Living kidney donation prior to euthanasia has never previously been reported and is not incorporated into current clinical guidelines. This study aims to discuss the unique medical, procedural, psychological and ethical considerations of living donation prior to euthanasia based on 3 Dutch cases. Of the 3 candidates, 2 successfully donated without detrimental effects to physical or mental health; one was declined for medical reasons. In two cases, euthanasia has been performed; in one case donation was transformative and the request for euthanasia was withdrawn after donation. Medically, normal life-expectancy after donor nephrectomy should be presumed as euthanasia remains uncertain. Procedurally, timing can create tension between these two processes as postponing euthanasia could be harmful. Psychologically, potential exacerbation in psychopathology should be weighed against the impact of being declined for donation. Ethically, autonomy, capacity to consent and risk-benefit ratio must be rigorously assessed, especially given the degree of suffering in these cases. We conclude that living donation and euthanasia should be seen as independent processes and a euthanasia request should not be considered an absolute contra-indication for living donation. Our initial experiences underscore the need for international dialogue and policy development.

Published Donor Risk Indices are often used to estimate the risk associated with transplanting a donor liver. Such indices have been constructed by considering only livers that are transplanted and estimating the risk of graft loss or patient death. Until now, there has been no index available that reflects the chance of an offered organ not being transplanted in the United Kingdom (UK). This paper presents a UK Donor Utilisation Index (UKDUI) which quantifies the impact of donor factors upon liver non-use. By comparing our developed UKDUI with a commonly used UK Donor Risk Index, we are able to see that there are differences between the factors that influence liver non-use and the factors that influence liver post-transplant outcomes. Importantly, this UKDUI can be used in future studies to characterise and identify offered livers that are either more or less likely to be transplanted. For example, the UKDUI can be used for study inclusion criteria or for risk adjustment/stratification.

Allograft nephrectomy (AN) is a serious complication of kidney transplantation. Beyond surgical morbidity, AN has important immunological implications. We performed a systematic review to synthesize current evidence on the immunological impact of AN and post-allograft failure immunosuppressive strategies. A systematic review was conducted according to PRISMA guidelines. PubMed/Medline® was searched for studies published from 01/2000 to 03/2026 on transplantectomy indications and surgical techniques. Eligible designs included meta-analyses, randomized trials, and prospective or retrospective studies evaluating the immunological impact of AN and/or immunosuppression management before, during, or after graft removal in adult or pediatric kidney transplant recipients returning to dialysis. Consistent evidence indicates that immunosuppression withdrawal is the principal driver of allosensitization after graft failure. Multiple studies demonstrated marked increases in anti-HLA antibodies following the cessation of immunosuppression, regardless of nephrectomy status. When AN was performed under maintained immunosuppression, its independent effect on sensitization and retransplant outcomes appeared limited. Meta-analyses showed comparable survival after retransplantation, although higher PRA levels, delayed graft function, and acute rejection were more frequent in patients with prior nephrectomy. Allosensitization after graft failure is primarily driven by immunosuppression withdrawal/reduction rather than AN itself. Individualized immunosuppressive management balancing immunological and infectious risks is essential.

Perfusion technologies preserve and/or improve organ viability by restoring circulation to donor organs either outside the body (machine perfusion, MP) or inside the body of the deceased donor (normothermic regional perfusion, NRP). Ethical debates surrounding perfusion raise questions about its acceptability for transplant recipients. This study explores patient perspectives on perfusion techniques and preferences regarding informed consent. Five online focus groups were conducted with 32 kidney, liver, and heart patients, both pre- and post-transplant. Sessions were analyzed using qualitative content analysis in Atlas.ti. Participants were generally accepting of MP and NRP, valuing clinical benefits. However, they were more hesitant toward NRP due to ethical concerns about post-mortem use of the donor's body and potential emotional impacts on donor families. Drivers of acceptance were patients' medical urgency and certainty that donor and donor family were respected. Most participants wanted to receive detailed information about perfusion techniques. While patients were broadly accepting of perfusion techniques, NRP raised more concerns than MP. To ensure ethical implementation and social acceptability as these technologies evolve, patient perspectives should be embedded into perfusion guidelines, informed consent processes, and policy development.

[This corrects the article DOI: 10.3389/ti.2026.16689.].

Size matching is an important concern during lung allocation for lung transplantation (LTx). Although some mismatch is accepted-often favoring larger grafts for patients with chronic obstructive pulmonary disease (COPD)-the optimal strategy remains unclear. This study evaluated the impact of graft size mismatch on postoperative outcomes in COPD. We retrospectively reviewed 130 of 491 patients who underwent LTx at a single center between January 2013 and December 2023. Patients were classified into three groups based on donor-to-recipient predicted total lung capacity ratio: undersized (<0.9), size-matched (0.9-1.1), and oversized (≥1.1). Donor and recipient characteristics were collected. Primary graft dysfunction (PGD) was the primary endpoint; overall survival was secondary. Of the 130 patients, 17 (13%) received undersized grafts, 67 (52%) size-matched grafts, and 46 (35%) oversized grafts. The undersized group had a lower incidence of PGD at 48 and 72 h than other groups (p < 0.01 and p = 0.02). Grade 3 PGD at 72 h was less frequent among groups (p = 0.03). Overall survival was higher in the undersized group (p = 0.018 and p = 0.045). Oversized grafts may not be optimal for LTx in COPD. Undersized grafts appear to be a viable strategy.

Living donor kidney transplantation (LDKT) offers superior outcomes for most patients with end-stage kidney disease (ESKD), yet its uptake across Europe remains highly variable. This proceedings article summarizes key themes from a pan-European symposium held in November 2025 in Prague, organized by the European Kidney Transplant Association (EKITA) in collaboration with the DESCaRTES Working Group. Discussions highlighted substantial heterogeneity in LDKT activity across Europe, driven by differences in healthcare capacity, legal frameworks, donor evaluation practices, and access to kidney exchange programmes. Marked inequities persist between regions, particularly in the Balkans and Western Balkans, for women those who are socioeconomically disadvantaged, ethnic minority populations, paediatric and elderly patients and individuals with obesity. The symposium identified wide variation in donor selection criteria, risk assessment, informed consent practices, and long-term donor follow-up, despite existing international guidelines. Emerging strategies to address these challenges include harmonisation of donor evaluation and consent, expansion of paired and cross-border kidney exchange programmes, increased use of unspecified kidney donation, and adoption of innovative surgical and immunological approaches to safely broaden donor eligibility. Advances in outcome measurement, including validated surrogate endpoints, machine learning methods, and integrated, harmonised transplant registries, were discussed as critical tools to improve quality, transparency, and research efficiency. Collectively, the proceedings underscore the need for coordinated clinical, policy, and data-driven solutions to reduce inequities and unlock the full potential of LDKT across Europe, with implications for international transplant practice.

The sustainability of transplantation surgery (TS) relies on the ability to attract and retain the next generation of surgeons. This study aims to assess how surgical residents perceive TS as a career pathway in Germany, and to identify barriers in choosing TS as a career. An anonymous 30-item online survey was distributed to surgical residents at all transplant centers registered with the Deutsche Stiftung Organtransplantation (DSO, German Organ Procurement Organization). Quantitative data were analyzed using SPSS (version 29), free-text responses underwent thematic content analysis. Sixty-eight complete surveys were analyzed. TS was considered by 25% of respondents as a subspecialty training. Transplant-specific education was occasional or absent, though desired by >80%. Motivators included personal interest, patient care, and career development, while barriers were structural: lack of defined fellowship programs and limited autonomy during residency. Structured fellowship programs (46%), mentorship (27%) and enhanced operative autonomy (25%) were identified as key factors to encourage recruitment of surgeons in their early career stages. Surgical residents in their early career stages in Germany regard TS as an appealing career option. A structured training framework is a perceived unmet need to enhance recruitment to TS. Transplantation surgery, workforce sustainability, medical education.

Paediatric controlled donation after circulatory determination of death (pcDCDD) is a well described pathway for deceased organ donation, but there has been wide variability in global uptake. There are substantial and differing barriers to pcDCDD across countries, including clinical, legal, and ethical issues. This process utilized a Delphi consensus methodology involving 30 international experts to develop recommendations to guide the development and operation of pcDCDD programs. Two survey rounds evaluated agreement on system requirements, donor identification, medical suitability, communication, end-of-life care, and ante-mortem interventions. Consensus recommendations emphasized the need for robust administrative and legal frameworks that explicitly support pcDCDD, multidisciplinary approaches for donor suitability assessment, and normalization of integrating donation into paediatric end-of-life care. The particularities of obtaining consent for both donation and antemortem interventions necessary for pcDCDD for patients that have never expressed a valid intent to donate were addressed. While our findings demonstrated international variability, strong consensus was obtained for multiple recommendations, suggesting the possibility of developing pcDCDD in varied international settings. The process also highlighted areas of knowledge gaps along the pcDCDD process that would benefit from sustained research.

Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after heart transplantation (HTx). We retrospectively analyzed 830 consecutive HTx performed between 1984 and 2021. After excluding patients <18 years and those with missing data, 667 adult recipients remained. ISHLT PGD criteria were applied and perioperative variables and outcomes were reviewed. PGD occurred in 70 patients (10.5%), including 41 (6.1%) with left ventricular PGD and 29 (4.3%) with right ventricular PGD. Most LV-PGD cases were severe (88%). Patients with PGD were younger and more frequently had pretransplant dialysis, ventricular assist device support, or prior cardiac surgery. No donor-related factors were associated with PGD. Recipient-related factors and longer cardiopulmonary bypass time were associated with increased risk. PGD was associated with prolonged mechanical ventilation and ICU stay, and increased need for mechanical circulatory support, dialysis, reoperation, and treatment for sepsis. Mortality or re-transplantation was significantly higher in PGD patients at 30 days (45% vs. 3%) and 1 year (51% vs. 8%; HR 6.89, 95% CI 4.01-11.83, p < 0.0001).

Recurrent primary sclerosing cholangitis (rPSC) remains a significant challenge. Although Klebsiella pneumoniae (Kp) has been implicated in PSC pathogenesis, its association with rPSC remains unclear. We retrospectively analyzed 62 patients who underwent LT for PSC at our institution between 1996 and July 2024 and survived for more than 1 year. We assessed the association between Kp detection in postoperative clinical cultures and rPSC. rPSC was observed in 22 of 62 patients (35.5%). Kp was detected more frequently in the rPSC group than in the non-rPSC group (31.8% vs. 7.5%). In multivariate Cox regression analysis, Kp detection in clinical cultures (Hazard ratio: 3.83, 95% confidence interval: 1.44-10.21, p = 0.007) and identification of three or more bacterial species in clinical cultures (Hazard ratio: 0.31, 95% confidence interval: 0.12-0.78, p = 0.01) were indpendently associated with rPSC. Recurrence-free survival was significantly shorter in patients with Kp detection (10-year recurrence-free survival: 28% with Kp vs. 56.7% without Kp, p = 0.03). These findings suggest a potential association between postoperative Kp detection and rPSC.