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It is unknown whether dialysis facility staff are aware of the new kidney allocation system implemented in December 2014, which changed how deceased donor kidneys are allocated and waiting time is calculated. U.S. dialysis facilities with low annual waitlisting (

Background In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation. Methods Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies. Results We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors. Conclusions A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.

Background and objectives The fraction of kidneys procured for transplant that are discarded is rising in the United States. Identifying donors from whom only one kidney was discarded allows us to control for donor traits and better assess reasons for organ discard. Design, setting, participants, & measurements We conducted a retrospective cohort study using United Network for Organ Sharing Standard Transplant Analysis and Research file data to identify deceased donors from whom two kidneys were procured and at least one was transplanted. Unilateral pairs were defined as kidney pairs from a single donor from whom one kidney was discarded (“unilateral discard”) but the other was transplanted (“unilateral transplant”). Organ quality was estimated using the Kidney Donor Risk Index and Kidney Donor Profile Index (KDPI). We compared all-cause graft failure rates for unilateral transplants to those for bilateral transplant Kaplan–Meier methods, and life table methodology was used to evaluate 1-, 2-, 3-, and 5-year survival rates of transplants from bilateral and unilateral donors. Results Compared with bilateral donors (i.e., both kidneys transplanted) (n=80,584), unilateral donors (i.e., only one kidney transplanted) (n=7625) had higher mean terminal creatinine (1.3±2.1 mg/dl versus 1.1±0.9 mg/dl) and KDPI (67%±25% versus 42%±27%), were older, and were more likely to have hypertension, diabetes, hepatitis C, terminal stroke, or meet Centers for Disease Control and Prevention high-risk donor criteria. Unilateral discards were primarily attributed to factors expected to be similar in both kidneys from a donor: biopsy findings (22%), no interested recipient (13%), and donor history (7%). Anatomic abnormalities (14%), organ damage (11%), and extended ischemia (6%) accounted for about 30% of discards, but were the commonest reasons among low KDPI kidneys. Among kidneys with KDPI≥60%, there was an incremental difference in allograft survival over time (for unilateral versus bilateral transplants, 1-year survival: 83% versus 87%; 3-year survival: 69% versus 73%; 5-year survival: 51% versus 58%). Conclusions A large number of discarded kidneys were procured from donors whose contralateral kidneys were transplanted with good post-transplant outcomes.

Rationale & Objective There are many barriers to meeting the goal of increasing kidney transplants in the United States. It is important to understand dialysis and transplant center providers’ existing practices and identified barriers to increasing the number of dialysis patients who are evaluated for and get wait-listed for a transplant. Study Design Cross-sectional survey of dialysis unit and transplant center staff in End Stage Renal Disease Network 6 (Georgia, North Carolina, South Carolina). Setting & Participants Ninety-one transplant staff from all 9 transplant centers in the region and 421 dialysis staff from 421 facilities responded to the survey. Predictors N/A Outcome Provider perceptions of barriers faced by patients in the kidney transplant evaluation process and suggestions for improving care. Analytical Approach Mixed methods. Descriptive analyses of responses to multiple-choice questions and qualitative analysis of open-ended survey responses. Results The top 5 barriers to kidney transplantation as reported by transplant staff were transportation (63.7%), low health literacy (50.5%), lack of understanding about the transplant process (37.4%), distance to transplant center (29.7%), and low socioeconomic status (28.6%). When asked how dialysis units can help patients complete the evaluation process, the most common responses from transplant center staff were educating patients about transplant (54%), helping patients through steps in the process (35%), and better communication with transplant centers (15%). When dialysis unit staff were asked what could be done to help the facility improve its transplant wait-list rate, the most common responses were educational materials for patients and staff (55%), better communication with transplant centers (12%), and transportation and financial assistance (9%). Limitations Survey responses are from 1 end stage renal disease network. Conclusions Dialysis units, transplant centers, and ESRD networks can work together to help patients address key barriers to transplantation to improve the country’s transplantation rate., Graphical abstract

Belatacept, a T cell costimulation blocker, demonstrated superior renal function, lower cardiovascular risk, and improved graft and patient survival in renal transplant recipients. Despite the potential benefits, adoption of belatacept has been limited in part due to concerns regarding higher rates and grades of acute rejection in clinical trials. Since July 2011, we have utilized belatacept-based immunosuppression regimens in clinical practice. In this retrospective analysis of 745 patients undergoing renal transplantation at our center, we compared patients treated with belatacept (n = 535) with a historical cohort receiving a tacrolimus-based protocol (n = 205). Patient and graft survival were equivalent for all groups. An increased rate of acute rejection was observed in an initial cohort treated with a protocol similar to the low-intensity regimen from the BENEFIT trial versus the historical tacrolimus group (50.5% vs. 20.5%). The addition of a transient course of tacrolimus reduced rejection rates to acceptable levels (16%). Treatment with belatacept was associated with superior estimated GFR (belatacept 63.8 mL/min vs. tacrolimus 46.2 mL/min at 4 years, p < 0.0001). There were no differences in serious infections including rates of cytomegalovirus or BK viremia. We describe the development of a costimulatory blockade-based strategy that ultimately allows renal transplant recipients to achieve calcineurin inhibitor-free immunosuppression.

While regional organ availability dominates discussions of distribution policy, community-level disparities remain poorly understood. We studied micro-geographic determinants of survival risk and their distribution across Donor Service Areas (DSAs). Scientific Registry of Transplant Recipients records for all adults waitlisted for liver transplantation 2002-2014 were reviewed. The primary exposure variables were county-level sociodemographic risk, as measured by the Community Health Score (CHS), a previously-validated composite index local health conditions, and distance to listing transplant center. Among 114 347 patients, the median CHS was 19.4 (range: 0-40). Compared the lowest risk counties (CHS 1-10), highest-risk counties (CHS 31-40) had more black (14.6% vs. 5.4%), publicly insured (44.9% vs. 33.0), and remote candidates (34.0% vs. 15.1% living >100 miles away). Higher-CHS candidates had greater waitlist mortality in Cox multivariable (HR 1.16 for CHS 31-40, 95% CI 1.11-1.21) and competing risks analysis (sHR 1.07, 95% CI 0.99-1.14). Post-transplant survival was similar across CHS quartiles. Living >25 miles from the transplant center conferred excess mortality risk (sHR 1.08, 95% CI 1.03-1.12). Proposed distribution changes would disproportionately impact DSAs with more high-CHS or distant candidates. Low-income, rural and minority patients experience excess mortality while awaiting transplant, and risk disproportionately worse outcomes with reduced organ availability under current proposals.

Dialysis providers in the United States may soon be held accountable for their patients' 30-day hospital readmissions. However, few studies have evaluated the timing of readmissions, which determines the window in which dialysis providers could act to prevent readmission. We therefore examined the timing of readmissions of hemodialysis patients in the United States and its association with mortality among 285,795 prevalent adult Medicare-primary hemodialysis patients from a national registry. Patients had at least one hospitalization in 2010-2013 (first index) and survived for 30 days or more. Readmission timing was defined as 0-7, 8-14, or 15-30 days after the index discharge. Multivariable Cox proportional hazards models were used to estimate the association between readmission timing (referent no readmission) and mortality, censored at one year. Overall, 23.1% of patients had readmissions within 30 days of the index discharge, of which over one-third (35.9%) were within the first week. Regardless of timing, patients with readmissions had a higher risk of death within one year, compared to those with no readmissions, with hazard ratios of 2.04 (95% confidence interval 2.00-2.09) for being readmitted within 15-30 days; 1.98 (1.93-2.04) for being readmitted within 8-14 days; and 1.76 (1.71-1.80) for being readmitted within 0-7 days. Thus, opportunities for dialysis providers to intervene and prevent early readmission may be limited. Regardless of the timing, readmission appears independently associated with a substantially increased risk of mortality in this population.

Urbanization is expected to increase in low and middle-income countries (LMICs), and might contribute to the increased disease burden. The association between urbanization and CKD is incompletely understood among LMICs. Recently, Inoue et al., explored the association of urbanization on renal function from the China Health and Nutrition Survey. The study found that individuals living in an urban environment had a higher odds of reduced renal function independent of behavioral and cardiometabolic measures, and this effect increased in a dose dependent manner. In this commentary, we discuss the results of these findings and explain the need for more surveillance studies among LMICs.

Background Because initiation of dialysis therapy often occurs in the setting of acute illness and may signal worsening health and functional decline, we examined whether rates of serious fall injuries among older hemodialysis patients differ before and after dialysis therapy initiation. Study Design Retrospective cohort study of claims data from the 2 years spanning dialysis therapy initiation among patients initiating dialysis therapy in 2010 to 2012. Setting & Participants Claims from 81,653 Medicare end-stage renal disease beneficiaries aged 67 to 100 years. Predictor Post– versus pre–dialysis therapy initiation periods, defined as on or after versus before dialysis therapy initiation. Outcomes Serious fall injuries were defined using diagnostic codes for falls in combination with fractures, brain injuries, or joint dislocation. Incidence rate ratios (overall and stratified) for post– versus pre–dialysis therapy initiation periods were estimated using generalized estimating equation models with a negative binomial link. Results Overall, 12,757 serious fall injuries occurred in the pre– and post–dialysis therapy initiation periods. Annual rates of serious fall injuries were 64.4 (95% CI, 62.7-66.2) and 107.8 (95% CI, 105.4-110.3) per 1,000 patient-years, respectively, in the pre– and post–dialysis therapy initiation periods (incidence rate ratio, 1.62; 95% CI, 1.56-1.67). Relative rates of serious fall injuries in the post– vs pre–dialysis initiation periods were of greater magnitude among patients who were younger ( 3g/dL, were able to walk and transfer, did not need assistance with activities of daily living, and were not institutionalized compared with relative rates among their counterparts. Limitations Potential misclassification due to the use of claims data and survival bias among those initiating hemodialysis therapy. Conclusions Among older Medicare beneficiaries receiving hemodialysis, serious fall injuries are common, the post–dialysis initiation period is a high-risk time for falls, and dialysis therapy initiation may be an important time to screen for fall risk factors and implement multifactorial fall prevention strategies.

Prior to the 2014 implementation of a new kidney allocation system by the United Network for Organ Sharing, white patients were more likely to receive a kidney transplant than black or Hispanic patients. To determine the effect of the new kidney allocation system on these disparities, we examined 179,071 waitlisting events from the United Network for Organ Sharing database from June 2013 to September 2016 and calculated monthly kidney transplantation rates among waitlisted patients. Implementation of the new system was associated with a narrowing of the disparity in the average monthly kidney transplantation rate by 0.29 percentage points for blacks compared to whites (p

For the more than 636,000 adults with end-stage renal disease (ESRD) in the USA, kidney transplantation is the preferred treatment compared to dialysis. Living donor kidney transplantation (LDKT) comprised 31% of kidney transplantations in 2015, an 8% decrease since 2004. We aimed to summarize the current literature on decision aids that could be used to improve LDKT rates. Decision aids are evidence-based tools designed to help patients and their families make difficult treatment decisions. LDKT decision aids can help ESRD patients, patients’ family and friends, and healthcare providers engage in treatment decisions and thereby overcome multifactorial LDKT barriers. We identified 12 LDKT decision aids designed to provide information about LDKT, and/or to help ESRD patients identify potential living donors, and/or to help healthcare providers make decisions about treatment for ESRD or living donation. Of these, four were shown to be effective in increasing LDKT, donor inquiries, LDKT knowledge, and willingness to discuss LDKT. Although each LDKT decision aid has limitations, adherence to decision aid development guidelines may improve decision aid utilization and access to LDKT.

Introduction The United Network for Organ Sharing (UNOS) implemented a new Kidney Allocation System (KAS) in December 2014 that is expected to substantially reduce racial disparities in kidney transplantation among waitlisted patients. However, not all dialysis facility clinical providers and end-stage renal disease (ESRD) patients are aware of how the policy change could improve access to transplantation. Methods We describe the ASCENT (Allocation System Changes for Equity in Kidney Transplantation) study, a randomized, controlled effectiveness-implementation study designed to test the effectiveness of a multicomponent intervention to improve access to the early steps of kidney transplantation among dialysis facilities across the United States. The multicomponent intervention consists of an educational webinar for dialysis medical directors, an educational video for patients and an educational video for dialysis staff, and a dialysis facility−specific transplantation performance feedback report. Materials will be developed by a multidisciplinary dissemination advisory board and will undergo formative testing in dialysis facilities across the United States. Results This study is estimated to enroll ∼600 US dialysis facilities with low waitlisting in all 18 ESRD networks. The co-primary outcomes include change in waitlisting and waitlist disparity at 1 year; secondary outcomes include changes in facility medical director knowledge about KAS, staff training regarding KAS, patient education regarding transplantation, and the intent of the medical director to refer patients for transplantation evaluation. Discussion The results from the ASCENT study will demonstrate the feasibility and effectiveness of a multicomponent intervention designed to increase access to the deceased donor kidney waitlist and to reduce racial disparities in waitlisting.

OBJECTIVES/GOALS: The new Kidney Allocation System (KAS) was implemented in 2014 and it is not fully understood how its changes to patient incentives may have impacted dialysis facility waitlisting rates. We examine differences in facility performance and how such differences may have been impacted by this policy change. METHODS/STUDY POPULATION: We used Dialysis Facility Report data from 2011 to 2017 to study waitlisting rates at 3,392 dialysis facilities in the US, using waitlisting counts in the numerator, and the total number of ESRD patients in a facility as the denominator. We examined changes in waitlisting rates over by year at the facility, regional, and national level, and report national trends in waitlisting pre- and post-KAS. Facilities were stratified based on waitlisting rate in 2011 and then we examined whether each facility moved into a higher or lower quartile or stayed in the same quartile in 2017. RESULTS/ANTICIPATED RESULTS: Among n = 3,392 dialysis facilities, the average change in dialysis facility waitlisting rates from 2011 to 2017 was −4.74 percentage points (range -54.4% to 42.3%). Average change in dialysis facility waitlisting rates from 2011 to 2014 was −0.57 percentage points while the average change in dialysis facility waitlisting rates from 2014 to 2017 was −4.17 percentage points. Half of facilities in the 2011 lowest quartile remained in the lowest quartile in 2017; 45% of facilities in the top 2011 quartile dropped into a lower quartile. The middle 2 quartiles were fairly evenly split between worsening, improving, and not changing. DISCUSSION/SIGNIFICANCE OF IMPACT: Average waitlisting rates have declined since KAS implementation. Many facilities switched quartiles from 2011-17 suggesting that facility waitlisting rates are unstable over time. The decline in waitlisting rates post-KAS suggests that new allocation rules may be discouraging patients and/or providers from getting ESRD patients waitlisted.

IMPORTANCE: For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population. OBJECTIVE: To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study that included 1 478 564 patients treated at 6511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report). EXPOSURES: The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (

BACKGROUND: The relationship between muscle strength and chronic kidney disease (CKD) in children is unknown. This study aims to quantify the association between grip strength (GS) and kidney function and to explore factors associated with grip strength in children and adolescents with CKD. METHODS: We included 411 children (699 GS assessments) of the Chronic Kidney Disease in Children (CKiD) study. They were matched by age, sex, and height to a healthy control from the National Health and Nutrition Examination Survey to quantify the relationship between GS and CKD. Linear mixed models were used to identify factors associated with GS among CKD patients. RESULTS: Median GS z-score was − 0.72 (IQR − 1.39, 0.11) among CKD patients with CKD stages 2 through 5 having significantly lower GS than CKD stage 1. Compared with healthy controls, CKiD participants had a decreased GS z-score (− 0.53 SD lower, 95% CI − 0.67 to − 0.39) independent of race/ethnicity and body mass index. Factors associated with reduced GS included longer duration of CKD, pre-pubertal status, delayed puberty, neuropsychiatric comorbidities, need of feeding support, need for alkali therapy, and hemoglobin level. Decreased GS was also associated with both a lower frequency and intensity of physical activity. CONCLUSIONS: CKD is associated with impaired muscle strength in children independent of growth retardation and BMI. Exposure to CKD for a prolonged time is associated with impaired muscle strength. Potential mediators of the impact of CKD on muscle strength include growth retardation, acidosis, poor nutritional status, and low physical activity. Additional studies are needed to assess the efficacy of interventions targeted at these risk factors.

Background Readmission within 30 days of hospital discharge is common and costly among end-stage renal disease (ESRD) patients. Little is known about long-term outcomes after readmission. We estimated the association between hospital admissions and readmissions in the first year of dialysis and outcomes in the second year. Methods Data on incident dialysis patients with Medicare coverage were obtained from the United States Renal Data System (USRDS). Readmission patterns were summarized as no admissions in the first year of dialysis (Admit-), at least one admission but no readmissions within 30 days (Admit+/Readmit-), and admissions with at least one readmission within 30 days (Admit+/Readmit+).We used Cox proportional hazards models to estimate the association between readmission pattern and mortality, hospitalization, and kidney transplantation, accounting for demographic and clinical covariates. Results Among the 128,593 Medicare ESRD patients included in the study, 18.5% were Admit+/Readmit+, 30.5% were Admit+/Readmit-, and 51.0% were Admit-. Readmit+/Admit+ patients had substantially higher long-term risk of mortality (HR = 3.32 (95% CI, 3.21–3.44)), hospitalization (HR = 4.46 (95% CI, 4.36–4.56)), and lower likelihood of kidney transplantation (HR = 0.52 (95% CI, 0.44–0.62)) compared to Admit- patients; these associations were stronger than those among Admit+/Readmit- patients. Conclusions Patients with readmissions in the first year of dialysis were at substantially higher risk of poor outcomes than either patients who had no admissions or patients who had hospital admissions but no readmissions. Identifying strategies to both prevent readmission and mitigate risk among patients who had a readmission may improve outcomes among this substantial, high-risk group of ESRD patients. Electronic supplementary material The online version of this article (10.1186/s12882-019-1473-0) contains supplementary material, which is available to authorized users.

Supplemental Digital Content is available in the text., Background. A better understanding of the risk factors of posttransplant hospital readmission is needed to develop accurate predictive models. Methods. We included 40 461 kidney transplant recipients from United States renal data system (USRDS) between 2005 and 2014. We used Prentice, Williams and Peterson Total time model to compare the importance of various risk factors in predicting posttransplant readmission based on the number of the readmissions (first vs subsequent) and a random forest model to compare risk factors based on the timing of readmission (early vs late). Results. Twelve thousand nine hundred eighty-five (31.8%) and 25 444 (62.9%) were readmitted within 30 days and 1 year postdischarge, respectively. Fifteen thousand eight hundred (39.0%) had multiple readmissions. Predictive accuracies of our models ranged from 0.61 to 0.63. Transplant factors remained the main predictors for early and late readmission but decreased with time. Although recipients’ demographics and socioeconomic factors only accounted for 2.5% and 11% of the prediction at 30 days, respectively, their contribution to the prediction of later readmission increased to 7% and 14%, respectively. Donor characteristics remained poor predictors at all times. The association between recipient characteristics and posttransplant readmission was consistent between the first and subsequent readmissions. Donor and transplant characteristics presented a stronger association with the first readmission compared with subsequent readmissions. Conclusions. These results may inform the development of future predictive models of hospital readmission that could be used to identify kidney transplant recipients at high risk for posttransplant hospitalization and design interventions to prevent readmission.

Electronic Health Records (EHRs) have been heavily used to predict various downstream clinical tasks such as readmission or mortality. One of the modalities in EHRs, clinical notes, has not been fully explored for these tasks due to its unstructured and inexplicable nature. Although recent advances in deep learning (DL) enables models to extract interpretable features from unstructured data, they often require a large amount of training data. However, many tasks in medical domains inherently consist of small sample data with lengthy documents; for a kidney transplant as an example, data from only a few thousand of patients are available and each patient's document consists of a couple of millions of words in major hospitals. Thus, complex DL methods cannot be applied to these kinds of domains. In this paper, we present a comprehensive ensemble model using vector space modeling and topic modeling. Our proposed model is evaluated on the readmission task of kidney transplant patients and improves 0.0211 in terms of c-statistics from the previous state-of-the-art approach using structured data, while typical DL methods fail to beat this approach. The proposed architecture provides the interpretable score for each feature from both modalities, structured and unstructured data, which is shown to be meaningful through a physician's evaluation., 4 pages, IEEE BHI 2019

This chapter reviews outcomes of kidney transplantation using data derived from surveillance and registry data from the United States, Europe, Australia and New Zealand, in addition to data from individual transplant center reports and multicenter trial data. Comparative outcomes for kidney transplantation versus dialysis and living versus deceased donor transplantation are assessed, as are factors influencing outcomes, including donor and recipient age, race/ethnicity, obesity, genetic factors, organ preservation factors, and immunosuppressive regimen and compliance factors. Allograft survival following kidney transplantation is extensively reviewed, along with posttransplant cancer risk, transplantation in human immunodeficiency virus-positive patients, and pregnancy and fertility outcomes following transplantation. Quality of life, rehospitalization following transplantation, and long-term outcomes of renal transplantation will be briefly addressed.

Renal vascular thrombosis (RVT) is a major cause of early allograft loss in the first year following pediatric kidney transplantation. We examined recent trends in allograft loss due to RVT and identified associated risk factors. We identified 14,640 kidney-only transplants performed between 1995 and 2014 with follow-up until June 30, 2016, in 13,758 pediatric patients aged

Introduction: There are pervasive racial disparities in access to living donor kidney transplantation, which for most patients with end-stage renal disease (ESRD) represents the optimal treatment. We previously developed a theory-driven, culturally sensitive intervention for African American (AA) patients with kidney disease called Living ACTS (About Choices in Transplantation and Sharing) as a DVD and booklet, and found this intervention was effective in increasing living donor transplant knowledge. However, it is unknown whether modifying this intervention for a Web-based environment is effective at increasing access to living donor transplantation. Methods: We describe the Web-based Living ACTS study, a multicenter, randomized controlled study designed to test the effectiveness of a revised Living ACTS intervention in 4 transplant centers in the southeastern United States. The intervention consists of a Web site with 5 modules: Introduction, Benefits and Risks, The Kidney Transplant Process, Identifying a Potential Kidney Donor, and ACT Now (which encourages communication with friends and family about transplantation). Results: This study will enroll approximately 800 patients from the 4 transplant centers. The primary outcome is the percentage of patients with at least 1 inquiry from a potential living donor among patients who receive Living ACTS as compared with those who receive a control Web site. Conclusion: The results from this study are expected to demonstrate the effectiveness of an intervention designed to increase access to living donor transplantation among AA individuals. If successful, the Web-based intervention could be disseminated across the >250 transplant centers in the United States to improve equity in living donor kidney transplantation. Keywords: education, intervention, kidney transplant

Importance Clinical productivity measures may be factors in financial incentives for providing care to specific patient populations and thus may perpetuate inequitable health care. Objective To identify the association of patient race, age, and sex with work relative value units (wRVUs) generated by outpatient dermatology encounters. Design, setting, and participants This cross-sectional study obtained demographic and billing data for outpatient dermatology encounters (ie, an encounter performed within a department of dermatology) from September 1, 2016, to March 31, 2020, at the Emory Clinic, an academic dermatologic practice in Atlanta, Georgia. Participants included adults aged 18 years or older with available age, race, and sex data in the electronic health record system. Main outcomes and measures The primary outcome was wRVUs generated per encounter. Results A total of 66 463 encounters among 30 036 unique patients were included. Patients had a mean (SD) age of 55.9 (18.5) years and were predominantly White (46 575 [70.1%]) and female (39 598 [59.6%]) individuals. In the general dermatologic practice, the mean (SD) wRVUs per encounter was 1.40 (0.71). In adjusted analysis, Black, Asian, and other races (eg, American Indian or Native American, Native Hawaiian or Other Pacific Islander, and multiple races); female sex; and younger age were associated with fewer wRVUs per outpatient dermatology encounter. Compared with general dermatologic visits with White patients, visits with Black patients generated 0.27 (95% CI, 0.25-0.28) fewer wRVUs per encounter, visits with Asian patients generated 0.22 (95% CI, 0.20-0.25) fewer wRVUs per encounter, and visits with patients of other race generated 0.19 (95% CI, 0.14-0.24) fewer wRVUs per encounter. Female sex was also associated with 0.11 (95% CI, 0.10-0.12) fewer wRVUs per encounter, and wRVUs per encounter increased by 0.006 (95% CI, 0.006-0.006) with each 1-year increase in age. In the general dermatologic practice excluding Mohs surgeons, destruction of premalignant lesions and biopsies were mediators for the observed differences in race (56.2% [95% CI, 53.1%-59.3%] for Black race, 53.2% [95% CI, 45.6%-63.8%] for Asian race, and 53.6% [95% CI, 40.4%-77.4%] for other races), age (65.6%; 95% CI, 60.5%-71.4%), and sex (82.3%; 95% CI, 72.7%-93.1%). In a data set including encounters with Mohs surgeons, the race, age, and sex differences in wRVUs per encounter were greater than in the general dermatologic data set. Mohs surgery for basal cell and squamous cell carcinomas was a mediator for the observed differences in race (46.0% [95% CI, 42.6%-49.4%] for Black race, 41.9% [95% CI, 35.5%-49.2%] for Asian race, and 34.6% [95% CI, 13.8%-51.5%] for other races), age (49.2%; 95% CI, 44.9%-53.7%), and sex (47.9%; 95% CI, 42.0%-54.6%). Conclusions and relevance This cross-sectional study found that dermatology encounters with racial minority groups, women, and younger patients generated fewer wRVUs than encounters with older White male patients. This finding suggests that physician compensation based on wRVUs may encourage the provision of services that exacerbate disparities in access to dermatologic care.

Efforts to improve care of patients with ESRD and the policies that guide those activities depend on evidence–based best practices derived from clinical trials and carefully conducted observational studies. Our review describes this process in the context of the translational research model (bench to bedside to populations), with a particular emphasis on bedside care. We illustrate some of its accomplishments and describe the limitations of the data and evidence supporting policy and practice.

Introduction After renal transplantation, decreased renal function is associated with increased risk of cardiovascular disease, graft loss, and mortality. We investigated whether declining renal function was associated with hospitalization after transplantation. Methods Adult, first-time, kidney transplant recipients between 2004 and 2006 from the United Network for Organ Sharing database and hospitalizations 1 year after the 6-month posttransplant follow-up visit were examined. Generalized linear models explored the relationship between estimated glomerular filtration rate (eGFR) measured at 6 months and the number of hospitalizations in the following year. Results Of 15,778 kidney transplant recipients, 19.1% were admitted in the year after the 6-month follow-up visit. Among those hospitalized, the mean number of hospitalizations was 1.71, which increased with decreasing eGFR. In multivariable models, a decrease in eGFR was significantly associated with increased hospitalizations: for every 10 ml/min per 1.73 m2 decrease in eGFR, there was an 11% increase in hospitalization rate (P < 0.001). Lower eGFR after the first 6 months after transplantation was associated with an increase in late hospitalizations among adult kidney transplant recipients. Discussion Identifying patients with declining eGFR and other risk factors may help prevent morbidity and mortality associated with hospitalization after transplantation.

Georgia has the lowest kidney transplant rates in the United States and substantial racial disparities in transplantation. We determined the effectiveness of a multicomponent intervention to increase referral of patients on dialysis for transplant evaluation in the Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT), a randomized, dialysis facility–based, controlled trial involving >9000 patients receiving dialysis from 134 dialysis facilities in Georgia. In December of 2013, we selected dialysis facilities with either low transplant referral or racial disparity in referral. The intervention consisted of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients conducted from January to December of 2014. We examined the proportion of patients with prevalent ESRD in each facility referred for transplant within 1 year as the primary outcome, and disparity in the referral of black and white patients as a secondary outcome. Compared with control facilities, intervention facilities referred a higher proportion of patients for transplant at 12 months (adjusted mean difference [aMD], 7.3%; 95% confidence interval [95% CI], 5.5% to 9.2%; odds ratio, 1.75; 95% CI, 1.36 to 2.26). The difference between intervention and control facilities in the proportion of patients referred for transplant was higher among black patients (aMD, 6.4%; 95% CI, 4.3% to 8.6%) than white patients (aMD, 3.7%; 95% CI, 1.6% to 5.9%; P

We sought to evaluate the prevalence of medication understanding and non-adherence of entire drug regimens among kidney transplantation (KT) recipients and to examine associations of these exposures with clinical outcomes. Structured, in-person interviews were conducted with 99 adult KT recipients between 2011 and 2012 at two transplant centers in Chicago, IL; and Atlanta, GA. Nearly, one-quarter (24%) of participants had limited literacy as measured by the Rapid Estimate of Adult Literacy in Medicine test; patients took a mean of 10 (SD=4) medications and 32% had a medication change within the last month. On average, patients knew what 91% of their medications were for (self-report) and demonstrated proper dosing (via observed demonstration) for 83% of medications. Overall, 35% were non-adherent based on either self-report or tacrolimus level. In multivariable analyses, fewer months since transplant and limited literacy were associated with non-adherence (all P

Objective To estimate and identify factors associated with the incidence of all-cause end-stage renal disease (ESRD) among newly diagnosed systemic lupus erythematosus (SLE) patients. Methods Data from a national registry of treated ESRD were linked to data from a lupus registry of SLE patients who were newly diagnosed and living in Atlanta, Georgia, 2002–2004 (median followup 7.8 years). Cumulative incidence and incidence rates (ESRD treatment initiations per 1,000 patient-years) were calculated, and age- and race-adjusted Poisson models were used to calculate incidence rate ratios (IRRs). Results Among 344 newly diagnosed SLE patients, 29 initiated ESRD treatment over 2,603.8 years of followup. Incidence rates were 13.8 (95% confidence interval [95% CI] 9.4–20.3) among black patients and 3.3 (95% CI 0.8–13.0) among white patients, per 1,000 patient-years; corresponding 5-year cumulative incidence was 6.4% and 2.5% among black and white patients, respectively. Lupus nephritis documented prior to 2005, which occurred in 80% of those who progressed to ESRD, was the strongest risk factor for incident ESRD (IRR 6.7 [95% CI 2.7–16.8]; incidence rate 27.6 per 1,000 patient-years). Results suggested that patients who were black versus white (IRR 3.9 [95% CI 0.9–16.4]) or

Objectives To investigate racial and ethnic differences in graft and recipient survival in elderly kidney transplant recipients. Design Retrospective cohort. Setting First-time, kidney-only transplant recipients aged 60 and older of age at transplantation transplanted between July 1996 and October 2010 (N = 44,013). Participants United Network for Organ Sharing (UNOS) database. Measurements Time to graft failure and death obtained from the UNOS database and linkage to the Social Security Death Index. Neighborhood poverty from 2000 U.S. Census geographic data. Results Of the 44,013 recipients in the sample, 20% were black, 63% non-Hispanic white, 11% Hispanic, 5% Asian, and the rest “other racial groups.” In adjusted Cox models, blacks were more likely than whites to experience graft failure (hazard ratio (HR) = 1.23, 95% confidence interval (CI) = 1.15–1.32), whereas Hispanics (HR = 0.77, 95% CI = 0.70–0.85) and Asians (HR = 0.70, 95% CI = 0.61–0.81) were less likely to experience graft failure. Blacks (HR = 0.84, 95% CI = 0.80–0.88), Hispanics (HR = 0.68, 95% CI = 0.64–0.72), and Asians (HR = 0.62, 95% CI = 0.57–0.68) were less likely than whites to die after renal transplantation. Conclusion Elderly blacks are at greater risk of graft failure than white transplant recipients but survive longer after transplantation. Asians have the highest recipient and graft survival, followed by Hispanics. Further studies are needed to assess additional factors affecting graft and recipient survival in elderly adults and to investigate outcomes such as quality of life.

The emergency department (ED) has become the nexus for acute care medicine in the United States. With greater than one quarter of all newly arising medical problems being managed by emergency physicians, who represent

Introduction La transplantation renale pediatrique presente des specificites, notamment chez les receveurs les plus jeunes. A ce jour, aucun modele predictif de survie du greffon n’existe chez les jeunes receveurs pour aider a la selection du donneur. Description Notre objectif etait de developper et valider un modele predictif de survie du greffon a partir d’une cohorte internationale de jeunes receveurs pediatriques. Nous avons inclus les transplantations renales avant l’âge de 5 ans dans 5 pays (France, Etats-Unis, Royaume-Uni, Australie, Nouvelle-Zelande), entre 2005 et 2018. Methodes Un modele de Cox a ete utilise a partir des donnees americaines pour creer le modele predictif. La discrimination du modele (C-statistique) et la calibration ont ete evaluees de facon interne puis externe sur les donnees non americaines. Resultats Au total, 2543 transplantations renales ont ete inclues. La survie renale globale a 10 ans etait de 80,0 % (IC95 % = 77,7 %–82,2 %). Etant donne l’interaction entre l’âge du receveur et certains predicteurs, deux modeles ont ete developpes, selon l’âge du receveur (± 36 mois), incluant : rapport de surface corporelle donneur/receveur, duree d’ischemie froide, poids du donneur et matching immunologique. L’effet du matching immunologique augmentait avec l’âge du receveur tandis que la morphologie jouait un role predictif preponderant chez les jeunes patients. Les C-statistiques sur la cohorte de developpement etaient de 0,63 (IC95 % = 0,57–0,68) et 0,65 (IC95 % = 0,59–0,71). La Fig. 1 presente la discrimination au cours du suivi et la calibration a 10 ans sur la cohorte de validation. Conclusion Nous confirmons la bonne survie renale des patients transplantes avant l’âge de 5 ans. Nous avons developpe et valide, a partir de predicteurs pre-transplantation, des modeles predictifs de perte de greffon ou de deces applicables en pratique clinique.

Access to quality hospital care is a persistent problem for rural patients. Little is known about disparities between rural and urban populations regarding in-hospital outcomes for end-stage liver disease (ESLD) patients. We aimed to determine whether rural ESLD patients experienced higher in-hospital mortality than urban patients and whether disparities were attributable to the rurality of the patient or the center. This was a retrospective study of patient admissions in the National Inpatient Sample, a population-based sample of hospitals in the United States. Admissions were included if they were from adult patients who had an ESLD-related admission defined by codes from the International Classification of Diseases, Ninth Revision, between January 2012 and December 2014. The primary exposures of interest were patient-level rurality and hospital-level rurality. The main outcome was in-hospital mortality. We stratified our analysis by disease severity score. After accounting for patient- and hospital-level covariates, ESLD admissions to rural hospitals in every category of disease severity had significantly higher odds of in-hospital mortality than patient admissions to urban hospitals. Those with moderate or major risk of dying had more than twice the odds of in-hospital mortality (odds ratio [OR] for moderate risk, 2.41; 95% confidence interval [CI], 1.62-3.59; OR for major risk, 2.49; 95% CI, 1.97-3.14). There was no association between patient-level rurality and mortality in the adjusted models. In conclusion, ESLD patients admitted to rural hospitals had increased odds of in-hospital mortality compared with those admitted to urban hospitals, and the differences were not attributable to patient-level rurality. Our results suggest that interventions to improve outcomes in this population should focus on the level of the health system.

BackgroundEmergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS). The addition of advanced diagnostic imaging (ADI), namely CT, ultrasound (U/S), and MRI to ED encounter work up is a predictor of longer length of stay. Earlier and improved prediction of patients' need for advanced imaging may improve overall ED efficiency. The aim of the study was to detect the association between ADI utilization and the structured and unstructured information immediately available during ED triage, and to develop and validate models to predict utilization of ADI during an ED encounter.MethodsWe used the United States National Hospital Ambulatory Medical Care Survey data from 2009 to 2014 to examine which sociodemographic and clinical factors immediately available at ED triage were associated with the utilization of CT, U/S, MRI, and multiple ADI during a patient's ED stay. We used natural language processing (NLP) topic modeling to incorporate free-text reason for visit data available at time of ED triage in addition to other structured patient data to predict the use of ADI using multivariable logistic regression models.ResultsAmong the 139,150 adult ED visits from a national probability sample of hospitals across the U.S, 21.9% resulted in ADI use, including 16.8% who had a CT, 3.6% who had an ultrasound, 0.4% who had an MRI, and 1.2% of the population who had multiple types of ADI. The c-statistic of the predictive models was greater than or equal to 0.78 for all imaging outcomes, and the addition of text-based reason for visit information improved the accuracy of all predictive models.ConclusionsPatient information immediately available during ED triage can accurately predict the eventual use of advanced diagnostic imaging during an ED visit. Such models have the potential to be incorporated into the ED triage workflow in order to more rapidly identify patients who may require advanced imaging during their ED stay and assist with medical decision-making.

Quality metrics have a long history in the field of kidney transplantation. These metrics are highly visible, with significant ramifications to transplantation centers based on their use in regulatory review and other stakeholders. In this perspective, we review the history of quality metrics in this field, discuss the perceptions and empirical evidence evaluating the impact of metrics on care delivery, and summarize the current landscape of quality oversight. Based on the research findings and opinions of the transplantation community, we suggest that significant reforms are needed for the evaluation of quality in the field based on more appropriately aligning metrics with optimizing patient outcomes. Moreover, there are vast potential uses of the current data that should be emphasized in a learning environment rather than a highly punitive system. In our view, these reforms would enhance care delivery, improve patient care, and better align incentives for providers of care that treat transplantation patients.

In accordance with the National Organ Transplant Act and Department of Health and Human Services' Final Rule, the Scientific Registry of Transplant Recipients (SRTR) publicly releases biannual program-specific reports that include analyses of transplant centers' risk-adjusted waitlist mortality, organ acceptance ratios, transplant rates, and graft and patient survival. Since the inception of these center metrics, 1-year posttransplant graft and patient survival have improved, and center variation has decreased, casting uncertainty on their clinical relevance. The SRTR has recently modified center evaluations by ranking centers into 5 tiers rather than 3 tiers in an attempt to discriminate between programs performing within a tight range, further exacerbating this uncertainty. The American Society of Transplantation/American Society of Transplant Surgeons convened an expert taskforce to examine both the utility and unintended consequences of transplant center metrics. Estimates of center variation in outcomes in adjacent tiers are imprecise and fleeting, but can result in consequential changes in clinician and center behavior. The taskforce has concerns that current metrics, based principally on 1-year graft and patient survival, provide minimal if any benefit in informing patient choice and access to transplantation, with the untoward effect of decreased utilization of organs and restriction of research and innovation.

BACKGROUND Kidney and liver transplant recipients must manage a complex care regimen after kidney transplant. Although the use of Web-based patient portals is known to improve patient-provider communication and health outcomes in chronic disease populations by helping patients manage posttransplant care, disparities in access to and use of portals have been reported. Little is known about portal usage and disparities among kidney and liver transplant recipients. OBJECTIVE The aim of this study was to examine patient racial/ethnic, socioeconomic, and clinical characteristics associated with portal usage among kidney and liver transplant recipients. METHODS The study included all adult kidney and liver transplant recipients (n=710) at a large academic transplant center in the Southeastern United States between March 2014 and November 2016. Electronic medical record data were linked with Cerner portal usage data. Patient portal use was defined as any portal activity (vs no activity) recorded in the Cerner Web-based portal, including viewing of health records, lab results, medication lists, and the use of secure messaging. Multivariable log-binomial regression was used to determine the patient demographic, clinical, and socioeconomic characteristics associated with portal usage, stratified by organ. RESULTS Among 710 transplant recipients (n=455 kidney, n=255 liver), 55.4% (252/455) of kidney recipients and 48.2% (123/255) of liver recipients used the patient portal. Black patients were less likely to use the portal versus white patients among both kidney (57% black vs 74% white) and liver (28% black vs 55% white) transplant recipients. In adjusted multivariable analyses, kidney transplant recipients were more likely to use the portal if they had higher education; among liver recipients, patients who were white versus black and had higher education were more likely to use the portal. CONCLUSIONS Despite studies showing that patient portals have the potential to benefit transplant recipients as a tool for health management, racial and socioeconomic disparities should be considered before widespread implementation. Transplant centers should include portal training and support to all patients to encourage use, given its potential to improve outcomes.

The proportion of deceased donor kidneys procured for transplant but subsequently discarded has been growing steadily in the United States, but factors contributing to the rising discard rate remain unclear. To assess the reasons for and probability of organ discard we assembled a cohort of 212,305 deceased donor kidneys recovered for transplant from 2000-2015 in the SRTR registry that included 36,700 kidneys that were discarded. 'Biopsy Findings' (38.2%) was the most commonly reported reason for discard. The median Kidney Donor Risk Index of discarded kidneys was significantly higher than transplanted organs (1.78 vs 1.12), but a large overlap in the quality of discarded and transplanted kidneys was observed. Kidneys of donors who were older, female, Black, obese, diabetic, hypertensive or HCV-positive experienced a significantly increased odds of discard. Kidneys from donors with multiple unfavorable characteristics were more likely to be discarded, whereas unilaterally discarded kidneys had the most desirable donor characteristics and the recipients of their partner kidneys experienced a one-year death-censored graft survival rate over 90%. There was considerable geographic variation in the odds of discard across the United States, which further supports the notion that factors beyond organ quality contributed to kidney discard. Thus, while the discard of a small fraction of organs procured from donors may be inevitable, the discard of potentially transplantable kidneys needs to be avoided. This will require a better understanding of the factors contributing to organ discard in order to remove the disincentives to utilize less-than-ideal organs for transplantation.

Many patients with end-stage kidney disease (ESKD) do not appreciate how their survival may differ if treated with a kidney transplant compared with dialysis. A risk calculator (iChoose Kidney) developed and validated in the United States provides individualized mortality estimates for different treatment options (dialysis vs living or deceased donor kidney transplantation). The calculator can be used with patients and families to help patients make more educated treatment decisions.To validate the iChoose Kidney risk calculator in Ontario, Canada.External validation study.We used several linked administrative health care databases from Ontario, Canada.We included 22 520 maintenance dialysis patients and 4505 kidney transplant recipients. Patients entered the cohort between 2004 and 2014.Three-year all-cause mortality.We assessed model discrimination using the C-statistic. We assessed model calibration by comparing the observed versus predicted mortality risk and by using smoothed calibration plots. We used multivariable logistic regression modeling to recalibrate model intercepts using a correction factor, when appropriate.In our final version of the iChoose Kidney model, we included the following variables: age (18-80 years), sex (male, female), race (white, black, other), time on dialysis (6 months, 6-12 months,12 months), and patient comorbidities (hypertension, diabetes, and/or cardiovascular disease). Over the 3-year follow-up period, 33.3% of dialysis patients and 6.2% of kidney transplant recipients died. The discriminatory ability was moderate (C-statistic for dialysis: 0.70, 95% confidence interval [CI]: 0.69-0.70, and C-statistic for transplant: 0.72, 95% CI: 0.69-0.75). The 3-year observed and predicted mortality estimates were comparable and even more so after we recalibrated the intercepts in 2 of our models (dialysis and deceased donor kidney transplantation). As done in the United States, we developed a Canadian Web site and an iOS application called Dialysis vs. Kidney Transplant- Estimated Survival in Ontario.Missing data in our databases precluded the inclusion of all variables that were in the original iChoose Kidney (ie, patient ethnicity and low albumin). We were unable to perform all preplanned analyses due to the limited sample size.The original iChoose Kidney risk calculator was able to adequately predict mortality in this Canadian (Ontario) cohort of ESKD patients. After minor modifications, the predictive accuracy improved. The Dialysis vs. Kidney Transplant- Estimated Survival in Ontario risk calculator may be a valuable resource to help ESKD patients make an informed decision on pursuing kidney transplantation.Plusieurs patients atteints d’insuffisance rénale terminale (IRT) ignorent à quel point leurs chances de survie varient selon qu’ils sont traités par dialyse ou par une greffe rénale. Un modèle de prévision des risques (l’outil de calculValider l’outil de calculUne étude de validité externe.Plusieurs bases de données couplées du système de santé ontarien (Canada).Un total de 22 520 patients dialysés et de 4 505 receveurs d’une greffe de rein ont été inclus entre 2004 et 2014.La mortalité toutes causes sur une période de trois (3) ans.Nous avons évalué le pouvoir discriminant du modèle à l’aide de la statistique C. L’étalonnage du modèle a été établi en comparant les risques de mortalité observé et prédit, et à l’aide de courbes d’étalonnage lissées. Des modèles de régression logistique multivariés ont été employés pour réétalonner les valeurs à l’origine en utilisant au besoin un facteur de correction.Notre version définitive du modèle de prévision inclut les variables suivantes : l’âge du patient (18 à 80 ans), son genre, sa race (blanc, noir, autre), son expérience en dialyse (moins de 6 mois, entre 6 et 12 mois, plus de 12 mois) et ses comorbidités (hypertension, diabète et maladies cardiovasculaires). Au cours des trois ans de suivi, 33,3 % des patients dialysés et 6,2 % des receveurs d’une greffe sont décédés. Le pouvoir discriminant s’est avéré modéré avec une valeur de statistique C de 0,70 (IC 95 % : 0,69-0,70) pour la dialyse et de 0,72 (IC 95 % : 0,69-0,75) pour les greffes. Les taux de mortalité observé et estimé au cours des trois ans étaient comparables, et davantage après le réétalonnage des valeurs à l’origine dans deux de nos modèles (dialyse et receveur d’un rein d’un donneur décédé). Comme aux États-Unis, nous avons développé un site Web et une application iOS canadiens nommésDes informations manquantes dans les bases de données consultées nous ont empêchés de tenir compte de toutes les variables incluses dans le modèleLa version originale du modèle de prévision des risques

We previously developed a mobile- and web-based decision aid (iChoose Kidney) that displays individualized risk estimates of survival and mortality for the treatment modalities of dialysis versus kidney transplantation. We examined the effect of iChoose Kidney on change in transplant knowledge and access to transplant in a randomized controlled trial among patients presenting for evaluation in three transplant centers. A total of 470 patients were randomized to standard transplantation education (control) or standard education plus iChoose Kidney (intervention). Change in transplant knowledge (primary outcome) among intervention versus control patients was assessed using nine items in pre- and postevaluation surveys. Access to transplant (secondary outcome) was defined as a composite of waitlisting, living donor inquiries, or transplantation. Among 443 patients (n = 226 intervention; n = 216 control), the mean knowledge scores were 5.1 ± 2.1 pre- and 5.8 ± 1.9 post-evaluation. Change in knowledge was greater among intervention (1.1 ± 2.0) versus control (0.4 ± 1.8) patients (P < .0001). Access to transplantation was similar among intervention (n = 168; 74.3%) versus control patients (n = 153; 70.5%; P = .37). The iChoose Kidney decision aid improved patient knowledge at evaluation, but did not impact transplant access. Future studies should examine whether combining iChoose Kidney with other interventions can increase transplantation. (https://Clinicaltrials.gov NCT02235571)

Fecal microbiota transplantation (FMT) is increasingly being performed for Clostridium difficile infection in solid organ transplant patients; however, little is known about the potential pharmacokinetic or pharmacomicrobial effects this may have on tacrolimus levels. We reviewed the medical records of 10 solid organ transplant patients from September 2012 – December 2016 who were taking tacrolimus at time of FMT for recurrent Clostridium difficile infection. We compared the differences in tacrolimus concentration / dose ratio (C/D ratio) three months prior to FMT vs three months after FMT. The mean of the differences in C/D ratio calculated as ng/mL / mg/kg/day was -17.65 (95% CI -1.25 – 0.58) ng/mL / mg/kg/day, p-value 0.43 by Wilcoxon signed-rank test. The mean of the differences in C/D ratio calculated as ng/mL / mg/day was -0.33 (95% CI -1.25 – 0.58) ng/mL / mg/day, p-value 0.28 by Wilcoxon signed-rank test. Of these patients, 2/10 underwent allograft biopsy for allograft dysfunction in the year after FMT, with no evidence of allograft rejection on pathology. These preliminary data suggest that FMT may not predictably alter tacrolimus levels and support its safety for solid organ transplant patients however further study in randomized trials is needed.

Background Racial disparities persist in access to kidney transplantation. Racial differences in preemptive referral, or referral prior to dialysis start, may explain this discrepancy. Methods Patient-level data on kidney transplant referrals (2005-2012) from all Georgia transplant centers were linked to the United States Renal Data System to examine racial disparities in preemptive referral, waitlisting, and living donor transplant. Adjusted logistic regression and Cox proportional hazard models determined the associations between race (African American vs white) and preemptive referral, and placement on the waitlist and receipt of a living donor kidney, respectively. Results Among 7752 adults referred for transplant evaluation, 20.38% (n = 1580) were preemptively referred. The odds of African Americans being preemptively referred for transplant evaluation were 37% (OR = 0.63; [95% CI: 0.55 0.71]) lower than white patients. Among preemptively referred patients, there was no racial difference (African Americans compared to white patients. HR = 0.96; [95% CI: 0.88, 1.04]) in waitlisting. However, African Americans were 70% less likely than white patients to receive a living donor transplant (HR = 0.30; [95% CI: 0.21, 0.42]). Conclusion Racial disparities in transplant receipt may be partially explained by disparities in preemptive referral. Interventions to reduce racial disparities in kidney transplant access may need to be targeted earlier in the disease process.

Background The Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT) was an End-Stage Renal Disease (ESRD) Network 6-developed, dialysis facility-level randomized trial testing the effectiveness of a 1-year multicomponent education and quality improvement intervention in increasing referral for kidney transplant evaluation among selected Georgia dialysis facilities. Methods To assess implementation of the RaDIANT intervention, we conducted a process evaluation at the conclusion of the intervention period (January–December 2014). We administered a 20-item survey to the staff involved with transplant education in 67 dialysis facilities randomized to participate in intervention activities. Survey items assessed facility participation in the intervention (fidelity and reach), helpfulness and willingness to continue intervention activities (sustainability), suggestions for improving intervention components (sustainability), and factors that may have influenced participation and study outcomes (context). We defined high fidelity to the intervention as completing 11 or more activities, and high participation in an activity as having at least 75% participation across intervention facilities. Results Staff from 65 of the 67 dialysis facilities completed the questionnaire, and more than half (50.8%) reported high adherence (fidelity) to RaDIANT intervention requirements. Nearly two-thirds (63.1%) of facilities reported that RaDIANT intervention activities were helpful or very helpful, with 90.8% of facilities willing to continue at least one intervention component beyond the study period. Intervention components with high participation emphasized staff and patient-level education, including in-service staff orientations, patient and family education programs, and patient educational materials. Suggested improvements for intervention activities emphasized addressing financial barriers to transplantation, with financial education materials perceived as most helpful among RaDIANT educational materials. Variation in facility-level fidelity of the RADIANT intervention did not significantly influence the mean difference in proportion of patients referred pre- (2013) and post-intervention (2014). Conclusions We found high fidelity to the RaDIANT multicomponent intervention at the majority of intervention facilities, with sustainability of select intervention components at intervention facilities and feasibility for dissemination across ESRD Networks. Future modification of the intervention should emphasize financial education regarding kidney transplantation and amend intervention components that facilities perceive as time-intensive or non-sustainable. Trial registration Clinicaltrials.gov number NCT02092727. Registered 13 Mar 2014 (retrospectively registered). Electronic supplementary material The online version of this article (10.1186/s12882-017-0807-z) contains supplementary material, which is available to authorized users.