Faculty Bibliography

Liver transplant (LT) recipients experience a wide range of comorbidities, leading to frequent healthcare encounters. Until now, national registries, which have limited exposures and outcomes, and laborious small cohort studies have been the main data sources for LT research. Cosmos database offers electronic health record (EHR)-based insights into LT recipients at the national level with granular data. We evaluated if Cosmos data is representative of the entire US LT recipient population. Using Cosmos (N=20,235) and the national Scientific Registry of Transplant Recipients (SRTR) (N=51,281), we identified adult, first-time LT recipients between 7/2016-12/2022. We compared demographics, clinical data, and mortality across datasets, calculating Kaplan-Meier survival estimates and multi-variable Cox regressions. Recipient characteristics were highly comparable (e.g., female: Cosmos=36.5% vs. SRTR=36.4%, Black: 6.8% vs. 7.2%; BMI: 28.5 kg/m2 [24.8-32.9] vs. 28.2 [24.6-32.4]). Lab values were similar across cohorts, including MELD (24 [17-30] vs. 23 [16-30]). Transplant indications, donor characteristics, and 5-year survival (Cosmos 83.1% [82.3-83.8) vs. SRTR 80.9% [80.4-81.3]) were similar. The associations of clinical factors with survival were similar across both groups. Cosmos database demonstrated acceptable generalizability to the general US LT recipient population, which may advance LT research through a better understanding about LT recipients' experiences and outcomes.

BACKGROUND:Due to high prevalence of Kaposi Sarcoma (KS)-Associated Herpesvirus (KSHV) among people with HIV, KSHV-associated disease (KAD) may be increased after kidney transplantation from donors with HIV (HIV D+) to recipients with HIV (HIV R+). METHODS:Anti-KSHV antibodies were measured in HIV R+ and donors with and without HIV (HIV D-) using a 30-antigen multiplex assay within three multicenter kidney transplantation studies. KSHV seropositivity was defined as reactivity to conventional KSHV antigens (≥1 ORF73 or K8.1); reactivity to expanded 5-antigen and 30-antigen panels were also reported. Risk factors were identified using modified Poisson regression. Recipients were monitored for post-transplant anti-KSHV antibody changes and KAD. RESULTS:KSHV seroprevalence was 40.6% (143/352) among HIV R+, 25.2% (33/131) among HIV D+, and 7.5% (4/53) among HIV D-. In the multivariable model, only men who have sex with men (MSM) was associated with KSHV seropositivity: relative risk 1.51 (95% confidence interval [CI] 1.07-2.14) in recipients and 2.39 (95%CI 1.03-5.53) in donors. Among 418 HIV R+ (215 HIV D+/R+, 203 HIV D-/R+), there were 5 KAD cases (incidence 0.63 cases/100 person-years, 95%CI 0.26-1.52): 3 skin-only KS, 1 multicentric Castleman disease, 1 allograft KS. The allograft KS occurred in a female HIV D+/R+ and was likely donor-derived. Remaining KAD cases occurred in male HIV D-/R+ and were likely recipient KSHV reactivation or acquisition. CONCLUSIONS:In the United States, KSHV seroprevalence in donors and recipients with HIV was high, particularly among MSM. Reassuringly, KSHV-associated disease was rare, and primarily attributed to recipient rather than donor-derived KSHV.

INTRODUCTION/BACKGROUND:Predicting graft failure risk in pediatric liver transplantation (LT) recipients could identify areas for improving management. Persistent cognitive, motor, academic, and functional deficits are common in recipients and their impact on graft survival following LT helps inform risk prediction. METHODS:Using SRTR data 2008-2023, we evaluated the cognitive, motor, academic, and functional deficits of LT recipients at time of transplant to 14 years post-LT. We compared all cause graft failure (ACGF) among patients with versus without pre-LT and 1-year post-LT deficits using Cox regression, adjusting for recipient characteristics. We calculated an individual risk score for ACGF. RESULTS:In 8062 pediatric LT recipients median age 3 (IQR: 1, 10), 28.0%, 29.5%, 35.0%, and 79.8% of recipients had pre-LT deficits in cognition, motor, academic activity, and functional status respectively. This decreased to 23.0%, 18.1%, 14.2%, and 38.7% 1-year post-LT. Increased hazard of ACGF was noted in recipients with pre-LT decreased functional status (aHR = 1.13 (per 10% decrease), 95% CI: 1.10-1.15, p < 0.001), definite motor delay (aHR = 1.60, 95% CI: 1.21-2.10, p < 0.001), and inability to participate in academics (aHR = 1.49, 95% CI: 1.08-1.89, p = 0.01), but not delays in cognition (aHR = 0.91, 95% CI: 0.69-1.21, p = 0.19). Our risk score predicting ACGF demonstrated improved predictive performance compared to clinical parameters alone (C-statistic = 0.70 (0.67, 0.72) vs. 0.66 (0.64, 0.69), p < 0.001). CONCLUSIONS:Pediatric LT recipients with pre- or post-LT motor, academic, and functional deficits are at higher risk for ACGF. Care should be taken to assess deficits to identify patients who may benefit from functional intervention to potentially reduce ACGF risk.

BACKGROUND:Organ Procurement and Transplantation Network (OPTN) policy requires 2 years of follow-up for living kidney donors (LKDs); however, many transplant hospitals struggle to meet this requirement. We developed and tested a mobile health (mHealth) system for LKD follow-up in a pilot randomized-controlled trial (RCT). METHODS:LKDs were randomly assigned to either the intervention (mHealth + standard of care) or control arm (standard of care). We assessed OPTN policy-defined completeness and timeliness of 6-month, 1-year, and 2-year follow-ups. Four hundred LKDs were enrolled in the study (June 2018 to February 2021). RESULTS:At 6-month follow-up, a higher proportion of the intervention arm participants completed composite visits (97.5% vs. 91.5%, p = 0.01). Both arms had similar compliance rates at 1- and 2-year follow-up (92.0% vs. 89.5%, p = 0.49, and 66.5% vs. 65.0%, p = 0.83). Intervention arm participants completed 6-month follow-up 11 days earlier than their counterparts (p = 0.009). CONCLUSION/CONCLUSIONS:mHealth technologies improved 6-month follow-up, but did not impact 1- and 2-year LKD follow-up in this single-center RCT. Other strategies, such as providing services beyond data collection, may be necessary to improve donor engagement and support LDK's long-term follow-up.

Artificial intelligence (AI) is rapidly transforming healthcare, and the field of kidney transplantation (KT) is no exception. While much of the AI-related work has focused on deceased donor KT, there is a growing body of research applying AI tools to living kidney donation (LKD). This review explores AI's current and potential roles in LKD, focusing on predictive and social applications of AI in LKD. Additionally, we discuss the challenges and limitations of implementing AI in clinical settings and highlight emerging research trends. This review consolidates existing research and provides a foundation for both transplant professionals and data scientists seeking to integrate AI responsibly into living donor programs.

IMPORTANCE/UNASSIGNED:Residence in a disadvantaged neighborhood is a key driver of racial and ethnic disparities in the diagnosis and management of chronic diseases; however, its impact on disparities in access to waitlisting and kidney transplantation (KT) is unclear. OBJECTIVE/UNASSIGNED:To examine the association between neighborhood disadvantage and access to waitlisting and KT. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective cohort study (January 1, 2015, to December 31, 2021) used a US national registry to assess adults (aged ≥18 years) with end-stage kidney disease (ESKD) and adult KT candidates. Statistical analysis was performed in March 2025. EXPOSURE/UNASSIGNED:Residential neighborhood disadvantage score (built environment disadvantage, criminal injustice, education disadvantage, unemployment, housing instability, poverty, social fragmentation, transportation barrier, and wealth inequality) ascertained by American Community Survey and other public data sources. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The adjusted hazard ratios (AHRs) of waitlisting and KT (any KT, live-donor KT [LDKT], and preemptive KT) were assessed across tertiles of the neighborhood disadvantage score using cause-specific hazard models. Interaction terms were used to quantify these aforementioned associations by race and ethnicity. RESULTS/UNASSIGNED:The study included 501 444 adults with ESKD initiating dialysis (mean [SD] age, 63.9 [14.6] years; 293 937 [58.6%] male; 25 790 [5.1%] Asian [Asian American, Native Hawaiian, and Pacific Islander], 133 923 [26.7%] Black, 66 323 [13.2%] Hispanic, and 275 408 [54.9%] White) and 95 068 KT candidates on the waitlist (mean [SD] age, 53.7 [13.0] years; 60 328 [63.5%] male; 6956 [7.3%] Asian, 25 215 [26.5%] Black, 15 685 [16.5%] Hispanic, and 47 212 [49.7%] White). A total of 173 880 adults with ESKD (34.7%) and 26 718 KT candidates (28.1%) resided in high-disadvantage neighborhoods. After adjustment, adults residing in high-disadvantage neighborhoods were less likely to be waitlisted (AHR, 0.71; 95% CI, 0.69-0.72) compared with those in low-disadvantage neighborhoods. Specifically, Asian (AHR, 0.87; 95% CI, 0.80-0.95), Black (AHR, 0.68; 95% CI, 0.66-0.70), Hispanic (AHR, 0.89; 95% CI, 0.86-0.92), and White (AHR, 0.68; 95% CI, 0.66-0.71) adults in high-disadvantage neighborhoods were less likely to be waitlisted compared with White adults in low-disadvantage neighborhoods. Overall, candidates residing in high-disadvantage neighborhoods were less likely to receive any KT (AHR, 0.89; 95% CI, 0.87-0.92), LDKT (AHR, 0.65; 95% CI, 0.62-0.69), and preemptive KT (AHR, 0.62; 95% CI, 0.58-0.67). Notably, Black candidates residing in high-disadvantage neighborhoods were less likely to receive KT (AHR, 0.60; 95% CI, 0.58-0.62), LDKT (AHR, 0.23; 95% CI, 0.21-0.25), and preemptive KT (AHR, 0.22; 95% CI, 0.20-0.25) compared with White candidates in low-disadvantage neighborhoods. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cohort study of adults with ESKD and KT candidates, residence in high-disadvantage neighborhoods was associated with reduced access to waitlisting and KT; it also was associated with persistent racial and ethnic disparities in LDKT and preemptive KT. These results suggest that to support equitable access, clinicians and transplant programs should work with social workers and community advocates to implement initiatives (eg, outreach and financial support) that address structural barriers and direct resources to affected neighborhoods.

INTRODUCTION/BACKGROUND:The United States Organ Procurement and Transplantation Network mandates collection of 6-month, 1-year, and 2-year post-donation follow-up data on living kidney donors (LKDs), but many centers struggle to meet these requirements. This study investigated whether providing a financial incentive (mailed gift card) could increase patient compliance with LKD follow-up. METHODS:A parallel, non-blinded, 1:1 superiority randomized control trial of LKDs was conducted at two centers from March 2017 to February 2021. The control arm received standard of care (SOC): instructions to complete the mandated LKD follow-up consisting of a health questionnaire and laboratory measurements at 6 months, 1 year, and 2 years post-donation. The intervention arm received SOC and was mailed a $25 gift card for each timely completed follow-up. Compliance rates were compared at each timepoint using Poisson regression. RESULTS:at 2 years). Similarly, no differences were observed in compliance with clinical follow-up, laboratory follow-up, or individual questions or lab values. CONCLUSION/CONCLUSIONS:Mailed gift cards did not improve patient compliance with LKD follow-up requirements; such interventions may be counterproductive among LKDs. Further research is needed to investigate and address barriers to completing LKD follow-up. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov identifier: NCT03090646.

OBJECTIVE:Given frailty and comorbidities that occur with both aging and end-stage kidney disease (ESKD), it is unclear if older patients with ESKD derive the improved survival and kidney transplant (KT) access associated with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS:Using 2006-2021 USRDS data, we identified 876 patients with RYGB and 1508 patients with SG and compared 5-year mortality by age-group (18-29/30-39/40-49/50-59/60-69/≥ 70 years) to nonsurgical matched controls using 1:3 Mahalanobis distance matching, Kaplan-Meier, and Cox regression. We also compared age-stratified KT incidence between waitlisted patients and controls. RESULTS:) for patients with SG versus controls. CONCLUSIONS:RYGB in older patients with ESKD is associated with increased mortality and lower KT likelihood, whereas SG is associated with decreased mortality and higher KT likelihood compared to nonsurgical matched controls. Choice of bariatric surgery type may play a role in improving survival for older patients with ESKD.

BACKGROUND:on dementia may be more severe in this population. METHODS:and dementia risk factors using a Wald test. Models were adjusted for confounders, including social determinants of health. RESULTS:was associated with 1.90-fold higher odds of global cognitive impairment (95% CI: 1.48-2.46), and 3.29-fold higher risk of dementia (95% CI: 1.14-9.55). CONCLUSION/CONCLUSIONS:neighborhoods should discuss cognitive assessments and ways to increase physical activity with providers.