Peter G. Stock

Background.: Widely accessible education on organ donation and transplantation (ODT) is a tool to reduce waiting lists, as <10% of transplant needs are met (Global Observatory on Donation and Transplantation). We aimed to assess the current state of access to education on ODT worldwide. Methods.: We surveyed transplant physicians and surgeons worldwide. Respondents were classified according to the mean deceased donation (DD) rate per million population (PMP) of their countries from 2016 to 2021 (excluding 2020): Group (G) 1 (G1) no DD reported, or no data provided to Global Observatory on Donation and Transplantation; (G2) <10 DD PMP; (G3) 10–19.9; (G4) 20–29.9; and (G5) ≥30. We inquired about the availability of education on ODT in countries and regions. Results.: We analyzed 311 respondents. We observed that the availability of education on ODT was as follows: in postgraduate education (77.2% in countries, 70.4% in regions), in undergraduate medical school (52.8%, 50.6%), in elementary school (14.2%, 14.2%), in high school (24.6%, 25.7%), and for the public (58.8%, 57.2%). The highest challenges were observed mainly in countries with lower DD rates. Conclusions.: This worldwide survey suggests that there are areas for improvement at a global level in education on ODT, spanning from schoolchildren to the public and from undergraduate to postgraduate medical students. This is a “Call to Action” to close the global education gap.

Background.: Global organ shortage is well documented; yet systemic barriers constraining access to transplantation remain poorly defined. Our study aimed to identify and map these barriers. Methods.: A web-based survey was conducted from May 2022 to March 2023 among physicians and surgeons involved in organ donation and transplantation (ODT) from transplantation societies worldwide: (1) Hospital structure, legislation and policies, and financial barriers, addressed to program directors; (2) Questions on education on ODT directed to all participants, and questions about donor acceptance for transplant specialists; (3) Questions on donor identification for critical care specialists and questions about organ acceptance directed to transplant specialists; (4) Demographic questions for everyone. Respondents were grouped according to the mean deceased donation (DD) rate per million population from years 2016 to 2019 and 2021: Group (G) 1 (G1) No DD reported, or no data provided to global observatory on donation and transplantation; (G2) <10 DD per million population; (G3) 10–19.9; (G4) 20–29.9; (G5) ≥30. Results.: We present answers from program directors. There were 150 program directors from 438 respondents. Financial barriers ranked highest, negatively affecting access to transplantation worldwide. G1 indicated the highest percentage of challenges. Those from G4 and G5 provided the least amount of challenges; however, training programs remain areas for improvement. Responses from G2 and G3 were similar, positioned between those from G1, and G4 and G5. Conclusions.: The organ shortage emergency is exacerbated by parallel system-level deficiencies. This global survey identifies specific, actionable deficits that must be addressed to build equitable transplant systems worldwide.

The survival benefit of liver transplantation (LT) for hepatocellular carcinoma (HCC) varies by waitlist dropout risk, yet allocation policy applies uniform prioritization, and center practices remain poorly characterized. We performed a retrospective cohort study using the United Network for Organ Sharing database, including LT candidates with HCC between February 4, 2020, and October 1, 2024. Low-dropout-risk (LDR) HCC was defined as MELDp <0.001). Waitlist outcomes for LDR candidates and post-transplant survival did not differ by center type. These findings suggest substantial center variation exists for LDR HCC and may disadvantage access among higher-need candidates despite similar post-transplant survival.

This study provides the first quantitative evidence that human stem cell-derived islets are more resistant to hypoxia than primary human islets. Stem cell-derived islets maintain viability at substantially lower oxygen levels and exhibit markedly reduced variability in hypoxia tolerance. These findings identify hypoxia resistance as a key functional advantage of stem cell-derived islets, with important implications for transplantation into low-oxygen environments and for scalable islet fabrication strategies.

Background.: Pure laparoscopic and hand-assisted approaches are the predominant techniques for living donor nephrectomy, yet high-quality multicenter comparisons remain limited. Methods.: Using prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program Transplant pilot (from March 2017 to July 2020), we compared outcomes between pure laparoscopic and hand-assisted donor nephrectomy. Outcomes included operative duration, postoperative length of stay (LOS), and 30-d unplanned readmission. Mixed-effects linear, Poisson, and logistic regression models with hospital-level random intercepts quantified center variation and the independent association of surgical approach with outcomes. Results.: Among 1542 donors, 890 (57.7%) underwent pure laparoscopic and 652 (42.3%) hand-assisted nephrectomies. Donors were predominantly female (63%), mean age 43.4 y, and 61.8% were overweight or obese. Pure laparoscopic procedures had longer operative times (180 versus 150 min; P < 0.001). Median LOS was similar (2 d for both), although pure laparoscopy had more extended-stay cases ( P < 0.001). Readmission was rare and comparable (2.4% versus 2.9%; pure laparoscopic versus hand-assisted; P = 0.50). Center-level variation was substantial for operative duration (intraclass correlation coefficient = 0.51), and notable for LOS (median rate ratio [RR] = 1.25) and readmission (median odds ratio = 1.60). In unadjusted and adjusted models, pure laparoscopy was not associated with differences in operative duration relative to hand-assisted (β = 5.05 min; 95% confidence interval [CI], –4.56 to 14.66 and adjusted β = 5.59; 95% CI, –3.71 to 14.88), LOS (RR = 0.99; 95% CI, 0.87-1.13 and adjusted RR = 0.98; 95% CI, 0.86-1.12), or readmission (odds ratio = 0.63; 95% CI, 0.28-1.44). Conclusions.: In this national, multicenter analysis using prospectively collected data, pure laparoscopic and hand-assisted donor nephrectomy demonstrated similar perioperative outcomes and very low complication rates. Surgical approach did not independently influence operative duration or LOS. Readmission was rare. Substantial center-level variation suggests institutional practice patterns may play a larger role than technique selection.

BACKGROUND: Transplanting kidneys from donors with HIV to recipients with HIV has become standard clinical practice. However, donors with HIV may have higher prevalence of viral and bacterial infections and autoimmunity that could increase allograft rejection in recipients. METHODS: We included deceased kidney donors (60 with HIV and 41 without HIV) who participated in a multicenter prospective study of HIV kidney transplantation between April 2018 and September 2021. Using phage immunoprecipitation sequencing, we compared the human antibody repertoire (allergens, autoantibodies, viruses, and bacterial toxins) between donors with and without HIV and evaluated their association with recipient allograft rejection. Moderated t tests were used to assess reactivity and a multivariate logistic regression model adjusted for donor sex and kidney donor profile index assessed the association between donor adenovirus reactivity and recipient allograft rejection. RESULTS: Compared with donors without HIV, donors with HIV had lower BMI and were more likely to be African American. The median number of positive autoantibodies was marginally higher among donors with HIV (499 [IQR, 357, 579]) compared with that of donors without HIV (395 [IQR, 256, 538], P = 0.058). Donors with HIV additionally had significantly higher antibody reactivity to Epstein-Barr virus and cytomegalovirus ( q < 0.05). Among all donors with and without HIV, antibodies against adenovirus were significantly associated with increased rejection among recipients, including after adjusting for false discovery ( q < 0.05) and also adjusting for demographic factors using multivariable logistic regression (odds ratio = 4.97; 95% CI = 1.89–13.61). CONCLUSION: The presence of antibodies against adenovirus infection in kidney donors with HIV may be associated with allograft rejection. TRIAL REGISTRATION: ClinicalTrials.gov NCT03500315. FUNDING: US NIH.

Background.: Kidney transplant physicians believe that the cardiac status of kidney transplant recipients influences posttransplant outcomes. However, the Scientific Registry of Transplant Recipients (SRTR) does not include cardiac variables in its risk-adjustment model, raising the question of whether it fairly risk adjusts recipients. Methods.: This study conducted a retrospective analysis of the prospectively collected National Surgical Quality Improvement Program Transplant database to assess the impacts of pretransplant cardiac revascularization and left ventricular ejection fraction (LVEF) P = 0.001), delayed graft function (39.2% versus 28.3%, P < 0.001), myocardial infarction (4.4% versus 0.8%, P < 0.001), longer length of stay (6.57 versus 5.54 d, P = 0.001), and more readmissions (32.9% versus 23.1%, P < 0.001). In univariable analysis, previous revascularization was associated with death (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.11-5.1; P = 0.03) but not graft loss (HR, 1.3; 95% CI, 0.54-3.1; P = 0.55). LVEF P = 0.011). After adjusting for SRTR variables (age, diabetes, peripheral vascular disease), previous revascularization was not independently associated with death (HR, 1.33; 95% CI, 0.57-3.1; P = 0.50). Conclusions.: Previous cardiac revascularization is associated with patient survival and complications, more than LVEF <55%. However, we show that existing variables of the SRTR risk model largely capture the impact of previous cardiac revascularization on patient survival.

Purpose of review: We provide a review on the incidence, consequences, and management of obesity in patients before and after pancreas transplant. Recent findings: Obesity is common in patients with both type 1 and type 2 diabetes. Obesity at the time of pancreas transplant is associated with worse graft and patient survival, while weight gain after transplant is associated with insulin resistance and posttransplant diabetes. Currently, lifestyle interventions are the backbone of obesity management and can improve insulin sensitivity, but result in only modest weight loss. Metabolic and bariatric surgery (MBS) offers the potential for substantial and durable weight loss. Laparoscopic sleeve gastrectomy is the procedure of choice and can be performed safely both before and after pancreas transplant. Antiobesity medications (AOMs) may also be effective, but concerns remain regarding determine the safety and efficacy when used in pancreas transplant recipients. More evidence is needed to guide the use of AOMs and MBS in pancreas transplant recipients. Summary: Lifestyle interventions, MBS, and AOMs each have a role in managing obesity after pancreas transplantation. In light of limited evidence and unique challenges in pancreas transplant patients, obesity management in pancreas transplant patients requires an individualized approach that leverages multidisciplinary expertise.