Acute Rejection Research Articles

Aspergillus After Lung Transplantation: Prophylaxis, Risk Factors, and the Impact on Chronic Lung Allograft Dysfunction.

Invasive pulmonary aspergillosis (IA) poses significant challenges for lung transplant (LTx) patients, with unclear risk factors and preventive strategies. The effectiveness of nebulized amphotericin B (AmB) or statins for IA prevention and the effect of IA on chronic lung allograft dysfunction (CLAD) and mortality remain questionable. Data were collected from all LTx patients transplanted between December 1, 2013 and January 1, 2022 at the University Medical Center Groningen. IA, was defined according to published criteria. Prespecified risk factors were compared between patients with and without IA post-LTx and were entered in a logistic regression model. Two additional logistic regression models were built with factors that might be associated with statin or AmB prophylaxis and IA. A matched case-control study was conducted for the association between statins and IA, with matching based on follow-up time. Aspergillus was cultured in 110 /274 (40%) patients post-LTx and 89/110 (81%) were classified as probable IA. MMF use, airway stenosis, Aspergillus cultured pre-LTx, CLAD, and acute rejection (AR), were significantly associated with IA. Statin use was associated with a lower incidence of IA, while AmB prophylaxis showed no significant effect. A significant statin effect could not be confirmed by the case control analysis. There was no significant difference in all-cause mortality between patients with and without IA (34% vs. 29%). The high incidence of IA post-LTx necessitates more effective strategies. Key targets for intervention include prior positive cultures, airway stenosis, AR, and the use of MMF. The role of statins remains unclear and requires further research.

Maintenance of graft tissue-resident Foxp3+ cells is necessary for lung transplant tolerance in mice.

Mechanisms that mediate allograft tolerance differ between organs. We have previously shown that Foxp3+ T cell-enriched bronchus-associated lymphoid tissue (BALT) is induced in tolerant murine lung allografts and that these Foxp3+ cells suppress alloimmune responses locally and systemically. Here, we demonstrated that Foxp3+ cells that reside in tolerant lung allografts differed phenotypically and transcriptionally from those in the periphery and were clonally expanded. Using a mouse lung re-transplant model, we showed that recipient Foxp3+ cells were continuously recruited to the BALT within tolerant allografts. We identified distinguishing features of graft-resident and newly recruited Foxp3+ cells and showed that graft-infiltrating Foxp3+ cells acquired transcriptional profiles resembling those of graft-resident Foxp3+ cells over time. Allografts underwent combined antibody-mediated rejection (AMR) and acute cellular rejection (ACR) when recruitment of recipient Foxp3+ cells was prevented. Finally, we showed that local administration of IL-33 could expand and activate allograft-resident Foxp3+ cells providing a platform for the design of tolerogenic therapies for lung transplant recipients. Our findings establish graft-resident Foxp3+ cells as critical orchestrators of lung transplant tolerance and highlight the need to develop lung-specific immunosuppression.

Night-Time Chronotherapy with Methylprednisolone Prevents an Acute Rejection in Pediatric Patients with Liver Transplantation: ARandomized Clinical Trial.

While endogenous cortisol secretion rises in the early morning, the number of lymphocytes in the blood is higher at night, thus exhibiting an antiphase pattern to cortisol secretion. Therefore, compared with the daytime, the infiltration of lymphocytes into immune-reactive tissues is enhanced at night. This study aimed to determine whether the administration of methylprednisolone (mPSL) in the evening is more effective against T cell-mediated rejection (TCMR) after liver transplantation compared with morning administration. This study used a randomized, open-label, parallel-group comparison design. Pediatric patients scheduled to undergo living-donor liver transplantation were randomly divided into morning (8:00 a.m.) and evening (8:00 p.m.) mPSL administration groups. The primary endpoint was the occurrence of TCMR within 14 days of surgery. Sixty-two patients were enrolled between 2014 and 2023, and six patients were excluded from the analysis as their dose of mPSL deviated from the protocol within 14 days after surgery. Of the 56 subjects analyzed, TCMR was detected in 10 of the morning group (n = 29) and three of the evening group (n = 27) within 14 days after surgery. Stratified analysis of patients who did not receive preoperative rituximab treatment showed that none of the evening group and 36.4% of the morning group developed TCMR within 14 days after surgery (P < 0.01, 95% confidence interval; 2.00-infinity). Safety evaluation results were comparable between the two groups. This study shows that the evening administration of mPSL is an effective approach for suppressing TCMR. This study is hypothesis generating, and replication in further studies is needed.

LXRα agonists ameliorates acute rejection after liver transplantation via ABCA1/MAPK and PI3K/AKT/mTOR signaling axis in macrophages

IntroductionLiver X receptor α (LXRα) plays an important role in inflammatory immune response induced by hepatic ischemia-reperfusion injury (IRI) and acute rejection (AR). Macrophage M1-polarization play an important role in the occurrence and development of AR. Although the activation of LXR has anti-inflammatory effects, the role of LXRα in AR after liver transplantation (LT) has not been elucidated.ObjectiveWe aimed to investigate LXRα anti-inflammatory and macrophage polarization regulation effects and mechanisms in acute rejection rat models.MethodsLXRα anti-inflammatory and liver function protective effects was initially measured in primary Kupffer cells and LT rat models. Subsequently, a flow cytometry assay was used to detect the regulation effect of LXRα in macrophage polarization. HE staining, TUNEL and ELISA were used to evaluate the co-treatment effects of TO901317 and tacrolimus on hepatic apoptosis and liver acute rejection after LT.ResultsIn this study, we found that LPS can inhibit the expression of LXRα and activate MAPK pathway and PI3K/AKT/mTOR. We also found that LXRα agonist (TO901317) could improve liver function and rat survival after LT by activating the level of ABCA1 and inhibiting MAPK. TO901317 could inhibit macrophage M1-polarization by activating PI3K/AKT/mTOR signal pathway to improve the liver lesion of AR rats after liver transplantation. Additionally, co-treatment with TO901317 and tacrolimus more effectively alleviated the damaging effects of AR following LT than either drug alone.ConclusionOur results suggest that the activation of LXRα can improve liver function and rat survival after LT by regulate ABCA1/MAPK and PI3K/AKT/mTOR signaling axis in macrophages.

Promising Long-Term Outcomes of Lung Transplantation With Hepatitis C Positive Donors: Insights From the UNOS Registry.

Promising Long-Term Outcomes of Lung Transplantation With Hepatitis C Positive Donors: Insights From the UNOS Registry.

Dolutegravir-Based Antiretroviral Therapy in People with HIV with Solid Organ Transplantation: A Single-Arm Pilot Clinical Trial (DTG-SOT)

Abstract Background This study assessed the pharmacokinetic interactions between dolutegravir (DTG)-based antiretroviral therapy (ART) and immunosuppressants in solid organ transplantation (SOT) recipients with human immunodeficiency virus (HIV) and ART safety. Methods Phase IV, single-center, open-label, single-arm clinical trial (DTG-SOT, NCT03360682) including adult SOT recipients with HIV conducted between 2017 and 2019. People with HIV (PHIV) with plasma viral load &amp;lt;50 copies/mL during ≥12 months and receiving stable raltegravir-based ART during ≥6 months were switched to tenofovir disoproxil fumarate (TDF)/Emtricitabine (FTC) or Lamivudine (3TC)/Abacavir (ABC)+DTG and followed up for 48 weeks. Immunosuppressant pharmacokinetic parameters were compared before and two weeks after ART switch (primary outcome). Efficacy and safety were analyzed at 48 weeks by intention-to-treat analysis (ITT). Results Nineteen consecutive participants (median 57 years, IQR 51-60), mostly liver recipients (63·2%), received DTG/3TC/ABC (63·2%) and DTG+FTC/TDF (36·8%). Pharmacokinetic parameters changed, albeit not significantly, before and after ART, for mycophenolic acid (MPA) (Cmax +63%, Cmin +53%, AUC +16%; n=7) and cyclosporine A (Cmax -64%, Cmin +14%, AUC -47%; n=2), with smaller changes for tacrolimus (Cmax +14%, Cmin -29%, AUC -9%; n=7). No participants experienced acute rejection or virological failure and CD4+ cell counts and percentages remained unchanged during follow-up. Three (15·8%) discontinued treatment due to AEs. Estimated glomerular filtration rate decreased (p=0·0015) and creatinine increased (p=0·0001) slightly. Conclusions DTG-based ART lacked clinically significant drug-drug interactions with tacrolimus and MPA. Switching to DTG-based ART was effective in PHIV SOT recipients. More studies are needed to evaluate DTG safety in this setting.

Combination Automated Microfluidics Measurement of Urine CCL2, CXCL9, CXCL10 and VEGF-A for Monitoring Patients with a Kidney Transplant.

Recent studies indicate that up to 36% of pediatric and adult kidney transplant recipients with stable serum creatinine levels will have acute rejection detected on surveillance biopsy. The purpose of this study was to develop and validate a risk algorithm for identifying low- and high-risk patients using a novel automated platform that simultaneously measures urinary CCL2, CXCL9, CXCL10 and VEGF-A with high precision. We designed a multicenter observational study to evaluate the performance of urinary CCL2, CXCL9, CXCL10 and VEGF-A in a training set of 517 banked samples collected at the time of surveillance or indication kidney biopsies from both adult and pediatric recipients. Risk algorithms combining all four analytes were developed in the training set, and subsequently validated in three laboratory sites in two additional pediatric cohorts (N=174). The automated platform had remarkably high throughput, generating reproducible results in 60-70 minutes. Analysis was initially performed in the training set (N=517), which included biopsies read as normal (N=330), acute rejection (N=92) or borderline rejection (N=95). We found that each biomarker independently discriminated normal biopsies vs. those with acute rejection (P < 10-5). A risk algorithm utilizing all four biomarkers (score4) had excellent diagnostic performance for acute rejection in both for-cause and surveillance biopsies performed on patients with stable GFRs, outperforming any individual biomarker as well as estimated GFR assessments. Validation assays performed in the two additional pediatric cohorts in three laboratory sites demonstrated a robust correlation of results; score4 retained excellent diagnostic performance (75% specificity and 92% negative predictive value). Automated measurements of urine CCL2, CXCL9, CXCL10 and VEGF-A can distinguish kidney transplant recipients at low- vs. high-risk for rejection. We suggest that this assay can advantage clinical decision-making in routine post-transplant monitoring due to its low cost, rapid throughput, and operator independence.

Maintenance Immunosuppression in Kidney Transplantation: A Review of the Current Status and Future Directions

Kidney transplantation remains the gold standard for managing end-stage kidney disease, providing superior survival and quality-of-life outcomes compared to dialysis. Despite the ongoing gap between organ availability and demand, it is inevitable that kidney transplantation will continue to grow. This is owed to broader organ sharing, increased comfort of transplant programs with marginal kidney utilization, and the expansion of paired exchange among living donor kidneys. The evolution of kidney transplantation could not have been possible without the availability of effective immunosuppressive regimens that prevent rejection and maintain graft function. Mycophenolic acid and calcineurin inhibitors continue to serve as the foundation of modern maintenance immunosuppression. While these agents have markedly reduced acute rejection rates, their long-term efficacy in graft survival remains suboptimal. Alternative immunosuppressive therapies, including belatacept and mammalian target of rapamycin inhibitors, have demonstrated potential benefits. However, concerns regarding an increased risk of rejection have limited their widespread adoption as primary treatment options. In addition to ongoing efforts to refine steroid- and calcineurin inhibitor-sparing strategies, the identification of practical and quantifiable biomarkers for predicting long-term graft survival remains a critical objective. This review evaluates contemporary immunosuppressive protocols, highlights existing challenges, and explores future directions for optimizing long-term transplant outcomes.

Sludging: A Postoperative Clinical Finding After Ocular Surface Stem Cell Transplantation.

The objective of this study was to describe a postoperative clinical finding coined "sludging." Sludging is defined as a noninflammatory vascular phenomenon observed following ocular surface stem cell transplantation (OSST) characterized by dilated blood vessels localized to the graft. Also, the aim of our study was to identify associated risk factors and the impact on OSST graft outcomes. A total of 261 eyes of 196 patients who underwent OSST to treat severe limbal stem cell deficiency from 2006 to 2016 were included in this retrospective review. Clinical characteristics were collected, including patient and donor demographics as well as clinical outcomes. The clinical features of sludging include painless dilation of blood vessels localized on the graft, with an absence of inflammation, limbal injection, and corneal epithelial abnormalities. The overall prevalence of sludging was 77 of 261 eyes (29.5%), and the mean time of appearance after OSST was 1.31 ± 1.48 years. Sludging resolved in 54 of 77 eyes (70.1%) after 0.93 ± 1.04 years. Sludging was most commonly seen after keratolimbal allograft (KLAL) (43.4%) as compared with living-related conjunctival limbal allograft (13.5%, P = 0.00012). The presence of sludging was associated with higher rates of both future graft rejection (P = 0.0012) and graft failure (P = 0.0053). There were no significant donor characteristics associated with developing sludging among KLAL recipients. Sludging is a noninflammatory postoperative clinical finding following OSST, particularly KLAL. Prompt recognition of sludging is critical to differentiate from acute graft rejection as the management and prognosis is different.

PERFECCIONANDO EL DIAGNÓSTICO DE RECHAZO

The mechanisms of acute rejection and its diagnosis are analyzed, and we concluded: The diagnosis of rejection requires a high level of suspicion, knowledge of the patient’s situ- ation and access to different diagnostic approximation techniques. Diagnosis and treatment must be early. Biopsy remains the gold standard for diagnosis. New methods for early diagnosis are in the study and in validation, with many limitations for massification of these techniques and possibly of implementation in our environment. The best prevention of rejection is the selection of a good donor, adequate immunosuppres- sion and monitoring of this, which should be of very low intensity favoring rejection, or of very high intensity exposing the patient to toxicity from it.

Heart Transplant Equity: Effect of 2018 Allocation Policy Change on Recipient Mortality and Morbidity by Race and Ethnicity.

In 2018, the US heart allocation policy was changed from 3-tiers to 6-tiers for a more granular assessment of patients' medical urgency. Given previous studies showing significant discrepancies in post-transplant outcomes among Black and Hispanic minority groups, we investigated the effects of the allocation policy change on these groups. Adult heart transplant patients from 10/18/2014-10/18/2022 were included from the United Network for Organ Sharing (UNOS) database. Multiorgan transplants and retransplants were excluded. 1:1 propensity-matching were performed by race/ethnicity and allocation score era. Primary outcome was overall(4-year) survival assessed using multivariable Cox regression in unmatched cohort; secondary outcomes were in-hospital and 1-year rejection, short-term mortality, and graft failure, assessed using conditional logistic regression in the matched cohort. The total cohort included 19,731 patients; 13,001 White, 4784 Black, and 1946 Hispanic. White, Black, and Hispanic cohorts in matched analysis demonstrated post-allocation change improvements in in-hospital and 1-year rejection (all p<0.05) and comparable short-term mortality and graft failure (all p>0.05). In adjusted analyses, Black recipients had comparable overall mortality to White recipients both pre- (aHR=1.04[0.92,1.18], p=0.514) and post-allocation change (aHR=1.10[0.95,1.27], p=0.194). Post-allocation change, Black recipients had a higher risk of overall mortality (aHR=1.20[1.01,1.42], p=0.033) while Hispanic recipients had lower risk of mortality (aHR=0.72[0.55,0.94], p=0.015) compared to White recipients. This analysis demonstrates improved acute rejection rates post allocation change, by race/ethnicities however, there remain disparities in short and long-term recipient mortality for Black recipients in the post-allocation change era. Future studies will explore the factors impacting long-term survival among these groups.

Characterizing the urobiome and associated metabolic profiles during acute rejection in renal transplant patients: A pilot study.

Characterizing the urobiome and associated metabolic profiles during acute rejection in renal transplant patients: A pilot study.

GBP1 promotes acute rejection after liver transplantation by inducing Kupffer cells pyroptosis.

GBP1 promotes acute rejection after liver transplantation by inducing Kupffer cells pyroptosis.

Total plasma cfDNA methylation in pediatric kidney transplant recipients provides insight into acute allograft rejection pathophysiology

Total plasma cfDNA methylation in pediatric kidney transplant recipients provides insight into acute allograft rejection pathophysiology

Suppressing, stimulating and/or inhibiting: The evolving management of HCC patient after liver transplantation.

Suppressing, stimulating and/or inhibiting: The evolving management of HCC patient after liver transplantation.

Diagnostic Performance of Gene Expression and dd-cfDNA in Multiorgan Transplant Recipients.

The aim of this analysis was to evaluate early signals of the utility of gene expression profile (GEP) and donor-derived cell-free DNA (dd-cfDNA) for ruling out subclinical rejection in multiorgan transplant recipients. This was a prospective, single-center, observational pilot study that began enrolling patients in September 2022. Participants were enrolled after providing informed consent and had biomarker samples drawn before surveillance or for-cause biopsy. GEP result of TX was considered negative and a dd-cfDNA of ≤0.69% was considered negative, regardless of a nonrenal organ. There were 49 participants with 55 surveillance and/or for-cause biopsies. After exclusion of biopsies not paired with biomarkers, 51 biopsies were evaluated with at least 1 biomarker. Fifty-one biopsies had paired GEP results, whereas 47 biopsies had paired dd-cfDNA results. Overall, there were 12 biopsy-proven acute rejections (24%), 5 of which were T cell-mediated rejections (4-1A and 1-1B), 2 were antibody-mediated rejections, and 5 were borderline for T cell-mediated rejections. GEP by itself in 51 biopsies demonstrated a sensitivity of 17%, specificity of 74%, positive predictive value of 17%, negative predictive value of 74%, and balanced accuracy of 61%. Among 47 paired biopsies, dd-cfDNA demonstrated a sensitivity of 67% and specificity of 37%. Median dd-cfDNA was above the positivity threshold for both participants with rejection on biopsy and without (1.86% versus 1.35%, respectively). When evaluating GEP, specifically in surveillance biopsies and patients with liver transplants, diagnostic performance was maintained. In this pilot analysis, GEP maintained a high negative predictive value in a multiorgan cohort, regardless of the nonrenal organ. dd-cfDNA did not have good performance when using the kidney threshold cutoff, which was expected and driven by the liver component of multiorgan recipients. Further technological advances with dd-cfDNA to differentiate organs and multiple donors could be impactful. The results support the use of GEP for ruling out kidney rejection in a multiorgan population, including those with a liver transplant. Further evaluation is necessary to confirm the results.

Multiple omics-based machine learning reveals specific macrophage sub-clusters in renal ischemia-reperfusion injury and constructs predictive models for transplant outcomes.

Multiple omics-based machine learning reveals specific macrophage sub-clusters in renal ischemia-reperfusion injury and constructs predictive models for transplant outcomes.

OUTCOMES IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE AFTER SOLID ORGAN TRANSPLANTATION

Abstract BACKGROUND Data on patients with inflammatory bowel disease (IBD) undergoing solid organ transplantation (SOT) are scarce. Most studies have focused on liver transplantation (LT) in IBD patients with primary sclerosing cholangitis (PSC), while IBD-related outcomes in other organ transplants are less well-described. In this study, we sought to characterize the population of patients with IBD undergoing SOT and describe both IBD and SOT outcomes. METHODS A single-centered, retrospective cohort study of patients with IBD who had an SOT from 2010 through 2022. Electronic records were reviewed for demographics, IBD, and transplantation history. IBD clinical activity (based on provider assessment), endoscopic activity, and medication use were assessed at time of SOT, one-year post-transplant, and at most recent follow-up. SOT outcomes evaluated included post-transplant medication use, rejection, and re-transplantation. RESULTS 69 patients with IBD underwent SOT (Table 1). The most common SOT was LT (n= 43), followed by kidney (KT)(n= 17), heart (n= 7), and liver/kidney (n= 2). The most common indication for LT was PSC (81%). The most common indications for KT were IgA nephropathy and interstitial nephritis (both n= 3). Nonischemic cardiomyopathy was the most common indication for heart transplant (71%). The mean follow-up time was 5.3 years post-SOT. At the time of SOT, 96% of patients were in clinical IBD remission. 15 patients had previously undergone colectomy. At the time of SOT, 36% patients were on no IBD therapy, 23% were on 5-ASA, 19% on immunomodulators, and 28% on advanced therapy (AT). At 1-year post-SOT, 91% were in clinical remission (Table 2) however 17% of patients who underwent endoscopic evaluation had endoscopic inflammation. There was a non-significant trend towards more IBD activity on endoscopy at 1-year post-SOT in patients on no IBD medications post-SOT (44% v 31%, p=0.5). 67% patients were on no specific IBD therapy 1-year post-SOT (SOT immunosuppression only). At 1-year post-SOT, only 12% were on AT; 1 patient was started post-SOT. The most common AT was vedolizumab (n= 7) followed by infliximab (n= 6). At last follow-up, 22% patients were on AT. Post-SOT, 29% of patients had an episode of acute rejection within 1 year, and 10% required re-transplantation of organ within the follow-up period. There was no statistical association between IBD status at the time of SOT or IBD advanced therapy use on transplant outcomes (data not shown). 29% of the patients were deceased at the end of our follow-up period with an average time to death of 4.95 years post-SOT. CONCLUSION In our cohort, most IBD patients undergoing SOT are in clinical remission at the time of SOT and do not require specific IBD therapy post-transplant. Despite the use of immunosuppression for SOT, some IBD patients still require AT for control of their disease. Table 1. Patient Characteristics Table 2. Pre- and Post-Transplant IBD Related Outcomes

Echocardiographic Evaluation of the Post-Heart Transplant Patient.

Significant practice variability exists with respect to the role and frequency of echocardiography after heart transplantation. We sought to illustrate key studies relating to the utility and diagnostic accuracy of echocardiography for the post-heart transplant patient. Several echocardiographic parameters correlate with acute heart transplant rejection, but there is enough heterogeneity between study results or in diagnostic accuracy, such that it precludes parameter use in isolation to rule out rejection. Newer techniques such as strain echocardiography may have better sensitivity. Similarly, resting and stress echocardiography can be combined with modern techniques such as myocardial contrast echocardiography to diagnose and prognosticate cardiac allograft vasculopathy, but studies have again demonstrated variable accuracy. Echocardiography remains an accessible tool in the evaluation and management of patients after heart transplantation. This modality can guide clinical judgment with real-time data and several fairly sensitive parameters for the detection of rejection, cardiac allograft vasculopathy, and other abnormalities. Often, auxiliary diagnostic modalities need to be combined to optimize diagnostic accuracy.

Deceased Donor Renal Transplantation: Our Experience at a Tertiary Care Centre in Karnataka, India

Introduction and Objective: End-stage renal disease (ESRD) causes renal failure requiring renal replacement therapies like dialysis or transplantation. [1] With the increasing incidence of diabetes, hypertension and aging population ESRD prevalence is rising [2]. In India, 1,75,000 ESRD patients are added every year out of which only 10% receive renal replacement therapy and 2.4% undergo transplantation. Due to limited live donor pool and stringent rules on unrelated donors there is a significant organ shortage. Deceased Donor Renal Transplantation (DDRT) is an effective solution for bridging the gap in demand and supply [4]. This paper presents our five-year DDRT experience (Jan 2019 – Sept 2024), analysing demographics, outcomes and various other factors highlighting the need to expand DDRT to meet rising demand of renal transplantation among ESRD patients, especially without a live related donor.Methods: A retrospective study was done, and data was compiled and analysed of 32 recipients who underwent deceased donor renal transplantations done between January 2019 – September 2024 under the Department of Urology at our centre. Various donor and recipient characteristics were analysed with other factors affecting the outcome of deceased donor renal transplantation, postoperative complications along with graft and patient survival.Results: The mean recipient age was 45 ± 11 years and donor age was 39 ± 12 years, with 31% of recipients and 22% of donors being female. Chronic interstitial nephritis was the primary cause of ESRD, followed by chronic glomerulonephritis. All patients received preoperative induction with anti-thymocyte globulin (ATG) and postoperative immunosuppression with a Tacrolimus-based regimen. The mean cold ischemia time (CIT) was 573 ± 217 minutes, with CIT &gt;600 minutes showing a statistically significant association with delayed graft function (DGF) and acute rejection (p = 0.038). DGF occurred in 47% of patients, while acute rejection affected 18%, with antibody-mediated rejection (ABMR) as the predominant type (50%). Graft nephrectomy was required in 12.5% of cases, primarily due to ABMR. Post-transplant mortality was 18.8%, mainly due to sepsis and cardiovascular events. Patient survival rates were 76% at 1 year and 73.3% at 2 years, while graft survival was 72% at 1 year and 66.6% at 2 years. Kaplan-Meier analysis showed mean patient survival of 46.6 ± 4.8 months and mean graft survival of 51.6 ± 3.8 months.Conclusion: Our study highlights the effectiveness of DDRT at our centre, with favourable patient and graft survival rates. Our study also concludes that DDRT is an excellent alternative to fill the organ shortage by increasing the donor pool for renal transplantation and improve the outcome and QOL of ESRD patients especially without a live related donor awaiting transplantation.