Psychosocial characteristics of potential and actual living kidney donors.

The psychosocial assessment is an essential component of the living kidney donor (LKD) evaluation. However, it remains uncertain how specific psychosocial factors impact LKD eligibility. We performed a retrospective chart review of LKD candidates who initiated the evaluation process and who had completed a required, in-person licensed social work (LSW) visit. LSW notes were reviewed for frequency of psychosocial factors that may impact the success of LKD candidate approval by the selection committee. 325 LKD candidates were included in the study: 104 not-approved and 221 approved. Not-approved LKD candidates were more likely to receive a negative family reaction to wanting to donate than approved LKD candidates (8.7% vs 1.4%, p < 0.01). On multivariate analysis, Black race, history of psychiatric illness, highest level of education being high school, and high psychosocial risk score assignment were all associated with a lower odds ratio of being approved. The majority of not-approved LKD candidates were disqualified for medical reasons (N = 76, 73.1%). In conclusion, psychosocial factors impact donation even after LKD candidates make it to an in-person evaluation.

Discrepant Outcomes between National Kidney Transplant Data Registries in the United States.

SIGNIFICANCE STATEMENT: Effects of reduced access to external data by transplant registries to improve accuracy and completeness of the collected data are compounded by different data management processes at three US organizations that maintain kidney transplant-related datasets. This analysis suggests that the datasets have large differences in reported outcomes that vary across different subsets of patients. These differences, along with recent disclosure of previously missing outcomes data, raise important questions about completeness of the outcome measures. Differences in recorded deaths seem to be increasing in recent years, reflecting the adverse effects of restricted access to external data sources. Although these registries are invaluable sources for the transplant community, discrepancies and incomplete reporting risk undermining their value for future analyses, particularly when used for developing national transplant policy or regulatory measures. BACKGROUND: Central to a transplant registry's quality are accuracy and completeness of the clinical information being captured, especially for important outcomes, such as graft failure or death. Effects of more limited access to external sources of death data for transplant registries are compounded by different data management processes at the United Network for Organ Sharing (UNOS), the Scientific Registry of Transplant Recipients (SRTR), and the United States Renal Data System (USRDS). METHODS: This cross-sectional registry study examined differences in reported deaths among kidney transplant candidates and recipients of kidneys from deceased and living donors in 2000 through 2019 in three transplant datasets on the basis of data current as of 2020. We assessed annual death rates and survival estimates to visualize trends in reported deaths between sources. RESULTS: The UNOS dataset included 77,605 deaths among 315,346 recipients and 61,249 deaths among 275,000 nonpreemptively waitlisted candidates who were never transplanted. The SRTR dataset included 87,149 deaths among 315,152 recipients and 60,042 deaths among 259,584 waitlisted candidates. The USRDS dataset included 89,515 deaths among 311,955 candidates and 63,577 deaths among 238,167 waitlisted candidates. Annual death rates among the prevalent transplant population show accumulating differences across datasets-2.31%, 4.00%, and 4.03% by 2019 from UNOS, SRTR, and USRDS, respectively. Long-term survival outcomes were similar among nonpreemptively waitlisted candidates but showed more than 10% discordance between USRDS and UNOS among transplanted patients. CONCLUSIONS: Large differences in reported patient outcomes across datasets seem to be increasing, raising questions about their completeness. Understanding the differences between these datasets is essential for accurate, reliable interpretation of analyses that use these data for policy development, regulatory oversight, and research. PODCAST: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_10_24_JASN0000000000000194.mp3.

Deceased donor kidneys from higher distressed communities are significantly less likely to be utilized for transplantation.

The proportion of kidneys procured for transplantation but not utilized exceeds 20% in the United States. Factors associated with nonutilization are complex, and further understanding of novel causes are critically important. We used the national Scientific Registry of Transplant Recipients data (2010-2022) to evaluate associations of Distressed Community Index (DCI) of deceased donor residence and likelihood of kidney nonutilization (n = 209 413). Deceased donors from higher distressed communities were younger, had an increased history of hypertension and diabetes, were CDC high-risk, and had higher terminal creatinine and donation after brain death. Mechanisms and circumstances of death varied significantly by DCI. The proportion of kidney nonutilization was 19.9%, which increased by DCI quintile (Q1 = 18.1% to Q5 = 21.6%). The adjusted odds ratio of nonutilization from the highest quintile DCI communities was 1.22 (95% CI = 1.16-1.28; reference = lowest DCI), which persisted stratified by donor race. Donors from highly distressed communities were highly variable by the donor service area (range: 1%-51%; median = 21%). There was no increased risk for delayed graft function or death-censored graft loss by donor DCI but modest increased adjusted hazard for overall graft loss (high DCI = 1.05; 95% CI = 1.01-1.10; reference = lowest DCI). Results indicate that donor residential distress is associated with significantly higher rates of donor kidney nonutilization with notable regional variation and minimal impact on recipient outcomes.

Community Members as Reviewers of Medical Journal Manuscripts: a Randomized Controlled Trial.

BACKGROUND: Community members may provide useful perspectives on manuscripts submitted to medical journals. OBJECTIVE: To determine the impact of community members reviewing medical journal manuscripts. DESIGN: Randomized controlled trial involving 578 original research manuscripts submitted to two medical journals from June 2018 to November 2021. PARTICIPANTS: Twenty-eight community members who were trained, supervised, and compensated. INTERVENTIONS: A total of 289 randomly selected control manuscripts were reviewed by scientific reviewers only. And 289 randomly selected intervention manuscripts were reviewed by scientific reviewers and one community member. Journal editorial teams used all reviews to make decisions about acceptance, revision, or rejection of manuscripts. MAIN MEASURES: Usefulness of reviews to editors, content of community reviews, and changes made to published articles in response to community reviewer comments. KEY RESULTS: Editor ratings of community and scientific reviews averaged 3.1 and 3.3, respectively (difference 0.2, 95% confidence interval [CI] 0.1 to 0.3), on a 5-point scale where a higher score indicates a more useful review. Qualitative analysis of the content of community reviews identified two taxonomies of themes: study attributes and viewpoints. Study attributes are the sections, topics, and components of manuscripts commented on by reviewers. Viewpoints are reviewer perceptions and perspectives on the research described in manuscripts and consisted of four major themes: (1) diversity of study participants, (2) relevance to patients and communities, (3) cultural considerations and social context, and (4) implementation of research by patients and communities. A total of 186 community reviewer comments were integrated into 64 published intervention group articles. Viewpoint themes were present more often in 66 published intervention articles compared to 54 published control articles (2.8 vs. 1.7 themes/article, difference 1.1, 95% CI 0.4 to 1.8). CONCLUSIONS: With training, supervision, and compensation, community members are able to review manuscripts submitted to medical journals. Their comments are useful to editors, address topics relevant to patients and communities, and are reflected in published articles. TRIAL REGISTRATION: ClinicalTrials.gov NCT03432143.

Sources of Variation in the Carbon Footprint of Hemodialysis Treatment.

BACKGROUND: Greenhouse gas emissions from hemodialysis treatment in the United States have not been quantified. In addition, no previous studies have examined how much emissions vary across facilities, treatments, and emission contributors. METHODS: To estimate the magnitude and sources of variation in the carbon footprint of hemodialysis treatment, we estimated life-cycle greenhouse gas emissions in carbon dioxide equivalents (CO2-eq) associated with 209,481 hemodialysis treatments in 2020 at 15 Ohio hemodialysis facilities belonging to the same organization. We considered emissions from electricity, natural gas, water, and supply use; patient and staff travel distance; and biohazard and landfill waste. RESULTS: Annual emissions per facility averaged 769,374 kg CO2-eq (95% CI, 709,388 to 848,180 kg CO2-eq). The three largest contributors to total emissions were patient and staff transportation (28.3%), electricity (27.4%), and natural gas (15.2%). Emissions per treatment were 58.9 kg CO2-eq, with a three-fold variation across facilities. The contributors with the largest variation in emissions per treatment were transportation, natural gas, and water (coefficients of variation, 62.5%, 42.4%, and 37.7%, respectively). The annual emissions per hemodialysis facility are equivalent to emissions from the annual energy use in 93 homes; emissions per treatment are equivalent to driving an average automobile for 238 km (149 miles). CONCLUSIONS: Similar medical treatments provided in a single geographic region by facilities that are part of the same organization may be expected to have small variations in the determinants of greenhouse gas emissions. However, we found substantial variation in carbon footprints across facilities, treatments, and emission contributors. Understanding the magnitude and variation in greenhouse gas emissions may help identify measures to reduce the environmental effect of hemodialysis treatment.

A tool for decision-making in kidney transplant candidates with poor prognosis to receive deceased donor transplantation in the United States.

The primary outcomes for kidney transplant candidates are receipt of deceased or living donor transplant, death or removal from the waiting list. Here, we conducted a retrospective analysis of national Scientific Registry of Transplant Recipients data to evaluate outcomes for 208,717 adult kidney transplant candidates following the 2014 Kidney Allocation System in the United States. Competing risks models were utilized to evaluate Time to Equivalent Risk (TiTER) of deceased donor transplantation (DDTX) and death versus waitlist removal. We also evaluated TiTER based on kidney donor profile index (KDPI) and donor age. For all groups, the cumulative incidence of DDTX was initially higher from time of listing than death or waitlist removal. However, following accrued time on the waiting list, the cumulative incidence of death or waitlist removal exceeded DDTX for certain patient groups, particularly older, diabetic, blood type B and O and shorter pre-listing dialysis time. TiTER for all candidates aged 65-69 averaged 41 months and for 70 and older patients 28 months. Overall, 39.6% of candidates were in risk groups with TiTER under 72 months and 18.5% in groups with TiTER under 24 months. Particularly for older candidates, TiTER for kidneys was substantially shorter for younger donors or lower KDPI. Thus, our findings reveal that a large proportion of wait-listed patients in the United States have poor prognoses to ever undergo DDTX and our data may improve shared decision-making for candidates at time of waitlist placement. Hence, for specific patient groups, TiTER may be a useful tool to disseminate and quantify benefits of accepting relatively high risk donor organs.

Geographic hot spots of kidney transplant candidates wait-listed post-dialysis.

INTRODUCTION: Preemptive wait-listing of deceased donor kidney transplant (DDKT) candidates before maintenance dialysis increases the likelihood of transplantation and improves outcomes among transplant patients. Previous studies have identified substantial disparities in rates of preemptive listing, but a gap exists in examining geographic sources of disparities, particularly for sub-regional units. Identifying small area hot spots where delayed listing is particularly prevalent may more effectively inform both health policy and regionally appropriate interventions. METHODS: We conducted a retrospective cohort study utilizing 2010-2020 Scientific Registry of Transplant Recipients (SRTR) data for all DDKT candidates to examine overall and race-stratified geospatial hot spots of post-dialysis wait-listing in U.S. zip code tabulation areas (ZCTA). Three geographic clustering methods were utilized to identify robust statistically significant hot spots of post-dialysis wait-listing. RESULTS: Novel sub-regional hot spots were identified in the southeast, southwest, Appalachia, and California, with a majority existing in the southeast. Race-stratified results were more nuanced, but broadly reflected similar patterns. Comparing transplant candidates in hot spots to candidates in non-clusters indicated a strong association between residence in hot spots and high area deprivation (OR: 6.76, 95%CI: 6.52-7.02), indicating that improving access healthcare in these areas may be particularly beneficial. CONCLUSION: Our study identified overall and race-stratified hot spots with low rates of preemptive wait list placement in the U.S., which may be useful for prospective healthcare policy and interventions via targeting of these narrowly defined geographical areas.

Self-reported marijuana use and its effects on overall approval in potential living kidney donors.

BACKGROUND: Past and present substance use is an important part of the psychosocial evaluation of potential living kidney donors (LKDs). Increasing state legalizations and social acceptance of marijuana (MJ) use can create challenges for transplant centers. METHODS: We investigated the frequency of reporting MJ use, and its effect on the LKD evaluation. A retrospective chart review was performed on all living donor candidates from December 2016 to December 2019 for reports of MJ use, both on an electronic intake form and during clinical evaluation with a licensed social worker (SW). Active MJ use was defined as current use or use within 1 year of evaluation. Baseline characteristics between MJ users and non-users were compared at each step of donor evaluation. We explored variables associated with MJ use including additional consults and testing during the donor evaluation. Overall approval and donation rates for living donors with active MJ use were compared to non-users. Additionally, 1-year donor follow-up was compared between the two groups. Results of 1818 living donor candidates who completed the intake form, 132 admitted to active MJ use. Compared to non-users, MJ users were more likely to be younger, male, single, renting a home, and with a lower level of education. Thirty three out of 338 candidates who completed a social work evaluation reported MJ use. Compared to non-users, MJ users were more frequently classified as moderate or high risk on SW evaluation, and often required a toxicology screen or psychiatry visit for clearance to donate. Altogether 24.2% of MJ users versus 9.5% of non-users discontinued their evaluation (p < .01). Altogether 42.4% of MJ users versus 56.1% of non-users donated their kidney (p = .13). For those who donated, MJ users were less likely than non-users to follow up at 1 year (57.1% vs. 83.0, p-value .02). CONCLUSION: MJ users were often asked to complete additional steps in their evaluation before an approval decision was made, which may have led to the higher rate of donor drop out observed in this group. Further research is needed to assess the effects of MJ use on living donor candidacy, as well as any effects of MJ use on long-term donor outcomes.

Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities.

BACKGROUND: Kidney transplantation is associated with the best outcomes for most patients with ESKD. The national Kidney Allocation System prioritizes patients with Estimated Post-Transplant Survival (EPTS) scores in the top 20% for expedited access to optimal deceased donor kidneys. METHODS: We studied adults aged ≥18 years in the United States Renal Data System with top 20% EPTS scores who had been preemptively waitlisted or initiated dialysis in 2015-2017. We evaluated time to waitlist placement, transplantation, and mortality with unadjusted and multivariable survival models. RESULTS: Of 42,445 patients with top 20% EPTS scores (mean age, 38.0 years; 57% male; 59% White patients, and 31% Black patients), 7922 were preemptively waitlisted. Among 34,523 patients initiating dialysis, the 3-year cumulative waitlist placement incidence was 37%. Numerous factors independently associated with waitlisting included race, income, and having noncommercial insurance. For example, waitlisting was less likely for Black versus White patients, and for patients in the lowest-income neighborhoods versus those in the highest-income neighborhoods. Among patients initiating dialysis, 61% lost their top 20% EPTS status within 30 months versus 18% of patients who were preemptively listed. The 3-year incidence of deceased and living donor transplantation was 5% and 6%, respectively, for patients who initiated dialysis and 26% and 44%, respectively, for patients who were preemptively listed. CONCLUSIONS: Many patients with ESKDqualifying with top 20% EPTS status are not placed on the transplant waiting list in a timely manner, with significant variation on the basis of demographic and social factors. Patients who are preemptively listed are more likely to receive benefits of top 20% EPTS status. Efforts to expedite care for qualifying candidates are needed, and automated transplant referral for patients with the best prognoses should be considered. PODCAST: This article contains a podcast athttps://www.asn-online.org/media/podcast/JASN/2021_07_30_JASN2020081146.mp3.

An opt-out model for kidney transplant referral: The time has come.

Disparities that affect equity in access to kidney transplantation for patients with kidney failure have been well described. Many robust clinical trials have tested the effectiveness of interventions to reduce disparities and equilibrate access to kidney transplantation. Moreover, policy changes have been enacted to achieve the same aims. Despite these efforts, rates of kidney transplant waitlisting within the first year of end-stage kidney disease have remained unchanged over the past 2 decades, while incident rates of end-stage kidney disease have climbed. Because prior interventions have not durably increased transplant access, disruptive change is clearly needed. The Advancing American Kidney Health Executive Order sets bold goals to transform kidney care for patients and caregivers. In this spirit, we discuss an Opt-Out for Transplant Referral Model as a compelling solution to improve equity in access to kidney transplantation.

Effects of body mass index on kidney transplant outcomes are significantly modified by patient characteristics.

Body mass index (BMI) is a known risk factor associated with kidney transplant outcomes and is incorporated for determining transplant candidate eligibility. However, BMI is a coarse health measure and risks associated with BMI may vary by patient characteristics. We evaluated 296 807 adult (age > 17) solitary kidney transplant recipients from the Scientific Registry of Transplant Recipients (2000-2019). We examined effects of BMI using survival models and tested interactions with recipient characteristics. Overall, BMI demonstrated a "J-Shaped" risk profile with elevated risks for overall graft loss with low BMI and obesity. However, multivariable models indicated interactions between BMI with recipient age, diagnosis, gender, and race/ethnicity. Low BMI was relatively higher risk for older recipients (>60 years), people with type I diabetes, and males and demonstrated no additional risk among younger (18-39) and Hispanic recipients. High BMI was associated with elevated risk for Caucasians and attenuated risk among African Americans and people with type II diabetes. Effects of BMI had variable risks for mortality vs graft loss by recipient characteristics in competing risks models. The association of BMI with posttransplant outcomes is highly variable among kidney transplant recipients. Results are important considerations for personalized care and risk stratification. Findings suggest that transplant contraindications should not be based on absolute BMI thresholds but modified based on patient characteristics.

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States.

Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center-level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center-level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts.

Hemodialysis Quality Metrics in the First Year Following a Failed Kidney Transplant.

BACKGROUND: Failure of a previously transplanted kidney is a common cause of end-stage renal disease (ESRD) and represents 5% of incident dialysis patients in the United States. Patients with native kidney failure ESRD (Nat-ESRD) who receive predialysis care from a nephrologist have better outcomes in the first 12 months on dialysis than those who don't. Because many patients with a failed kidney transplant ESRD (Tx-ESRD) receive care from nephrologists, they would also be expected to have good dialysis outcomes. We sought to compare the quality metrics of Tx-ESRD patients and Nat-ESRD patients during the first 12 months of hemodialysis. METHODS: We used data from the United States Renal Data System to identify hemodialysis patients who began treatment between May 2012 and December 2013 and who received nephrology care prior to starting hemodialysis. Quality metrics by quarter for the first 12 months of treatment were dichotomized according to practice guidelines to determine the percentage of patients in each quarter who met quality of care goals. RESULTS: Compared to Nat-ESRD (n = 96,063) patients, Tx-ESRD (n = 5,528) patients had 10-19% lower rates of at goal hemoglobin levels, 6-12% lower rates of at goal serum phosphorus, and 3-11% lower rates of at goal albumin levels. Compared to Nat-ESRD patients, -Tx-ESRD patients had a 6% higher rate of fistula use in the first quarter but a 3-7% lower rate in subsequent quarters. CONCLUSIONS: Tx-ESRD patients have worse quality metrics related to anemia, phosphorus, albumin, and vascular access compared to Nat-ESRD patients. Nephrology care for patients with Tx-ESRD should be improved to address these quality metrics gaps.

Comparison of the Availability and Cost of Foods Compatible With a Renal Diet Versus an Unrestricted Diet Using the Nutrition Environment Measures Survey.

OBJECTIVE: Hemodialysis patients' ability to access food that is both compatible with a renal diet and affordable is affected by the local food environment. Comparisons of the availability and cost of food items suitable for the renal diet versus a typical unrestricted diet were completed using the standard Nutrition Environment Measures Survey and a renal diet-modified Nutrition Environment Measures Survey. DESIGN: Cross-sectional study. SETTING: Twelve grocery stores in Northeast Ohio. MAIN OUTCOME MEASURE: Availability and cost of food items in 12 categories. RESULTS: The mean total number of food items available differed significantly (P ≤ .001) between the unrestricted diet (38.9 ± 4.5) and renal diet (32.2 ± 4.7). The mean total cost per serving did not differ significantly (P = 0.48) between the unrestricted diet ($5.67 ± 2.50) and renal diet ($5.76 ± 2.74). CONCLUSION: The availability of renal diet food items is significantly less than that of unrestricted diet food items, but there is no difference in the cost of items that are available in grocery stores. Further work is needed to determine how to improve the food environment for patients with chronic diseases.

Relationship of Social Deprivation Among Living Kidney Donor-Recipient Pairs.

Background: Living kidney transplant is the most effective renal replacement therapy for patients with end-stage kidney disease. Community-level factors contribute to pervasive socioeconomic and racial disparities in access to living donor kidney transplantation. Little is known about social and environmental conditions between living donors and recipients. Further understanding of these relationships may enhance opportunities for transplantation. Methods: From 2010 to 2020, 59 575 living kidney donor-recipient pairs (≥18 y old) were identified using the Scientific Registry of Transplant Recipients. Living donors and recipients were geocoded to area-level social deprivation index (SDI). The primary outcome was difference between recipient and donor SDI. We used multivariable logistic regression to examine recipient and donor characteristics association with residence in different SDI communities. Results: Living kidney donation occurs across all strata of social deprivation; including when donors, recipients or both reside in more disadvantaged communities. Donor-recipient race combination and biological relationship are associated with differences in SDI. When compared with White recipients of White donors, Black and Hispanic recipients were more likely to reside in more disadvantaged areas (odds ratio = 2.41 [2.19-2.66] and 1.97 [1.78-2.19]). Recipients in anonymous and paired donations were more likely to reside in areas of more disadvantage than their donors (odds ratio = 1.27 [1.15-1.40] and 1.32 [1.23-1.41] compared with biological); attenuating socioeconomic disparities in access to living donor transplantation. Conclusions: Findings illustrate the social and environmental relationships between living kidney donor-recipient pairs that are important to develop targeted approaches and address barriers to living kidney transplantation. Best practices from areas of high deprivation with successful living kidney transplantation can be shared.

Accuracy of dialysis medical records in determining patients' interest in and suitability for transplantation.

BACKGROUND: We sought to determine the accuracy of dialysis medical records in identifying patients' interest in and suitability for transplantation. STUDY DESIGN: Cluster randomized controlled trial. SETTING AND PARTICIPANTS: A total of 167 patients recruited from 23 hemodialysis facilities. INTERVENTION: Navigators met with intervention patients to provide transplant information and assistance. Control patients continued to receive usual care. OUTCOMES: Agreement at study initiation between medical records and (i) patient self-reported interest in transplantation and (ii) study assessments of medical suitability for transplant referral. MEASUREMENTS: Medical record assessments, self-reports, and study assessments of patient's interest in and suitability for transplantation. RESULTS: There was disagreement between medical records and patient self-reported interest in transplantation for 66 (40%) of the 167 study patients. In most of these cases, patients reported being more interested in transplantation than their medical records indicated. The study team determined that all 92 intervention patients were medically suitable for transplant referral. However, for 38 (41%) intervention patients, medical records indicated that they were not suitable. About two-thirds of these patients successfully moved forward in the transplant process. CONCLUSION: Dialysis medical records are frequently inaccurate in determining patient's interest in and suitability for transplantation.