On the cover: The biology of deceased donor kidney quality. In this issue, two papers explore the biology of deceased donor kidney quality. He et al. (page 2529) examine age-based differences in the intra-renal immune microenvironment of mouse kidney transplants. The recipient-derived cells that infiltrate aged compared to young allografts exhibit more vigorous effector functions that may be result from the higher expression of Class II and costimulation molecules by donor endothelial and epithelial cells. Notably, transplantation of kidneys from aged mice pre-treated with a senolytic, a drug that induces apoptosis of senescent cells, modulated the profile of graftinfiltrating cells and, notably, improved allograft function. Archer et al. (page 2515) aimed to determine whether the transcriptional profile of back-bench human kidney biopsies can predict post-transplant allograft function. The investigators identified that, prior to transplantation, low functioning grafts showed upregulation of innate and adaptive immune response genes and downregulation of metabolic process genes. Three clinical parameters in combination with 13 differentially expressed genes led to the derivation and validation of a risk calculator for kidney allograft function two years after transplantation. Helantera and Divard (page 2497) delve into study design issues and emphasize the importance of not only finding biomarkers but also demonstrating that they yield clinical benefit. Also: Kidney allocation: Complexity begets inefficiency.

This month's installment of “The AJT Report” addresses the ways in which controversial new performance metrics for Organ Procurement Organizations have focused attention on the variability of their performance. Also, the Texas case of a death row inmate requesting to become an organ donor raises ethical questions.

Host immune response to graft commensals promotes allograft rejection resistant to therapies.

This editorial critically reviews the manuscript by Archer (page 2515) which describes the derivation of a risk calculator for post-transplant allograft function by gene expression profiling of deceased donor kidney biopsies.

The authors comment on Reddy et al's insights (page 2661) into a single center's experience with the increased number of organ offers after kidney and liver allocation system changes, emphasizing the increased workload, potential outcomes and possible solutions.

This minireview highlights the vital role of connexin gap junction proteins in endothelial cell health and barrier integrity and discusses its importance as a therapeutic target for solid organ transplantation.

Analysis of OPTN/UNOS data before and after acuity circles policy implementation shows that, despite evidence of increased access to deceased donor livers for the sickest patients, large center- and region-level variation in practice patterns remains.

Breakthrough of COVID-19 cases despite prophylaxis with cilgavimab-tixagevimab in kidney transplant recipients confirm the recent FDA recommendations to increase cilgavimab-tixagevimab dosing.

This retrospective single-center study of solid organ transplant recipients during the Omicron BA.1 era shows that treatment with nirmatrelvir/ritonavir or sotrovimab, compared to no SARS-CoV2-specific treatment, is associated with a lower incidence of 30-day hospitalization or death.

In a case series of graft versus host disease (GVHD) after liver transplantation, the authors detec clonal expansion of anti-host T cells prior to disease onset and suggest that recipient vulnerability to GVHD may tract to their pre-transplant immune status.

The authors present two cases of successful liver transplantation in patients with active COVID-19 infection and discuss the rationale behind the decision to proceed with transplantation.

This article describes 313 healthcare providers in Colorado who were exposed to patients with monkeypox and had low rates of personal protective equipment use and postexposure prophylaxis vaccination. Despite this, through 21 days of follow-up, none of the healthcare providers had acquired monkeypox infection, suggesting the risk for acquiring monkeypox among U.S. healthcare providers is very low. This is reassuring data for organ procurement teams who are exposed to potential organ donors with possible monkeypox infection or undiagnosed skin lesions.