The Exposome Era in Kidney Transplantation: A New Frontier in Graft Outcomes and Precision Medicine

Despite substantial advances in surgical technique and immunosuppressive therapy, kidney transplantation continues to face limitations in long-term graft and patient survival. Increasingly, attention is shifting toward the exposome, the comprehensive profile of environmental, social, and biological exposures accumulated across the lifespan, as a critical yet under-investigated determinant of transplant outcomes. Evidence from diverse domains, including air pollution, heavy metal burden, dietary composition, infections, microbiome dynamics, psychosocial context, and digital health engagement, suggests that these factors exert profound effects on immune regulation, metabolic health, and graft integrity. By applying innovative approaches such as exposome-wide association studies, high-resolution biomonitoring, and multi-omics integration, researchers can begin to unravel complex exposure-disease relationships and identify previously unrecognized modifiable risks. Positioning the exposome within the kidney transplantation paradigm offers a pathway toward precision environmental medicine, enabling refined risk stratification, novel preventive strategies, and ultimately improved durability of both graft function and patient survival. However, exposome influences are highly individualized and interact in complex, non-additive ways; current evidence remains largely associative and hypothesis-generating rather than causal.