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.

BACKGROUND:Chronic Kidney Disease (CKD) impacts ~40% of US adults aged ≥ 60 years. Palliative care, which can improve symptoms of serious illness, is underutilized in CKD despite it's association with a high symptom burden. We conducted a scoping review of palliative care interventions in CKD, with particular attention to older adults. METHODS:We searched PubMed, CINAHL, EMBASE, Cochrane Central, PsycInfo, ClinicalTrials.gov, and Web of Science for: (1) kidney disease; (2) palliative care; and (3) study design. Palliative care interventions were defined as medical strategies that address ≥ 1 domain of the Clinical Practice Guideline for Quality Palliative Care. We characterized studies, quantified palliative care domains assessed, summarized symptom and quality of life outcomes, and identified studies limited to older adults. RESULTS:Of 2046 studies screened, 25 (1%) met inclusion criteria. Ten studies (40%) were randomized controlled designs. The most common quality domains addressed were physical aspects of care (21, 84%) and structure and processes of care (16, 64%). Twenty-four (96%) studies measured symptoms, 12 (48%) measured quality of life, and 11 (44%) measured both. Twenty-one different instruments were used to measure symptoms or quality of life. Six (24%) studies were limited to older adults. CONCLUSIONS:In our sample of studies evaluating CKD palliative care interventions, limited quality domains were addressed, a variety of measurement tools were used, and less than a quarter of studies were conducted only in older adults. Future research should address the holistic nature of palliative care, apply standardized instruments, and increase inclusion of older adults.

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.

KEY POINTS/CONCLUSIONS:In this cohort study of 720,348 adults referred for kidney transplantation from 2014 to 2025, only 48% were evaluated and 19% were waitlisted. Progression from referral to evaluation, waitlisting and kidney transplantation was limited by individual, center-level, and geographic factors. Some centers evaluated and waitlisted patients at rates far below the national average, and low-volume centers had lower rates of transplantation. BACKGROUND:Kidney transplantation is a cost-effective, lifesaving treatment of kidney failure, compared with dialysis. Unfortunately, most patients with kidney failure never undergo transplantation. METHODS:Using Epic Cosmos electronic health record data on all patients referred for kidney transplantation from 2014 to 2025, we assessed the stage-specific progression and attrition in the process of evaluation, waitlisting, and kidney transplantation. Center-level and individual (socioeconomic, geographic, and insurance status) factors associated with access to evaluation, waitlisting, and kidney transplantation were characterized using modified Poisson regression. RESULTS:Among 720,348 referred candidates, the median age was 55 years (interquartile range [IQR], 42-64); 47% of patients were White, 52% were male, and 87% were English speaking. Eighty-five percent of patients lived in urban areas. Of the referred candidates, 48% initiated evaluation, 19% were waitlisted, and 10% ultimately underwent transplantation. Among the referred patients who initiated evaluation, the median (IQR) time to evaluation initiation was two (1-4) months after referral; among the patients who were waitlisted, the median (IQR) time to waitlisting was four (2-9) months after evaluation initiation. Patients who were never married (0.94; 95% confidence interval [CI], 0.93 to 0.94), had severe obesity (0.70; 95% CI, 0.69 to 0.72), or were from rural zip codes (relative risk, 0.98; 95% CI, 0.97 to 1.00) were less likely to initiate evaluation. Low-volume centers had lower relative rates of transplantation (0.92; 95% CI, 0.88 to 0.96). In centers with documentation for nonprogression to evaluation, reasons for removal included not meeting criteria/not a candidate (18%), patient decision (13%), unable to contact (12%), death (4%), and financial/insurance complications (7%). CONCLUSIONS:Our study shows substantial attrition before kidney transplant waitlisting.

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.

IMPORTANCE/UNASSIGNED:Neighborhood segregation, a mechanism of structural racism, is associated with racial and ethnic disparities in health care access and outcomes. Live donor liver transplant (LDLT) is the ideal treatment for cirrhosis, improving survival and quality of life. Understanding the role of segregation in LDLT access is important to address disparities. OBJECTIVE/UNASSIGNED:To assess the associations between residential and transplant center neighborhood segregation and LDLT access. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cohort study used data from a US national transplant registry on adult candidates (age ≥18 years) for first-time liver transplant between February 1, 2016, and June 30, 2025, at centers that performed 1 or more LDLT annually during that time. EXPOSURE/UNASSIGNED:Residential and transplant center neighborhood segregation, measured using the Thiel H method at the zip code tabulation area level and dichotomized at the respective median values. MAIN OUTCOMES AND MEASURES/UNASSIGNED:A Cox proportional hazards regression model quantified the adjusted hazard ratio (AHR) of LDLT and included interactions with race and ethnicity and insurance. LDLT access within high-segregation residential neighborhoods by racial and ethnic composition (predominantly White or predominantly racial and ethnic minoritized population) was also quantified. RESULTS/UNASSIGNED:Among 22 223 adult liver transplant candidates, mean (SD) age was 55.3 (11.2) years, 13 518 (60.8%) were male, 1476 (6.6%) were Black, 5097 (22.9%) were Hispanic or Latino, and 15 650 (70.4%) were White. Most (11 669 [52.5%]) had private insurance. After adjustment, candidates residing in high-segregation neighborhoods had lower likelihood of LDLT access (AHR, 0.81; 95% CI, 0.74-0.88). Hispanic or Latino candidates in high-segregation neighborhoods had lower likelihood of LDLT access than their counterparts in low-segregation neighborhoods (AHR, 0.59; 95% CI, 0.49-0.72; P < .001 for interaction), but associations between neighborhood segregation and LDLT did not vary significantly by insurance type (P = .52 for interaction). Candidates wait-listed at transplant centers in high-segregation neighborhoods had lower likelihood of LDLT access (AHR, 0.64; 95% CI, 0.59-0.70). Candidates with Medicare or Medicaid wait-listed at centers in high-segregation neighborhoods had lower likelihood of LDLT access than their counterparts in low-segregation neighborhoods (AHR, 0.53; 95% CI, 0.45-0.51; P < .001 for interaction). Within high-segregation residential neighborhoods, candidates in neighborhoods with a larger racial and ethnic population had lower likelihood of LDLT access than those living in neighborhoods with a larger White population (AHR, 0.68; 95% CI, 0.59-0.78). CONCLUSION AND RELEVANCE/UNASSIGNED:In this national cohort study, living in or being wait-listed at centers in high-segregation neighborhoods was associated with lower likelihood of LDLT access and candidates living in high-segregation neighborhoods with a larger racial and ethnic minority population compared with a larger White population had lower likelihood of LDLT. Investing in high-segregation neighborhoods to address these structural disadvantages may help improve equity in LDLT access.

BACKGROUND/UNASSIGNED:Although technology usage is steadily increasing among older adults, adoption and confidence greatly lag behind their younger counterparts. Sociocultural and health disparities intersect with aging to present distinct structural and psychosocial barriers to the adoption of newer technologies. Digital health literacy interventions can improve task-specific skills, technological self-efficacy, and use frequency, but most do not systematically incorporate older adults' values and goals, which are key drivers of sustained behavior change. OBJECTIVE/UNASSIGNED:The proposed study aims to develop and evaluate the acceptability and feasibility of a person-directed, values-based, in-home digital literacy intervention for older adults, entitled values-informed solutions for technology adoption (VISTA). METHODS/UNASSIGNED:VISTA begins with a values and goals discussion rather than a skills test, mapping "What Matters Most" to individualized, SMART (specific, measurable, achievable, relevant, and time-bound) technology goals. Over 8 to 12 weeks, interventionists co-developed personalized learning plans with participants, delivering up to 6 in-home biweekly visits and interim phone calls. The study provided a tablet and assistance with obtaining home internet when needed. Outcomes included digital literacy (Mobile Device Proficiency Questionnaire), technology and chronic disease self-efficacy, social networks, multimorbidity, and frailty (Fried Frailty Phenotype). Feasibility was assessed via recruitment, retention or completion, data collection rates, survey administration time, withdrawal, intervention fidelity, and per-person cost; acceptability was assessed via a postintervention satisfaction survey (Likert and open-ended items) and willingness to recommend. RESULTS/UNASSIGNED:Funding was secured in November 2023. Institutional review board approval, intervention development, and focus groups were completed throughout 2024. Recruitment and baseline assessments occurred from January 2025 to July 2025, enrolling 21 participants and randomizing 11 to immediate intervention and 10 to waitlist control (waitlist participants received the intervention after a 3-month control period). One consented participant was unable to participate early in the intervention and is not included in analyses. Inclusion criteria included being aged 65 years and older, having English proficiency, and demonstrating a willingness to improve digital literacy. Exclusion criteria involved severe cognitive impairment. At baseline, participants had a mean age of 75.7 (SD 7.74) years and were predominantly female (n=13, 65%) and Black (n=19, 95%); most reported having a low income (10/12, 83%), living alone (12/14, 85.7%), and multimorbidity (mean disease count 3.95, SD 2.46). Follow-up assessments concluded in March 2026; data cleaning and analysis are ongoing, with primary feasibility and acceptability findings anticipated for fall 2026. CONCLUSIONS/UNASSIGNED:This protocol offers a unique model centering on the values and goals of older adults to improve access, use, and understanding of technology. Tapping into the motivators of older adults may provide a more beneficial way to encourage older adult technology use. VISTA could be useful in many general contexts, more specifically for older adults who are homebound or have serious illnesses, or as a preintervention for interventions involving advanced technology understanding.