Purpose Sarcopenia is an increasingly recognised marker of physiological vulnerability in surgical patients, yet its impact on outcomes after kidney transplantation remains unclear. This study evaluated the relationship between psoas muscle index (PMI)–defined sarcopenia and post-transplant outcomes, with a focus on patient survival. Methodology We performed a retrospective cohort study of 331 adult kidney transplant recipients transplanted between 2019 and 2025 at a tertiary centre. Pre-transplant CT-derived PMI at the L3 vertebral level was available for approximately 260 patients and indexed to height. Sarcopenia was defined using established sex-specific thresholds (≤6.6 cm²/m² for males and ≤4.8 cm²/m² for females). PMI was analysed as both categorical and continuous variables. The primary outcome was 12-month mortality. Secondary outcomes included graft-related outcomes, length of stay, and post-operative complications. Multivariable logistic regression adjusted for age, body mass index, frailty score, and dialysis duration. Results Sarcopenia was prevalent and associated with greater frailty and longer dialysis duration. Lower PMI as a continuous measure was associated with increased odds of 12-month mortality on both unadjusted and adjusted analysis, with a trend approaching statistical significance. On adjusted analysis, lower PMI as a continuous measure remained independently associated with mortality, along with dialysis duration. No significant associations were observed between sarcopenia and graft-related outcomes. Urinary and wound complications were the most common post-operative events among sarcopenic recipients. Conclusion PMI-defined sarcopenia identifies kidney transplant recipients at increased risk of early post-transplant mortality but does not predict graft outcomes. Routine assessment of muscle mass using pre-transplant imaging may improve peri-operative risk stratification and inform targeted optimisation strategies.

Purpose: Fibromuscular dysplasia (FMD) is a non-atherosclerotic systemic arterial disease that is not infrequently discovered during kidney donor evaluation (approximately 2-6% of living kidney donors). This can be diagnosed pre-operatively in living donors or intra-operatively/post-operatively in deceased donor allografts. There are no guidelines on renal allografts with FMD. The short and long-term consequences remain uncertain, but it is hypothesised that FMD can cause early graft dysfunction due to renal artery stenosis or dissection. We review the literature on symptomatic renal allografts with FMD and the management techniques. Methodology: A literature review was performed in MedLine, PubMed, and Embase for search terms “fibromuscular dysplasia”, “kidney transplantation” or “renal transplantation”, and “renal artery stenosis”. All relevant articles were included. Results: 19 studies (17 case reports and 2 case reviews) were included and reviewed. Management of FMD in renal allografts were either prophylactically performed or for therapeutic purposes. Prophylactic techniques described include resection of affected segment +/- reconstruction with venous graft or arterial graft. Symptomatic FMD in renal allografts present as graft dysfunction such as hypertensive crisis or rising creatinine. Therapeutic techniques described include open surgical revision and endovascular treatment of renal artery stenosis. Follow up ranged from 1 week to 5 years. Primary outcomes were blood pressure and measured creatinine. Majority of studies showed stable allograft function post intervention, with two studies resulting in transplant nephrectomies. Conclusion: Renal allografts with FMD may have a role in renal transplantation, but clinicians and transplant surgeons must be wary of their potential complications. Both open surgical and endovascular techniques have been described to treat symptomatic FMD or prophylactically treat renal allografts with FMD. Successful treatment has been observed but little is known about long-term outcomes and further studies are warranted.

Purpose Tunnelled dialysis catheters are intended as temporary access, yet in regions with high dialysis demand they frequently become the default rather than a bridge to definitive access. This reliance carries implications for patient outcomes, surgical workload and resource allocation. This study examines tunnelled dialysis catheter insertion over a three-year period at a high-volume centre, aiming to characterise utilisation patterns, access pathways and clinically relevant outcomes. Methodology A retrospective review was undertaken of all tunnelled dialysis catheter insertions performed over a three-year period at a tertiary hospital servicing a high dialysis-burden population. Data collected included patient demographics, indications for catheter insertion, insertion site and setting, operator specialty, early complications, catheter dwell time and progression to definitive vascular access, including arteriovenous fistula or graft formation. Descriptive analysis was used to identify practice patterns and potential areas for service improvement. Results Tunnelled dialysis catheters were widely utilised for both urgent dialysis initiation and ongoing access in patients without immediate alternatives. Preliminary review suggests prolonged catheter dependence in a substantial proportion of patients, reflecting access delays, patient comorbidity and system constraints. While major procedural complications were uncommon, catheter-related morbidity remained clinically relevant. The procedural volume highlights the significant and sustained surgical workload associated with catheter-based access in high-demand settings. Conclusion: Prolonged permacath use was common in this cohort. While no association was observed with age or diabetes, prolonged catheter dependence was associated with delays in access creation and progression through the access pathway. These findings suggest that factors beyond patient characteristics may contribute to extended catheter use. In this context, tunnelled dialysis catheters may not consistently function as short-term bridging access and, in some cases, may represent an initial or sustained mode of dialysis access. Further work is required to better characterise where delays occur within the access pathway and to determine whether targeted system-level interventions may reduce catheter dependence and improve patient outcomes.

Introduction: Existing donor and composite liver transplant scores quantify perioperative risk but largely omit body composition and metabolic mismatch between donor and recipient. A novel VAT-focused donor–recipient scoring system (V-FIT: Visceral Fat and Frailty Index Threshold Score) has been developed to integrate key donor and recipient characteristics, as well as the donation pathway, with the aim of refining the prediction of graft outcomes, particularly early allograft dysfunction (EAD), biliary complications, and long-term survival. The proposed scoring system includes inputs such as donor VAT (high/low), age, steatosis (≥30%/<30%), and DCD/DBD pathway, in addition to recipient VAT, MELD (>20/≤20), age, and steatotic liver disease. Each variable is weighted (DCD = 2, steatosis ≥30% = 2; other adverse factors = 1), resulting in a 0–9 score stratified as low (0–3), medium (4–6), and high risk (7–9), with corresponding recommendations ranging from standard implantation to machine perfusion or graft avoidance. Unlike currently utilized scores, V-FIT is the first to prioritize imaging-defined VAT in both donor and recipient, directly addressing mechanisms such as ischaemia-reperfusion injury, biliary complications, and early allograft dysfunction that are biologically linked to metabolic phenotype rather than BMI alone. Results: The V-FIT Score is expected to show superior discrimination for graft loss and EAD, particularly in obese donors and DCD grafts, by capturing metabolic mismatch. High-risk combinations (for example, high donor and recipient VAT with DCD) are anticipated to be identified, which are associated with increased biliary and ischaemia-reperfusion injury risks, where standard scores may underestimate the danger. Conclusion: Current liver transplant scores quantify surgical and logistic risk but neglect donor–recipient metabolic mismatch. A VAT-based, bidirectional donor–recipient score delivers a novel, mechanistically grounded framework.

Background: Since early reports of combined thoracic–renal transplantation in the late 1970s, dual-organ heart–kidney and lung–kidney transplantation has emerged as a strategy to address irreversible chronic kidney disease (CKD) in thoracic transplant candidates, where calcineurin-inhibitor nephrotoxicity and pre-existing renal dysfunction confer excess mortality and dialysis dependence. Early series demonstrated technical feasibility and suggested lower rejection rates with same-donor concurrent transplantation. Methods: We reviewed contemporary international literature on combined heart–kidney and lung–kidney transplantation, focusing on survival, graft outcomes, and post-transplant dialysis. We also describe the Alfred Health experience (the major heart/lung transplant service in Australia) using Australasian Vascular Audit data from 2010-2025 with 292 renal transplants, including 3 heart–kidney and 3 lung–kidney procedures. Results: Registry and single-centre studies show that simultaneous heart–kidney transplantation improves survival compared with isolated heart transplantation in patients on dialysis or with pre-transplant GFR<40, with 5-year survival of ~70–75% and reduced cardiac rejection and allograft vasculopathy. Lung–kidney transplantation is associated with improved 1–3-year survival and lower dialysis dependence versus isolated lung transplantation in recipients with eGFR<30 or pre-transplant dialysis, though kidney allograft loss is higher than in isolated kidney recipients. Evidence supports considering prophylactic renal transplantation at mGFR<40–50 in selected patients, balancing operative efficiency and renal benefit against graft attrition and allocation ethics. Conclusions: Dual thoracic–renal transplantation offers meaningful survival, immunologic, and renal benefits in patients with advanced cardiorespiratory failure and CKD. Emerging data support prophylactic kidney transplantation in those with mGFR<50 at highest risk of post-transplant renal failure.

Purpose Ex vivo normothermic machine perfusion (EVNMP) provides a near physiological environment for assessment and reconditioning of kidneys prior to transplantation. Although early studies demonstrated feasibility in salvaging marginal donor kidneys, EVNMP protocols remain heterogeneous. This scoping review aimed to characterise human kidney performance during EVNMP and identify priorities for optimisation. Methodology Systematic searches of Embase, MEDLINE, and the Cochrane Library were conducted from 1960 to January 2026. Studies applying EVNMP to human kidneys in pre-clinical and clinical settings were included. Data were extracted on perfusion systems and parameters, perfusate composition, temperature, duration, biomarkers, viability assessment strategies, and transplant outcomes. Results 29 studies were included, 25 used customised circuits and four used commercial systems. Blood-based perfusates were used in 25 studies, with non-cellular perfusates in four. Perfusion strategies varied between pressure and flow controlled approaches, with urine output ranging from 10 to 500 mL/h. Biomarkers were assessed in 20 studies alongside macroscopic appearance and renal blood flow. EVNMP duration ranged from 1–2 hours to ≥24 hours. Approximately 224 discarded kidneys were used in pre-clinical research and 245 kidneys were transplanted following EVNMP, including kidneys that may otherwise have been discarded. Conclusion EVNMP enables human kidneys to function as metabolically active organs ex vivo and has progressed from experimental research to clinical application in kidney salvage for transplantation. Discarded human kidneys have been central to technique development. However, substantial heterogeneity persists across devices, perfusates, temperatures, perfusion parameters, biomarkers, and duration. This review identifies key knowledge gaps and provides a framework to guide EVNMP optimisation and future research.