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This issue runs from where organs come from to how recipients are kept safe on immunosuppression. On donor utilisation, a Transplantation Society ethics statement sets out safeguards for organ donation after medical assistance in dying, while a single-centre series asks how far the paediatric-donor pool can be stretched by using small single kidneys rather than en bloc grafts. A perioperative thread tests whether the choice of intraoperative crystalloid changes delayed graft function. Two papers address long-term graft survival and the immunological management around it — a network meta-analysis of prophylaxis for recurrent focal segmental glomerulosclerosis, and a systematic review of when allograft nephrectomy is justified after graft failure. Infection dominates the recipient-safety strand: a multicentre cohort shows it is the leading attributed cause of death with a functioning graft in older recipients, and a UK single-centre study weighs systematic against targeted latent-tuberculosis screening before listing. The issue closes on pharmacology, quantifying how calcineurin inhibitors push direct oral anticoagulant exposure above target. Together the papers map a field trying to widen the donor pool while sharpening the routine, unglamorous decisions — fluids, screening, drug interactions — that determine whether those grafts last.
1. Ethical Implementation of Organ Donation Following Medical Assistance in Dying: Recommendations of the Ethics Committee of the Transplantation Society.
Van Assche K, Mulder J, Ahn C, Allen RDM, Bollen J, Bramstedt KA, Burra P, Cras P, Dhital K, Dittmer I, Domínguez-Gil B, Downar J, Fadhil RAS, Ferdinande P, Forsythe JLR, Fortin MC, Freeman MA, Gerritsen RT, Grayson KE, Healey A, Kazemi A, Kute VB, Martin DE, Monbaliu D, Muller E, Nino-Murcia A, Olthuis G, Opdam HI, Parent B, Pérez Blanco A, Shemie SD, Siebelink M, Silva A, Silva E Silva V, Sonneveld HP, Stock PG, Ten Hoopen R, Thiessen C, van Mook W, Van Raemdonck D, Wall AE, Weiss MJ, Woodyatt L, Ysebaert D, Thomson D. Transplantation, 2026. PMID: 42418265.
This consensus statement, developed under the auspices of the Ethics Committee of The Transplantation Society, sets out how organ donation following medical assistance in dying (MAiD) can be implemented without eroding trust in either practice. Rather than reporting new patient data, the authors — a multidisciplinary group of medical, ethical, and legal experts — analysed the guidelines and protocols of the six jurisdictions where donation after MAiD is currently performed: Australia, Belgium, Canada, the Netherlands, New Zealand, and Spain. From that comparison they distilled three domains of ethical concern. The first is safeguarding the integrity of the patient’s decision, covering voluntariness, informed consent, and how and when donation is raised so that it does not influence the choice to pursue MAiD. The second is the governance of the donation itself, including adherence to the Dead Donor Rule, rigorous death determination, and consent for premortem interventions. The third addresses the effects on care relationships and professional practice, from end-of-life impact and donor anonymity to conscientious objection. Headline recommendations include clear and consistent national policies, a patient-centred and non-directive approach, rigorous eligibility and voluntariness assessment, and strict separation between the MAiD and the donation/transplantation teams. As a normative document it offers guidance rather than evidence of outcomes, and its recommendations are inevitably shaped by the six-country experience it draws on. For UK practice, where assisted-dying legislation is under active parliamentary debate, this provides a ready-made ethical scaffold should donation after MAiD ever become relevant, and a reminder that the firewall between the two teams is the central safeguard.
2. Outcomes of Single Pediatric Kidney Grafts: An Experienced Single-center Retrospective Study.
Sur PJ, Dawany N, Kelly YM, Cerise AC, Matsuoka L, Alexopoulos SP, Sageshima J, Perez RV, Goussous N. Transplant Direct, 2026. PMID: 42404282.
This single-centre retrospective review examined whether kidneys from small paediatric donors can be safely used as single grafts, a source that remains underutilised because of uncertainty over when to split en bloc pairs. The authors reviewed all deceased-donor transplants using single kidneys from paediatric donors weighing 20 kg or less performed between 2005 and 2023, comparing recipients by donor weight below 15 kg versus 15 kg or above. Seventy-two recipients were identified (50% male, median age 48.3 years at transplant), with donor weights ranging from 7 to 20 kg — 24 grafts from donors under 15 kg and 48 from donors of 15 kg or more. Kidneys measured 6 to 9 cm, and those from the smallest donors were significantly shorter (median 7 versus 7.5 cm; P=0.05). The under-15 kg grafts came from donors with a higher Kidney Donor Profile Index (60 versus 50; P=0.002) and were far more often placed on hypothermic machine perfusion (96% versus 63%; P=0.002). Critically, primary non-function was confined to the smallest-donor group (12.5% versus 0.0%; P=0.03), while the only thrombotic graft loss occurred in the larger-donor group; overall five-year graft survival approached 91% with no significant difference between weight strata. The authors conclude that single paediatric grafts, particularly from donors above 15 kg, deliver excellent long-term outcomes, whereas those below 15 kg warrant particular caution over donor quality and cold ischaemia time. As a single-centre series of modest size, it cannot fully adjust for selection in how these marginal kidneys were allocated. For UK practice, where the paediatric-donor pool is scarce and en bloc versus single-graft decisions are made case by case, it supports greater confidence in using single kidneys from donors above 15 kg to expand transplant capacity.
3. Ringer Lactate Versus Hybrid Isotonic/Hypotonic Saline in Delayed Graft Function in Deceased-donor Kidney Transplantation: A Real-world Protocol Change Study.
Manfro AG, Bertuol Junior VC, da Silva Alves FC, Bauer AC. Transplant Direct, 2026. PMID: 42404287.
This retrospective, single-centre, quasi-experimental study asked whether switching perioperative crystalloid strategy reduces delayed graft function (DGF) after deceased-donor kidney transplantation, exploiting a protocol change to create two comparison groups. The unit moved from a hybrid regimen — intraoperative 0.9% saline followed by postoperative hypotonic 0.45% saline — to a strategy of intraoperative and postoperative Ringer’s lactate, and DGF was the primary outcome. A total of 257 recipients were analysed (142 Ringer lactate, 115 hybrid isotonic/hypotonic saline), with comparable baseline characteristics. DGF incidence was essentially identical between arms (47.9% with Ringer lactate versus 52.2% with hybrid saline; P=0.49), as were days to graft recovery (5.7 versus 5.7; P=0.96) and DGF duration (10.5 versus 10.2 days; P=0.78). Twelve-month mortality, graft loss, and biopsy-proven rejection did not differ, and covariate-adjusted longitudinal modelling showed no separation in estimated glomerular filtration rate between groups, with only modest differences in electrolyte trajectories. The authors conclude that Ringer lactate conferred no advantage over a hybrid isotonic/hypotonic saline strategy for DGF or early graft function. As a single-centre before-and-after design, it is vulnerable to secular changes in practice over the study period and lacks the power of a randomised comparison. For UK practice it tempers the expectation — extrapolated largely from Plasma-Lyte data — that any balanced or low-chloride fluid will lower DGF, and reinforces that the specific chloride question deserves a dedicated randomised trial rather than a protocol switch.
4. Prophylactic interventions for focal segmental glomerulosclerosis recurrence after kidney transplantation: a systematic review and network meta-analysis.
Paraskevas T, Kanta A, Perdiki P, Papachristou E, Papasotiriou M. Clin Transplant Res, 2026. PMID: 42421428.
This systematic review and network meta-analysis addressed one of the most feared complications in transplant nephrology: recurrence of primary focal segmental glomerulosclerosis (FSGS), a frequent cause of premature allograft failure for which no standard prophylaxis exists. The authors searched PubMed and Embase through July 2025 for randomised and non-randomised studies of any intervention given before FSGS recurrence — either pre-transplant or shortly after — in patients with primary FSGS, with post-transplant recurrence as the primary outcome and proteinuria, time to recurrence, and adverse events as secondary endpoints. Twenty-five unique studies evaluating six distinct interventions were included. None of the prophylactic strategies significantly reduced recurrence compared with control. The combination of rituximab and plasma exchange produced lower effect estimates than either component alone, but the difference did not reach statistical significance, and evidence for belatacept and bleselumab rested on single studies that the authors flagged as hypothesis-generating rather than confirmatory. Adverse events were only infrequently reported across the included studies, limiting any safety comparison. The authors conclude that current evidence supports no definitive prophylactic regimen and that adequately powered randomised trials, with standardised recurrence definitions and prophylaxis timing, are needed. The reliance on heterogeneous, largely non-randomised data and inconsistent outcome definitions is the principal limitation. For UK practice, it argues against committing to any routine pre-emptive protocol — including empirical rituximab and plasma exchange — outside a trial or an individualised high-risk decision, while keeping the combination as the most promising candidate to test.
5. When and why to perform allograft nephrectomy? A systematic review from the AFU-SFT collaboration.
Frontczak A, Del Bello A, Kassab D, Prudhomme T, Goujon A, Culty T. Transplant Rev (Orlando), 2026. PMID: 42418985.
This PRISMA-compliant systematic review, from a French urology and transplantation collaboration, tackled the persistently unsettled question of when to remove a failed kidney allograft. The authors searched the literature published between January 2000 and March 2024 for studies addressing the indications, timing, complications, and downstream consequences of allograft nephrectomy (AN), including 39 studies. Reported prevalence varied widely but was under 10% in most contemporary cohorts and had fallen since the cyclosporine era. The indications separated by timing: early nephrectomy was driven mainly by primary non-function, severe acute rejection, and surgical or vascular complications, whereas late transplantectomy more often followed graft intolerance syndrome, refractory hypertension, or chronic infection. The procedure was not benign, carrying overall morbidity of roughly 18% and mortality of about 4%, with the highest risk in emergency settings. Importantly, AN was not associated with improved recipient or graft survival after retransplantation, and may instead increase HLA sensitisation and early graft-related events in the subsequent transplant. The authors noted that nephrectomy appeared more frequent in children than adults, though the paediatric evidence was sparse. As a synthesis of heterogeneous, mostly retrospective cohorts with inconsistent definitions, it can describe associations but not establish causal effects of removal. For UK practice, it reinforces AN as an indication-driven operation — reserved for symptomatic or septic failed grafts — rather than a routine step before relisting, and flags the sensitisation cost that must be weighed against any benefit when a retransplant is planned.
6. Renal transplantation in older recipients - results of the DZIF transplant cohort.
Sommerer C, Schröter I, Schindler D, Schork A, Renders L, Kemmner S, Willerding JM, Tönshoff B, Zeier M, Giese T, et al. BMC Geriatr, 2026. PMID: 42410372.
This multicentre German cohort characterised outcomes, and particularly infection burden, in older kidney transplant recipients — a group expanding across Europe but under-represented in detailed longitudinal data. The investigators followed 355 recipients aged 65 to 80 years (67.6% male) for a median of 3.8 years, deriving cumulative incidences of infection, graft loss, and death and identifying independent risk factors by Cox regression. Delayed graft function occurred in 23.9%, and one year after transplantation median serum creatinine was 1.72 mg/dL (IQR 1.40–2.45) with an eGFR of 38.7 mL/min (IQR 26.2–51.3). Patient survival was reassuring — all-cause mortality was 3.2% at one year and 11.8% at five years — but infection was pervasive, with a cumulative first-infection incidence of 67.6% at one year rising to 81.9% at five years; bacterial infections predominated, viral infections persisted throughout, and fungal infections clustered early. Death with a functioning graft was the dominant mode of graft loss (35 of 48 events), and infection was the leading attributed cause of that death (51.4%). In multivariable analysis a prolonged initial hospital stay was consistently linked to infectious outcomes and subsequent death with a functioning graft, delayed graft function independently raised that hazard (HR 2.54, 95% CI 1.29–5.00), and fungal infection carried a particularly high subsequent hazard (HR 2.67, 95% CI 1.23–5.77). Notably, outcomes were broadly similar between men and women and between recipients aged 65–69 and 70 or older. As an observational cohort it cannot separate immunosuppression intensity from frailty and comorbidity. For UK practice it supports transplanting carefully selected recipients well into their seventies, while making the case that infection prevention — not rejection — is where the survival gains in this group will be won.
7. The Impact of Systematic Latent Tuberculosis Infection Screening in Kidney Transplant Candidates: Experience From a Single UK Transplant Center.
Segamwenge IL, Anijeet H, Rao A, Hammad A, Howse M. Transpl Infect Dis, 2026. PMID: 42423560.
This single-centre retrospective study, from the Royal Liverpool University Hospital, tested whether the UK’s targeted approach to latent tuberculosis infection (LTBI) screening in transplant candidates misses cases that systematic testing would catch — a live tension between UK guidance, which recommends risk-factor-based screening, and international guidelines favouring universal testing. Adult kidney transplant candidates assessed between July 2021 and December 2024 underwent systematic interferon-gamma release assay (IGRA) testing, and the authors compared this against a hypothetical targeted strategy restricted to high-risk candidates using risk ratios, numbers needed to screen, and diagnostic performance. Of 527 candidates assessed, 465 had definitive IGRA results, comprising 27 LTBI-positive and 438 LTBI-negative individuals, giving an LTBI prevalence of 5.8% (95% CI 3.9%–8.3%). Among the 96 candidates classified as high-risk, 17 (17.7%) were positive — but a targeted strategy would have missed 10 cases (37.0%; 95% CI 19.4%–57.6%) sitting in the low-risk group, yielding a sensitivity of only 63.0%. On multivariable analysis, LTBI positivity was associated with birth outside the UK, older age, and an abnormal chest radiograph, and all 22 candidates who were treated completed therapy without hepatotoxicity or subsequent active tuberculosis. The single-centre, low-prevalence design and the hypothetical nature of the targeted comparator limit generalisability. For UK practice, it provides direct domestic evidence that risk-stratified screening lets a substantial minority of LTBI cases through, and makes a concrete case for considering routine pre-transplant IGRA testing in comparable UK units.
8. Direct oral anticoagulant use and drug-drug interactions in transplant recipients receiving calcineurin inhibitors.
Verstraete A, Dreesen E, Van Thillo Q, Erard M, Kuypers DRJ, Jacquemin M, Rega F, Van Cleemput J, Verbeek J, Vos R, Verhamme P, Van der Linden L, Vanassche T. J Thromb Haemost, 2026. PMID: 42413824.
This retrospective single-centre study quantified how calcineurin inhibitors affect direct oral anticoagulant (DOAC) exposure in transplant recipients, a common co-prescription whose clinical relevance has been poorly defined. Because DOACs are metabolised by CYP3A4 and transported by P-glycoprotein — both inhibited by ciclosporin and tacrolimus — the authors reviewed all adults at University Hospitals Leuven between 2013 and 2024 who received both a DOAC and a calcineurin inhibitor and had at least one DOAC plasma level, comparing concentrations against on-therapy ranges from the phase 3 trials. Among 495 co-prescribed patients, 216 had 360 DOAC measurements (median age 66 years, IQR 59–72), and lung (31%) and kidney (29%) recipients were the largest groups. DOAC dosing matched product labelling in 73% of measurements, and samples were drawn at trough (58%), intermediate (30%), or peak (12%) intervals. Overall, 11% of measurements exceeded the reference range, but the risk was strongly drug-dependent — 4% for edoxaban, 18% for apixaban, and 20% for rivaroxaban — and above-range levels were associated with concomitant strong CYP3A4 or P-glycoprotein inhibitors, lower body weight, lower eGFR, and ciclosporin rather than tacrolimus. As a retrospective analysis confined to patients already selected for DOAC level monitoring, it likely enriches for suspected interactions and cannot establish bleeding outcomes. For UK practice, it offers a practical hierarchy for anticoagulating kidney recipients on calcineurin inhibitors: edoxaban appears least prone to supratherapeutic exposure, while rivaroxaban and apixaban — especially alongside ciclosporin, low weight, or reduced graft function — warrant closer scrutiny and a lower threshold for plasma-level monitoring.
Generated 2026-07-11 from PubMed search results for kidney transplantation published 2026-06-27 to 2026-07-11. Articles already recorded in prior issues were excluded. PubMed is the source of all metadata and abstracts.
How this digest is made: From a literature-search skill to a self-running evidence digest.