IPTA created the SMARTER Initiative to address persistent gaps in pediatric transplant education worldwide. Through webinars, podcasts, case discussions, and interactive resources, SMARTER provides trainees and allied professionals with accessible, peer-reviewed content across all major organ systems. The program is designed for global reach, with downloadable modules, mobile compatibility, and recorded sessions to accommodate different regions and time zones. Since its launch, SMARTER has shown strong engagement, with fellows reporting that the platform helps them prepare for board exams, improve clinical decision-making, and connect learning directly to patient care. Survey feedback highlights high satisfaction and identifies opportunities for further growth, such as expanded case-based modules, procedural videos, and simulation exercises. By reducing disparities in transplant training and supporting collaboration, SMARTER is positioned to strengthen existing curricula and promote a better-prepared, more globally connected transplant workforce.

Right bundle branch block (RBBB) is commonly seen in post-heart transplant (HT) but the risk factors and long-term implications in pediatric recipients are poorly studied. This study examines the RBBB development and outcomes in pediatric HT patients.

Marfan syndrome (MFS) is a connective tissue disorder associated with significant cardiovascular complications, including heart failure. Orthotopic heart transplantation (OHT) is considered controversial in this population due to concerns about post-transplant aortic complications, particularly in children.

Primary hyperoxaluria type 1 (PH1) is a rare autosomal recessive disorder that leads to systemic oxalosis and end-stage renal disease (ESRD). Before the advent of siRNA therapy, liver transplantation, often combined with kidney transplantation, was the only definitive treatment.

Cytokine release syndrome (CRS) is a frequent early complication of T cell-replete peripheral blood haploidentical hematopoietic stem cell transplantation (PB-haploHSCT), particularly in pediatric recipients. Post-transplant cyclophosphamide (PTCy) is the standard for graft-versus-host disease (GVHD) prophylaxis, but the role of early cyclosporine initiation in this setting remains underexplored.

Machine perfusion (MP) can help expand the donor pool, yet its use in pediatric liver transplantation (LT) has been limited. We aimed to compare the characteristics and outcomes of children undergoing LT with vs. without MP.

The global burden of acute lower respiratory tract infections, including viral etiologies, equated to 725 557 deaths in 2021 in children under 4 years of age. Community-acquired respiratory viral infections (RVI) also carry a high burden among pediatric solid organ transplant recipients (PSOTR), accounting for 14.5% of hospitalizations in the first year post-transplant in an American cohort. This mini review on behalf of the International Pediatric Transplant Association (IPTA) infectious diseases committee discusses novel preventative and prophylactic strategies and includes pertinent updates for vaccine-preventable RVI including influenza, SARS-CoV-2, and RSV in PSOTR.

Over the past 34 years, a single transplant team in São Paulo, Brazil, has performed 1560 pediatric liver transplants (PLT)-including 1352 LDLT, 179 DDT, and 29 domino procedures using donors with maple syrup urine disease-achieving outstanding long-term outcomes. In our most recent cohort of 500 PLT (2018-2024), 1- and 5-year patient survival rates were 96.7% and 94.8%, respectively. From 2015 to 2024, our team performed 35.1% of all PLT in Brazil and 45.5% of those in children under 5 years of age, with 98.1% of the latter using LDLT. This milestone highlights not only clinical achievement but also the persistent structural challenges facing PLT in low- and middle-income countries. We outline some key barriers to sustainable and equitable PLT development in Brazil, including underfunding, geographic disparities, lack of outcome transparency, bureaucratic delays, and gaps in transition to adult care. A set of guiding principles is proposed to support national progress and inform similar efforts elsewhere. Our center's experience demonstrates that excellence in PLT is achievable in resource-constrained settings, but long-term success depends on institutional commitment, strategic investment, and national coordination to ensure equitable access for all children.

Hemophagocytic lymphohistiocytosis (HLH) is a rare complication of solid organ transplantation and is a syndrome of systemic hyperinflammation secondary to dysregulation of the inflammatory response, primarily involving lymphocytes and macrophages. It is often fatal and therefore early recognition and treatment are crucial. Among 11 adult cases of HLH in post-lung transplant cases found in the literature, only one patient survived.

Proteinuria is a relatively frequent complication in both adults and children after kidney transplantation (40%-80%). It is usually mild and predominantly of tubular origin and is caused mainly by rejection, mTOR inhibitors, or hypertension; however, proteinuria could also be in the nephrotic range and of glomerular origin if caused by the recurrence of idiopathic FSGS or rejection. Proteinuria is a risk factor impacting graft and patient survival in adults and graft survival in children. Proteinuria should be assessed by protein/creatinine ratio regularly in pediatric kidney transplant recipients. In children with idiopathic FSGS, proteinuria should be assessed daily during the first 2-3 weeks post-transplant to enable prompt diagnosis of recurrence. The etiology of proteinuria should be identified (recurrence, rejection, mTOR-inhibitors, hypertension, etc.). If no apparent cause is found, a graft biopsy should be considered. Antiproteinuric therapy is primarily focused on treating the causes of the proteinuria, and this is usually done using Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs). The long-term follow-up goal should be normalization of proteinuria with a protein/creatinine ratio < 20 mg/mmol (200 mg/g). Because of the role elevated blood pressure may play in exacerbating proteinuria, antihypertensive medications should be used in those who are resistant to initial antiproteinuric therapy to achieve lower BP.

Solid organ transplantation (SOT) is a life-saving intervention for pediatric patients with end-stage organ failure. Due to the limited availability of pediatric donor organs, organs from older donors are frequently utilized, increasing the risk of age-mismatched transplants. Older donor organs are linked to heightened immunogenicity, rejection rates, and impaired long-term outcomes. Emerging evidence suggests that aged donor organs may transfer senescence to pediatric recipients, accelerating aging-like processes such as frailty, cognitive decline, and organ dysfunction. Additionally, the induction of senescence could alter pediatric conditions like chronic kidney disease (CKD), juvenile idiopathic arthritis (JIA), and pediatric brain tumors which have been linked to augmented senescence. Animal models have shown that older donor organs induce senescence-associated changes in young recipients, including immune dysfunction and physical and cognitive impairments. This review highlights the role of cellular senescence in pediatric organ transplantation and discusses strategies to mitigate its impact. Therapies targeting senescence, such as senolytics, offer a potential approach to improve outcomes in pediatric recipients. Further research is needed to validate these findings in human studies and guide clinical strategies that expand the donor pool while prioritizing age-matched transplantation for pediatric patients.

Hematopoietic stem cell transplantation (HSCT) has become an essential curative strategy for various malignant and non-malignant pediatric diseases. However, HSCT recipients remain highly vulnerable to complications, often requiring pediatric intensive care unit (PICU) admission. Identifying key risk factors and predictors of mortality is crucial for improving patient outcomes. This study aims to evaluate the clinical characteristics, risk factors, and outcomes of pediatric HSCT patients requiring PICU admission, focusing on organ failure, respiratory and cardiovascular dysfunction, and the impact of supportive therapies.

Schimke Immuno-Osseous Dysplasia Is a Rare Autosomal Recessive Multisystem Disorder Caused by Biallelic Pathogenic Variants in the SMARCAL1 Gene, Which Encodes a DNA Annealing Helicase Essential for Replication Fork Stability and Genomic Maintenance. Loss of SMARCAL1 Function Leads to Genomic Instability, Resulting in a Characteristic Clinical Triad of Disproportionate Short Stature, Steroid-Resistant Nephrotic Syndrome and Immunodeficiency. Kidney Transplantation Is the Standard Treatment for End-Stage Renal Disease in Schimke Immuno-Osseous Dysplasia. However, the Underlying Genomic Fragility and Immunodeficiency Heighten the Risk of Post-Transplant Complications, Particularly Epstein-Barr Virus-Associated Post-Transplant Lymphoproliferative Disorder.

Over the last decades, long-term survival after pediatric liver transplantation has improved substantially, highlighting the importance of long-term graft and recipient outcomes. About one in five pediatric liver transplant recipients will develop post-transplant metabolic syndrome (PTMS), a combination of cardiovascular risk factors increasing morbidity and mortality. In contrast to the classical metabolic syndrome (MetS), it is not always characterized by (abdominal) obesity. There are several contributing factors, among which sustained exposure to immunosuppression is a major contributor. As subclinical target organ damage is already present in childhood, cardiometabolic risk factors must be actively sought for and a structured approach including nephrological, endocrinological, and cardiological assessment is necessary. This work provides an overview of the existing literature on screening and management of post-transplant metabolic syndrome and its components. Despite consensus guidelines lacking, a patient-centered, multidisciplinary approach from the transplant team to the primary care providers is crucial to enhance long-term, meaningful survival of pediatric liver transplant recipients.

Parents of children with advanced heart failure face complex, emotionally charged decisions regarding mechanical circulatory support (MCS) and heart transplantation. Understanding their informational needs and decision-making factors is crucial to optimizing their education and providing support.

Heart transplantation is the main treatment for refractory end-stage heart failure in patients of all ages, but its use is limited by the availability of organs, especially in pediatric populations. The International Hospital of Colombia has been a pioneer and the single center with the capability in the country for providing ventricular assist device (VAD) support using the CentriMag/PediMag-Levitronix paracorporeal VAD for pediatric patients awaiting transplant, with over a decade of experience albeit with many challenges.

The use of romiplostim, a thrombopoietin agonist, has increased in the last decade for the treatment of immune mediated thrombocytopenia and severe aplastic anemia. Its utility has been explored in the management of delayed platelet engraftment and secondary platelet failure during stem cell transplant (SCT), but its use has remained largely anecdotal in pediatric allogeneic SCT.

Loss of muscle mass is closely associated with short-term postliver transplant complications in children with biliary atresia. However, studies examining the impact of sarcopenia on long-term outcomes such as growth are very limited.

Monoclonal antibodies, including rituximab and daratumumab, play a pivotal role in the management of antibody-mediated rejection (AMR) following solid organ transplantation. Although generally effective, these agents can induce rare but potentially fatal complications.

Donor-derived cell-free DNA (dd-cfDNA), a biomarker demonstrated to increase with allograft injury, has been considered a possible diagnostic tool for allograft rejection in place of the current gold standard which is invasive kidney biopsies. We tested whether dd-cfDNA levels were predictive of rejection in our single-center cohort of pediatric kidney transplant (KT) recipients.

Clostridioides difficile infection (CDI) poses a significant risk to pediatric hematopoietic stem cell transplant (HSCT) due to microbiome disruption, mucosal injury, and graft versus host disease (GVHD). While oral vancomycin prophylaxis (OVP) is effective for preventing recurrent CDI, evidence for its role in preventing initial infection is limited. Our institution employs empiric OVP during the first HSCT admission to prevent initial CDI.