Comparative outcomes of DSA positive, crossmatch negative living donor kidney transplants versus remaining on the waitlist for an HLA compatible deceased donor.

INTRODUCTION: The clinical relevance of preformed donor specific antibodies in the setting of a negative crossmatch (DSA + XM-) remains controversial. In this study we investigate the outcomes of patients with a DSA + XM- living donor (LDi) who proceeded with an HLA-incompatible (HLAi) transplant compared with those who waited for an HLA-compatible deceased donor (DDc). MATERIALS AND METHODS: We investigated 359 patients on the transplant waiting list who had at least one potential HLAi living donor, from which 203 DSA + XM- pairs were identified and outcomes analysed. RESULTS: Out of 203 patients, 96 (47.3%) received a LD transplant: 52/96 (54.2%) a LDi, and 44/96 (45.8%) an alternative compatible LD. In addition, 107 patients out of 203(52.7%) waited for a DDc, of which 47(43.9%) were subsequently transplanted. Our adjusted analysis showed that the LDi transplantation did not offer a superior patient survival over waiting for a DDc transplant. For those transplanted, there was no difference in patient (p = 0.065) or death censored allograft survival (p = 0.37) between DDc and LDi recipients. However, there was a higher incidence of acute allograft rejection (p = 0.043) and antibody-mediated rejection (p = 0.005) in the LDi group. Having a high pre-transplant calculated reaction frequency and preformed DSA to both class I and class II antigens were associated with inferior outcomes in the LDi transplants. CONCLUSIONS: Given the lack of difference in allograft survival between LDi and DDc transplants, in the absence of an alternative compatible living donor, proceeding with a LDi should be supported despite a higher rejection risk, providing individual risk assessment and shared decision making is undertaken.

Modularity Implications of an Overground Exoskeleton on Plantar Pressures, Strength, and Spasticity in Persons with Acquired Brain Injury.

This study explored the effects of a modular overground exoskeleton on plantar pressure distribution in healthy individuals and individuals with Acquired Brain Injury (ABI). The research involved 21 participants, including ABI patients and healthy controls, who used a unique exoskeleton with adaptable modular configurations. The primary objective was to assess how these configurations, along with factors such as muscle strength and spasticity, influenced plantar pressure distribution. The results revealed significant differences in plantar pressures among participants, strongly influenced by the exoskeleton's modularity. Notably, significant distinctions were found between ABI patients and healthy individuals. Configurations with two modules led to increased pressure in the heel and central metatarsus regions, whereas configurations with four modules exhibited higher pressures in the metatarsus and hallux regions. Future research should focus on refining and customizing rehabilitation technologies to meet the diverse needs of ABI patients, enhancing their potential for functional recovery.

Application of HLA molecular level mismatching in ethnically diverse kidney transplant recipients receiving a steroid-sparing immunosuppression protocol.

Defining HLA mismatch at the molecular compared with the antigen level has been shown to be superior in predicting alloimmune responses, although data from across different patient populations are lacking. Using HLA-Matchmaker, HLA-EMMA and PIRCHE-II, this study reports on the association between molecular mismatch (MolMM) and de novo donor-specific antibody (dnDSA) in an ethnically diverse kidney transplant population receiving a steroid-sparing immunosuppression protocol. Of the 419 patients, 51 (12.2%) patients had dnDSA. De novo DSA were seen more frequently with males, primary transplants, patients receiving tacrolimus monotherapy, and unfavorably HLA-matched transplants. There was a strong correlation between MolMM load and antigen mismatch, although significant variation of MolMM load existed at each antigen mismatch. MolMM loads differed significantly by recipient ethnicity, although ethnicity alone was not associated with dnDSA. On multivariate analysis, increasing MolMM loads associated with dnDSA, whereas antigen mismatch did not. De novo DSA against 8 specific epitopes occurred at high frequency; of the 51 patients, 47 (92.1%) patients with dnDSA underwent a pretreatment biopsy, with 21 (44.7%) having evidence of alloimmune injury. MolMM has higher specificity than antigen mismatching at identifying recipients who are at low risk of dnDSA while receiving minimalist immunosuppression. Immunogenicity consideration is important, with more work needed on identification, especially across different ethnic groups.

Observational Study About the Impact of Simulation Training of Non-Technical Skills on Teamwork: Towards a Paradigm Shift in Undergraduate Medical Training.

INTRODUCTION: Recently, simulation as an educational method has gained increasing importance in Medicine. However, medical education has favored the acquisition of individual knowledge and skills, while overlooking the development of teamwork skills. Since most errors in clinical practice are due to human factors, i.e., non-technical skills, the aim of this study was to assess the impact that training in a simulation environment has on teamwork in an undergraduate setting. MATERIAL AND METHODS: This study took place in a simulation center, with a study population of 23 participants, fifth year undergraduate students, randomly divided into teams of four elements. Twenty simulated scenarios of teamwork in the initial assessment and resuscitation of critically ill trauma patients were recorded. Video recordings were made at three distinct learning moments (before training, end of the semester, and six months after the last training), and a blinded evaluation was performed by two independent observers, who applied the Trauma Team Performance Observation Tool (TPOT). Additionally, the Team STEPPS Teamwork Attitudes Questionnaire (T-TAQ) was applied to the study population before and after the training to assess any change in individual attitudes towards non-technical skills. A 5% (or 0.05) significance level was considered for statistical analysis. RESULTS: With a moderate level of inter-observer agreement (Kappa = 0.52, p = 0.002), there was a statistically significant improvement in the team's overall approach, evidenced by the TPOT scores (median of 4.23, 4.35 and 4.50, in the three time-points assessed, respectively, p = 0.003). In the T-TAQ, there was an improvement in non-technical skills, that was statistically significant for "Mutual Support" (median from 2.50 to 3.00, p = 0.010). CONCLUSION: In this study, incorporating non-technical skills education and training in undergraduate medical education was associated with sustained improvement in team performance in the approach to the simulated trauma patient. Consideration should be given to introducing non-technical skills training and teamwork in the emergency setting during undergraduate training.

Histopathological growth patterns and tumor-infiltrating lymphocytes in breast cancer liver metastases.

Liver is the third most common organ for breast cancer (BC) metastasis. Two main histopathological growth patterns (HGP) exist in liver metastases (LM): desmoplastic and replacement. Although a reduced immunotherapy efficacy is reported in patients with LM, tumor-infiltrating lymphocytes (TIL) have not yet been investigated in BCLM. Here, we evaluate the distribution of the HGP and TIL in BCLM, and their association with clinicopathological variables and survival. We collect samples from surgically resected BCLM (n = 133 patients, 568 H&E sections) and post-mortem derived BCLM (n = 23 patients, 97 H&E sections). HGP is assessed as the proportion of tumor liver interface and categorized as pure-replacement ('pure r-HGP') or any-desmoplastic ('any d-HGP'). We score the TIL according to LM-specific guidelines. Associations with progression-free (PFS) and overall survival (OS) are assessed using Cox regressions. We observe a higher prevalence of 'any d-HGP' (56%) in the surgical samples and a higher prevalence of 'pure r-HGP' (83%) in the post-mortem samples. In the surgical cohort, no evidence of the association between HGP and clinicopathological characteristics is observed except with the laterality of the primary tumor (p value = 0.049) and the systemic preoperative treatment before liver surgery (p value = .039). TIL is less prevalent in 'pure r-HGP' as compared to 'any d-HGP' (p value = 0.001). 'Pure r-HGP' predicts worse PFS (HR: 2.65; CI: (1.45-4.82); p value = 0.001) and OS (HR: 3.10; CI: (1.29-7.46); p value = 0.011) in the multivariable analyses. To conclude, we demonstrate that BCLM with a 'pure r-HGP' is associated with less TIL and with the worse outcome when compared with BCLM with 'any d-HGP'. These findings suggest that HGP could be considered to refine treatment approaches.

Algae as a potential source of protein meat alternatives.

With the rise of plant-based meat alternatives, there is a growing need for sustainable and nutritious sources of protein. Alga is a rich protein source, and initial studies show that it can be a good component in developing protein meat alternatives. However, there are certain limitations in their use as the need for efficient and optimal technical process in large-scale protein extraction and purification, as well as overcoming certain negative effects such as potentially harmful compounds, allergenicity issues, or sensorial affections, especially in color but also in textural and flavor characteristics. This review offers a vision of the fledgling research about using alga protein in the development of meat alternatives or supplementing meat products.

Effects of Unconventional Work and Shift Work on the Human Gut Microbiota and the Potential of Probiotics to Restore Dysbiosis.

The work environment is a factor that can significantly influence the composition and functionality of the gut microbiota of workers, in many cases leading to gut dysbiosis that will result in serious health problems. The aim of this paper was to provide a compilation of the different studies that have examined the influence of jobs with unconventional work schedules and environments on the gut microbiota of workers performing such work. As a possible solution, probiotic supplements, via modulation of the gut microbiota, can moderate the effects of sleep disturbance on the immune system, as well as restore the dysbiosis produced. Rotating shift work has been found to be associated with an increase in the risk of various metabolic diseases, such as obesity, metabolic syndrome, and type 2 diabetes. Sleep disturbance or lack of sleep due to night work is also associated with metabolic diseases. In addition, sleep disturbance induces a stress response, both physiologically and psychologically, and disrupts the healthy functioning of the gut microbiota, thus triggering an inflammatory state. Other workers, including military, healthcare, or metallurgy workers, as well as livestock farmers or long-travel seamen, work in environments and schedules that can significantly affect their gut microbiota.

Steroid Sparing Maintenance Immunosuppression in Highly Sensitised Patients Receiving Alemtuzumab Induction.

This analysis reports on the outcomes of two different steroid sparing immunosuppression protocols used in the management of 120 highly sensitised patients (HSPs) with cRF>85% receiving Alemtuzumab induction, 53 maintained on tacrolimus (FK) monotherapy and 67 tacrolimus plus mycophenolate mofetil (FK + MMF). There was no difference in the median cRF or mode of sensitisation between the two groups, although the FK + MMF cohort received more poorly matched grafts. There was no difference in one-year patient or allograft survival, however rejection free survival was inferior with FK monotherapy compared with FK + MMF at 65.4% and 91.4% respectively, p < 0.01. DSA-free survival was comparable. Whilst there was no difference in rates of BK between the cohorts, CMV-free survival was inferior in the FK + MMF group at 86.0% compared with 98.1% in the FK group, p = 0.026. One-year post-transplant diabetes free survival was 89.6% and 100.0% in the FK and FK + MMF group respectively, p = 0.027, the difference attributed to the use of prednisolone to treat rejection in the FK cohort, p = 0.006. We report good outcomes in HSPs utilising a steroid sparing protocol with Alemtuzumab induction and FK + MMF maintenance and provide granular data on immunological and infectious complications to inform steroid avoidance in these patient groups.

Application of the Banff Human Organ Transplant Panel to kidney transplant biopsies with features suspicious for antibody-mediated rejection.

The Banff Classification for Allograft Pathology includes the use of gene expression in the diagnosis of antibody-mediated rejection (AMR) of kidney transplants, but a predictive set of genes for classifying biopsies with 'incomplete' phenotypes has not yet been studied. Here, we developed and assessed a gene score that, when applied to biopsies with features of AMR, would identify cases with a higher risk of allograft loss. To do this, RNA was extracted from a continuous retrospective cohort of 349 biopsies randomized 2:1 to include 220 biopsies in a discovery cohort and 129 biopsies in a validation cohort. The biopsies were divided into three groups: 31 that fulfilled the 2019 Banff Criteria for active AMR, 50 with histological features of AMR but not meeting the full criteria (Suspicious-AMR), and 269 with no features of active AMR (No-AMR). Gene expression analysis using the 770 gene Banff Human Organ Transplant NanoString panel was carried out with LASSO Regression performed to identify a parsimonious set of genes predictive of AMR. We identified a nine gene score that was highly predictive of active AMR (accuracy 0.92 in the validation cohort) and was strongly correlated with histological features of AMR. In biopsies suspicious for AMR, our gene score was strongly associated with risk of allograft loss and independently associated with allograft loss in multivariable analysis. Thus, we show that a gene expression signature in kidney allograft biopsy samples can help classify biopsies with incomplete AMR phenotypes into groups that correlate strongly with histological features and outcomes.

Effect of Partial Meat Replacement by Hibiscus sabdariffa By-Product and Pleurotus djamor Powder on the Quality of Beef Patties.

The effects of Hibiscus sabdariffa (roselle; Hs) by-product (2-5%) and Pleurotus djamor (pink oyster; Pd) powder (5-7.5%) as meat replacers on the physicochemical and sensorial properties of beef patties were analyzed. The addition of these non-meat ingredients significantly decreased moisture and increased fiber content, and did not affect the protein level of the product. The antioxidant effect of the roselle by-product was limited, while Pleurotus djamor favored the oxidation processes. The samples supplemented with roselle by-product and mushroom powder presented significantly lower microbial counts (total viable counts, enterobacteria, and Pseudomonas) than control, but texture and sensorial parameters were significantly affected. The patties darkened due to the presence of the Hibiscus by-product, while the color of the samples containing 5% Pleurotus djamor was hardly modified. These samples, together with the control samples, were the most sensorially appreciated. The addition of these ingredients provoked a decrease in texture parameters, being less pronounced in the samples with only 2% of roselle by-product. In spite of the good antimicrobial and antioxidant properties of Hibiscus by-products, its inclusion in meat should be moderate (2-2.5%) to avoid consumer rejection when Pleurotus djamor is also included in the formulation.

STELO: A New Modular Robotic Gait Device for Acquired Brain Injury-Exploring Its Usability.

In recent years, the prevalence of acquired brain injury (ABI) has been on the rise, leading to impaired gait functionality in affected individuals. Traditional gait exoskeletons are typically rigid and bilateral and lack adaptability. To address this, the STELO, a pioneering modular gait-assistive device, was developed. This device can be externally configured with joint modules to cater to the diverse impairments of each patient, aiming to enhance adaptability and efficiency. This study aims to assess the safety and usability of the initial functional modular prototype, STELO, in a sample of 14 ABI-diagnosed participants. Adverse events, device adjustment assistance and time, and gait performance were evaluated during three sessions of device use. The results revealed that STELO was safe, with no serious adverse events reported. The need for assistance and time required for device adjustment decreased progressively over the sessions. Although there was no significant improvement in walking speed observed after three sessions of using STELO, participants and therapists reported satisfactory levels of comfort and usability in questionnaires. Overall, this study demonstrates that the STELO modular device offers a safe and adaptable solution for individuals with ABI, with positive user and therapist feedback.

A DFT Study of the Reaction of Acrylamide with L-Cysteine and L-Glutathione.

Thermal processing of certain foods implies the formation of acrylamide, which has been proven to provoke adverse effects on human health. Thus, several strategies to mitigate it have been developed. One of them could be the application of organosulfur compounds obtained from natural sources to react with the acrylamide, forming non-toxic adducts. A DFT study of the acrylamide reaction with the organosulfur model compounds L-cysteine and L-glutathione by Michael addition and a free radical pathway complemented by a kinetic study of these model molecules has been applied. The kinetic evaluation results demonstrate that the L-glutathione reaction exhibited a higher rate constant than the other studied compound.

Chemical, Physicochemical and Sensorial Characterization of Nitrite-Free Dry-Cured Bísaro Shoulders.

The aim of the current experiment was to characterize and evaluate the effect of the dry-curing process on chemical composition, physicochemical properties, and sensory characteristics of the dry-cured Bísaro shoulders. For this purpose, thirty-eight raw forelegs were used, and no nitrites were added during the dry-curing process. This process increased protein, fat, ash content, and pH, with a decrease in moisture and water activity (p < 0.001). The dry-cured shoulders were darker (L*), less red (a*), and less yellow (b*) than the raw shoulders (p < 0.001), and this may be mainly due to the moisture reduction. The proportion of polyunsaturated fatty acids (PUFA) decreased during processing, whereas the saturated fatty acids (SFA) and monounsaturated fatty acids (MUFA) increased (p < 0.001), which could be related with the oxidative degradation. The sensory analysis showed that dry-cured Bísaro shoulders presented similar organoleptic characteristics to other dry-cured meat products. Also, the chemical composition and fatty acid profile of the dry-cured Bísaro shoulder showed results comparable to those of other cured products. This study revealed that it is possible to obtain safer and healthier dry-cured Bísaro shoulder products judging by these characteristics, since nitrites were not added in its preparation. These findings, along with the product's high sensory attributes similar to more popular products such as ham, would give more advantage for its acceptability and market demand.

Natural Antimicrobials: A Clean Label Strategy to Improve the Shelf Life and Safety of Reformulated Meat Products.

Meat is a nutrient-rich matrix for human consumption. However, it is also a suitable environment for the proliferation of both spoilage and pathogenic microorganisms. The growing demand to develop healthy and nutritious meat products with low fat, low salt and reduced additives and achieving sanitary qualities has led to the replacement of the use of synthetic preservatives with natural-origin compounds. However, the reformulation process that reduces the content of several important ingredients (salt, curing salts, etc.), which inhibit the growth of multiple microorganisms, greatly compromises the stability and safety of meat products, thus posing a great risk to consumer health. To avoid this potential growth of spoiling and/or pathogenic microorganisms, numerous molecules, including organic acids and their salts; plant-derived compounds, such as extracts or essential oils; bacteriocins; and edible coatings are being investigated for their antimicrobial activity. This review presents some important compounds that have great potential to be used as natural antimicrobials in reformulated meat products.

Antioxidant Effect of Pumpkin Flower (Cucurbita maxima) in Chicken Patties.

In this work, the antioxidant effect of pumpkin flower powder was evaluated in chicken patties. For this purpose, three drying methods were proposed to obtain the pumpkin flower powder and preserve its properties (antioxidants, color, odor): foam-mat drying, freeze drying, and oven drying. The drying process of the powder plays an important role in the conservation of bioactive compounds. The foam-mat drying method would allow the preservation of these compounds after cooking and after cold storage due to encapsulation like mechanism of the added proteins. Thus, these powders were selected as the most adequate vehicle to incorporate in the formulation, since patties with these additives presented the better antioxidant scores for DPPH, ABTS, and FRAP even after 7 days of storage. In addition, total polyphenolic content and the presence or thiobarbituric acid reactive substances (TBARS) were better scored in samples with the pumpkin flowers. The incorporation of the pumpkin flower additives in the patty formulation improved sensorial attributes of the chicken patties and consumers acceptance after cold storage.

Can the Introduction of Different Olive Cakes Affect the Carcass, Meat and Fat Quality of Bísaro Pork?

The present study aimed to evaluate the effect of the inclusion of different olive cakes in the diet of Bísaro pigs on the carcass, meat and fat. The carcasses of 40 animals fed a diet with five treatments (T1­Basic diet and commercial feed; T2­Basic diet + 10% crude olive cake; T3­Basic diet + 10% olive cake, two phases; T4­Basic diet + 10% exhausted olive cake; T5­Basic diet + 10% exhausted olive cake + 1% olive oil) were used to study the effect on carcass traits, physicochemical meat quality and lipid composition of meat and backfat. There were no significant differences between treatments for the conformation measurements performed, except for the length at the seventh and last rib (p < 0.05). The percentage of prime cuts of the carcass in Bísaro pig is within the values indicated by the Portuguese Standard 2931. No significant differences between treatments for body weight, pH and carcass weight were found. The values of ultimate pH (5.7), L* (51−52), b* (11−12) and SF (3.4−4.2) observed confirm a non-exudative and firm meat without quality deviations, such as DFD or PSE. Thus, as a general conclusion, the inclusion of different olive cakes in the diet of Bísaro pigs did not cause any negative consequences on the carcass characteristics and conformation as well as in the meat and lipidic quality. In addition, the inclusion of this olive industry by-product in the animal diet would be an important contribution to solving the problem of the great environmental impact from olive-mill wastewaters from the extractive industries.

Enhanced removal of neonicotinoid pesticides present in the Decision 2018/840/EU by new sewage sludge-based carbon materials.

Due to the increasingly strict legislation about the disposal of sewage sludge, it is necessary to find sustainable solutions to manage this waste at low-cost conditions. In addition, priority contaminants are now attracting much attention since they are usually detected in WWTP effluents. In this work, five sludge have been used as precursors for the synthesis of activated carbons subsequently tested in the removal by adsorption of three neonicotinoid pesticides listed in the EU Watch List: acetamiprid (ACT), thiamethoxam (THM), and imidacloprid (IMD). Generally, the activated carbons were prepared by chemical activation using ZnCl2 as an activating agent and then the resulting materials were pyrolyzed at 800 °C for 2 h. The synthesized activated carbons showed different textural properties; thus, the best adsorption results were found for AC-Industrial activated carbon, obtained from an industrial origin sewage sludge, with high equilibrium adsorption capacities (qe = 104.2, 137.0, and 119.9 mg g-1), for ACT, THM, and IMD, respectively. Furthermore, it was elucidated that the use of CO2 in the synthesis generated an opening, followed by widening, of the narrowest microporosity, increasing the specific surface area of the carbon materials. The kinetic and isotherm adsorption experimental data were obtained for each of the pesticide-activated carbon systems; thus, the kinetic curves were well-fitted to the pseudo-second-order kinetic model, as well as, Freundlich and Guggenheim-Anderson-de Boer (GAB) empirical models were used for the fitting of the equilibrium adsorption isotherms, finding that GAB model best fitted the experimental data. Additionally, the regeneration of the activated carbons using methanol as a regenerating agent and the single and simultaneous adsorption of a hospital wastewater effluent, fortified with the three studied pesticides have been explored.

Fluorescence assay for acrylamide determination in fried products based on AgInS2/ZnS quantum dots.

AgInS2/ZnS quantum dots were synthesized via solvothermal aqueous phase method using 3-mercaptopropionic acid as the stabilizer. AgInS2/ZnS quantum dots were employed for acrylamide sensing under two strategies: (1) quenching of the fluorescence signal by the synthesis of polyacrylamide under UV light and (2) use of 2-naphthalenethiol for quenching of the fluorescence signal of quantum dots followed by a recovery of the signal after the addition of acrylamide. Both methodologies display adequate limits of detection, 15.6 and 4.8 µg L-1, respectively. However, the 2-napthalenethiol based method exhibited better precision and selectivity compared to the other methodology. Both methodologies were applied for acrylamide detection in fried snack products and acceptable accuracy was obtained using 2-napthalenethiol method.

Functional fermented meat products with probiotics-A review.

Fermentation has been an important strategy in the preservation of foods. The use of starter cultures with probiotic activity has gained the attention of researchers to produce functional fermented meat products. This review aims to overview the main strengths, weakness, opportunities and threats of fermented meat products with probiotics. Fermented meat products can be considered as a relevant matrix for the delivery of probiotics with potential health benefits. Moreover, fermented meat products produced by traditional methods are sources of probiotics that can be explored in the production of functional meat products. However, some barriers are limit the progression with these products: the complex selection process to obtain new and tailored probiotic strains, the current perception of healthiness associated with meat and meat products, and the limited application of probiotic to fermented sausages. Promising opportunities to improve the value of functional fermented meat products have been developed by exploring new meat products as functional fermented foods, improving the protection of probiotics with microencapsulation and improving the quality of meat product (reducing nitrate and nitrate salts, adding dietary fibre, and exploring the inherent antioxidant and cardioprotective activity of meat products). Attention to potential threats is also indicated such as the unclear future changes in meat and meat products consumption due to changes in consumer preferences and the presence of competitors (dairy, fruit and vegetable-based products, for instance) in more advanced stages of development and commercialization. SIGNIFICANCE AND IMPACT OF STUDY: This review provides an overview of the Strengths, Weakness, Opportunities and Threats related to the development of functional fermented meat products with probiotics. Internal and external factors that explain the current scenario and strategies to advance the production are highlighted.

Diagnostic application of transcripts associated with antibody-mediated rejection in kidney transplant biopsies.

BACKGROUND: The diagnosis of antibody-mediated rejection (AMR) is reached using the Banff Classification for Allograft Pathology, which now includes gene expression analysis. In this study, we investigate the application of 'increased expression of thoroughly validated gene transcripts/classifiers strongly associated with AMR' as diagnostic criteria. METHOD: We used quantitative real-time polymerase chain reaction for 10 genes associated with AMR in a retrospective cohort of 297 transplant biopsies, including biopsies that met the full diagnostic criteria for AMR, even without molecular data (AMR, n = 27), biopsies that showed features of AMR, but that would only meet criteria for AMR with increased transcripts [suspicious for AMR (AMRsusp), n = 49] and biopsies that would never meet criteria for AMR (No-AMR, n = 221). RESULTS: A 10-gene AMR score trained by a receiver-operating characteristic to identify AMR found 16 cases with a high score among the AMRsusp cases (AMRsusp-high) that had significantly worse graft survival than those with a low score (AMRsusp-low; n = 33). In both univariate and multivariate Cox regression analysis, the AMR 10-gene score was significantly associated with an increased hazard ratio (HR) for graft loss (GL) in the AMRsusp group (HR = 1.109, P = 0.004 and HR = 1.138, P = 0.012, respectively), but not in the whole cohort. Net reclassification index and integrated discrimination improvement analyses demonstrated improved risk classification and superior discrimination, respectively, for GL when considering the gene score in addition to histological and serological data, but only in the AMRsusp group, not the whole cohort. CONCLUSIONS: This study provides evidence that a gene score strongly associated with AMR helps identify cases at higher risk of GL in biopsies that are suspicious for AMR but do not meet full criteria.