Faculty Bibliography

BACKGROUND/UNASSIGNED:Kidney transplant recipients are at risk for adverse health outcomes. Digital health tools such as wearable accelerometers and continuous glucose monitors (CGMs) can provide detailed, noninvasive tracking of health behaviors and measures, such as physical activity, sleep, and glucose levels, that may offer insights into future health concerns, such as posttransplant diabetes mellitus, cognitive health, and transplant rejection. However, there is limited evidence on the feasibility and acceptability of these devices in kidney transplant candidates older than 50 y. METHODS/UNASSIGNED:This observational cross-sectional pilot study aimed to examine the feasibility of 2 digital health tools: an accelerometer and a continuous glucose monitor. Participants were eligible for the study if they were living donor kidney transplant candidates, aged 50 y or older, had no known cognitive impairments, and could provide informed consent. Participants were asked to wear a CGM and an accelerometer for up to 14 d before their kidney transplant surgery. Device feasibility was quantified by (1) the total time the devices were worn, and (2) the validated System Usability Scale survey administered after the devices were returned. RESULTS/UNASSIGNED:20 participants enrolled in the study (mean age 64 ± 9 y, 25% women, 40% with type 2 diabetes). The median number of days of accelerometer and CGM wear were 7 (interquartile range, 6-10) d and 7 (interquartile range, 7-10) d, respectively. Ninety percent of participants reported a favorable opinion of both devices. Participants wore the CGM 100% of the time and the accelerometer 90% of the time, indicating high adherence. CONCLUSIONS/UNASSIGNED:The use of digital devices was acceptable among kidney transplant candidates aged older than 50 y, paving the way for larger studies to identify early digital biomarkers of health outcomes in this high-risk population.

BACKGROUND:Frailty is a multi-system syndrome of decreased physiologic reserve with high prevalence, early incidence, and prognostic significance in kidney disease. Apart from the Physical Frailty Phenotype (PFP), less is known regarding psychometric properties of other instruments. We critically appraise the validity and reliability of frailty instruments across the kidney disease continuum, acknowledge limitations, and highlight knowledge gaps. METHODS:Following PRISMA-ScR guidelines, we searched PubMed, EMBASE, Cochrane, CINAHL, Web of Science, ClinicalTrials.gov, and PsycInfo from website inception through 9/2024. Eligible studies applied a validated frailty instrument apart from the PFP to a kidney disease population. RESULTS:We identified 136 articles after screening 4,048 initial results. The most commonly cited instruments were the Clinical Frailty Scale (CFS; N=56), FRAIL Scale (N=30), and Edmonton Frail Scale (N=16). Most studies included adults receiving hemodialysis (N=85) and with chronic kidney disease (N=39). Median age ranges were 53-83 years. Most frailty instruments demonstrated predictive validity for mortality and hospitalizations. Concurrent validity was most frequently demonstrated between frailty and older age, female sex, greater comorbidities, and lower albumin. Seven studies reported reliability. While some instruments were feasible (CFS, FRAIL scale), their measurement could result in higher frailty prevalence compared to the PFP. Existing instruments do not capture the full spectrum of psychosocial and physiologic domains of frailty. CONCLUSIONS:The CFS demonstrates the strongest validity, apart from the PFP, although its use may result in higher measured frailty prevalence. Further research should test the feasibility of screening for frailty in clinical practice; the psychometric properties (i.e., responsiveness) of frailty instruments in younger adults, those with acute kidney injury, kidney transplant recipients, and those receiving conservative kidney management; and whether adding psychosocial and/or physiological markers improves frailty measurement validity. Addressing these gaps will facilitate wider frailty measurement in kidney disease research and aid adoption into practice.

INTRODUCTION/BACKGROUND:Elevated concentrations of air pollutants in residential neighborhoods are associated with poorer survival, cognitive, and cardiovascular health among older adults. Older kidney transplant (KT) recipients may be more vulnerable due to chronic immunosuppression and age-related co-morbidities. Therefore, we quantified the associations between pollutant concentrations and post-KT outcomes among older recipients. METHODS:]) were obtained from the Center for Air, Climate and Energy Solutions, and matched by ZIP code and year of KT. We used shared frailty models (cluster = state) to estimate the adjusted hazard ratios (aHR) of mortality and death-censored graft failure (DCGF) and competing risk models with cluster-robust standard errors to estimate the adjusted subhazard ratios (aSHR) of dementia and stroke by pollutant concentrations. RESULTS:concentrations were associated with a 3% (aSHR = 1.03, 95% CI: 1.00-1.07) and 4% higher risk of stroke (aSHR = 1.04, 95% CI: 1.02-1.07), respectively. CONCLUSION/CONCLUSIONS:Residence in neighborhoods with high concentrations of ambient air pollutants can worsen patient and graft survival, as well as increase the risk of stroke among older KT recipients. Early screening and interventions targeting older recipients living in such neighborhoods may be crucial for preserving cognitive and cerebrovascular health, as well as improving longitudinal quality of life.

BACKGROUND:Sarcopenia and myosteatosis are indicators of abnormal body composition (BC). Computed tomography (CT) imaging has proven to be an accurate modality for BC quantification in kidney transplantation (KT). We tested whether pre-KT CT-based BC was associated with both all-cause graft loss (ACGL) and mortality among adult recipients from two centers (Johns Hopkins Hospital [JHH] and University Medical Center Groningen [UMCG]). METHODS:Patients who underwent a KT between 2003 and 2020 were followed for a median (interquartile range) follow-up of 6.4 (4.6-8.5) years at JHH and 6.3 (5.1-7.5) years at UMCG. Cox proportional hazard models were used to estimate the associations of BC with ACGL/ mortality. Fine and Gray regression analysis was performed to assess the association between BC and death-censored graft loss. Prior to KT, 49% of recipients had sarcopenia and 66% had myosteatosis. RESULTS:In total 608 patients were included from JHH (N= 294) and UMCG (N=314). Sarcopenia was not associated with post-KT outcomes. Myosteatosis was associated with a higher risk of ACGL (adjusted hazard ratio 1.78, 95%CI:1.08 - 2.93) and mortality (adjusted hazard ratio 2.35, 95%CI: 1.27 - 4.33) at JHH, but showed no significant association at UMCG after adjusting for confounders. Myosteatosis did not show a significant association with death-censored graft loss at both centers. CONCLUSION/CONCLUSIONS:Myosteatosis ascertained from existing CT scans could help identify recipients at higher risk for ACGL who may benefit most from prehabilitation.

RATIONALE & OBJECTIVE/UNASSIGNED:exposure and mortality, overall and by race and ethnicity. STUDY DESIGN/UNASSIGNED:Cohort study (2003-2019). SETTING & PARTICIPANTS/UNASSIGNED:National registry for patients with kidney failure. EXPOSURES/UNASSIGNED:), segregation scores (Theil's H method), deprivation scores (American Community Survey), and built environment factors (medically underserved areas [MUA] and urbanicity) by patients' residential ZIP code at dialysis initiation. OUTCOME/UNASSIGNED:All-cause mortality. ANALYTICAL APPROACH/UNASSIGNED:and mortality, overall and stratified by race and ethnicity. RESULTS/UNASSIGNED:< 0.001]). LIMITATIONS/UNASSIGNED:may not reflect individual-level exposures. CONCLUSIONS/UNASSIGNED:and reduce related mortality.

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.

BACKGROUND/UNASSIGNED:; environmental injustice) by racial/ethnic segregation (social injustice) on dementia diagnosis in ESKD. METHODS/UNASSIGNED:concentrations (annualized and matched to older adults' residential ZIP code at dialysis initiation) and by segregation scores (Theil's H method). FINDINGS/UNASSIGNED:and segregation. INTERPRETATION/UNASSIGNED:experienced an increased risk of dementia; this risk was particularly pronounced among individuals in high segregation and predominantly minority neighborhoods. Environmental and social injustices likely drive racial and ethnic disparities in dementia for older adults with ESKD, underscoring the need for interventions and policies to mitigate these injustices. FUNDING/UNASSIGNED:National Institutes of Health.

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.