Faculty Bibliography

[This corrects the article DOI: 10.1016/j.lana.2024.100895.].

INTRODUCTION/UNASSIGNED:Older adults with chronic kidney disease (CKD) likely face higher dementia risk because of vascular injury and chronic inflammation, potentially intensified among racially minoritized groups and those in rural or deprived neighborhoods. We quantified this association and examined variation by race and ethnicity, urbanicity, and neighborhood deprivation. METHODS/UNASSIGNED:We identified 211,321 older adults with CKD stages 3 to 5 from the Medicare 5% sample (2010-2022) using International Classification of Diseases (ICD)-9 and/or ICD-10 codes. Zone Improvement Plan (ZIP)-code level urbanicity was defined using Rural-Urban Commuting Area Codes, and neighborhood deprivation was derived from the American Community Survey. We used cause-specific hazard models with time-varying CKD stage (reference = stage 3) to quantify the adjusted hazard ratio (aHR) of dementia and included interaction terms to test the differential effect of these associations by race and/or ethnicity, urbanicity, and neighborhood deprivation. RESULTS/UNASSIGNED:= 0.04). Among older Black (stage 4 aHR: 1.38, 95% CI: 1.28-1.48; stage 5 aHR: 2.01, 95% CI: 1.88-2.15) and Hispanic adults (stage 4 aHR: 1.33, 95% CI: 1.10-1.62; stage 5 aHR: 1.98, 95% CI: 1.67-2.34), stages 4 and 5 were associated with a higher risk of dementia. Among older adults in high-deprivation neighborhoods, stage 5 was associated with a higher risk of dementia (aHR: 1.89, 95% CI: 1.80-1.99). CONCLUSION/UNASSIGNED:CKD stages 4 and 5 were associated with a higher dementia risk, particularly among older Black adults and those in high-deprivation neighborhoods. These findings may inform targeted interventions for early detection and management of cognitive decline in advanced CKD.

INTRODUCTION/BACKGROUND:Biological parental donations provide the best option for many pediatric recipients, yielding unique immunological benefits that may enable minimization of immunosuppression in transplanted children. However, living related maternal donation in the postpartum period may introduce an increased risk of donor complications due to the physiological changes of pregnancy and childbirth, and the optimal timing of postpartum living donation is unknown. METHODS:Using US national registry data, we characterized donor and recipient outcomes for pediatric living donor liver transplants performed between 2004 and 2022 where a biological mother donated to a child ≤ 24 months old. RESULTS:Our study population included 256 donor-recipient pairs, with biliary atresia representing the most common indication for transplantation (68.0%). Donors had a median [IQR] age of 30 [25, 34] years, and the median [IQR] time from birth to donation was 9.0 [6.8, 13.0] months. 6.3% of donors experienced a biliary or other complication. When stratifying by donors who donated ≤ 6 vs. > 6 months postpartum, we found no significant differences in donor complications or readmission. Stratified analyses were also comparable for recipient mortality, graft survival, and rejection-free survival. Donors ≤ 6 months postpartum (n = 64) were more likely to experience reoperation than mothers who donated > 6 months postpartum (n = 192) (6.2% vs. 1.0%, p = 0.04). CONCLUSIONS:While maternal living donor liver transplantation is safe for most donors, there is a higher risk of reoperation when donation is performed ≤ 6 months postpartum. Surgeons should be aware that these donors are a higher risk population, requiring discussion upon consent and warranting close post-operative monitoring.

BACKGROUND:As a 6-month waiting period is required to receive exception points to prioritize patients with hepatocellular carcinoma (HCC) for liver transplantation, prompt addition to the waitlist is critical in access to LT. METHODS:Using Epic Cosmos data on patients with HCC referred for LT 1/2018-10/2024, we used modified Poisson regression to calculate rates of waitlisting. Center-level and individual (socioeconomic, geographic, and insurance) factors were measured among those who progressed. RESULTS:Among 11,422 HCC patients referred for LT at 70 centers, with median age 63 [IQR: 58, 68], 71.5% initiated evaluation and, of those who began evaluation, 57.6% were waitlisted for LT. Of those referred, patients who were older (age 70+ vs. 51-60; RR 0.77, 95% CI: 0.65-0.90, p < 0.001), on Medicaid (0.83, 95% CI: 0.71-0.97, p = 0.02), never-married (0.82, 95% CI: 0.73-0.91, p < 0.001), or low SES (Q4: 0.87, 95% CI: 0.77-0.97, p = 0.002) had lower rates of waitlisting. Among waitlisted patients, median time from referral was 3.3 months [IQR: 2.0, 5.3]. Despite adjustment for patient level covariates, there was high center-level variation in rate of waitlisting within 12 months; 13% of centers listed patients at a rate ≥ 20% below the national median. CONCLUSION/CONCLUSIONS:Only a fraction of referred patients with HCC are waitlisted for LT. High variation in access to waitlisting based on non-clinical factors suggests barriers to waitlisting that must be addressed. Centers should focus on interventions to reduce barriers to waitlisting in patients with HCC.

BACKGROUND:Care coordination between primary care providers and nephrologists is crucial for preemptive kidney transplantation (KT), which confers health advantages over KT after dialysis. Residence in areas with limited primary care (Medically Underserved Areas [MUAs]/Health Professional Shortage Areas [HPSAs]) and nephrology access may differentially affect preemptive listing/KT. OBJECTIVE:To quantify access to preemptive KT by residence in limited primary care/nephrology access areas. DESIGN/METHODS:Retrospective cohort study from the US national registry. PARTICIPANTS/METHODS:A total of 353,636 adult KT candidates (age ≥ 18) listed between 2005-2020. EXPOSURES/METHODS:ZIP-code level MUA and HPSA information (HRSA), and distance to nearest nephrologist (CMS; urbanicity-specific thresholds for "far" from nephrologists: suburban, > 5.8 km; urban, > 2.3 km; small town, > 19.4 km; rural, > 25.2 km). MAIN MEASURES/METHODS:Poisson regression with robust variance estimator quantified adjusted prevalence ratios (aPRs) of preemptive listing, and cause-specific hazards models quantified adjusted hazard ratios (aHRs) of preemptive KT by MUAs/HPSAs/distance to nephrologists. Interaction terms quantified differences in the aforementioned associations by race and ethnicity/neighborhood urbanicity/socioeconomic determinants. KEY RESULTS/RESULTS: < 0.05). Lastly, there were no associations between distance to nephrologists and preemptive listing/KT. CONCLUSIONS:Limited primary care access may impede KT access. Greater investment in primary care within MUAs/HPSAs, addressing geographic/linguistic barriers, and improved nephrology care coordination may increase transplant equity. CLINICAL TRIAL NUMBER/BACKGROUND:Not applicable.

BACKGROUND:Semaglutide and tirzepatide have transformed obesity treatment, but recent changes to bariatric surgery utilization are not well understood. METHODS:Epic's nationwide Cosmos database was queried for patients who underwent primary sleeve gastrectomy or gastric bypass between 2018 and 2025. Patient characteristics including preoperative semaglutide or tirzepatide dispense history were compared using chi-squared and Wilcoxon rank sum tests. Modified Poisson regression was used to identify factors independently associated with pre-surgery GLP-1RA use. Multilevel models were used to examine hospital- and state-level variation in pre-surgery GLP-1RA use. RESULTS:Bariatric surgery utilization increased after Q3 2018, peaked in Q4 2022, and subsequently decreased 39% through Q4 2025. Between Q4 2018 and Q4 2025, the proportion of Hispanic bariatric surgery patients increased (8.1% vs. 16.8%, p < 0.001), and the proportion of patients who received pre-surgery GLP-1RA increased (0.2% vs. 35.3%, p < 0.001). Factors associated with receiving pre-surgery GLP-1RA were year, private insurance, White race, type 2 diabetes (RR 2.94 [2.88-3.00]), older age, sleep apnea, and metabolic dysfunction-associated steatotic liver disease. Factors associated with receiving surgery upfront were Hispanic ethnicity, Black race, and public or no insurance. After adjusting for patient characteristics and year, there was a 15-fold difference in pre-surgery GLP-1RA use between the highest and lowest hospitals (RR 0.19-2.88). CONCLUSIONS:In the Epic Cosmos database, bariatric surgery utilization decreased from 2022 to 2025, and those who underwent bariatric surgery increasingly received GLP-1RA before surgery. Patients who received pre-surgery GLP-1RA were older, White, privately insured, with diabetes and other weight-related comorbidities, while patients who received surgery upfront were Hispanic, Black, and publicly insured. Pre-surgery GLP-1RA use was also driven by center-specific non-clinical factors.

INTRODUCTION/BACKGROUND:Technological advances in organ preservation and reconditioning have enabled increased use of donation after circulatory death (DCD) organs. We aimed to characterize temporal trends in pediatric DCD (pDCD) in the United States. METHODS:We used Organ Procurement and Transplantation Network data to identify all pediatric (age < 18 years) deceased organ donors in the US, 2000-2025. We calculated the number and proportion of pediatric donation after brain death (pDBD) and pDCD donors by year. We calculated the number and type of recovered and transplanted pDBD and pDCD organs by year. RESULTS:The annual number of pDBD donors fell from 985 in 2000 to 530 in 2025, whereas pDCD donors increased from 21 to 244. The rise in pDCD recovery was observed for all organs: 32%, 19%, 16%, 14%, and 12% of recovered pediatric kidneys, livers, lungs, hearts, and pancreata by 2025. Among transplants with pediatric recipients in 2000, there was 1 pDCD liver transplant and no pDBD kidney, heart, lung, or pancreas transplants. By 2025, pDCD transplants accounted for 3%, 2%, and 8% of kidney, liver, and heart transplants with pediatric recipients. CONCLUSION/CONCLUSIONS:pDBD donors have fallen over the last 25 years, whereas pDCD donors have increased over 10-fold over the same period. Given the ongoing need for pediatric organ transplantation and the ethical importance of preserving opportunities for donation, there is an urgent need to develop a parallel communication and ethical framework to support families, clinicians, and transplant teams in navigating these donation opportunities.

OBJECTIVE:Directly compare the real-world effectiveness of semaglutide and tirzepatide to bariatric operations: sleeve gastrectomy and gastric bypass. METHODS:This study included adults with BMI ≥ 35 who received injectable semaglutide or tirzepatide (GLP-1RAs) or sleeve gastrectomy or gastric bypass (bariatric surgery) at two urban health systems from 2018 to 2024. Total weight loss (TWL) was compared up to 3 years post treatment with inverse probability weighting and mixed linear models. Intention-to-treat (any GLP-1RA) and per-protocol (1 year of continuous GLP-1RA orders) analyses were performed. RESULTS:Of 44,025 patients studied, bariatric surgery was associated with greater weight loss at 1, 2, and 3 years post treatment: semaglutide (n = 25,804) TWL (95% CI): 5.4% (5.3%-5.6%), 6.5% (6.4%-6.7%), and 7.4% (7.3%-7.6%); tirzepatide (n = 7308): 9.1% (8.9%-9.4%) and 10.8% (10.2%-11.3%); sleeve gastrectomy (n = 8728): 24.4% (24.3%-24.6%), 22.4% (22.3%-22.5%), and 22.0% (21.8%-22.1%); gastric bypass (n = 2185): 29.8% (29.7%-29.9%), 28.1% (28.0%-28.2%), and 28.4% (28.3%-28.5%). With 1 year of continuous GLP-1RA, findings were: semaglutide TWL: 7.2% (7.0%-7.4%), 8.0% (7.8%-8.2%), and 8.8% (8.6%-9.0%); tirzepatide TWL: 11.7% (11.4%-11.9%) and 11.9% (11.5%-12.3%). CONCLUSIONS:In this retrospective two-center study, bariatric surgery was associated with greater weight loss than GLP-1RAs among patients eligible for both options.

BACKGROUND:Depressive symptoms are common in end-stage kidney disease (ESKD) patients, and may persist after stopping dialysis due to challenges post-KT despite clinical benefits. We sought to assess changes in depressive symptoms pre- and post-KT. METHODS:We leveraged a multi-center prospective cohort of 4,661 adult (aged ≥18) potential KT candidates and 1,215 recipients (2008-2025). Participants reported depressive symptoms via the Center for Epidemiologic Studies Depression (CES-D) scale (range 0-60, high depressive symptoms≥16) at evaluation, KT, and post-KT. We used linear mixed-effect models to estimate post-KT trajectories of CES-D scores overall and by characteristics at KT admission. RESULTS:19% of potential candidates at evaluation and 15% of recipients at admission had depressive symptoms; 46% and 38%, respectively, were non-Hispanic Black. Over the first 4 years post-KT, depressive symptoms slightly worsened (slope=0.4 points/year, 95% confidence interval [CI]:0.3, 0.6) but remained below the threshold for clinical depression. Post-KT CES-D score change differed by pre-KT high depressive symptoms score (difference=-1.2 points/year, 95%CI:-1.8, -0.6). Specifically, post-KT depressive symptoms were 0.7 points/year lower (95%CI:-1.2, -0.1) among recipients with pre-KT high depressive symptoms and 0.5 points/year higher (95%CI:0.3, 0.7) among those without. CES-D score change also differed by preemptive KT status (difference=-0.6 points/year, 95%CI:-1.0, -0.1, non-preemptive versus preemptive). CONCLUSIONS:Depressive symptoms worsened slightly over the first 4 years post-KT but remained below the threshold for clinical depression. Notably, post-KT CES-D scores decreased in recipients with high pre-KT depressive symptoms. Clinicians should discuss the mental health impact of KT with patients and tailor care decisions to individual needs.