Transplantation

BACKGROUND: Increased left ventricular mass (LVM) at a single time point after heart transplantation (HT) predicts future adverse outcomes. However, dynamic changes in LVM could have better biological relevance and reflect adverse graft remodeling (AGR). The prognostic significance of such serial changes has not been studied. METHODS: Using an automated, electronic health record-based institutional data infrastructure, we studied 439 HT recipients with 5,563 LVM measurements. Separate Bayesian joint models estimated the simultaneous associations of current LVM and its instantaneous rate of change with graft dysfunction (GD) and mortality. A joint-model-derived remodeling score combining patient-specific deviations in LVM and slope was dichotomized to define AGR and non-AGR groups. A mixed-effects analysis of all clinical variables was performed to assess associations with LVM both between and within patients. An independent cohort of 35 patients with 79 surveillance-biopsy RNA-sequencing samples was used to examine early stress-responsive pathways associated with the remodeling score. RESULTS: LVM declined by approximately 7 g/year after transplantation, with regression attenuating over time. Sixty patients (13.7%) had GD, and 75 (17.1%) died. Higher LVM was associated with subsequent GD (hazard ratio [HR] per 10 g, 1.14; 95% credible interval [CrI], 1.02-1.28) and mortality (HR, 1.10; 95% CrI, 1.02-1.19). A more positive LVM slope was associated with GD (HR per 1 g/year, 1.21; 95% CrI, 1.06-1.42) and with cardiac allograft vasculopathy (CAV) grade 2 or 3 (HR, 1.39; 95% Crl, 1.02-1.96). LVM regressed more slowly in the AGR group (-5.8 vs -8.4 g/year), with higher GD (21.0% vs 6.4%) and mortality (24.2% vs 10.0%). Time-updated GD was associated with subsequent death (HR, 8.12; 95% Confidence Interval [CI], 4.67-14.14). Transcriptomic analysis showed enrichment of interferon-mediated signaling and vascular endothelial activation with higher remodeling scores, whereas lower scores were associated with mitochondrial and metabolic processes, ribosome biogenesis, and pathways related to tissue repair and stress responses. CONCLUSIONS: AGR is an easily accessible imaging biomarker that reflects the changes in the allograft in response to various stressors and predicts future adverse outcomes. Discovery of molecular mechanisms of AGR could lead to novel therapies to protect the allograft from chronic rejection.

Background: Adult congenital heart disease (ACHD) patients are prone to HLA-antibody formation from multiple surgeries, transfusions, and prosthetic surgical material. Females with ACHD may accrue additional, non-surgical alloantigen exposure. Whether sex modifies the impact of allosensitization on heart transplant (HT) access and outcomes in ACHD remains unknown. Methods: We retrospectively analyzed the OPTN/UNOS registry of adults with ACHD listed for first-time HT (2018-2025). Sensitization was defined by calculated panel reactive antibodies (cPRA) at listing. We tested the sex x sensitization (highly sensitized, cPRA >50%) interaction on transplant access using Fine-Gray competing-risks regression, treating transplantation as the event of interest and death or removal from the waitlist as competing events, and on post-transplant survival using multivariable Cox proportional-hazards regression, both adjusted for age at listing, mechanical support at listing, and the number of distinct prior cardiac surgery categories. Results: Among 856 candidates (38% female), females were more often highly sensitized than males (23% vs 14%; age-adjusted OR 1.81, 95% CI 1.26-2.61), even after adjusting for surgical burden. Sensitization reduced transplant access in females (84% to 71%; median wait 60 to 110 days, p < 0.001) but not males (79% vs 79%, median wait 88 vs 98 days). In adjusted Fine-Gray models, the subdistribution hazard for transplant was reduced in sensitized females (sHR 0.54, 95% CI 0.41-0.72) with no effect in males (sHR 0.96, 95% CI 0.73-1.26), and the sex x sensitization interaction was significant (interaction sHR 0.64, 95% CI 0.44-0.94, p = 0.02). Post-transplant mortality was numerically higher in sensitized than non-sensitized candidates in both sexes and the sex x sensitization interaction on 1-year mortality was not significant. The sex-asymmetric effect persisted and was more pronounced in the multiorgan candidates. Conclusions: Allosensitization is not a sex-neutral barrier to transplant in HT candidates with ACHD. Females are more sensitized and have reduced transplant access without differences in 1-year mortality. The female excess in sensitization is not accounted for by surgical burden, and the exposures responsible remain to be defined. These findings warrant a sex-aware listing strategy and further studies.

Haplo-identical hematopoietic cell transplantation (haploHCT) is an integral treatment paradigm for patients with leukemia. While overall survival (OS) post-haploHCT has steadily improved, relapse-free survival (RFS) remains relatively stagnant. Upon the discovery of killer immunoglobulin-like receptors (KIRs) on natural killer (NK) cells and their cognate human leukocyte antigen (HLA) ligands, algorithms have been developed to enhance graft versus leukemia effects. However, these algorithms fail to yield consistent predictions in patient outcomes. We utilized a combination of in silico protein folding and interactions to determine KIR:HLA reactivity in conjunction with in vitro acoustic force microscopy to measure cell avidity (CA) as a readout for KIR signal strength. CA was determined using monoallelic HLA expressing K562 cell lines, monoallelic KIR Jurkat cells, and peripheral blood NK cells. We extended the CA results and performed standard cytotoxicity assays as well. We discovered that HLA-B*35 interacts with KIR2DS4. We applied the newly discovered interaction to predict outcomes for HCT patients. Stratifying patients based on their HLA-B*35 positivity and donor KIR2DS4 status, we delineated a correlation to survival (P=0.061) when donors only had full-length KIR2DS4. Patients who received a haploHCT and NK cell addback from donors with only full-length KIR2DS4 had a significantly improved RFS (P=0.001) and OS (P=0.016) compared to truncated (KIR1D) and full-length KIR2DS4 donors. This was independently validated in a diverse 10/10 HLA matched European cohort with RFS (P=0.0255) and OS (P=0.0388). Thus, the identified novel KIR2DS4:HLA-B*35 interaction axis predicts patient survival, in both haplo-identical and fully matched, HCT and highlights that our current understanding of the KIR:HLA interactome is incomplete and requires remapping for enhanced therapeutic applications.

Purpose: Adults with high- or very high-risk acute leukemia (AL) or myelodysplastic syndrome (MDS) face substantial relapse risk after allogeneic hematopoietic stem-cell transplantation. We evaluated single-unit cord blood (CB) transplantation after ex vivo expansion with UM171 in this population. Patients and Methods: Two prospective, single-arm phase II trials at four centers enrolled 64 adults with high- or very high-risk AL or MDS; 60 received a UM171-expanded CB transplant and comprised the analysis population. CB units were preferentially selected at a 5/8 HLA match to maximize the graft versus leukemia effect. Patients received intermediate- or high-intensity conditioning with tacrolimus/mycophenolate mofetil graft-versus-host-disease (GVHD) prophylaxis. Endpoints included safety, feasibility, non-relapse mortality (NRM), relapse-free survival (RFS), overall survival (OS), GVHD, GVHD-free relapse-free survival (GRFS), chronic GVHD-free relapse free survival (CRFS). Results: Thirty-two percent of patients had undergone previous transplantation, 17% of patients with AL were not in remission and 24% of those with AML/MDS had TP53 mutations. Of 62 patients who remained eligible for transplantation, 60 had a graft successfully manufactured and infused. Median times to neutrophil and platelet engraftment were 17 and 38 days, respectively. NRM was 5.1% at day 100 and 15.2% at 1 year. Two-year cumulative incidence of relapse was 22.3%. Two-year OS and RFS were 63.9% and 60.4%, respectively. Grade III-IV acute GVHD incidence was 20.3% at 1 year and moderate-to-severe chronic GVHD incidence was 6.8% at 2 years. Conclusion: UM171-expanded CB transplantation was feasible and provided prompt engraftment, durable disease control, and infrequent clinically significant chronic GVHD in adults with high- and very high-risk AL/MDS. Comparative studies are warranted to define its role relative to contemporary donor platforms.

The human kidney contains highly specialized cell populations. Despite numerous single-cell and single-nucleus transcriptomics studies, differences in cohorts, technologies, analytical pipelines, and annotation frameworks have limited the ability to define consensus kidney cell states, identify disease-associated populations and interpret kidney disease genetic susceptibility. Here, we assembled 18 human kidney single-cell and single-nucleus RNA-sequencing datasets spanning 232 donors and five major disease contexts into a uniformly processed and computationally integrated Human Kidney Cell Atlas (HKCA), comprising over one million high-quality cells (816,895) and nuclei (215,308). The HKCA resolves 63 cell types and 120 harmonized cell states, including rare epithelial and stromal populations associated with kidney diseases. Integration with spatial transcriptomics, intercellular communication networks, and human genetic association data further defined the anatomical context and disease relevance of these populations. The HKCA also provides a framework for automated annotation of independent kidney human and mouse datasets. Together, the HKCA establishes a comprehensive reference for human kidney biology, enabling disease interpretation and genetic risk localization at cellular resolution.

Background Cardiac magnetic resonance imaging (CMR) T1 and T2 mapping accurately detect acute heart transplant rejection, but the diagnostic value of CMR-derived strain imaging remains uncertain, particularly for right ventricular strain. Data incorporating donor-derived cell-free DNA (dd-cfDNA) into a composite reference standard are limited. We evaluated the diagnostic accuracy of CMR-derived left and right ventricular strain and ejection fraction for detecting acute rejection in pediatric and adult heart transplant recipients. Methods Blinded analysis of 1.5T CMR studies was performed in pediatric and adult heart transplant recipients 1-24 months post-transplant, as well as during five additional episodes of acute rejection occurring 3-14 years post-transplant. Left and right ventricular strain and ejection fraction were quantified using semi-automated post-processing. Acute rejection was defined using a composite reference standard comprising endomyocardial biopsy (EMB), clinical assessment, and dd-cfDNA. Diagnostic performance was assessed using cut-off values derived from receiver operator characteristic (ROC) analysis. Results Among 214 CMR studies in 58 patients, 13 cases of acute rejection were identified. Diagnostic performance for detecting acute rejection was moderate for pediatric right ventricular longitudinal strain (AUC 0.782, 95% CI 0.565-0.999), whereas all other cardiac functional parameters demonstrated limited discrimination in both pediatric and adult patients (AUC 0.536-0.739). Models based on individual rejection indicators (EMB, clinical assessment, and dd-cfDNA) also showed poor diagnostic accuracy. Conclusion CMR-derived left and right ventricular strain and ejection fraction demonstrated limited ability to independently detect acute rejection. However, strain abnormalities, particularly RVLS in pediatric patients, may reflect downstream functional effects in more advanced rejection and may complement T1 and T2 mapping in assessing rejection severity.

Pre-infusion cerebrospinal fluid (CSF) proteomics may enable risk stratification for immune effector cell-associated neurotoxicity syndrome (ICANS) after chimeric antigen receptor T-cell therapy, but disease-specific baseline variation may influence biomarker interpretation. We compared pre-infusion CSF proteomic profiles from 28 patients with diffuse large B-cell lymphoma (DLBCL) and 9 with multiple myeloma (MM). Although principal component analysis showed substantial overlap, orthoPLS-DA identified significant disease-associated discrimination supported by permutation testing. Proteins contributing to this separation were enriched for plasma cell-related, extracellular, and metabolic signatures. ICANS occurred in 7 of 28 DLBCL patients but in none of the 9 MM patients. MM cases aligned with the ICANS-negative group in binary analysis while remaining distinct from both DLBCL subgroups in three-group analysis. These findings indicate that pre-infusion CSF proteomics captures disease-specific molecular structure that should be considered when developing and interpreting biomarkers of CAR-T-associated neurotoxicity.

BACKGROUND: The transport and storage conditions of thawed plasma are not strictly regulated by the FDA and applying red blood cell transport standard of 1-10 degrees Celcius to recently thawed plasma often results in high discard rates. This study evaluated the extended 120-hour (5-day) coagulation factor stability and sterility of thawed plasma frozen within 24 hours (PF24) following a 6-hour transport cooler simulation. STUDY DESIGN AND METHODS: Fourteen PF24 units (8 group O, 6 group B) were thawed at 30-37 degrees Celcius and assigned as control (n=7, direct 1-6 degrees Celcius refrigeration) or experiment (n=7) units. Experiment units were held at room temperature for 30 minutes, stored in validated transport coolers for 6 hours, and then transferred to 1-6 degrees Celcius refrigeration. Measurements of temperature, prothrombin time (PT), Factor V (FV) activity, and Factor VIII (FVIII) activity were conducted at 0-, 6-, 24-, and 120-hour post-thaw. Sterility testing was performed at 0-hour and 120-hour using automated aerobic and anaerobic blood cultures. RESULTS: No statistically significant differences were observed between control and experiment units at 120-hour for mean PT (15.09 vs. 15.16 seconds, p = .44), FV activity (81.14 vs. 74.57%, p = .23), or FVIII activity (61.86 vs. 53.00%, p = .22). Delta analysis (120h-0h) confirmed equivalent factor decay rates between groups. All bacterial cultures showed no growth at 120-hour. CONCLUSION: A 6-hour cooler time of thawed PF24 does not accelerate coagulation factor degradation or compromise sterility over an extended 5-day shelf life. These findings validate flexible inventory return policies, allowing blood banks to reduce product waste.

Objective: To investigate the distribution frequencies of Rh blood group antigens (C, c, D, E, e) and phenotypes in the population of Hengyang, Hunan Province, and to analyze the production of Rh alloantibodies in repeatedly transfused patients, thereby providing a basis for developing precise transfusion strategies. Methods: Rh phenotyping, antibody screening, and antibody identification were performed on 3,635 hospitalized patients and 5,326 blood donors using Rh blood group typing cards. A blood transfusion management system was used to identify and track patients' historical specific antibodies, with automatic alerts for inconsistent results. Results: The antigen frequency distribution in patients was D (99.56%) > e (94.69%) > C (91.64%) > c (48.06%) > E (38.79%). The phenotypic distribution frequencies among Rh(D)-positive patients were as follows: CCDee (51.31%) > CcDEe (30.01%) > CcDee (9.37%) > ccDEE (5.00%) > ccDEe (2.79%) > CCDEe (0.80%) > ccDee (0.39%) > CcDEE (0.28%) > CCDEE (0.05%). From March to October 2023, after implementing Rh phenotyping and antigen-matched compatible transfusions for five antigens, the antibody screening positivity rate decreased to 0.97%, compared to 1.14% during the same period in 2022 (p < 0.05). Antibody identification in 276 antibody-positive samples revealed that alloantibodies against the Rh system accounted for the highest proportion (46.01%, 127/276), which was lower than the 55.21% observed in 2022 (p < 0.05). Unexpected antibodies in the Rh system were the primary cause of crossmatch incompatibility in clinical transfusions, accounting for 46.01%. Conclusion: Rh phenotyping and sustained antigen-matched compatible transfusions in repeatedly transfused patients can effectively prevent and reduce alloantibody production. Continuous tracking of specific antibodies and transfusion efficacy evaluation can be achieved through an efficient blood transfusion management system.

Background: Sepsis is a life-threatening condition triggered by infection and associated with dysregulated immune response of the patient followed often by multiorgan dysfunction or failure. In the clinical evolution of sepsis towards organ dysfunction, early initiation of a suited therapy significantly increases patient outcomes and reduces mortality rates. Since electronic health records provide data in a machine-readable format, this process could be supported by computerized systems. Methods: We developed an interoperable, time-sensitive CDSS that able to detect systemic inflammation and the different classifications of sepsis (bacterial/viral, suspected/proven, on admission/PICU acquired) in pediatric patients based on the analysis of routine clinical data. This application is provided as part of this publication as an open demonstrator (web application), and the usability and accuracy of the CDSS is shown by a retrospective creation of sepsis outcome labels for a routine data set of 4,655 pediatric patients. As a reference standard, the patients were manually assessed by blinded clinical experts. Results: In comparison with the reference standard, the CDSS achieved sensitivity of 96.9% (95% CI: 80.9-99.6%) and specificity of 99.1% (95% CI: 95.1-99.8%). In the context of a sepsis outcome labeling for 4,655 patients, the CDSS detected 4,342 episodes of inflammation of which 1,723 were classified as sepsis. Conclusions: We demonstrated that our routine-data based CDSS is able to perform a complex sepsis detection process with high diagnostic accuracy. Such CDSS with the ability to differentiate between SIRS, sepsis on admission, suspected and proven sepsis can prospectively support clinical management, monitoring and quality management.

Major histocompatibility complexes (MHC) govern antigen presentation and T cell receptor (TCR) selection. Accurate in vivo modeling of human immunity therefore requires physiological human MHC TCR interactions. Humanized NOD scid IL2null (NSG) mice engrafted with human CD34+ hematopoietic stem cells are widely used to provide preclinical platforms for the development of advanced therapies; however, interactions between murine MHC and human TCR can promote xenoreactivity and alter T cell development. Here, we investigated how elimination of murine MHC together with different conditioning regimens shapes human T cell maturation in vivo. CD34+ cells from ten cord blood donors were transplanted into conventional NSG mice or murine MHC deficient NSG derivatives (DKO) following either sublethal irradiation or myeloablative busulfan conditioning. Integrated analyses combining flow cytometry, plasma cytokine profiling, and bulk and single cell TCR sequencing revealed marked differences in T cell differentiation across models. Busulfan conditioned DKO mice developed highly proliferative, activated, and cytotoxic T cells together with clonally expanded TCR repertoires. In contrast, irradiated NSG mice preferentially accumulated naive, NKT, and regulatory T cell populations. Busulfan-conditioned DKO mice showed no evidence of xenogeneic graft versus host disease and represent a refined enabling platform for human T cell development and provide a foundation for future preclinical evaluation of advanced gene and cell therapies.

Large genomically annotated acute myeloid leukaemia (AML) datasets exist, but population-based contemporary cohorts remain scarce. Here we report clinicopathological, genomic, and outcome data from Danish AML patients. 2,512 AML patients were identified between 2015-2022, of whom 33.8% had available NGS data (NGS+). In patients [&le;]70 years, baseline characteristics and outcomes were comparable between NGS+ and NGS- groups. In patients >70 years, more NGS+ patients received intensive treatment, but survival was similar among intensively treated patients. The distribution of mutations varied significantly by age and sex, with older age and male sex exhibiting higher frequencies of adverse-risk gene mutations. In intensively treated NGS+ patients, ELN2017 stratified 5-year OS: 58.4% (favorable), 43.4% (intermediate), and 28.2% (adverse), with hazard ratios (HRs) of 0.63 (favorable) and 1.45 (adverse) relative to intermediate. ELN2022 yielded corresponding OS rates of 56.9%, 51.8%, and 29.7%, with HRs of 0.78 and 1.86. The two models had comparable predictive performance for OS in a time-dependent model. In conclusion, outcomes of intensively treated AML patients were comparable irrespective of NGS status, underscoring the representativeness of the REFORM-AML database for the Danish AML population. Age and male sex correlated with adverse-risk mutations, and both ELN2017 and ELN2022 robustly predicted survival.

BackgroundTraditional immunohistochemistry (IHC) with chromogen detection has limited multiplex capacity, detecting at most 4 protein markers per tissue section simultaneously, thereby restricting comprehensive spatial analysis of valuable human biopsies. We developed and validated a robust serial IHC (sIHC) staining method to detect multiple antigens on a single kidney biopsy slide, maximizing data yield for diagnosing and studying complex kidney diseases. MethodsFormalin-fixed, paraffin-embedded kidney biopsy sections were subjected to repeated IHC/imaging cycles with antibody removal using an optimized sodium dodecyl sulfate-glycerol buffer stripping protocol. Images were then co-registered, and analysis was performed using a variety of methodologies, including color deconvolution, cell segmentation, and spatial clustering. ResultsThis optimized sIHC method successfully detected up to 20 antigens on a single slide. Combining image analysis and artificial intelligence software, for example with HALO (Indica Labs), the assay assembles high-dimensional images and enables quantitative histology and single-cell spatial analysis. Using this advanced method, we were able to identify rare cell populations, such as double-negative T cells, that are challenging to detect conventionally. ConclusionWe have developed a validated, high-capacity sIHC protocol that uses standard IHC procedures with commercially available, clinically validated off-the-shelf antibodies. This method is a valuable, cost-effective tool for obtaining extensive, high-dimensional single-cell-resolved spatial data from limited pathology samples, such as a human kidney biopsy.

Dysfunction of the tubulointerstitial compartment is a key driver of chronic kidney disease (CKD) progression. However, tubular function remains largely unaddressed by routine clinical assessment. Here, we show that the urine ammonium-pH index (uAPI), a composite of urinary ammonium and pH, reflects kidney tubular function and predicts kidney function decline. Using acid/base, dietary, and potassium perturbations, segmental disruption of tubular ammonium handling, mathematical modelling, and data from patients with renal tubular acidosis, we identified defective ammoniagenesis as the main uAPI determinant. The uAPI was suppressed across four kidney disease models and dissociated from GFR. Kidney proteomics and single-nucleus RNA sequencing indicated downregulation of ammoniagenesis in proteinuric and diabetic kidney disease. In type 2 diabetes patients with preserved GFR, a reduced uAPI was associated with faster kidney function decline. In three CKD cohorts, low uAPI predicted CKD progression and significantly improved risk prediction. Together, this positions the uAPI as a scalable, non-invasive measure of kidney tubular function.

Hematologic diagnostics and especially cytomorphologic assessment are time-intensive and require high levels of expertise. Vision Language Models (VLM) show promise in medical image analysis in radiology and histopathology, while an evaluation on detecting acute myeloid leukemia (AML) is lacking. Our goal was to evaluate three Vision Language Models regarding their diagnostic accuracy and safety in clinical decision support in detecting AML from digitized bone marrow smears (BMS). Whole slide images were obtained from bone marrow smears of 50 AML patients and 50 bone marrow donors. Ten representative fields of view per sample were extracted manually. Three VLMs were used, two of which are considered generalist models (Qwen3.5-397B-A17B-FP8, GLM-4.6V-FP8), while the other one is a medically adapted model (Medgemma-27b-it). All models performed zero-shot analysis using two prompting strategies: First, a context-rich prompt requesting reporting of WHO/FAB diagnostic criteria in a structured manner, and secondly a minimal prompt without specific hematologic context. Overall diagnostic accuracy was poor for all models as they exhibited the overwhelming tendency to classify most samples as leukemic: With context-rich prompts, GLM4.6 identified 90% of leukemic samples while also labeling 92% of bone marrow donors as AML. The medical specialist model MedGemma-27b showed similar failure, misclassifying 86% of healthy donors and correctly detecting AML in only 66% of cases. Qwen3.5 performed best under detailed prompting, achieving a specificity of 0.26 and accuracy of 0.51. Accuracy of all models improved with context-free prompts (accuracies range 0.47-0.79), yet they still lacked the ability to correctly distinguish between leukemia and healthy bone marrow. Qwen3.5 was the only model to maintain meaningful specificity (0.64) and correctly identified 94% of AML, yielding an overall accuracy of 0.79. Morphologic feature-level agreement with human expert reports was poor across all models, indicating poor recognition of cell-level morphologies. This failure is likely driven by the fact that pathology imaging archives are vastly scraped during model training while hematological samples are not as widely available and therefore, hematology is an out-of-bounds use-case for these models, rendering them currently unsuitable for clinical decision support in hematology.

Large Language Models (LLMs) are increasingly used by clinicians and patients for medical queries, yet their accuracy and safety at the specialist level in hematology remain insufficiently characterised. We benchmarked ten frontier proprietary and open-weight LLMs across two generations on 1,477 board-style hematology multiple-choice questions (MCQs) derived from five educational datasets spanning nine disease areas and six clinical skill domains, including text-only and multimodal case vignettes. Claude Opus 5 had the highest mean accuracy (92.7% text, 76.9% multimodal), followed closely by Gemini-3.1 Pro (91.4% and 78.7%), Gemini-3.6 Flash (91.0% and 74.8%) and GPT-5.6 Sol (89.9% and 76.7%). Accuracy significantly correlated with model size both for text-only and multimodal MCQs. Between model generations, the largest improvements in accuracy were seen for open-weight models whereas proprietary models showed only marginal gains. In error analysis, top-performing models exhibited highly concordant failure patterns, suggesting shared limitations on challenging cases. Frontier LLMs exhibit substantial specialist hematology knowledge across diverse subspecialist domains and clinical skill sets. Yet, despite high accuracy on board-style questions in hematology, continuous expert-on-the-loop output monitoring is paramount.

Acquired aplastic anaemia is caused by immune-mediated loss of haematopoietic stem and progenitor cells (HSPCs), but the regulatory states that sustain cytotoxic immunity and their relationship to inherited susceptibility remain incompletely understood. We integrated two single-cell RNA-sequencing cohorts spanning healthy, non-severe and severe aplastic anaemia with single-cell chromatin accessibility profiling, genome-wide association meta-analysis, Bayesian fine-mapping and stratified LD-score regression. Single-cell transcriptomics revealed a coordinated shift across the immune and haematopoietic compartments. Cytotoxic CD8 and {gamma}{delta} T cells converged on a shared NKG7/CCL5/PRF1 effector program, indicating that cytotoxic differentiation extends across T-cell lineages. Effector-memory T cells combined inflammatory signalling with SOCS, DUSP, TNFAIP3, RGS1 and TOX, consistent with sustained stimulation accompanied by extensive feedback regulation. With increasing disease severity, these inflammatory states were further coupled to hypoxic, oxidative and unfolded-protein-response programmes, suggesting qualitative remodeling of the immune compartment rather than uniform amplification of perforin-granzyme expression. Single-cell chromatin accessibility provided a regulatory counterpart to these transcriptional states. Naive and memory-associated cells retained TCF7/LEF1/BACH2 accessibility, whereas cytotoxic cells acquired coordinated accessibility across CCL5, NKG7, PRF1, granzymes and killer-receptor loci. Pseudotime, motif activity and integrated RNA-chromatin profiles positioned AP-1, NFAT and TBX21 along this transition, linking loss of memory-associated regulation to acquisition of cytotoxic effector competence. Genetic meta-analysis independently recovered association at the HLA-B region, reinforcing antigen presentation as the principal inherited susceptibility axis. Fine-mapping additionally prioritized a non-HLA locus without resolving its effector gene, while stratified LD-score regression found no detectable preferential enrichment of common-variant heritability within effector-memory or cytotoxic regulatory elements. Integrated with the cellular data, these findings support a mechanistic hierarchy in which HLA-linked antigen presentation establishes the selective context, persistent cytotoxic T-cell state remodeling maintains pathogenic immune pressure, and IFN{gamma}-responsive HSPC suppression translates this pressure into haematopoietic failure.

Primary cilia coordinate signaling pathways that regulate tissue homeostasis and development, and defects in cilia contribute to numerous ciliopathies. However, the transcriptional consequences of disrupting ciliary protein localization remain poorly defined. ARL13B is a cilia-enriched regulatory GTPase required for ciliary trafficking and signaling. The ARL13BV358A variant is undetectable in cilia yet retains known biochemical functions, providing a unique model to investigate the functions of ciliary ARL13B independently of ciliogenesis. To define transcriptional programs associated with loss of ciliary ARL13B, we generated two independent Arl13bV358A/V358A kidney epithelial cell lines and matched rescue lines. The ARL13BV358A mutation did not affect ciliation frequency or cilia length but altered ciliary protein composition, including loss of ARL3 and INPP5E localization and increased accumulation of GPR161 and TULP3. RNA sequencing revealed expression changes in genes associated with ciliary biology, mechanotransduction, epithelial organization, and kidney-related phenotypes. Despite similar ciliary phenotypes, the independently-derived, mutant clones displayed substantial transcriptomic heterogeneity, highlighting a potential source of variation in CRISPR-based transcriptional studies. By integrating data from the independent mutant and rescue clones, we identified a high-confidence set of 131 genes whose expression reproducibly tracked with loss and restoration of ciliary ARL13B. Together, these findings demonstrate that ciliary ARL13B is required to maintain normal ciliary composition and gene expression programs and underscores the value of multi-clone, rescue-based experimental designs for robust transcriptomic analyses. Summary for ReviewersThis study examined how excluding the protein ARL13B from primary cilia affects kidney epithelial cells. The researchers created two independent cell lines carrying a modified form of ARL13B,along with matched rescue cell lines. The findings show that ciliary ARL13B helps maintain normal ciliary composition. By comparing the cell lines, the researchers identified a high-confidence set of genes associated with loss of ciliary ARL13B. By highlighting the importance of using independent gene-edited clones and rescue-based controls, these results advance understanding of how cilia regulate kidney cell function and provide guidance for designing robust transcriptomic analyses.

Background: Immigrant patients with limited dominant-language proficiency may face intersecting challenges when navigating cancer care and long-term oral anticancer treatment. Although studies have reported lower medication adherence among migrant and ethnic minority populations, less is known about how migration-related, linguistic, experiential and contextual factors shape treatment engagement from patients own perspectives. This study explored how immigrant patients experience illness, navigate treatment and engage with oral anticancer medication within the broader context of cancer care. Methods: Thirteen immigrant patients with limited dominant-language proficiency receiving oral anticancer medication for haematological malignancies were recruited from the haematology outpatient clinic of a Belgian university hospital. Semi-structured interviews were conducted in participants native languages using an adapted version of the McGill Illness Narrative Interview, with professional interpreters or intercultural mediators. Interviews were analysed using inductive reflexive thematic analysis within an interpretivist framework. Results: Analysis of patients illness narratives generated five experiential dimensions: 1) bodily, biographical and identity rupture; 2) temporal disruption and uncertainty; 3) linguistic vulnerability shaping the illness experience; 4) meaning-making and explanatory frameworks; and 5) resources sustaining treatment engagement. Linguistic vulnerability shaped access to biomedical knowledge, participation in healthcare encounters and patient autonomy, while patients mobilised personal, relational, existential, linguistic and institutional resources to sustain treatment continuity. Treatment engagement emerged as a dynamic and relational process embedded within broader migration-related, linguistic and healthcare contexts. Rather than representing fixed determinants or sequential stages, the five dimensions formed an evolving configuration whose relative salience varied throughout the illness trajectory. Conclusion: This study proposes a multidimensional interpretive model of engagement with oral anticancer medication among immigrant patients with limited dominant-language proficiency. Rather than conceptualising adherence as an isolated individual behaviour, the findings show how migration-related contexts shape the conditions under which treatment engagement becomes possible, difficult or fragile. By foregrounding immigrant patients lived experiences, the study identifies experiential, linguistic, relational and structural dimensions of cancer care that are difficult to capture through behavioural adherence measures alone and offers insights for more equitable, context-sensitive and patient-centred oncology care.

Research replication is essential to build trust in evidence produced from real-world data. However, methods for conducting and reporting these studies are lacking, particularly related to data quality and fitness assessments. We replicated a single-center study from Children's Hospital of Atlanta in a multi-institutional learning network (PEDSnet) to evaluate the long-term effects of hydroxyurea in children with severe sickle cell disease (SS/S{beta}0 genotype). An AS-IS arm applied the original study's criteria with no major data quality adjustments, while a Data Fitness Enhanced (DFE) arm used systematic data fitness assessment to inform adjustments to cohort inclusion criteria and variable definitions; both arms then replicated the original study's primary analyses. Data quality checks in the DFE arm refined cohort criteria and improved hydroxyurea capture, drug era computation, and hematology specialist mapping. The DFE cohort produced average treatment effects with higher face validity and greater concordance with the original study (e.g., change in ED visits: -0.44 (CI -0.60, -0.26) versus -0.36 (CI -0.57, -0.16) in the original study) than the AS-IS cohort (-0.08 (CI -0.26, 0.09)), which yielded several implausible results. These findings show that superficially plausible cohort characteristics do not guarantee valid results without transparent, systematic data fitness assessment.