Behçet disease (BD) is a multisystem inflammatory disorder characterized by a chronic relapsing course. Because immunosuppressive therapy is the mainstay of BD treatment, its use in transplant recipients may attenuate typical clinical manifestations, thereby complicating diagnosis. We report a case of new-onset intestinal BD that developed in a 28-year-old man 3 years after deceased donor kidney transplantation, following an episode of cytomegalovirus colitis. The patient presented with recurrent abdominal pain, diarrhea, weight loss, and hematochezia. Colonoscopy revealed a deep, oval ulcer with well-demarcated, edematous, and nodular margins in the terminal ileum as well as healed scars near the ileocecal valve, findings consistent with intestinal BD.The patient’s symptoms improved after 2 weeks of therapy with colchicine, mesalazine, and mercaptopurine. This case highlights the rare, de novo development of intestinal BD years after kidney transplantation. Intestinal BD should be considered in transplant recipients presenting with unexplained abdominal pain or diarrhea.

Emerging data on finerenone have drawn significant interest from nephrologists and cardiologists for its clinical potential in patient management. Its nonsteroidal structure, greater receptor selectivity, and reduced risk of hyperkalemia make it a distinctive choice for clinicians. Mineralocorticoid receptors (MRs) are expressed in the collecting ducts, endothelial and vascular smooth muscle cells of the interlobar arteries, as well as in podocytes, mesangial cells, and renal fibroblasts. These receptors are also present in cardiovascular and inflammatory cells. MR activation contributes to ischemia-reperfusion injury (IRI) and mediates calcineurin inhibitor (CNI) toxicity, proteinuria, and fibrosis in both the cardiovascular system and kidneys. Blocking MR activation with finerenone may exert therapeutic effects in renal allografts by mitigating IRI, preventing CNI toxicity, reducing proteinuria and renal fibrosis, and lowering the risk of renal and cardiovascular events. Preclinical and clinical studies in the general population with diabetes have demonstrated that finerenone effectively reduces proteinuria and improves renal and cardiovascular outcomes. However, clinical evidence in kidney transplant recipients remains extremely limited, and the efficacy and safety of finerenone in this population are yet to be established. To date, no clinical trials specifically investigating finerenone in kidney transplantation have been published, with only the EFFEKTOR trial currently underway. This review discusses the mechanistic rationale, extrapolates evidence from nontransplant populations, identifies key knowledge gaps, and proposes future research directions to evaluate the safety and efficacy of finerenone in kidney transplant recipients.

Background: Studies on whether donor-to-recipient sex match status affects long-term survival after liver transplantation (LT) have yielded contradictory results. This study evaluated whether donor-to-recipient sex match status influenced long-term survival after living donor liver transplantation (LDLT) or deceased donor liver transplantation (DDLT) at a high-volume center. Methods: The study included 6,664 patients who underwent primary LT between January 2000 and December 2022 at our institution. Patients were divided into four groups according to donor-to-recipient sex match status: male-to-male (n=3,427 [51.4%]), male-to-female (n=1,152 [17.3%]), female-to-male (n=1,385 [20.8%]), and female-to-female (n=700 [10.5%]). Results: Regarding clinical characteristics, the four groups differed significantly regarding background liver disease (P<0.001), model for end-stage liver disease score (P<0.001), serum protein induced by vitamin K absence or antagonist II level (P=0.003), presence of concurrent hepatocellular carcinoma (HCC; P<0.001), and type of LT (P=0.003). Overall survival (OS) of all LT recipients did not differ significantly among the groups (P=0.377). Donor-to-recipient sex match status did not affect long-term OS in either LDLT (P=0.176) or DDLT (P=0.220) groups. In addition, sex match status did not significantly influence posttransplant OS among patients who underwent LDLT without HCC (P=0.464), LDLT with HCC (P=0.236), DDLT without HCC (P=0.338), or DDLT with HCC (P=0.818). Conclusions Donor-to-recipient sex match status does not significantly affect posttransplant patient survival or HCC prognosis after LDLT or DDLT.

Background: We analyzed the status of organ distribution in pediatric deceased donor liver transplantation (DDLT) in Korea. Additionally, we estimated how many pediatric patients could have avoided living donor liver transplantation (LDLT) or survived if new criteria for splittable deceased donors were adopted. Based on the findings, we advocate expanding policy to promote the universal adoption of split liver transplantation (SLT). Methods: Using the Korean Network for Organ Sharing database, we identified patients who underwent DDLT between January 2000 and December 2020. We considered “po-tential splittable donors” those with a donor-to-recipient weight ratio of ≥1.0 who met the existing SLT criteria (age 10–40 years; weight ≥50 kg). By comparing the numbersof pediatric LDLT recipients and potential splittable donors annually, we estimated how many patients might have avoided LDLT if the left lateral section of each splittable liver had been allocated to a child. Additionally, we compared the number of deaths on the DDLT waiting list with the number of potential splittable donors to estimate possibly preventable deaths. Results: Overall, we identified 640 potential splittable donors. Over the 20-year period, 1,210 pediatric patients (<19 years old) received LDLT. If potentially splittable livers had been split, this number could have been nearly halved. Furthermore, 127 patients died while on the DDLT waiting list. Using SLT with potential splittable donors, these deaths might have been prevented. Conclusions SLT could reduce avoidable deaths among pediatric patients while decreasing the economic and social burden of LDLT, without compromising survival for adult DDLT recipients.

In children with biliary atresia, recurrent episodes of cholangitis often lead to portal vein (PV) phlebosclerosis. We report a case of pediatric living donor liver transplantation (LDLT) for biliary atresia with PV occlusion and a large splenorenal shunt. A 3-year-5-month-old girl was diagnosed with syndromic biliary atresia and polysplenia. Because the patient’s condition progressively deteriorated with worsening jaundice, we opted to perform LDLT using a left lateral section graft from her father. The recipient’s native PV was severely atrophic and completely occluded, and the collateral veins around the hepatoduodenal ligament were too small to serve as a viable source of portal inflow.Consequently, renoportal anastomosis (RPA) was selected as an alternative approach.Iliac vein interposition was performed to provide a new portal inflow source, and anatomy-compliant PV reconstruction was performed. The patient recovered from transplant surgery, but PV conduit stenosis occurred with the development of ascites 2 months posttransplant. This RPA-related vascular complication was resolved through percutaneous balloon angioplasty of the PV conduit. The patient has been doing well for 6 months posttransplantation. This case demonstrates that RPA can represent a viable reconstructive option for PV inflow in liver transplantation for pediatric patients with phlebosclerotic PV and prominent splenorenal shunt.

Background: Acute-on-chronic liver failure (ACLF) is associated with high mortality, but transplantation improves survival. Optimizing organ function is time-consuming and can increase infection risk. This study investigated the optimal pretransplant waiting period. Methods: In this retrospective study of patients with ACLF who underwent transplantation between January 2021 and August 2024, perioperative details and morbidity were compared between survival and mortality groups. Receiver operating characteristic (ROC) analysis was used to determine the cutoff for the pretransplant waiting period. Results: Among 112 patients with ACLF under the European Association for the Study of the Liver criteria, 61 (54.5%) underwent living donor liver transplantation (mean age, 41 years; 51 males [83.6%]). The most common etiology was viral infection (44.2%). The median Chronic Liver Failure Consortium (CLIF-C) score was 44 (respiratory failure, 14.7%; renal failure, 16.4%). There were 14 (22.9%) posttransplant deaths. The median waiting period between admission and surgery was longer in the mortality group (8 vs.4 days, P=0.2). The area under the ROC curve for the optimal pretransplant waiting period was 0.723 (P=0.01). A cutoff of 5 days predicted mortality with 71.4% sensitivity and 61.9% specificity. On univariate analysis, survivors and nonsurvivors differed significantly in age, hemoglobin level, warm ischemia time, and postoperative gastrointestinal (GI) bleeding; on multivariate analysis, postoperative GI bleeding independently predicted mortality. During a median follow-up of 17 months, no deaths occurred. Conclusions A pretransplant waiting period of 5 days predicted mortality; furthermore, postoperative GI bleeding was an independent predictor of mortality. Further studies are required to confirm these findings.

Background: Cytomegalovirus (CMV) infection remains a major cause of morbidity, mortality, and increased healthcare burden in recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Its clinical manifestations range from asymptomatic CMV replication to end-organ diseases such as pneumonia, gastroenteritis, and retinitis, all of which are associated with a higher rate of nonrelapse mortality. Methods: We reviewed case records of children who underwent allo-HSCT at our center between April 2013 and October 2024. CMV monitoring was performed weekly until at least day +100 post-HSCT using a quantitative polymerase chain reaction assay. All patients received acyclovir prophylaxis. Pre-emptive intravenous ganciclovir therapy was initiated when CMV-DNA levels exceeded 500 IU/mL Results: A total of 150 consecutive patients (58% male) were included. The median age at HSCT was 6.3 years (interquartile range [IQR], 3.4–11.3 years). Indications for HSCT were hematologic malignancy (n=81, 54.0%), inborn errors of immunity and bone marrow failure (n=46, 30.7%), and hemoglobinopathy (n=23, 15.3%). Donor and recipient CMV seropositivity rates were 86.7% and 94.0%, respectively. CMV infection occurred in 43.4% of patients, with a median onset of 30 days post-HSCT (IQR, 21–47 days). There were five (3.3%) cases of CMV disease, resulting in one (0.7%) CMV-related death. Human leukocyte antigen (HLA)-haploidentical donor status (odds ratio [OR], 5.00; 95% confidence interval [CI], 2.43–10.29; P<0.001) and the use of serotherapy in the conditioning regimen (OR, 2.87; 95% CI, 1.47–5.60; P=0.002) were significantly associated with an increased risk of CMV infection. Conclusions CMV infection was a common occurrence, particularly among patients with HLA-haploidentical donors. Preventive strategies such as weekly surveillance and pre-emptive ganciclovir therapy proved effective in preventing overt CMV disease.

Background: Obesity complicates open kidney transplantation (OKT), driving increasing interest in robot-assisted kidney transplantation (RAKT). This study compared intraoperative and postoperative outcomes of RAKT and OKT in patients with a body massindex ≥30 kg/m². Methods: Systematic searches of PubMed, Scopus, and the Cochrane Library were conducted through April 15, 2025. Four retrospective cohort studies (147 RAKT and 625 OKT cases) met the inclusion criteria. Pooled analyses evaluated cold and warm ischemia times, estimated blood loss, estimated glomerular filtration rate (eGFR) at 6 months and 1 year, serum creatinine at 6 months and 3 years, delayed graft function (DGF), graft survival at 1 and 3 years, length of stay, rejection rate, 1-year patient survival, and surgical site infection (SSI) using a random-effects model. Results: No significant differences were observed in cold ischemia time (mean difference [MD], 43.88 minutes; 95% confidence interval [CI], –88.06 to 175.82 minutes;P=0.51), warm ischemia time (MD, 3.21 minutes; 95% CI, –3.23 to 9.65 minutes; P=0.33), or estimated blood loss (MD, –41.30 mL; 95% CI, –95.60 to 12.99 mL; P=0.14). Other postoperative outcomes, including graft function (eGFR and creatinine), DGF, hospital stay, rejection, and 1-year survival, were also comparable. However, RAKT was associated with a significantly lower SSI incidence (risk ratio, 0.14; 95% CI, 0.04–0.45;P=0.0009). Conclusions In obese patients, RAKT yields outcomes comparable to OKT, with the added potential benefit of reducing SSI risk. Nonetheless, as most findings are based on very low-certainty evidence, these results should be interpreted with caution. Larger randomized trials are required to confirm these outcomes.

Type 4 renal tubular acidosis (RTA) is an uncommon but clinically significant complication in kidney transplant recipients, leading to hyperkalemia and non-anion gap metabolic acidosis due to aldosterone deficiency or resistance. Calcineurin inhibitors, especially tacrolimus, can contribute to this disorder by impairing distal tubular potassium secretion. We describe a 47-year-old male who underwent living donor kidney transplantation from his biological mother. Despite good early graft function, he developed severe recurrent hyperkalemia, requiring hemodialysis on postoperative days 11 and 23. Laboratory evaluation revealed non-anion gap metabolic acidosis (anion gap 10.8 mEq/L), urine pH 5.5, and a low transtubular potassium gradient of 2.5, consistent with type 4 RTA. At diagnosis, serum creatinine was 1.39 mg/dL (estimated glomerular filtration rate, 54.8 mL/min/1.73 m 2 ). The patient was treated with fludrocortisone (starting at 0.2 mg/day and tapered to 0.05 mg/day), a thiazide diuretic (12.5 mg twice daily), and reduction of tacrolimus dose with addition of sirolimus (2.5 mg/day). Electrolyte abnormalities resolved, and graft function remained stable without rejection. This case underscores the importance of recognizing tacrolimus-induced type 4 RTA early and using individualized treatment strategies to correct hyperkalemia and preserve allograft function.

Background: DNA methylation is under investigation as an early diagnostic biomarker for cancers such as hepatocellular carcinoma (HCC). p21-activated protein kinase 1 (PAK1) demonstrates a high methylation tendency in HCC. We assessed the diagnostic and prognostic performance of PAK1 methylation in liver transplantation (LT) recipients with and without HCC. Methods: To assess PAK1 methylation, stored pretransplant blood samples from LT recipients were analyzed by droplet digital polymerase chain reaction. Results: This study included 274 patients with HCC and 100 control patients without the disease. Ten-year survival rates in the HCC and control groups were 60.5% and 80.6%, respectively (P=0.001). The 10-year HCC recurrence rate was 39.0%. Ten-year survival rates in the HCC recurrence and nonrecurrence groups were 13.3% and 91.2%, respectively (P<0.001); median PAK1 methylation levels in the control and HCC groups were 50.0 and 108.0 copies (P=0.102). The area under the receiver operating characteristic curve was 0.599, and the Youden J index was 0.199, indicating 57.9% sensitivity and 62.0% specificity at a cutoff of 78 copies. With a cutoff of 5 copies, sensitivity was 94.1% and specificity was 14.0%. The positive likelihood ratio was 1.09 and the negative likelihood ratio was 0.42, indicating diagnostic accuracy below α-fetoprotein and protein induced by vitamin K absence or antagonist-II. PAK1 cutoffs of 5 and 10 copies did not affect HCC recurrence, but a cutoff of 2 copies appeared associated with lower recurrence. Conclusions These data suggest that PAK1 methylation is not a clinically useful biomarker for HCC in LT recipients. New DNA methylation biomarkers are required for early diagnosis.