Machine learning models including preoperative and postoperative albumin-bilirubin score: short-term outcomes among patients with hepatocellular carcinoma.

BACKGROUND: We sought to assess the impact of various perioperative factors on the risk of severe complications and post-surgical mortality using a novel maching learning technique. METHODS: Data on patients undergoing resection for HCC were obtained from an international, multi-institutional database between 2000 and 2020. Gradient boosted trees were utilized to construct predictive models. RESULTS: Among 962 patients who underwent HCC resection, the incidence of severe postoperative complications was 12.7% (n = 122); in-hospital mortality was 2.9% (n = 28). Models that exclusively used preoperative data achieved AUC values of 0.89 (95%CI 0.85 to 0.92) and 0.90 (95%CI 0.84 to 0.96) to predict severe complications and mortality, respectively. Models that combined preoperative and postoperative data achieved AUC values of 0.93 (95%CI 0.91 to 0.96) and 0.92 (95%CI 0.86 to 0.97) for severe morbidity and mortality, respectively. The SHAP algorithm demonstrated that the factor most strongly predictive of severe morbidity and mortality was postoperative day 1 and 3 albumin-bilirubin (ALBI) scores. CONCLUSION: Incorporation of perioperative data including ALBI scores using ML techniques can help risk-stratify patients undergoing resection of HCC.

Open vs robotic-assisted pancreaticoduodenectomy, cost-effectiveness and long-term oncologic outcomes: a systematic review and meta-analysis.

BACKGROUND: Whipple pancreaticoduodenectomy (PD) is a complex gastrointestinal surgery that is performed increasingly via minimally invasive approach through robotic platforms. We sought to provide a comparative review of available data regarding robot-assisted vs open PD in terms of cost-effectiveness, overall survival, and other perioperative and long-term oncologic outcomes. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria, PubMed, Scopus, and Web of Science databases were searched from 1980 to April 2024 using designated keywords. English-language studies comparing costs and oncologic outcomes of robotic vs open PDs were considered for inclusion. Reviews, abstracts, case reports, letters to the editor, and non-English articles were excluded. RESULTS: A total of 1733 studies were initially identified throughout the literature search. After the removal of duplicates, title and abstract screening identified 16 studies that were included in the review. No statistically significant differences were detected in terms of short-term complications (95% CI, 0.805-1.096; P = .42), mortality (95% CI, 0.599-1.123; P = .21), and readmission (95% CI, 0.959-1.211; P = .20) among patients undergoing open vs robotic PD. Robotic PDs was associated with a slightly better overall survival (95% CI, 1.020-1.233) and higher costs (95% CI, 0.134-1.139; P = .013). Mean length of stay (LOS) was higher in the open PD group (95% CI, -0.353 to 0.189; P < .001). CONCLUSION: Robotic-assisted PD had a slightly shorter LOS and improved overall survival. There were no differences in short-term complications, mortality, or readmission. The use of cohort studies and residual potential selection bias necessitate randomized controlled trials to define the benefit of robotic PD.

Racial and Ethnic Disparities in Peri-and Post-operative Cardiac Surgery.

Purpose of Review: Despite efforts to curtail its impact on medical care, race remains a powerful risk factor for morbidity and mortality following cardiac surgery. While patients from racial and ethnic minority groups are underrepresented in cardiac surgery, they experience a disproportionally elevated number of adverse outcomes following various cardiac surgical procedures. This review provides a summary of existing literature highlighting disparities in coronary artery bypass surgery, valvular surgery, cardiac transplantation, and mechanical circulatory support. Recent Findings: Unfortunately, specific causes of these disparities can be difficult to identify, even in large, multicenter studies, due to the complex relationship between race and post-operative outcomes. Current data suggest that these racial/ethnic disparities can be attributed to a combination of patient, socioeconomic, and hospital setting characteristics. Summary: Proposed solutions to combat the mechanisms underlying the observed disparate outcomes require deployment of a multidisciplinary team of cardiologists, anesthesiologists, cardiac surgeons, and experts in health care equity and medical ethics. Successful identification of at-risk populations and the implementation of preventive measures are necessary first steps towards dismantling racial/ethnic differences in cardiac surgery outcomes.

Development of an Artificial Intelligence Based Model to Predict Early Recurrence of Neuroendocrine Liver Metastasis Following Resection.

OBJECTIVE: We sought to develop an artificial intelligence (AI) based model to predict early recurrence (ER) following curative-intent resection of neuroendocrine liver metastases (NELM). METHODS: Patients with NELM, who underwent resection were identified from a multi-institutional database. ER was defined as recurrence within 12 months of surgery. Different AI based models were developed to predict ER using 10 clinicopathological factors. RESULTS: Overall, 473 NELM patients were included. Among 284 (60.0%) patients with recurrence, 118 (41.5%) patients developed an ER. An ensemble AI model demonstrated the highest area under ROC curves (AUC) of 0.763 and 0.716 in the training and testing cohorts, respectively. Maximum diameter of the primary neuroendocrine tumor, NELM radiologic tumor burden score (TBS), and bilateral liver involvement were the factors most strongly associated with risk of NELM ER. Patients predicted to develop ER had worse 5-year recurrence free survival and overall survival (21.4% vs. 37.1%; p=0.002 and 61.6% vs. 90.3%; p=0.03, respectively) versus patients not predicted to recur. An easy-to-use tool was made available online: (https://altaf-pawlik-nelm-earlyrecurrence-calculator.streamlit.app/). CONCLUSION: An AI-based model demonstrated excellent discrimination to predict ER of NELM following resection. The model may help identify patients who may benefit the most from curative-intent resection, risk-stratify patients according to prognosis, and guide tailored surveillance and treatment decisions, including consideration of non-surgical treatment options.

Pharmacy Accessibility and Social Vulnerability.

This cross-sectional study examines the association of availability of primary care practitioners and level of socioeconomic vulnerability with risk of pharmacy deserts in regions of the US.

The Association of Socio-Environmental Inequality and Outcomes Among Patients Undergoing Major Surgery.

INTRODUCTION: Environmental hazards may influence health outcomes and be a driver of health inequalities. We sought to characterize the extent to which social-environmental inequalities were associated with surgical outcomes following a complex operation. METHODS: In this cross-sectional study, patients who underwent abdominal aortic aneurysm repair, coronary artery bypass grafting, colectomy, pneumonectomy, or pancreatectomy between 2016 and 2021 were identified from Medicare claims data. Patient data were linked with social-environmental data sourced from Centers for Disease Control and Agency for Toxic Substances and Disease Registry data based on county of residence. The Environmental Justice Index social-environmental ranking (SER) was used as a measure of environmental injustice. Multivariable regression analysis was performed to assess the relationship between SER and surgical outcomes. RESULTS: Among 1,052,040 Medicare beneficiaries, 346,410 (32.9%) individuals lived in counties with low SER, while 357,564 (33.9%) lived in counties with high SER. Patients experiencing greater social-environmental injustice were less likely to achieve textbook outcome (odds ratio 0.95, 95% confidence interval 0.94-0.96, P < 0.001) and to be discharged to an intermediate care facility or home with a health agency (odds ratio 0.97, 95% confidence interval 0.96-0.98, P < 0.001). CONCLUSIONS: Cumulative social and environmental inequalities, as captured by the Environmental Justice Index SER, were associated with postoperative outcomes among Medicare beneficiaries undergoing a range of surgical procedures. Policy makers should focus on environmental, as well as socioeconomic injustice to address preventable health disparities.

Association of county-level provider density with hepatobiliary cancer incidence and mortality.

BACKGROUND: Access to healthcare providers is a key factor in reducing cancer incidence and mortality, underscoring the significance of provider density as a crucial metric of health quality. We sought to characterize the association of provider density on hepatobiliary cancer population-level incidence and mortality. STUDY DESIGN: County-level hepatobiliary cancer incidence and mortality data from 2016 to 2020 and provider data from 2016 to 2018 were obtained from the CDC and Area Health Resource File. Multivariable logistic regression was utilized to evaluate the relationship between provider density and hepatobiliary cancer incidence and mortality. RESULTS: Among 1359 counties, 851 (62.6%) and 508 (37.4%) counties were categorized as urban and rural, respectively. The median number of providers in any given county was 104 (IQR: 44-306), while provider density was 120.1 (IQR: 86.7-172.2) per 100,000 population; median household income was $51,928 (IQR: $45,050-$61,655). Low provider-density counties were more likely to have a greater proportion of residents over 65 years of age (52.7% vs. 49.6%) who were uninsured (17.4% vs. 13.2%) versus higher provider-density counties (p < 0.05). Moreover, all-stage incidence, late-stage incidence, and mortality rates were higher in counties with low provider density. On multivariable analysis, moderate, and high provider density were associated with lower odds of all-stage incidence, late-stage incidence, and mortality. CONCLUSION: Higher county-level provider density was associated with lower hepatobiliary cancer-related incidence and mortality. Efforts to increase access to healthcare providers may improve healthcare equity as well as long-term cancer outcomes.

Preoperative platelet count as an independent predictor of long-term outcomes among patients undergoing resection for intrahepatic cholangiocarcinoma.

BACKGROUND AND OBJECTIVES: An elevated platelet count may reflect neoplastic and inflammatory states, with cytokine-driven overproduction of platelets. The objective of this study was to evaluate the prognostic utility of high platelet count among patients undergoing curative-intent liver surgery for intrahepatic cholangiocarcinoma (ICC). METHODS: An international, multi-institutional cohort was used to identify patients undergoing curative-intent liver resection for ICC (2000-2020). A high platelet count was defined as platelets >300 *109/L. The relationship between preoperative platelet count, cancer-specific survival (CSS), and overall survival (OS) was examined. RESULTS: Among 825 patients undergoing curative-intent resection for ICC, 139 had a high platelet count, which correlated with multifocal disease, lymph nodes metastasis, poor to undifferentiated grade, and microvascular invasion. Patients with high platelet counts had worse 5-year (35.8% vs. 46.7%, p = 0.009) CSS and OS (24.8% vs. 39.8%, p < 0.001), relative to patients with a low platelet count. After controlling for relevant clinicopathologic factors, high platelet count remained an adverse independent predictor of CSS (HR = 1.46, 95% CI 1.02-2.09) and OS (HR = 1.59, 95% CI 1.14-2.22). CONCLUSIONS: High platelet count was associated with worse tumor characteristics and poor long-term CSS and OS. Platelet count represents a readily-available laboratory value that may preoperatively improve risk-stratification of patients undergoing curative-intent liver resection for ICC.

State-of-the-art imaging of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the third most fatal and fifth most common cancer worldwide, with rising incidence due to obesity and nonalcoholic fatty liver disease. Imaging modalities, including ultrasound (US), multidetector computed tomography (MDCT), and magnetic resonance imaging (MRI) play a vital role in detecting HCC characteristics, aiding in early detection, detailed visualization, and accurate differentiation of liver lesions. Liver-specific contrast agents, the Liver Imaging Reporting and Data System, and advanced techniques, including diffusion-weighted imaging and artificial intelligence, further enhance diagnostic accuracy. This review emphasizes the significant role of imaging in managing HCC, from diagnosis to treatment assessment, without the need for invasive biopsies.

The Association of Established Primary Care with Postoperative Outcomes Among Medicare Patients with Digestive Tract Cancer.

BACKGROUND: Primary care (PC) is essential to overall wellness and management of comorbidities. In turn, patients without adequate access to PC may face healthcare disparities. We sought to characterize the impact of established PC on postoperative outcomes among patients undergoing a surgical procedure for a digestive tract cancer. METHODS: Medicare beneficiaries with a diagnosis of hepatobiliary, pancreas, and colorectal cancer between 2005 and 2019 were identified within the Surveillance, Epidemiology, and End Results program and Medicare-linked database. Individuals who did versus did not have PC encounters within 1-year before surgery were identified. A postoperative textbook outcome (TO) was defined as the absence of complications, no prolonged hospital stay, no readmission within 90 days, and no mortality. RESULTS: Among 63,177 patients, 50,974 (80.7%) had at least one established PC visit before surgery. Patients with established PC were more likely to achieve TO (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.19) with lower odds for complications (OR, 0.85; 95% CI, 0.72-0.89), extended hospital stay (OR, 0.86; 95% CI, 0.81-0.94), 90-day readmission (OR, 0.94; 95% CI, 0.90-0.99), and 90-day mortality (OR, 0.87; 95% CI, 0.79-0.96). In addition, patients with established PC had a 4.1% decrease in index costs and a 5.2% decrease in 1-year costs. Notably, patients who had one to five visits with their PC in the year before surgery had improved odds of TO (OR, 1.21; 95% CI, 1.16-1.27), whereas individuals with more than 10 visits had lower odds of a postoperative TO (OR, 0.91; 95% CI, 0.84-0.98). CONCLUSION: Most Medicare beneficiaries with digestive tract cancer had established PC within the year before their surgery. Established PC was associated with a higher probability of achieving ideal outcomes and lower costs. In contrast, patients with more than 10 PC appointments, which was likely a surrogate of overall comorbidity burden, experienced no improvement in postoperative outcomes.

Trends in the Use of Observation for Small Nonfunctional Pancreatic Neuroendocrine Tumors.

This study assesses nationwide trends in the use of observation for pancreatic neuroendocrine tumors 2 cm or smaller and to evaluate factors associated with resection.

Community Privilege and Unplanned Surgery for Access-Sensitive Surgical Conditions.

OBJECTIVE: We sought to define the association of privilege on rates of unplanned surgery and perioperative outcomes for access-sensitive surgical conditions. BACKGROUND: Social determinants of health (SDOH) are critical in influencing timely access to healthcare. Privilege represents a right, benefit, advantage, or opportunity that positively influences all SDOH. METHODS: The California Department of Health Care Access and Information (HCAI) database identified patients who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2017 and 2020 and was merged using ZIP codes with the Index of Concentration of Extremes, a validated measure of racial and economic privilege obtained from the American Community Survey. Clustered multivariable regression was performed to assess the association between privilege and outcomes. RESULTS: Among 185,316 patients who underwent a surgical procedure for one of three access-sensitive surgical conditions, roughly 1 in 5 individuals resided in areas with the highest (Q5; n=37,308; 20.1%) or lowest (Q1; n=36,352, 19.6%) privilege. Nearly one-half of the surgeries were unplanned (n=88,814, 46.9%), and colectomy for colon cancer was the most performed emergent procedure. Patients residing in the lowest privileged areas had higher rates of unplanned surgery compared with those residing in the highest privilege (Q1; 55.4% vs. 39.4%; referent: Q5; adjusted odds ratio [OR], 1.23, 95%CI 1.16-1.31; P<0.001). For each access-sensitive surgical condition, patients in the least privileged areas were more likely to experience higher rates of inpatient mortality (Q1; 3.1% vs. 2.1%; referent: Q5; adjusted OR, 1.41, 95%CI 1.24-1.60; P<0.001), perioperative complications (Q1; 30.4% vs. Q5; 23.8%; referent: Q5; adjusted OR, 1.24, 95%CI 1.18-1.31; P<0.001) and extended hospital stays (Q1; 26.3% vs. 20.1%; referent: Q5; adjusted OR, 1.16, 95%CI 1.09-1.22; P<0.001). CONCLUSIONS AND RELEVANCE: Privilege was associated with rates of unplanned surgery and adverse clinical outcomes. This indicates the role privilege as a key SDOH that influences patient access to and quality of surgical care.

Recent advancements in management for noncolorectal, nonneuroendocrine hepatic metastases.

BACKGROUND: Owing to the heterogeneity of underlying primary tumors, noncolorectal, nonneuroendocrine metastases to the liver (NCNNMLs), although relatively rare, pose major challenges to treatment and long-term management. Despite being considered the gold standard for colorectal cancer liver metastases, the role of surgical resection for NCNNML remains controversial. Furthermore, advancements in locoregional treatment modalities, such as ablation and various chemotherapeutic modalities, have contributed to the treatment of patients with NCNNML. METHODS: This was a comprehensive review of literature that used Medline/PubMed, Google Scholar, the Cochrane Library, and the Web of Science, which were accessed between 2014 and 2024. RESULTS: NCNNMLs are rare tumor entities with varied presentation and outcomes. A multidisciplinary approach, which includes chemotherapy, surgery, and interventional radiologic techniques, can be implemented with good results. CONCLUSION: Given the complex nature of NCNNML, its management should be highly individualized and multidisciplinary. Locoregional treatments, such as surgical resection and/or ablation, may be more appropriate for select patients and should be offered as a viable therapeutic option for a subset of individuals.

County-level food insecurity is associated with outcomes following cardiac surgery.

BACKGROUND: As there is limited literature evaluating food insecurity status (FI) and surgical outcomes, we sought to assess the association between county-level FI and outcomes following cardiac surgery. METHODS: In a retrospective cohort, patients who underwent coronary artery bypass grafting between 2016 and 2020 were identified utilizing the Medicare Standard Analytic Files. Using County-level FI, patients were stratified into low, moderate, and high cohorts. The primary outcome was textbook outcomes, a measure of "optimal" post-operative outcomes. Adjusted multiple logistic regression and Cox regression models were utilized to evaluate outcomes and survival. RESULTS: Among 267,914 patients, patients residing in high FI regions were less likely to achieve textbook outcomes (OR: 0.94, 95 â€‹% CI: 0.90-0.99). When evaluating individual post-operative outcomes of interest, patients residing in high FI regions also had a greater odd of 90-day mortality (OR: 1.24, 95 â€‹% CI: 1.12-1.36) and extended LOS (OR: 1.07, 95 â€‹% CI: 1.01-1.14) (all p â€‹< â€‹0.0001). Moreover, this population was also at greater risk of 5-year mortality (HR: 1.11, 95 â€‹% CI: 1.06-1.17) compared with their counterparts from low food insecurity regions. Racial disparities persisted in high FI counties as Black patients had a greater risk of 5-year mortality (HR: 1.27, 95 â€‹% CI: 1.17-1.38, p â€‹< â€‹0.0001) compared with White patients within the same FI level. CONCLUSIONS: County-level FI was associated with worse outcomes following cardiac surgery.

Poverty and Its Impact on Surgical Care.

In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.

Defensins: Exploring Their Opposing Roles in Colorectal Cancer Progression.

Colorectal cancer (CRC) represents a significant global healthcare burden, with a particularly concerning rising incidence among younger adults. This trend may highlight potential links between diet, gut microbiome, and CRC risk. Novel therapeutic options have been increasingly based on the understanding of molecular mechanisms and pathways. The PI3K/AKT/mTOR pathway, a crucial cell growth regulator, offers a promising target for CRC therapy. mTOR, a key component within this pathway, controls cell growth, survival, and metabolism. Understanding the specific roles of defensins, particularly human ß-Defensin 1 (HBD-1), in CRC is crucial. HBD-1 exhibits potent antimicrobial activity and may influence CRC development. Deciphering defensin expression patterns in CRC holds the promise of improved understanding of tumorigenesis, which may pave the way for improved diagnostics and therapies. This article reviews recent advances in understanding regarding how HBD-1 influences CRC initiation and progression, highlighting the molecular mechanisms by which it impacts CRC. Further, we describe the interaction between defensins and mTOR pathway in CRC.

Long-term outcomes following hepatectomy in patients with lean non-alcoholic fatty liver disease-associated hepatocellular carcinoma versus overweight and obese counterparts: A multicenter analysis.

BACKGROUND & AIMS: With the rising prevalence of non-alcoholic fatty liver disease (NAFLD) as a significant etiology for hepatocellular carcinoma (HCC), lean NAFLD-HCC has emerged as a specific distinct subtype. This study sought to investigate long-term outcomes following curative-intent hepatectomy for early-stage NAFLD-HCC among lean patients compared with overweight and obese individuals. METHODS: A multicenter retrospective analysis was used to assess early-stage NAFLD-HCC patients undergoing curative-intent hepatectomy between 2009 and 2022. Patients were stratified by preoperative body mass index (BMI) into the lean (<23.0 kg/m2), overweight (23.0-27.4 kg/m2) and obese (≥27.5 kg/m2) groups. Study endpoints were overall survival (OS) and recurrence-free survival (RFS), which were compared among groups. RESULTS: Among 309 patients with NAFLD-HCC, 66 (21.3 %), 176 (57.0 %), and 67 (21.7 %) were lean, overweight, and obese, respectively. The three groups were similar relative to most liver, tumor, and surgery-related variables. Compared with overweight patients (71.3 % and 55.6 %), the lean individuals had a worse 5-year OS and RFS (55.4 % and 35.1 %, P = 0.017 and 0.002, respectively), which were comparable to obese patients (48.5 % and 38.2 %, P = 0.939 and 0.442, respectively). After adjustment for confounding factors, multivariable Cox-regression analysis identified that lean bodyweight was independently associated with decreased OS (hazard ratio: 1.69; 95 % confidence interval: 1.06-2.71; P = 0.029) and RFS (hazard ratio: 1.72; 95 % confidence interval: 1.17-2.52; P = 0.006) following curative-intent hepatectomy for early-stage NAFLD-HCC. CONCLUSIONS: Compared with overweight patients, individuals with lean NAFLD-HCC had inferior long-term oncological survival after hepatectomy for early-stage NAFLD-HCC. These data highlight the need for examination of the distinct carcinogenic pathways of lean NAFLD-HCC and its potential consequences in HCC recurrence.

Hepatectomy versus systemic therapy for liver-limited BRAF V600E-mutated colorectal liver metastases: multicentre retrospective study.

BACKGROUND: To date, only two studies have compared the outcomes of patients with liver-limited BRAF V600E-mutated colorectal liver metastases (CRLMs) managed with resection versus systemic therapy alone, and these have reported contradictory findings. METHODS: In this observational, international, multicentre study, patients with liver-limited BRAF V600E-mutated CRLMs treated with resection or systemic therapy alone were identified from institutional databases. Patterns of recurrence/progression and overall survival were compared using multivariable analyses of the entire cohort and a propensity score-matched cohort. RESULTS: Of 170 patients included, 119 underwent hepatectomy and 51 received systemic treatment. Surgically treated patients had a more favourable pattern of recurrence with most recurrences limited to a single site, whereas diffuse progression was more common among patients who received systemic treatment (19 versus 44%; P = 0.002). Surgically treated patients had longer median overall survival (35 versus 20 months; P < 0.001). Hepatectomy was independently associated with better OS than systemic treatment alone (HR 0.37, 95% c.i. 0.21 to 0.65). In the propensity score-matched cohort, surgically treated patients had longer median overall survival (28 versus 20 months; P < 0.001); hepatectomy was independently associated with better overall survival (HR 0.47, 0.25 to 0.88). CONCLUSION: BRAF V600E mutation should not be considered a contraindication to surgery for patients with resectable, liver-only CRLMs.

Waitlist Time, Age, and Social Vulnerability: Impact on the Survival Benefit of Deceased Donor Kidney Transplantation Versus Long-term Dialysis Among Patients With End-stage Renal Disease.

BACKGROUND: We sought to define the survival benefit of kidney transplantation versus long-term dialysis relative to waitlist time on dialysis, social vulnerability, and age among end-stage renal transplant candidates. METHODS: End-stage renal disease patients who were candidates for their first deceased donor kidney transplantation between 2008 and 2020 were identified using the US Renal Data System. Survival probabilities for patient survival were compared using the restricted mean survival times (RMSTs) across different age and social vulnerability index (SVI) ranges. RESULTS: Among 149 923 patients, 68 795 (45.9%) patients underwent a kidney transplant and 81 128 (54.1%) remained on dialysis. After propensity-score matching (n = 58 035 in each cohort), the 5-y RMST difference between kidney transplant and dialysis demonstrated an increasing trend in mean life-years gained within 5 y of follow-up relative to advancing age (<30 y: 0.40 y, 95% confidence interval, 0.36-0.44 y versus >70 y: 0.75 y, 95% confidence interval, 0.70-0.80 y). Conversely, disparities in 5-y RMSTs remained consistent relative to social vulnerability (median 5-y RMST difference: 0.62 y comparing low versus high SVI). When considering waitlist duration, stratified analyses demonstrated increasing trends across different age groups with the largest RMST differences observed among older patients aged ≥70 y. Notably, longer waitlist durations (>3 y) yielded more pronounced RMST differences compared with shorter durations (<1 y). CONCLUSIONS: These data underscore the survival benefit associated with kidney transplantation over long-term dialysis across various age and SVI ranges. Transplantation demonstrated a greater advantage among older patients who had a longer waitlist duration.