Faculty Bibliography

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.

OBJECTIVE:Peripheral artery disease (PAD) is a common comorbidity among patients waitlisted for deceased donor kidney transplant (DDKT). However, some centers consider PAD a contraindication for transplant given the higher risk of post-operative complications. We aimed to examine the survival benefit of DDKT among patients with and without PAD. METHODS:We used data from the Scientific Registry of Transplant Recipients (SRTR) from January 2003 to December 2022 to identify all DDK waitlist candidates. Kaplan-Meier survival estimates and multivariable Cox proportional hazards models were used to compare patient mortality for those who received a DDKT versus those remaining on the waitlist, stratified by PAD status. RESULTS:506,785 candidates were listed for adult kidney-only transplant during the study period, of which 8.7% had PAD and 36.0% received a DDKT. After a median follow-up time of 3.21 years from waitlist activation [interquartile range 1.11-7.03 years], mortality varied significantly according to DDKT and PAD status. After adjusting for baseline differences, DDKT was associated with a significantly lower hazard of death compared to remaining on the waitlist, regardless of PAD status [adjusted hazards ratio (aHR) 0.45-0.60, P<0.001]. Further stratifying by sex, race and ethnicity, and diabetes status did not substantially alter these results. CONCLUSION/CONCLUSIONS:PAD includes a spectrum of diseases with varying mortality risks. As captured and dichotomized in the SRTR database, DDKT conferred a similar long-term benefit relative to remaining on the waitlist for candidates with and without PAD. Therefore, PAD should not be an absolute contraindication to DDKT.

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

RATIONALE & OBJECTIVE/OBJECTIVE:Despite national efforts, the uptake of home dialysis (peritoneal dialysis or home hemodialysis) remains low. Characteristics of the built environment may differentially impact home dialysis use. STUDY DESIGN/METHODS:Retrospective cohort study (2010-2019). SETTING & PARTICIPANTS/METHODS:1,103,695 adults (aged≥18 years) initiating dialysis in the US Renal Data System. EXPOSURE/METHODS:We examined 3 built environment domains based on residential ZIP code: (1) medically underserved areas (MUAs), defined as neighborhoods with limited primary care access; (2) distance to the nearest dialysis facility; and (3) distribution of housing characteristics (structure and overcrowding). OUTCOME/RESULTS:Uptake of home dialysis modalities at dialysis initiation. ANALYTICAL APPROACH/METHODS:We quantified associations between built environment characteristics and home dialysis initiation using multilevel logistic regression stratified by urbanicity type (urban, suburban, small-town, and rural). RESULTS:Among adults initiating dialysis, 40.8% lived in MUAs. Across ZIP codes, the mean percentage of overcrowded housing was 4.2% (SD, 4.7%), and the percentage of detached housing was 61.1% (SD, 21.1%); mean distance to the nearest dialysis facility was 5.5km (SD, 9.1km). Living in MUAs was associated with reduced home dialysis use only in urban (OR, 0.94; 95% CI, 0.91-0.96) and suburban (OR, 0.92; 95% CI, 0.89-0.94) areas. Similarly, housing overcrowding was associated with decreased home dialysis use only in urban (OR, 0.88; 95% CI, 0.86-0.89) and suburban (OR, 0.91; 95% CI, 0.90-0.93) areas. Longer distance to a dialysis facility was the most salient neighborhood factor associated with increased home dialysis use in small towns (OR, 1.14; 95% CI, 1.12-1.16) and rural areas (OR, 1.17; 95% CI, 1.15-1.19). LIMITATIONS/CONCLUSIONS:Housing characteristics were measured at the ZIP code level. CONCLUSIONS:Built environment characteristics associated with home dialysis uptake vary by urbanicity. Policies should address built environment barriers that are specific to urbanicity level. For example, increasing the frequency of dialysate delivery schedules could address housing space constraints in urban and suburban areas, and promoting home dialysis might be more effective for patients living far from dialysis centers in small-town and rural areas.

Transplantation of kidneys from donors with HIV to recipients with HIV (HIV D+/R+) has been shown to be safe and effective, but there is a unique risk of donor-derived HIV-superinfection (HIV-SI) in these recipients. Recipients from a multicenter observational HIV D+/R+ study were examined for HIV-SI using site-directed next-generation sequencing (Illumina). Eighteen HIV D+/R+ kidney transplant recipients had both baseline and follow-up samples that successfully amplified. One recipient was confirmed to have experienced donor-derived HIV-SI at week 26, but did not experience any clinically significant changes. HIV-SI in HIV D+/R+ transplant recipients is rare, and the clinical ramifications appear negligible.

BACKGROUND:Extensive literature has highlighted the psychological burden experienced by kidney transplant recipients (KTRs) and its association with adverse outcomes. Psychological resilience can serve as a measure of baseline vulnerability, and low resilience is associated with poor mental health. We aimed to synthesize the existing literature that has explored the concept of resilience in kidney transplantation. METHODS:A scoping review was conducted due to the anticipated heterogeneity of the literature. Any empirical study that measured resilience using a validated tool in KTRs was included. Resilience could be a variable, a predictor, or an outcome. All study designs were considered with no time restrictions. RESULTS:Of the 4525 titles and abstracts screened, 14 were eligible for inclusion. Sample sizes ranged from 10 to 505 KTRs. One study exclusively focused on developing and validating a resilience scale while others used existing tools. Three studies compared resilience between different populations and the results were heterogeneous: similar resilience between KTRs and dialysis/pre-KT patients (n = 2) and another reporting better resilience in KTRs (n = 1). A decline in resilience scores after pediatric-adult transition (n = 1) and 3 months post-transplant (n = 1) was reported. In terms of outcomes, higher resilience was associated with medication adherence (n = 1), lower frailty (n = 2), and lower risk of psychopathology (n = 2). Two of the three included studies reported improvements in resilience scores with an exercise program and a resilience-enhancing program. CONCLUSIONS:Our review highlights that resilience is an underused and poorly explored construct in KTRs. We recommend explorative and interventional work as resilience is measurable and modifiable.

Research shows that donor families report feeling abandoned, lacking social support, and receiving insufficient aftercare services. To meet the needs of these families, Taylor's Gift Foundation developed a free, virtual grief support program that pairs participating donor family members with Caring Guides trained in assertive community engagement and offers peer-facilitated support groups. Project Aim: The aim was to assess participant experiences with Taylor's Gift Foundation grief support program to understand its impact on grief symptoms, donor family access to grief support, and perceived social support. Design: Researchers conducted a qualitative evaluation using semi-structured interviews with 21 program participants. Results were analyzed using rapid qualitative analysis and descriptive statistics. Results: Eighteen (86%) participants worked with Caring Guides, 12 (57%) attended an average of 7 support groups, and 8 (39%) worked with Caring Guides and attended support groups. Eleven (52%) program participants reported difficulties accessing mental health services. Most program participants (86%) reported a decrease in grief intensity since enrolling in the program. Conclusion: Effective aftercare services were critical in helping donor families cope with, and adapt to, their loss. The Taylor's Gift Foundation grief support program helped donor family members access otherwise inaccessible grief support services and provided a valuable means of social support.

The benefits of bilateral lung transplantation (BLT) versus single lung transplantation (SLT) are still debated. One impediment to clinical recommendations is that BLT vs. SLT advantages may vary based on underlying disease. Since both options are clinically tenable in patients with emphysema, we conducted a comprehensive assessment of lung allograft survival in this population. Using U.S. registry data, we studied time to all-cause allograft failure in 8,092 patients 12 years or older transplanted from 2006 to 2022, adjusting for recipient, donor, and transplant factors by inverse propensity weighting. Median allograft survival was 6.6 years in BLT compared to 5.3 years in SLT, a 25% risk-adjusted survival advantage of _0.81.3_1.8 years. Risk-adjusted bilateral survival advantages varied between 0.9 and 2.4 years across eleven subgroups. Median allograft survival in BLT was 1.2 years greater than right SLT and 2.0 years greater than left SLT. During the 16-year study period, allograft survival steadily improved for BLT but not for SLT. Although the 25% BLT survival advantage pre-dated the pandemic, COVID-19 may have contributed to an apparent SLT survival decline. Recognizing the possible influence of residual confounding due to selection biases, these findings may aid offer decision-making when both donor lungs are available.