Wadei, Hani M.

Background: Alopecia is a burgeoning area of patient interest and dermatologic investigation. Alopecia following a solid organ transplant has been relatively unexplored, despite the potential for significant symptomatic and psychological impact on patients posttransplant. Objective: We set out to study alopecia in patients following solid organ transplants, including presentation, etiology, evaluation, and management. Methods: We performed a retrospective analysis of patients who underwent solid organ transplant without a preceding history of alopecia at a single center between January 1, 2011, and December 31, 2020, to record new alopecia diagnoses posttransplant. Demographic data, transplant type, immunosuppressive regimen, and type of alopecia were all collected. Results: Between 2011 and 2020, a total of 3,732 patients underwent a solid organ transplant with a median age of 58 (range: 18-82) years. Sixty-two percent were men, 72.5% were White, and 8.4% identified as Hispanic or Latino. Out of 3,732 patients who underwent a solid organ transplant, 39 (1%) subsequently developed alopecia. Risk of alopecia was higher in females (hazard ratio [HR] = 12.26, P < .001), Hispanics (HR = 2.49, P = .043), and pancreas transplant patients (HR = 24.26, P < .001). Limitations: This is a retrospective review. Conclusion: In this study, alopecia was rare after a solid organ transplant, but further investigation is needed to assess for potential underdiagnosis of alopecia following transplant and the higher risks reported in certain populations.

Donation after circulatory death (DCD) liver transplants (LTs) are associated with increased risk of post-LT acute kidney injury (AKI). This retrospective study aimed to examine the effect of continuous normothermic machine perfusion (NMP) on the incidence and stage of AKI in DCD LT. The incidence of AKI within 48 hours was compared between 507 NMP-DCD and 472 static cold storage (SCS)-DCD LT transplanted between January 1, 2016, and December 31, 2024. AKI developed in 337 (34%) patients. On univariate analysis, AKI rate was lower in NMP-DCD compared with SCS-DCD (28% vs. 41%, p <0.001). Stages 2 and 3 AKI at 48 hours and renal replacement therapy (RRT) within the first 3 weeks were also lower in NMP-DCD compared with SCS-DCD ( p <0.001). After adjusting for multiple recipient, donor, and intraoperative factors using multivariate logistic regression, NMP-DCD was independently associated with a 37% lower odds of AKI (aOR: 0.63, CI: 0.46–0.85, p =0.003) and 55% lower odds of stages 2 and 3 AKI (aOR: 0.45, CI: 0.29–0.69, p <0.001) compared with SCS-DCD. To mitigate for the era effect and other unmeasured confounders, an inverse probability of treatment weighting (IPTW) analysis was performed using a propensity score model with average treatment effect (ATE). After weighting for multiple factors, NMP-DCD was associated with lower odds of AKI at 48 hours (OR: 0.65, CI: 0.53–0.81, p =0.001), stages 2 and 3 AKI at 48 hours (OR: 0.60, CI: 0.42–0.85, p =0.02), and RRT at day 7 (OR: 0.31, CI: 0.13–0.65, p =0.003) compared with SCS-DCD. In conclusion, compared with SCS-DCD, NMP-DCD was independently associated with lower odds of AKI at 48 hours, of stages 2 and 3 AKI at 48 hours from LT, and of RRT requirement at day 7 from LT, an effect that extended for the first 3 post-LT weeks.

Renal dysfunction is highly prevalent among patients with cirrhosis and has major implications for management, prognostication, and liver transplant decision-making. Both acute kidney injury (AKI) and chronic kidney disease (CKD) occur frequently in this population and are driven by a complex interplay of hemodynamic derangements, systemic inflammation, and intrinsic or functional renal injury. Accurate assessment of kidney function is essential, as serum creatinine and estimated glomerular filtration rate (eGFR) calculations directly influence MELD-based transplant allocation, eligibility for simultaneous liver–kidney transplantation (SLKT), and clinical decisions such as drug dosing and peri-transplant immunosuppression strategies. However, creatinine-based assessments are fundamentally limited in cirrhosis due to reduced creatinine production, sarcopenia, expanded volume of distribution, increased tubular secretion, and assay interference from hyperbilirubinemia, resulting in frequent overestimation of true GFR. Alternative methods, including cystatin C-based equations, combined creatinine–cystatin C equations, timed urine clearances, and direct GFR measurement using exogenous filtration markers (iohexol, iothalamate), offer potential advantages but also carry important limitations, particularly in decompensated disease with ascites or inflammation. Newer cirrhosis-specific eGFR equations such as the GRAIL and Royal Free Hospital formulas attempt to address these shortcomings, yet validation studies demonstrate inconsistent accuracy across patient cohorts. This review summarizes the pathophysiologic contributors to renal dysfunction in cirrhosis, evaluates the performance and pitfalls of existing kidney function assessment tools, and highlights the ongoing need for reliable, validated methods tailored to this unique population. Until improved approaches are widely accessible, serum creatinine remains the most practical—albeit imperfect—marker guiding clinical decision-making in cirrhotic patients.

The Omicron variant of SARS-CoV-2 is associated with milder symptoms and lower hospitalization and mortality rates than Delta variants, although the impact of Omicron on immunocompromised patients, especially solid organ transplant (SOT) recipients, is still unclear. This study compares the hospitalization rate and outcomes between immunocompromised, immunocompetent, and SOT patients during the Delta and Omicron periods. We included adult patients who tested positive for SARS-CoV-2 on PCR or nasopharyngeal antigen test between 26 June 2021 to 8 September 2022, at our institution. A total of 12,401 COVID-19 patients were included, of which 11,055 were immunocompetent, and 1346 were immunocompromised (375 SOT recipients). Throughout the Delta and Omicron outbreaks, immunocompromised patients exhibited higher comorbidities and 30-day hospitalizations, but rates of mechanical ventilation and ICU-level care were like immunocompetent patients. During the Omicron wave, immunocompromised patients had higher unadjusted relative risk estimates (RR = 2.37, 95% CI 1.96–2.87, p < 0.05) than Delta (RR = 1.58, 95% CI 1.24–2.01, p < 0.05), with higher adjusted relative risk for hospitalization in Omicron (RR = 1.50, 95% CI 1.10–2.03, p = 0.01). Analyses show increased hospitalization risk in immunocompromised during the Omicron wave compared to the Delta wave, with no significant difference in hospitalization outcomes. The relative risk of hospitalization for SOT patients was higher in both waves.

Abstract Objective To examine the impact of immunosuppressive regimens on chronic rhinosinusitis (CRS) development in kidney and liver transplant recipients. Study Design Retrospective cohort study. Setting Multisite study across Mayo Clinic Enterprise locations in Arizona, Florida, Minnesota, and Wisconsin. Methods Patients who underwent kidney or liver transplantation between November 1, 2021, and November 1, 2022, were included. Patients with documented sinonasal complaints before transplantation were excluded. Diagnoses were based on ICD‐10 codes assigned by board‐certified otolaryngologists, with follow‐up extending through November 2024. Demographic data, relevant comorbidities, CRS diagnoses, and immunosuppressive regimens were collected. Results In total, 1459 transplant recipients (986 kidney, 473 liver) with a mean age of 55.1 years and M:F ratio of 1.5:1 were included. Kidney recipients who received anti‐thymocyte globulin (ATG, Thymoglobulin®) for immunosuppressive induction had a greater risk of CRS compared to those who did not (odds ratio [OR] = 3.0, 95% CI [1.3, 6.9], P = .005). Among liver recipients, patients on cyclosporine, mycophenolate mofetil (MMF), and corticosteroids had a greater risk of CRS compared to those on tacrolimus‐based regimens (OR = 6.0, 95% CI [1.5, 24.1], P = .027). Cyclosporine use was also associated with an increased rate of endoscopic sinus surgery (ESS) compared to tacrolimus (4.2% vs 0.3%, P = .015). Conclusion Tacrolimus‐based regimens are associated with significantly decreased rates of CRS compared to cyclosporine, suggesting that immunosuppressive choice is a modifiable risk factor for sinonasal morbidity in this population.

Abstract Objective To estimate the incidence of de novo chronic rhinosinusitis and identify associated risk factors in kidney and liver transplant recipients without pre‐existing sinonasal complaints. Study design Retrospective cohort study. Setting Multisite study across Mayo Clinic Enterprise locations in Arizona, Florida, Minnesota, and Wisconsin. Methods Records of all patients who underwent kidney or liver transplantation between November 1, 2021, and November 1, 2022 were reviewed. Patients with documented sinonasal complaints prior to transplantation were excluded. Diagnoses were based on ICD‐10 codes assigned by board‐certified otolaryngologists, with follow‐up extending through November 2024. Demographic and clinical variables were collected, and multivariable logistic regression was used to identify predictors of de novo chronic rhinosinusitis. Results Among 1459 transplant recipients (mean age 55.1 years, 59.8% male), the cumulative 2‐year incidence of de novo chronic rhinosinusitis was 2.4% (24/986) in kidney and 2.3% (11/473) in liver transplant recipients ( P = .89). The overall incidence rate was 12.0 cases per 1000 person‐years, exceeding general population estimates. Transplant rejection (OR 3.2, 95% CI 2.5‐3.9, P < .001) and additional organ transplantation (OR 5.0, 95% CI 3.4‐6.5, P = .041) were independently associated with chronic rhinosinusitis development. Conclusion Kidney and liver transplant recipients experience a higher incidence of de novo chronic rhinosinusitis compared to the general population. Transplant rejection and additional organ transplantation significantly increase this risk. Early recognition and management of chronic rhinosinusitis in this population may support improved postoperative outcomes.

Key Points Atrial fibrillation after kidney transplantation is common and is associated with poor prognosis. Artificial intelligence applied to 12-lead electrocardiograms pretransplant accurately predicts the risk of new-onset atrial fibrillation in our cohort. High-risk artificial intelligence electrocardiography score was independently associated with increased risk of mortality and allograft failure. Background Incident atrial fibrillation (AF) is common after kidney transplantation (KTx) and is associated with worse clinical outcomes. Artificial intelligence electrocardiography (AI-ECG) algorithms have demonstrated efficacy in predicting risk of new-onset AF in the general population; however, their prognostic value in KTx recipients is relatively unknown. Methods Retrospective analysis was conducted on KTx recipients without AF, with at least one pretransplant ECG between 2011 and 2021 across three tertiary centers in the United States (Mayo Clinic sites in MN, AZ, and FL). A previously validated AI-ECG algorithm estimated the probability of incident AF for each patient. Based on AI-ECG probabilities, patients were categorized into high-risk and low-risk groups, with the optimal AI-ECG score cutoff determined. The incidence of new-onset AF, allograft failure, and mortality was compared between groups. Results Overall, 6246 patients (age 53.5±13.8 years; 58.9% male) were included. Pretransplant AI-ECG probability of AF ≥5% was the optimal cutoff for high risk of incident AF (sensitivity 72%, specificity 62%). High-risk scores were associated with true new-onset AF at 30 days (adjusted hazard ratio [aHR], 2.89; 95% confidence intervals [CI], 2.05 to 4.09; P < 0.001), 3 years (aHR, 2.54; 95% CI, 1.99 to 3.26, P < 0.001), and 5 years post-transplant (aHR, 2.48; 95% CI, 1.99 to 3.09, P < 0.001). High-risk AI-ECG scores were also associated with increased mortality (aHR, 1.56; 95% CI, 1.30 to 1.88, P < 0.001) and overall allograft failure (aHR, 1.50; 95% CI, 1.30 to 1.75, P < 0.001) through the 5-year follow-up. Conclusions This pretransplant AI-ECG parameter identified patients at increased risk of new-onset AF post-KTx and provided prognostic utility. Overall, this easy to obtain tool allows for risk stratification of patients who may benefit from closer monitoring, targeted risk factor modification, and early intervention.

ABSTRACT Background Sulfa antibiotic allergy labels (SALs) are encountered frequently in kidney transplant recipients (KTs). This often results in patients receiving second‐line prophylaxis for both Pneumocystis jiroveci and urinary tract infections (UTIs). The effect of SAL on outcomes including UTIs after KT is unclear. Methods In our single‐center retrospective cohort study, we investigated the effect of SALs on bacteriuria after KT. We identified patients with pre‐KT SALs from 2011 to 2022. A matched cohort was then created using KT with no pretransplant SALs. The groups were compared using proportional analysis and univariable and multivariable Cox proportional regression models. The primary outcome of interest was the proportion of individuals experiencing one or more episodes of bacteriuria within 1 year posttransplant. Secondary outcomes included bacteremic UTIs, acute kidney injury, and opportunistic infections. Results We found that the proportion of individuals experiencing bacteriuria within the first‐year posttransplant was significantly greater in the SAL group versus the control group ( n = 21, 28% vs. n = 22, 14.7%, p = 0.012). This result was also seen in univariable and multivariable survival analysis. In addition, episodes of UTI with associated bacteremia ( n = 11, 14.7% vs. n = 5, 3.3%, p = 0.002) were statistically significantly higher in the SAL group. Conclusion There was a significantly greater number of episodes of bacteriuria in the first‐year posttransplant in subjects with pretransplant SAL. Based on our findings, we suggest that all KTs with pretransplant SALs undergo evaluation and intervention prior to transplantation. image