Faculty Bibliography

Introduction/UNASSIGNED:Depressive symptoms, even without a clinical diagnosis of depression, are common in kidney failure patients and may be a barrier to completing the complex process of kidney transplant (KT) evaluation. We assessed depressive symptom burden and association between depressive symptoms and access to KT waitlist by age. Methods/UNASSIGNED:In a prospective cohort of 3728 KT patients (aged 18-88 years), the Center for Epidemiologic Studies-Depression (CES-D) scale was used to measure depressive symptoms at evaluation. Depressive symptom severity was defined as follows: none: 0; minimal: 1 to 15; mild: 16 to 20; moderate: 21 to 25; severe: 26 to 60. Hazard ratios (HRs) of active listing within 1 year after evaluation were estimated using Cox proportional hazards models, adjusted for clinical and social factors. Results/UNASSIGNED: < 0.001). After adjustment, every 5-point higher CES-D score (more depressive symptoms) was associated with a 13% lower chance of listing (HR = 0.87, 95% CI: 0.85-0.90); the strongest association was found among patients aged ≥70 years (adjusted HR [aHR] = 0.73, 95% CI: 0.62-0.86). Furthermore, minimal (HR = 0.69, 95% CI: 0.60-0.79), mild (HR = 0.57, 95% CI: 0.44-0.72), moderate (HR = 0.53, 95% CI: 0.39-0.71), and severe (HR = 0.44, 95% CI: 0.34-0.57) depressive symptoms were all associated with a lower chance of listing. Conclusion/UNASSIGNED:Older candidates were less likely to report depressive symptoms at KT evaluation. Regardless of age, candidates who did report depressive symptoms, and even minimal symptoms, had a lower chance of listing. Transplant centers should routinely screen patients for depressive symptoms and refer the affected patients to mental health services to improve access to KT.

Patient and graft survival are similar following whole versus split liver transplants (SLT) among pediatric and adult recipients, yet SLTs are rarely used. We sought to determine the survival benefit associated with accepting a splittable offer for SLT versus declining and waiting for a subsequent offer using 2010-2018 SRTR data on 928 pediatric and 1814 adult LT candidates who were ever offered a splittable graft. We compared eventual mortality, regardless of subsequent transplants, between those who accepted versus declined a splittable liver offer with adjustment for PELD/MELD, diagnosis, and weight among pediatric candidates, and matching for MELD, height, and offer among adult candidates. Among pediatric candidates ≤7kg, splittable offer acceptance versus decline was associated with a 63% reduction in mortality (aHR _0.17 0.37_0.80 , p=0.01; 93.1% versus 84.0% one-year survival post-decision). Within one year of decline for those ≤7kg, 6.4% died and 31.1% received a whole liver transplant. Among pediatric candidates >7kg, there was no significant difference associated with acceptance of a splittable offer (aHR _0.63 1.07_1.82 , p=0.81; 91.7% vs 94.4% one-year survival post-decision). Within one year of decline for those >7kg, 1.8% died and 45.8% received a whole liver. Among adult candidates, splittable offer acceptance was associated with a 43% reduction in mortality (aHR _0.39 0.57_0.83, p=0.005; 92.2% vs 84.4% one-year survival post-decision). Within one year of decline for adult candidates, 7.9% died and 39.3% received a whole liver. Conclusion: Accepting splittable offers for SLT could significantly improve survival for small children and adults on the waitlist.

BACKGROUND:In older adults (≥65) access to and outcomes following kidney transplantation (KT) have improved over the past three decades. It is unknown if there were parallel trends in re-KT. We characterized the trends, changing landscape, and outcomes of re-KT in older adults. METHODS:Among the 44,149 older kidney-only recipients (1995-2016) in the Scientific Registry of Transplant Recipients, we identified 1,743 who underwent re-KT. We analyzed trends and outcomes (mortality, death-censored graft failure [DCGF]) by eras (1995-2002, 2003-2014 and 2015-2016) that were defined by changes to the ECD and KDPI policies. RESULTS:Among all older kidney-only recipients during 1995-2002, 2003-2014, 2015-2016 the proportion that were re-KTs increased from 2.7%-4.2%-5.7% p<0.001, respectively. Median age at re-KT (67-68-68, p=0.04), years on dialysis after graft failure (1.4-1.5-2.2, p=0.003), donor age (40.0-43.0-43.5, p=0.04), proportion with PRA 80-100 (22.0%-32.7%-48.7%, p<0.001) and donations after circulatory death (1.1%-13.4%-19.5%, p<0.001) have increased. Despite this, the 3-year cumulative incidence for mortality (22.3%-19.1%-11.5%, p=0.002) and DCGF (13.3%-10.0%-5.1%, p=0.01) decreased over time. Compared with deceased donor re-transplant recipients during 1995-2002, those during 2003-2014 and 2015-2016 had lower mortality hazard (aHR=0.78, 95%CI:0.63-0.86 and aHR=0.55, 95%CI:0.35-0.86, respectively). These declines were noted but not significant for DCGF and in living donor re-KTs. CONCLUSIONS:In older re-transplant recipients, outcomes have improved significantly over time despite higher risk profiles; yet they represent a fraction of the KTs performed. Our results support increasing access to re-KT in older adults; however, approaches to guide the selection and management in those with graft failure need to be explored.

BACKGROUND:Air pollution is associated with cardiopulmonary disease and death in the general population. Fine particulate matter (PM2.5) is particularly harmful due to its ability to penetrate into areas of gas exchange within the lungs. Persons with advanced lung disease are believed to be particularly susceptible to PM2.5 exposure but few studies have examined the effect of exposure on this population. Here we investigate the association between PM2.5 exposure and adverse waitlist events among lung transplant (LT) candidates. METHODS:US registry data were used to identify LT candidates listed between 1/1/2010-12/31/2016. Annual PM2.5 concentration at year of listing was estimated for each candidate's ZIP Code using NASA's SEDAC Global Annual PM2.5 Grids. We estimated crude and adjusted hazard ratios for adverse waitlist events, defined as death or removal, using Cox proportional hazards regression. RESULTS:Of the 15,075 included candidates, median age at listing was 60, 43.8% were female and 81.7% were non-Hispanic white. Median ZIP Code PM2.5 concentration was 9.06µg/m3. When compared to those living in ZIP Codes with lower PM2.5 exposure (PM2.5 <10.53µg/m3), candidates in ZIP Codes in the highest quartile of PM2.5 exposure (≥10.53µg/m3) had 1.14-fold (95%CI 1.04-1.25) risk of adverse waitlist events. The result remained significant after adjusting for demographics, education, insurance, smoking, lung allocation score, BMI, and blood type (HR=1.17; 95%CI 1.07-1.29). CONCLUSIONS:Elevated ambient PM2.5 concentration was associated with adverse waitlist events among LT candidates. These findings highlight the impact of air pollution on clinical outcomes in this critically ill population.