Kidney transplantation is a life-saving intervention for end-stage renal disease; yet, the persistent gap between organ demand and supply remains a significant challenge. This paper explores the escalating discard rates of deceased donor kidneys in the United States to assess trends, discard reasons, demographical differences, and preservation techniques. Data from the Scientific Registry of Transplant Recipients from 2010 to 2021 was analyzed using chi-squared tests for trend significance and logistic regression to estimate odds ratios for kidney discard. Over the last decade, discard rates have risen to 25% in 2021. Most discarded kidneys came from extended criteria donor (ECD) donors and elevated kidney donor profile index (KDPI) scores. Kidney biopsy status was a significant factor and predictor of discard. Discard rates varied greatly between Organ Procurement and Transplantation Network regions. Of reasons for discard, “no recipient located” reached a high of 60%. Additionally, there has been a twofold increase in hypothermic machine perfusion (HMP) since 2010, with transportation difficulties being the main reason for the discard of perfused kidneys. Our findings suggest a need to recalibrate organ utilization strategies, optimize the use of lower-quality kidneys through advanced preservation methods, and address the evolving landscape of organ allocation policies to reduce kidney discard rates.

Purpose: To compare the intra-operative and post-operative outcomes of Single-Port Robotic Donor Nephrectomies (SP RDNs) and Laparoscopic Donor Nephrectomies (LDNs) Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intra-operative outcomes, post-operative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using Cumulative Sum Analysis. Results: 144 patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 min., SP RDN: 194.5 ± 35.1 min., p=0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 sec., SP RDN: 204.1 ± 52.2 sec, p<0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 sec., SP RDN: 275.4 ± 65.6 sec., p<0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term post-operative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes post-operative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

We compared the outcomes of transplanting expanded criteria donor (ECD) kidneys undergoing machine perfusion (MP) versus cold storage (CS). Data on all expanded criteria deceased donor kidney transplants performed at the University of Pittsburgh Medical Center from January 2003 through December 2012 were collected from an in-house electronic repository. There were 78 patients in the MP group and 101 patients in the CS group. The majority of the ECD kidneys were imported from other organ procurement organizations: 69 of 73 in the MP group (94.5%, 5 from unknown sources); and 90 of 99 in the CS group (91%), 2 from an unknown source). Most of the patients in the MP group (77 of 78) received a combination of MP and static CS. MP was performed just prior to transplantation in all MP patients. We used descriptive statistics to characterize our sample. We used logistic regression analysis to model the binary outcome of delayed graft function (DGF; i.e., “yes/no”) and Cox (proportional hazard) regression to model time until graft failure. The Kaplan-Meier product-limit method was used to estimate survival curves for graft and patient survival. A total of 179 transplants were done from ECD donors (MP, 78; CS, 101). The mean static cold storage time was 14 ± 4.1 hours and the mean machine perfusion time was 11.2 ± 6.3 hours in the MP group. The donor creatinine was higher (1.3 ± 0.6 mg/dl vs. 1.2 ± 0.4 mg/dl, p = 0.01) and the cold ischemia time was longer (28.9 ± 10 hours vs. 24 ± 7.9 hours, p = 0.0003) in the MP patients. There were no differences between the two groups in DGF rate (20.8% [MP] vs. 25.8% [CS], p = 0.46), six-year patient survival (74% [MP] vs. 63.2% [CS], p = 0.11), graft survival (64.3% [MP] vs. 51.5% [CS], p = 0.22), and serum creatinine levels (1.5 mg/dl vs. 1.5 mg/dl) on univariate analysis. On unadjusted analysis, MP subjects without DGF had longer graft survival compared to CS subjects with DGF (p < 0.0032) and MP subjects with DGF (p < 0.0005). MP subjects without DGF had longer death-censored graft survival compared to CS subjects with DGF (p < 0.0077) and MP subjects with DGF (p < 0.0016). However, on regression analysis, MP subjects had longer graft survival than CS subjects when DGF was not present. MP subjects without DGF had longer patient survival compared to CS subjects with DGF (p < 0.0289), on unadjusted analysis. MP subjects had a reduced risk of graft failure (hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.17, 0.68) and death-censored graft failure (HR, 0.44; 95% CI, 0.19, 1.00), compared to CS subjects when DGF was not present. Reduction of DGF rates for imported ECD kidneys is vital to optimize outcomes and increase their utilization. One strategy to decrease DGF rates may be to reduce static CS time during transportation, by utilizing a portable kidney perfusion machine.

Background: Patients with type 1 diabetes complicated by severe hypoglycemia and impaired awareness remain at high risk of mortality despite advances in diabetes treatment. Pancreas transplantation offers definitive β-cell replacement; however, contemporary real-world data on hypoglycemia outcomes are limited. Methods: We performed a retrospective single-center cohort study of adult patients undergoing pancreas transplantation at The Mount Sinai Hospital between 1 January 2010 and 31 December 2024. Transplant types included simultaneous pancreas–kidney (SPK), pancreas after kidney (PAK), and pancreas transplant alone (PTA). The primary outcome was the incidence of severe hypoglycemia following transplantation, with secondary outcomes including graft survival, patient survival, biopsy-proven rejection, and infectious complications. Post-transplant HbA1c and continuous glucose monitoring data were not systematically captured and could not be analyzed. Results: A total of 100 pancreas transplants were performed (SPK 73%, PAK 26%, PTA 1%), over a median follow-up of 8.5 years (IQR 4.5–13.7). Pretransplant hypoglycemia or hypoglycemia unawareness was present in 63% of recipients. Documented impaired awareness specifically was recorded in a smaller subset (9%). No episodes of severe hypoglycemia occurred following transplantation, and hypoglycemia unawareness resolved in all patients with available follow-up. Two patients (2%) had a hypoglycemic episode recorded post-transplant; in one, the episode occurred after graft failure while on insulin, and neither was a severe (third-party-assisted) event in a functioning graft. Death-censored graft survival was 94.0% at 1 year, 91.6% at 3 years, 83.0% at 5 years, and 80.5% at 10 years, while patient survival was 95.0%, 89.5%, 88.2%, and 84.2% at the same time points. Rejection occurred in 21%, and infectious complications in 31% of recipients. Conclusions: Pancreas transplantation provided complete and durable protection from clinically documented severe hypoglycemia, with excellent long-term graft and patient survival. In the absence of systematic post-transplant HbA1c and continuous glucose monitoring data, these findings should be read as freedom from clinically recognized severe hypoglycemic events rather than as documented normoglycemia, supporting its role as the most definitive β-cell replacement strategy in appropriately selected patients.