The shortage of transplantable organs remains one of the most significant unmet challenges in modern medicine. Despite advances in donor management, organ preservation, surgical techniques, and immunosuppression, organ demand continues to exceed supply worldwide. Xenotransplantation using genetically engineered porcine organs has emerged as a promising strategy to address this gap. Recent clinical pig-to-human heart and kidney transplantations have demonstrated the feasibility of clinical xenotransplantation and shifted attention from immunological barriers toward practical implementation. This review examines the logistical requirements for clinical xenotransplantation, with particular emphasis on donor herd management, biosafety, organ preservation technologies, and future distribution networks. The integration of donor production with advanced machine perfusion technologies may ultimately transform transplantation medicine from a donor-dependent emergency service into a predictable and scalable therapeutic platform.

Identification of sex differences in mortality may prompt sex-specific management strategies. Males worldwide have higher mortality than females; therefore, we compared sex differences in excess mortality. We compared excess mortality in female versus male first liver transplant recipients, accounting for modifying effects of donor sex and recipient current age using relative survival models. Models were fitted separately in Scientific Registry of Transplant Recipients and CTS cohorts (1988-2019) and subsequently combined using two-stage individual patient data meta-analysis. We analyzed 218,429 patients. Within the first 3 months post-transplant, female recipients ≥25 years showed significantly higher excess mortality regardless of donor sex and female recipients 13-24 years had significantly higher excess mortality when the donor was male. Subsequent to the first 3 months, female recipients 0-12 years had significantly lower excess mortality regardless of donor sex; female recipients ≥25 years had lower excess mortality, though only significantly among those 25-44 years with a female donor. Females ≥25 years showed higher excess mortality than males in the immediate post-transplant period but, among those who survived, the first 3 months, excess mortality was similar by sex or lower in females than males. After the first 3 months post-transplant, female recipients 0-12 years showed lower excess mortality.

Urinary CXCL10 chemokine levels correlate with inflammatory processes in the reno-urinary tract after kidney transplantation. The aim of this study was to investigate the diagnostic characteristics of urinary CXCL10/creatinine ratio to detect major inflammatory processes (i.e., subclinical rejection, relevant JC/BK polyomavirus DNAuria, or significant leukocyturia) in 405 stable renal allograft recipients with surveillance biopsies at 1 year posttransplant. Urinary CXCL10/creatinine had a significantly higher area under the curve (AUC) than serum creatinine or proteinuria (0.786 vs. 0.499 vs. 0.636; both p < 0.0001) for detection of inflammatory processes. The highest AUC was observed for the detection of BK polyomavirus DNAuria (0.936), but it was lower for detection of subclinical rejection (0.703). At an arbitrary rule-out cutoff (CXCL10/creatinine <3 ng/mmol; 59% of all patients; negative likelihood ratio 0.36), 51% of surveillance biopsies could be safely deferred, and the risk of subclinical rejection decreased from 15.8% to 5.4%. At an arbitrary rule-in cutoff (CXCL10/creatinine >10 ng/mmol; 12% of all patients; positive likelihood ratio 12.92), absence of any inflammatory pathologies was only 2%. These data support urinary CXCL10/creatinine measurements at 1-year posttransplant in stable allografts to detect inflammatory processes and guide further diagnostics. The preliminary cutoffs require external validation.

Extended criteria donor lungs falling below the arbitrarily set PaO2/FiO2 (PFR) threshold of 300 are frequently declined despite other acceptable parameters. This two-center retrospective analysis investigates whether donor PFR is a risk factor for outcomes after lung transplantation (LuTx). A retrospective cohort analysis was conducted at University Hospitals Leuven, Belgium and Motol University Hospital, Prague, Czech Republic including adult LuTx recipients from 2010 to 2022 (Leuven) and 2018-3/2023 (Prague). Primary endpoints: primary graft dysfunction (PGD) grade 3 at 24 and 72 h and 2-year overall survival. Secondary endpoints: incidence of ACR and CLAD-free survival. Donor PFR was measured from an arterial blood gas sample. Logistic and Cox regression analyses were employed to assess correlations, while survival was analyzed using Kaplan-Meier estimates. A total of 984 LuTx recipients were included. Median follow-up was 4 years. Recipients were predominantly male (54%), with chronic obstructive pulmonary disease being the most common indication for transplantation. Donor characteristics included median age of 51 years, and 18% of donors were DCD. Analyses identified lower donor PFR as a risk factor for PGD grade 3 at 24 h, but not at 72 h. PFR was not associated with the incidence of ACR or with 2-year overall survival after LuTx. Donor PFR does not appear to be a risk factor for development of late PGD or for adversely impacting outcomes. However, it is associated with increased risk of early PGD.

Intestinal transplantation (ITx) is a life-saving procedure for patients with complicated intestinal failure. In the acute phase, allograft permeability increases primarily due to ischemia-reperfusion injury. However, long-term allograft physiology after transplantation remains poorly understood, particularly the impact of lost autonomous graft innervation. This study aims to evaluate post-ITx allograft motility and permeability using orally administered fluorescein-labeled dextrans (TRITC70,FITC4). Lewis-to-Lewis orthotopic ITx (n = 6, 260-300 g) were performed. Intestinal permability and motility were evaluated in recipient at baseline (2 days pre-transplant, control) and 4 weeks post-transplant (experimental), using orally administered dextrans (TRITC70 and FITC4). Total GI motility was assessed by TRITC70 fecal excretion, while intestinal and colonic permeability were evaluated using TRITC70 (transcellular route) and FITC4 (paracellular route) plasma concentrations, measured at 3 h, 6 h, 24 h. Paired data were reported as mean (±SEM) and compared using paired t-test (normal distribution)/Wilcoxon rank test (non-normal distribution). Fecal excretion of TRITC70 was 9.58 (±0.85) hours in the control group and 11.02 (±1.40) hours in the experimental group (p = 0.287). Plasma concentrations (µg/mL) of FITC4 at 3 h, 6h, and 24 h were (control vs. experimental): 0.23 (±0.08) vs. 0.72 (±0.23) (p = 0.041), 0.12 (±0.06) vs. 0.53 (±0.16) (p = 0.031), and 0.04 (±0.02) vs. 0.12 (±0.04) (p = 0.625). For TRITC70, plasma concentrations were 11.20 (±1.81) vs. 11.11 (±1.39) (p = 0.975), 20.49 (±8.87) vs. 12.60 (±1.87) (p = 0.562), and 20.82 (±7.25) vs. 5.02 (±0.82) (p = 0.094). Finally, the AUC (µgh/mL) of FITC4 and TRITC70 absorption were 2.39 (±1.1) vs. 8.84 (±2.69) (p = 0.029) and 436 (±159) vs. 197 (±25) (p = 0.195), respectively. Four weeks after ITx, we observed an increased paracellular permeability compared to pre-transplant evaluation, while overall GI motility remained unchanged. Further research is needed to better understand intestinal graft physiology.

Liver grafts from donors after brain death (DBD) and donors after circulatory death (DCD) are exposed to distinct mechanisms of injury. We evaluated the feasibility of multi-compartment profiling of liver injury-associated microRNAs (miRNAs) across serum, liver tissue, and preservation fluid in deceased donor liver grafts and explored compartment-specific expression patterns according to donor type. In this prospective single-centre exploratory study, miR-122, miR-148a, miR-22, miR-222, and miR-155 were quantified by RT-qPCR in serum, liver tissue, and preservation fluid from 10 DBD and 10 DCD donors, including paired serum sampling before and during abdominal normothermic regional perfusion (aNRP). Three declined steatotic DBD grafts were analysed descriptively. A total of 79 samples were analysed. Baseline serum miRNA profiles and post-transplant outcomes were comparable between DBD and DCD grafts. Distinct compartment-specific expression patterns were observed, particularly in preservation fluid, where DCD grafts recovered following aNRP showed lower expression of miR-148a, miR-222, and miR-22 than DBD grafts. In DCD donors, serum during aNRP showed lower miR-148a expression. Exploratory descriptive analyses of declined steatotic grafts identified miRNA patterns consistent with hepatocellular injury. These findings demonstrate the feasibility of multi-compartment donor-derived miRNA profiling and provide a framework for future studies evaluating compartment-specific molecular markers for graft assessment.

Endomyocardial biopsy (EMB) is the gold standard for diagnosing post-heart transplant acute rejection (AR) but is invasive. Donor-derived cell-free DNA (dd-cfDNA) is a promising noninvasive biomarker, yet thresholds for Asian recipients remain undefined. This prospective study enrolled 80 patients, with 299 dd-cfDNA specimens analyzed via a novel Chinese-developed next-generation sequencing assay targeting 48 Indel sites. A reference cohort (n = 42) established post-transplant dd-cfDNA kinetics, while a biopsy cohort (n = 41, 18 acute cellular rejection [ACR], 9 antibody-mediated rejection [AMR], 14 no rejection [NR]) paired with EMB evaluated diagnostic performance. dd-cfDNA peaked at week 1, with a stable trend emerging from week 4 and stable levels reached by week 8. AR patients had significantly higher dd-cfDNA levels than NR patients (0.87% vs. 0.23%, P < 0.001). The optimal composite AR threshold was 0.33% (AUC = 0.874, sensitivity 81.0%, specificity 85.7%). dd-cfDNA decreased post-therapy (P = 0.011) and showed an inverse association with left ventricular ejection fraction (LVEF) (P = 0.004). This study provides initial evidence for an assay- and cohort-specific dd-cfDNA threshold (0.33%) for AR detection in Chinese recipients. Given the modest NPV (75.0%), this threshold is better suited for a "rule-in" strategy, and low values should not be used in isolation to defer biopsy. External validation in multicenter cohorts is required before routine clinical implementation.

Solid organ transplantation has achieved remarkable improvements in graft and patient survival, making traditional biomedical outcomes alone insufficient to fully define transplant success. Thus, attention is growing directed toward patient-reported outcomes, quality of life, psychological wellbeing, treatment burden, social reintegration, and the broader lived experience of transplant recipients. These dimensions are often subjective and context-dependent making them difficult to capture through quantitative methods alone. Qualitative research offers a complementary approach by exploring how patients, caregivers, donor families, and healthcare professionals perceive and give meaning to transplantation. In transplant medicine, qualitative methods may represent a relevant resource. Despite its potential, qualitative research remains underrepresented in leading transplantation journals and is often limited by misconceptions regarding rigor, lack of methodological training, and lacking editorial know-how. Integrating qualitative, quantitative, and mixed-methods approaches may help generate more comprehensive evidence. A new research agenda in transplantation should therefore move beyond graft survival to include lived experience as a central component of patient-centered care.

Living kidney donation requires rigorous medical, psychosocial, and ethical evaluation to safeguard donor welfare, ensure valid informed consent, and prevent wrongful exploitation. In Singapore, the Human Organ Transplant Act mandates review by a transplant ethics committee (TEC) for all living-donor transplants. However, ethical judgment is not reducible to TEC approval or procedural compliance; transplant programs themselves carry a broader responsibility to evaluate relational dynamics that may affect voluntariness and authenticity of consent. This paper examines three cases involving concealed marital infidelity history in either kidney donor or recipient candidates or ongoing extramarital relationships in potential kidney donors and recipients that raised ethical concerns. Key issues include the materiality of information for informed consent, risks of psychosocial harm, integrity of caregiving arrangements, and potential institutional complicity in ongoing deception. While personal moral discomfort alone does not justify rejection, undisclosed relational complexities may warrant conditional deferral to protect donor welfare, program credibility, and public trust. In certain contexts, proceeding without disclosure may be ethically permissible when consent remains autonomous, donor privacy is respected, and anticipated harm is minimal. Transplant programs must balance substantial clinical benefit with ethical stewardship to preserve public confidence and the moral credibility of living donation.