancreas-kidney (SPK) transplant recipients receiving tacrolimus who completed 61 treatment encounters with molnupiravir (800 mg twice daily for 5 days) for confirmed COVID-19. Tacrolimus trough levels and serum creatinine (SCr) were compared before and after treatment using the Wilcoxon signed-rank test, with Cohen’s d as the effect size estimate. Acute kidney injury (AKI) was classified by KDIGO criteria. Results: Among 52 unique patients, mean tacrolimus trough concentration was unchanged after treatment (pre 5.52 ± 2.26 vs. post 5.47 ± 1.97 ng/mL, mean difference -0.05 ng/mL, 95% CI -0.64 to 0.54; p = 0.941, Cohen’s d = -0.023). Serum creatinine was similarly unchanged (p = 0.706; d = 0.034). Five encounters (8.2%) met KDIGO AKI criteria. None though was attributable to molnupiravir. No adverse effects attributable to molnupiravir were reported, no mortalities, and 1.6% required hospitalization. Conclusions: Molnupiravir showed no evidence of a pharmacokinetic interaction with tacrolimus and no nephrotoxicity in this cohort, supporting its use as the preferred first-line outpatient COVID-19 antiviral for transplant recipients receiving calcineurin inhibitors. Because nirmatrelvir/ritonavir poses a life-threatening interaction risk in this population, primary care providers, emergency physicians, and general nephrologists should default to molnupiravir and consult a transplant pharmacist when uncertain.

Abstract: Donor-derived cell-free DNA (dd-cfDNA) is an emerging non-invasive biomarker of kidney allograft injury. Elevated dd-cfDNA has been associated with acute rejection, particularly antibody-mediated rejection; however, dd-cfDNA reflects graft-derived tissue injury rather than a specific alloimmune mechanism. Its interpretation may therefore be challenging in conditions characterized by endothelial and microvascular injury, such as atypical hemolytic uremic syndrome (aHUS). This retrospective observational study included 14 kidney transplant recipients who underwent their first kidney transplantation at Wroclaw Medical University between April and December 2022. Twelve non-aHUS recipients with stable renal function and two recipients with aHUS were assessed. Plasma samples were collected at four early post-transplant time points: day 7 (D7), day 14 (D14), month 1 (M1), and month 2 (M2). dd-cfDNA was measured using next-generation sequencing with the AlloSeq cfDNA assay. Donor-specific anti-HLA antibodies (DSA) were assessed using single-antigen bead testing. In non-aHUS recipients, median %dd-cfDNA declined from 0.72% [0.28%, 2.33%] at D7 to 0.12% [0.05%, 0.34%] by M1. In contrast, recipients with aHUS demonstrated persistently elevated dd-cfDNA values fluctuating around 1% [0.88%, 1.14%] during the first month of follow-up. No DSA were detected in any patient during the observation period. No apparent correlation was observed between %dd-cfDNA and serum creatinine in this small cohort. In this preliminary observational study, kidney transplant recipients with aHUS showed persistently elevated early post-transplant dd-cfDNA despite the absence of detectable DSA, absence of clinically documented rejection, and preserved graft function during follow-up. These findings suggest that universal dd-cfDNA thresholds may require cautious interpretation in aHUS. Larger biopsy-anchored studies integrating complement and endothelial injury markers are needed to clarify whether dd-cfDNA elevation in aHUS reflects alloimmune injury, complement-mediated microvascular injury, or overlapping mechanisms.

Abstract: Background/Objectives: Cardiac troponin I (cTnI) has shown inconsistent diagnostic performance for acute cellular rejection (ACR) after heart transplantation. We evaluated whether time-normalized cTnI kinetics provide incremental diagnostic value beyond the concurrent concentration for detecting ACR grade ≥2R. Methods: This retrospective single-center study included 1237 biopsy episodes from 139 heart transplant recipients after exclusion of ambiguous measurements and episodes without a preceding confirmed cTnI value. Two generalized linear mixed-effects logistic regression models with patient-specific random intercepts were compared. M1 included concurrent log₂-transformed cTnI, whereas M2 additionally included the time-normalized change in log₂-transformed cTnI per 7 days. Discrimination was assessed using leave-one-patient-out cross-validation; 95% confidence intervals were obtained from 2000 patient-level cluster bootstrap resamples. Results: In the overall cohort, M1 showed modest discrimination (AUC 0.641, 95% CI 0.592–0.689), whereas M2 provided no improvement (AUC 0.635, 95% CI 0.584–0.685; ΔAUC −0.007, 95% CI −0.021 to 0.007). Within 90 days after transplantation, neither model was informative (M1 AUC 0.503; M2 AUC 0.494). Beyond 90 days, M1 showed moderate discrimination (AUC 0.758, 95% CI 0.664–0.838), but M2 again provided no improvement (AUC 0.746, 95% CI 0.654–0.828; ΔAUC −0.012, 95% CI −0.037 to 0.008). Conclusions: Concurrent cTnI showed no discrimination within 90 days and moderate discrimination thereafter in exploratory stratified analyses. The kinetic term provided no incremental value. cTnI cannot replace endomyocardial biopsy but may warrant further evaluation as an adjunctive late-period marker.

Abstract: Background: Subnormothermic oxygenated machine perfusion has been shown to improve kidney preservation in the preclinical setting. However, whether oxygenated perfusion without an oxygen carrier provides superior protection over standard hypothermic machine perfusion at 4 °C in human kidneys has not been established. Methods: In this study, we assessed whether oxygenated University of Wisconsin (UW) solution perfusion at 22 °C provides improved protection compared with conventional hypothermic machine perfusion (HMP) at 4 °C using a paired human kidney model. Five pairs of discarded human kidneys were recruited for the study. For each donor pair, one kidney was randomized to 12 h oxygenated UW perfusion at 22 °C and the contralateral kidney was perfused at 4 °C with a clinically relevant kidney perfusion pump. After preservation, both kidneys were reperfused with whole blood at 37 °C for 4 h. Hemodynamic and functional parameters were assessed during preservation and reperfusion, including vascular resistance, renal blood flow, creatinine clearance, blood urea nitrogen, electrolyte levels, tissue oxygenation, and urine output. Histological injury was evaluated and a panel of kidney injury biomarkers were also measured. Results: Vascular resistance during the preservation period was significantly lower in the kidneys preserved at 22 °C compared to the HMP group, indicating improved flow dynamics. However, the improved vascular resistance observed during 22 °C preservation did not translate into superior post-reperfusion kidney function or tissue protection compared with 4 °C HMP. Renal blood flow, creatinine clearance, tissue oxygenation, cytochrome c release and malondialdehyde (MDA) levels were comparable between groups, while kidneys preserved at 22 °C had significantly higher acute tubular necrosis scores, higher blood urea nitrogen (BUN) levels, increased calbindin, glutathione S-transferase A1, monocyte chemoattractant protein-1 levels, and lower epidermal growth factor levels. Conclusion: These data demonstrate that oxygenated UW perfusion at 22 °C fails to provide superior protection to conventional HMP at 4 °C in discarded human kidneys transplantation model.

Abstract: Background/Objectives: Early allograft dysfunction (EAD) is a common complication after liver transplantation and is associated with inferior graft survival While normothermic machine perfusion (NMP) has reduced EAD incidence, prediction of early graft performance prior to implantation remains elusive. We aimed to correlate peri-transplant energetic and metabolic profile of liver grafts with post-transplant outcome in a cohort that included grafts preserved with NMP. Methods: Sequential biopsies were taken from 20 transplanted livers (10 immediate graft function [IGF] and 10 EAD), preserved by either static cold storage or NMP. Samples were collected immediately prior to implantation and 30 minutes after hepatic arterial reperfusion. Untargeted liquid chromatography-mass spectrometry was performed, and energy charge was calculated as (ATP + ½ ADP)/(ATP + ADP + AMP). Univariate and receiver operating characteristic analysis identified metabolites correlated with EAD and assessed predictive accuracy. Results: Hepatic concentrations of adenine nucleotides and calculated energy charge did not differ between outcome groups either before implantation or after reperfusion. In contrast, trans-urocanate was significantly enriched in IGF livers across both time points, and additional histidine catabolism pathway metabolites were preferentially increased in IGF grafts. Trans-urocanate demonstrated discriminatory performance for EAD with 80% sensitivity and 80% specificity, confirmed as the single strongest predictive feature among >1,600 detected metabolites. Conclusions: These data identify histidine catabolism as a novel metabolic pathway associated with early graft function and a potential indicator of allograft resilience to ischemia-reperfusion injury. Integration of histidine-pathway metabolites into perfusion-era viability assessment may serve as a discriminative biomarker of EAD and support future metabolite-guided graft optimization strategies.

Abstract: Accurate donor-recipient allograft size matching remains a critical determinant of outcomes in lung transplantation, yet current approaches rely predominantly on predicted total lung capacity (pTLC) and height-based metrics derived from population-based equations. These simplified surrogates fail to capture individual anatomical variability, disease-specific alterations in thoracic geometry, and the spatial relationship between donor lungs and recipient chest cavities. In this review, we examine the limitations of conventional size matching and synthesize emerging evidence supporting imaging-based approaches, including computed tomography (CT) volumetry, radiomics, and machine learning. CT-derived volumetric analysis enables individualized anatomical assessment and has been associated with clinically relevant prediction of primary graft dysfunction and mortality. Advanced computational methods may further support extraction of imaging-derived features and integration with clinical data, although these approaches remain investigational. Collectively, these developments signal a paradigm shift from crude population-based metrics toward imaging-driven and computational approaches in the modern era. With rigorous validation and careful clinical integration, imaging-based approaches may complement conventional size metrics and support more individualized donor-recipient assessment.

Abstract: Background: Psychosocial assessment is a critical component of transplant candidate evaluation, yet its clinical utility is often limited by the descriptive nature of existing tools such as the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT). Translating multidimensional assessment data into actionable clinical insights remains a challenge in routine practice. Methods: We developed a clinical decision support application that integrates SIPAT item-level data with probabilistic risk estimation, visualization, and cohort-referenced interpretation. The application was based on a retrospective dataset of 496 lung transplant candidates evaluated at a single tertiary transplant center. Random forest–based models were used to transform SIPAT item-level data into probabilistic risk representations to estimate domain-specific risks, including depression, anxiety, nicotine-related risk, alcohol-related risk, illicit drug use, social support deficits, and non-adherence. Risk estimates were expressed as calibrated probabilities and categorized into clinically interpretable levels. Additional components included domain-level burden scoring and unsupervised clustering of multidomain risk profiles. Results: Estimated risks were predominantly low across the cohort, with high-risk subgroups identified for depression (6.5%), anxiety (2.2%), nicotine-related risk (11.3%), alcohol-related risk (4.4%), illicit drug use (2.2%), social support deficits (8.1%), and non-adherence (1.4%). Clustering analysis revealed three distinct profiles: a low-risk majority group, a subgroup characterized by elevated nicotine-related risk, and a small high-burden group with substantially elevated psychological distress, reduced social support, and increased non-adherence risk. Risk estimates showed strong and domain-consistent correlations with SIPAT scores (Spearman rho up to 0.80, p < 0.001). Feature importance analyses confirmed that risk estimation was primarily driven by clinically relevant SIPAT items. The application generated structured outputs integrating risk estimates, visualization, and intervention prioritization. Conclusions: The proposed application translates SIPAT-based psychosocial assessment into structured, multidomain risk profiles that enhance clinical interpretability and support targeted psychosocial prehabilitation. This approach provides a practical framework for translating psychosocial assessment into individualized intervention planning in lung transplant settings.

Abstract: Background: Psychosocial assessment is central to lung transplant evaluation. Structured tools such as the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) can be used either to support exclusionary decisions or to guide psychosocial prehabilitation by identifying modifiable targets for intervention. We examined how SIPAT functions in a program that explicitly prioritizes remediation of modifiable psychosocial risks. Methods: We conducted a retrospective observational cohort study of consecutive adult lung transplant candidates evaluated at a single center in Poland between December 2021 and November 2025. Psychosocial risk was assessed using SIPAT (locally translated), including total and domain scores, candidate categories, and binary indicators of clinically relevant alcohol, illicit substance and nicotine related risk. The primary endpoint was a pragmatic program outcome, defined as ever being listed (including transplanted) versus not listed. Analyses focused on describing psychosocial risk profiles and their relationship to the program pathway rather than on building a predictive model of listing decisions. Results: In 491 candidates (mean age 57.2 years; 40.5% women), psychosocial burden was generally low (mean total SIPAT 12.4, SD 6.8) and most patients were rated as excellent or good candidates. SIPAT total, domain scores and candidate categories were not meaningfully associated with ever being listed. Nicotine related risk was more frequent among listed candidates, consistent with a clinical strategy in which smoking histories in predominantly COPD and emphysema patients trigger intensive cessation support rather than automatic exclusion. Cluster analyses identified a smaller high-risk subgroup, and ROC analyses showed modest discrimination for alcohol and nicotine related risk, supporting SIPAT as a structured needs assessment. Conclusions: In this prehabilitation oriented program, SIPAT did not operate as a binary gatekeeping instrument for listing. Instead, it primarily served to identify modifiable psychosocial targets that trigger tailored support. These findings support using SIPAT as a structured roadmap for psychosocial prehabilitation rather than a stand-alone exclusion tool.

Abstract: Kidney transplantation for patients affected by end stage renal failure is considered the best therapeutic option, but this possibility is limited by deceased donor shortage. Living donor kidney transplantation (LDKD) is a valuable option, frequently limited by immunological incompatibility between donor and recipient. This review will consider the to date possibility of performing living donor kidney donation in the case of AB0 blood group incompatibility and the progresses that have been made in this field. Kidney paired donation is one possibility. Such technique offers the best possibility if the number of pairs available is wide. This is possible by performing national and also international registries. The technique more diffuse is the desensitization of the recipients. Desensitization may be obtained by several ways that are extensively treated in this review. In the recent period some published studies document the possibility to enzymatically convert A or B group from the cells of the donor to 0 group. This possibility is only on the beginning, but may represent the future eventually associated to a mild desensitization.

Abstract: Background: Transparent and complete reporting of clinical trial information across registries and peer-reviewed publications is essential for reliable interpretation of clinical evidence. Previous studies have demonstrated discrepancies between trial registries and journal publications, but data specifically focusing on transfusion medicine trials remain limited. Objectives: To assess reporting completeness and consistency for key WHO Trial Registration Data Set (WHO TRDS) items and safety outcomes across the trial life cycle in transfusion medicine-related clinical trials. Methods: We conducted an observational study of clinical trials in transfusion medicine with available results registered in ClinicalTrials.gov between January 2011 and May 2019. Reporting of WHO TRDS items was evaluated at three predefined time points: initial registry entry, final registry update, and corresponding peer-reviewed journal publication. Changes and missing items were systematically assessed, and adverse event and mortality reporting were compared between registry records and journal publications. Results: A total of 67 eligible clinical trials were identified, of which 45 had corresponding peer-reviewed journal publications. At initial registration, several TRDS items were frequently missing, particularly timeline and outcome-related fields. Completeness improved substantially in the final registry updates but was not consistently maintained in journal publications, where incomplete or discordant reporting was common for enrolment and completion dates, eligibility criteria, and outcome definitions. Differences between final registry records and publications were observed in the majority of trials. Safety reporting also differed between sources: serious adverse events were reported at similar overall frequencies, but were more detailed in registry entries, whereas deaths were more frequently reported in publications and explicit reporting of zero adverse events was more common in the registry. Conclusions: Clinical trials in transfusion medicine show inconsistencies between registry records and corresponding journal publications across key methodological and safety reporting domains. These differences may limit transparency, reproducibility, and the reliability of evidence synthesis. Closer alignment between trial registries and scientific publications is needed to strengthen the trustworthiness of clinical information in transfusion medicine.

Abstract: Background: Lung transplantation (LTx) remains the final therapeutic option for patients with end-stage and irreversible respiratory failure. The most common complication after LTx is chronic lung allograft dysfunction (CLAD), which affects long-term outcomes. However, CLAD may be partially reversible, especially after early detection of the cause. For this reason, systematic monitoring of transplanted lung function, including spirom-etry values, is so important. In these cases, the usage of modern technologies and tele-medicine can be extremely useful and allow for early response to possible decreases of spirometry values. Objective: The aim of our study is to evaluate the feasibility and clinical usefulness of spirometry telemonitoring in lung transplant patients. Methods: This retrospective study compared lung transplant recipients, where the first group of patients was subjected to spirometry telemonitoring (N=21), the second group was monitored with standard home spirometry (N=23), and the control group underwent routine follow-ups only in the transplant center (N=32). Results: The mean number of emergency visits was found to be lower in the telemoni-toring vs routine care group (1.24 vs 2.34, P=.05). Additionally, the mean duration of all visits was higher in the routine care group (10.0 days) in comparison to the telemonitoring group (5.8 days, P< .001) and to the standard home spirometry group (8.7 days, P=0.03). Conclusions: Spirometry telemonitoring using digital devices is not only feasible in lung transplant recipients, but it may provide substantial clinical benefits in this group of patients. It makes it possible to react faster in the event of abnormalities, which results in a reduction in the number of emergency visits and their duration.

Abstract: Cerebral toxoplasmosis is a rare but potentially fatal opportunistic infection in renal transplant recipients receiving long-term immunosuppressive therapy. It may result from donor-derived transmission or reactivation of latent infection. We report the case of a 70-year-old female who underwent cadaveric kidney transplantation in 2004 for end-stage renal disease due to glomerulonephritis. She was maintained on cyclosporine, mycophenolate mofetil, and prednisone. In September 2024, she presented with headache, mood changes, and right-sided hemiparesis. Brain multislice computed tomography revealed a large temporoparietal lesion initially suspected to be glioblastoma. Craniotomy and histopathological analysis demonstrated encysted Toxoplasma gondii bradyzoites within gliotic tissue. Polymerase chain reaction testing confirmed the presence of T. gondii DNA, while human immunodeficiency virus testing was negative. The patient reported frequent contact with domestic cats. Treatment with pyrimethamine, sulfadiazine, and leucovorin, alongside adjustment of immunosuppressive therapy, led to marked neurological improvement and radiological regression of the lesion. However, nine months later, she succumbed to multidrug-resistant urosepsis. This case highlights the diagnostic challenges of cerebral toxoplasmosis in transplant recipients, as radiological findings are often nonspecific and can mimic neoplastic or lymphoproliferative lesions. Polymerase chain reaction and histopathological analysis remain essential for definitive diagnosis. Awareness of this rare complication is critical for early recognition and prompt initiation of anti-toxoplasma therapy, which can significantly improve outcomes. Although cerebral toxoplasmosis is uncommon after kidney transplantation, it should be considered in immunosuppressed patients presenting with neurological symptoms. Early detection and targeted therapy are key to reducing morbidity and mortality in this population.

Abstract: Background and hypothesis: Because of the narrow therapeutic range and inter-individual differences in tacrolimus trough levels, the total daily dose and their ratio are commonly used to determine proper tacrolimus. In our study, the Life-Cycle Pharma-tacrolimus formulation was compared to Immediate-release Tacrolimus in a real-life setting. Methods: This longitudinal observational study included kidney transplant patients at two Hungarian university clinic’s study centers. Sixty-three (63) patients completed the study and were included in the statistical analysis. They received either Life-Cycle Pharma-tacrolimus (n=40) or Immediate-release Tacrolimus (n=23) maintenance therapy as the two study arms, all combined with everolimus or mycophenolic acid and corticosteroid. Patients were enrolled in the study 4-6 weeks after transplantation and were observed for 48 months. Tacrolimus trough level, total daily dose and their ratio were recorded at each of the seven follow-up visits, during the 48 months study period. Epidemiology data, patient characteristics, blood parameters (including eGFR, de novo DSA, CMV and BK virus incidence), and the acute rejection episodes were monitored. Results: Mean age at enrolment was 53.35 years, males n=41 (65.08%). A steady, therapeutic maintenance trough level was achieved in both study arms. Dosing of Life-Cycle Pharma-tacrolimus required a 30% lower total daily dose compared to Immediate-release Tacrolimus to achieve the therapeutic trough level. A slow deterioration of eGFR was observed (mean decrease of 6.06 mL/min/1.73m2 over 4 years) in the Immediate-release Tacrolimus arm in contrast to the Life-Cycle Pharma tacrolimus arm, where the eGFR increased (by 4.76 mL/min/1.73m2) in 4 years period. Conclusions: Both formulations were both proper long-term immunosuppressive treatments for kidney transplant patients, maintaining a stable trough level. Life-Cycle Pharma tacrolimus might serve as a valuable choice in avoiding drug-specific side effects, reducing calcineurin-induced nephrotoxicity.

Abstract: Chronic allograft dysfunction (CLAD) is the main cause of graft loss after lung transplantation (LTR). Within the immunological factors involved in CLAD development, the antibody-mediated rejection (ABMR) has the most impact. However, ABMR diagnosis is difficult due to the limited sensitivity of histopathological, immunhistochemical, and immunological criteria currently used. Growing evidence is demonstrating the impact of molecular mismatch in ABMR; here, we ought to assess the potential role of molecular mismatch in CLAD development. A total of 457 LTR were recruited for the study, with HLA type from donors and recipients to assess molecular mismatch, and with a minimum follow-up of 180 days. The combination of molecular mismatch in class-II (HLA-EMMA and HLA-Matchmaker algorithms) with EMMA DR score >12 and antibody verified eplet mismatch in DRB1345 (AbV DRB1345) > 3 predicts CLAD development independently of ex-smoker, prolonged period of hospitalization (>33 days), acute cellular rejection (ACR), and ABMR. The HR of the prediction model for molecular mismatch in class-II was 1.52 (1.01-2.56, p=0.045). This observation could point to a potential role of poor molecular mismatch in class-II to fill the gap of underdiagnosis of ABMR, previous to CLAD development. Prospective studies should be addressed to confirm the utility of molecular mismatch in the identification of patients at risk of CLAD development.

Abstract: The management of asymptomatic bacteriuria (ASB) and candiduria (ASC) in kidney transplant recipients during the early post-transplant period is controversial. This study aimed to evaluate whether treating, versus not treating, ASB and ASC episodes in the first two months after kidney transplantation influences clinical outcomes and the emergence of multidrug resistant (MDR) infections. We conducted a single-center retrospective cohort study enrolling patients with ASB or ASC occurring in two first two month after kidney transplantation between January 2019 and July 2024. Patients were classified into treated and untreated groups. The primary endpoint was 30-day mortality. Secondary endpoints included mortality at 90, 180 and 360 days; incidence of sepsis or septic shock; bacteremia/candidemia, hospi-talization, graft loss; decline in renal function, urinary tract infections (UTIs), recur-rent UTI and rate of MDR colonization/infection. We enrolled 59 kidney transplant recipients and observed 147 episodes of ASB/ASC. Of the 147 episodes, 95 were untreated and 52 were treated. No significant differences were observed between treated and untreated patients in 30-day (2.1% vs. 3.8%) or 90-day mortality (2.1% vs. 1.9%), nor in any of the secondary clinical outcomes. How-ever, patients who received treatment tended to have a higher rate of MDR coloniza-tion/infection (63% vs. 46%). MDR pathogen isolation was significantly associated with increased risks of septic shock (OR 4.639,p=0.04), bacteremia/candidemia (OR 3.734,p=0.01), hospitalization (OR 2.183,p=0.03), and renal function deterioration (OR 3.93,p=0.03). Antimicrobial treatment of ASB and ASC in the early post-transplant period would seem not to confer clinical benefit and may increase the risk of MDR coloniza-tion/infection.

Abstract: Kidney transplantation activity at the University Hospital of Guadeloupe was briefly interrupted at the onset of the COVID-19 pandemic. This study assessed patient and graft survival in 335 recipients transplanted between 2013 and 2023, comparing those transplanted before 2020 and after the resumption of activity. Most patients (70%) received transplants before 2020, with 30% after-ward. ABO compatibility was observed in 98.2% of grafts from brain-dead do-nors. Peak transplant activity occurred in 2018, followed by a decline until 2021 and recovery from 2022. After 2020, recipients were more likely to be el-derly (≥70 years), immunized, obese, have heterozygous sickle cell disease, or polycystic kidney disease (p < 0.05). Mean cold ischemia time decreased (p = 0.009), while warm ischemia time increased (p < 0.001). Graft survival re-mained stable, with 97.5% at 6 months and 89.8% at 4 years for transplants before 2020, versus 100% and 96.9%, respectively, after 2020 (p = 0.160). Patient survival did not differ between periods (p = 0.199). Independent factors associ-ated with mortality included recipient age ≥ 60 years, diabetes, graft failure, transplantation before 2020, cold ischemia time ≥ 1200 minutes, and graft py-elonephritis. Despite an increased proportion of transplants with expanded criteria after 2020, graft and patient survival were not adversely affected.

Abstract: Background: Chyle leakage is known to be a rare postoperative complication following liver transplantation (LT), and continuously leaked large quantities of chyle leakage can worsen prognosis. However, there is no explicit understanding of its mechanism and no existing reports showing the influence of chyle leakage after LT on blood concentration of the drug tacrolimus. Case presentation: Despite escalating tacrolimus daily dose to 4.0 mg with CYP3A5 inhibitor, blood concentrations remained subtherapeutic (1.7–2.5 ng/mL) during active leakage. Conservative treatments failed, prompting intraperitoneal injection of erythromycin (0.75 g)-25% glucose solution (40 mL every other day). Following three treatments, chylous drainage diminished significantly, and tacrolimus concentrations abruptly increased to 14.7 ng/mL 2 days after leakage resolved. Dose adjustments subsequently stabilized levels at 4.6–6.2 ng/mL with daily dose of 2.0mg. Conclusions: Intraperitoneal injection of erythromycin hypertonic solution may promote lymphatic fistula closure via chemical stimulation. Chyle leakage may reduce tacrolimus blood concentration through drug loss in chylous fluid. This case highlights the need for clinical attention to the association between chyle leakage and immunosuppressant concentrations, though further studies are required for validation.

Abstract: Polyomavirus-associated nephropathy was first reported more than 50 years ago, however it still represents a cause of renal injury, with occurrence rates of 1%-10%, particularly in the firs two years following kidney transplantation. The role played by immunesuppression in viral reactivation is well aknowledged and the modulation of immunesuppression level is the main strategy for the management. Viral and immu-nological evaluation are fundamental for optimizing the diagnostic and clini-cal-therapeutic pathway. In this review, main features of polyomavirus BK and asso-ciated nephropathy will be addressed from a virological point of view.

Abstract: Background: The accurate evaluation of anti-ABO antibodies is essential for risk stratification in ABO-incompatible (ABOi) transplantation. Historically, hemaggluti-nation-based titration has been the cornerstone of such an assessment; however, dif-ferent tools are being evaluated in this context. In recent years, several novel methods have been reported. Methods: A narrative review was conducted using PubMed, Scopus, and Google Scholar, focusing on recent studies evaluating anti-ABO antibody measurement tech-niques in the context of ABOi organ transplantation. Results: In addition to the conventional tube method, techniques such as column ag-glutination technology, flow cytometry, and enzyme-linked immunosorbent assay are utilized for anti-ABO antibody assessment. However, any particular technique, sig-nificant interinstitutional and interoperator variabilities have been reported due to differences in the detailed protocols and the inherently subjective nature of some techniques. Moreover, these assays are based on the antibody binding to ABO anti-gens expressed on red blood cells, which might not accurately reflect the clinical con-text of organ transplantation. In recent years, technological advances have enabled the development of novel assays evaluating antibody responses specifically against the ABO antigens expressed on vascular endothelial cells. These include glycan mi-croarrays, which differentiate responses by ABO antigen subtypes, and CD31-based microarrays, wherein recombinant CD31 proteins expressing ABO antigens are im-mobilized. These approaches are applied to assess clinically relevant anti-ABO anti-bodies in the context of ABOi organ transplantation. Conclusions: The objective evaluation of antibody titers against ABO antigens on vascular endothelial cells might not only enable a more accurate risk assessment but also facilitate meaningful comparisons between institutions.

Abstract: Selecting donor organs is both a science and an art. The calculus is often complex evaluating recipients’ acute needs and the quality and risks of the donor organs. Sarcoidosis is usually a disease of exclusion and considered an idiopathic inflammatory granulomatous process frequently in the lung but often with multiorgan involvement. New insights into the interplay between the environmental or occupational antigens and the susceptible genetic host in sarcoidosis have come to light. One such occupational antigen with mixed data regarding the risk of developing sarcoidosis after exposure is silica dust. Despite strict exposure limitations enforced in the United States and several other governing bodies worldwide, clusters of silicosis are on the rise due to engineered stone (quartz), which contain silica particles that when cut can create a dust that can exceed exposure limitations. Data on the quartz-sarcoidosis relationship is minimal, and thus questions exist regarding the risk of silica dust exposure and the risk of sarcoidosis. Silicosis tends to only affect the lungs, preventing them usually from being transplanted while sarcoidosis is recognized as having a high probability of multiple organ involvement. An index case discovered during organ recovery highlights the possible association between silica exposure and sarcoidosis. This case also examples the complexity of donor organ evaluation and the challenges in organ procurement from exposed individuals.