Giving a voice to patient and caregiver perspectives on equity in transplantation.

Purpose Of Review: While prior reviews have assessed barriers to transplantation experienced by patients and their families, they have not summarized how these stakeholders feel about whether and how those barriers impact equity in transplantation. We seek to comprehensively present the literature of patients and family perspectives on disparities in transplant access and potential solutions.

Recent Findings: Some patients and their families report experiences of discrimination, while others from traditionally marginalized groups feel the system is equitable and do not perceive any different treatment as a result of their race/ethnicity, sex, age, religion, or geography.

Timing of parathyroidectomy after kidney transplantation: A cost-effectiveness analysis.

Introduction: Parathyroidectomy is the definitive treatment for tertiary hyperparathyroidism post-kidney transplantation. However, cinacalcet-based medical management is increasingly used as an alternative. The financial consequences of each treatment remain unclear.

Spatiotemporal immune atlas of a clinical-grade gene-edited pig-to-human kidney xenotransplant.

Pig-to-human xenotransplantation is rapidly approaching the clinical arena; however, it is unclear which immunomodulatory regimens will effectively control human immune responses to pig xenografts. Here, we transplant a gene-edited pig kidney into a brain-dead human recipient on pharmacologic immunosuppression and study the human immune response to the xenograft using spatial transcriptomics and single-cell RNA sequencing. Human immune cells are uncommon in the porcine kidney cortex early after xenotransplantation and consist of primarily myeloid cells.

Patient-Level and Center-Level Factors Associated with Required Predonation Weight Loss among Obese Living Kidney Donors.

Key Points: Among obese living kidney donors, year of donation, preoperative body mass index, hypertension, and center percent of living kidney donor transplants were associated with required predonation weight loss. There were no significant differences in the likelihood of predonation weight loss requirement by race, sex, or age or by markers of preoperative metabolic dysfunction.

Background: The proportion of overweight/mildly obese living kidney donors (OLKDs) has increased in the past few decades, with significant center variation in the body mass index (BMI) of LKDs.

Health Inequity in Likelihood and Time to Renal Recovery after Living Kidney Donation: Implications for Kidney Health in Black Americans.

Background: Live donor kidney transplantation has been popularized to help mitigate the organ shortage crisis. At the time of living donor nephrectomy, living donors lose 50% of their kidney function or glomerular filtration rate (GFR). Studies have shown that in healthy living donors, the remaining kidney is able to adapt and recover 10% to 25% of postdonation lost GFR.

Mitigating Health Disparities in Transplantation Requires Equity, Not Equality.

Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography.

Treatment of Hypercalcemic Hyperparathyroidism After Kidney Transplantation Is Associated With Improved Allograft Survival.

Background: Hyperparathyroidism (HPT) and malignancy are the most common causes of hypercalcemia. Among kidney transplant (KT) recipients, hypercalcemia is mostly caused by tertiary HPT. Persistent tertiary HPT after KT is associated with allograft failure.

Interpersonal Connections Are Important for Virtual Kidney Transplant Educational Program Development.

The Living Donor Navigator program is designed to mitigate disparities in living donor kidney transplantation, although geographic disparities in program participation were observed in the initial years of implementation. The purpose of this study was to understand participant perspectives regarding the use of a virtual option/alternative to expand program participation. Previous participants of the in-person navigator program were purposively sampled.

Family caregiver roles and challenges in assisting patients with cancer treatment decision-making: Analysis of data from a national survey.

Background: We aimed to describe the roles and challenges of family caregivers involved in patients' cancer treatment decision-making.

Methods: Family caregiver-reported data were analyzed from a national survey conducted in the United States by CancerCare® (2/2021-7/2021). Four select-all-that-apply caregiver roles were explored: (1) observer (patient as primary decision-maker); (2) primary decision-maker; (3) shared decision-maker with patient and (4) decision delegated to healthcare team.

Decision support training for advanced cancer family caregivers: Study protocol for the CASCADE factorial trial.

Background: Patients with advanced cancer face numerous decisions when diagnosed and often receive decision support from family caregivers. The CASCADE (CAre Supporters Coached to be Adept DEcision partners) factorial trial intervention aims to train caregivers in skills to provide effective decision support to patients and identify most effective intervention components.

Methods: This is a 2-site, single-blind, 2 factorial trial to test components of the CASCADE decision support training intervention for family caregivers of patients with newly-diagnosed advanced cancer delivered by specially-trained, telehealth, palliative care lay coaches over 24 weeks.

Spatiotemporal immune atlas of the first clinical-grade, gene-edited pig-to-human kidney xenotransplant.

Pig-to-human xenotransplantation is rapidly approaching the clinical arena; however, it is unclear which immunomodulatory regimens will effectively control human immune responses to pig xenografts. We transplanted a gene-edited pig kidney into a brain-dead human recipient on pharmacologic immunosuppression and studied the human immune response to the xenograft using spatial transcriptomics and single-cell RNA sequencing. Human immune cells were uncommon in the porcine kidney cortex early after xenotransplantation and consisted of primarily myeloid cells.

Diabetes-free survival among living kidney donors and non-donors with obesity: A longitudinal cohort study.

Background: Approval of living kidney donors (LKD) with end-stage kidney disease (ESKD) risk factors, such as obesity, has increased. While lifetime ESKD development data are lacking, the study of intermediate outcomes such as diabetes is critical for LKD safety. Donation-attributable diabetes risk among persons with obesity remains unknown.

Reclassification of CKD in living kidney donors with the refitted race-free eGFR formula.

Background: Chronic Kidney Disease (CKD) Epidemiology Collaboration eGFR 2021 formula removed Black race from the 2009 equation. Unintended consequences may lead to reclassifying Black living kidney donors as having more advanced CKD, exacerbating racial disparities in living donation.

Methods: We used national data to quantify CKD stage reclassification based on eGFR for Black living donors both pre- and post-donation.

Impact of refitted race-free eGFR formula on obesity pharmacotherapy options.

Objective: Recent changes to the Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (eGFR) formula (2021 CKD-EPI) removed race from the 2009 formula, increasing the number of Black people classified as having CKD, but these changes may impact eligibility and/or dosing for antiobesity medications. This study estimated the number of people with obesity nationwide who might have pharmacotherapy options impacted by the new formula.

Methods: Using National Health and Nutrition Examination Survey (NHANES) cohort study data, the number of people eligible for antiobesity medication was estimated, and the number who would require a dosage reduction or would no longer be eligible for specific medications based on the new eGFR formula was also estimated.

Change in Body Mass Index and Attributable Risk of New-Onset Hypertension Among Obese Living Kidney Donors.

Objective: To examine whether body mass index (BMI) changes modify the association between kidney donation and incident hypertension.

Background: Obesity increases hypertension risk in both general and living kidney donor (LKD) populations. Donation-attributable risk in the context of obesity, and whether weight change modifies that risk, is unknown.

Greater community vulnerability is associated with poor living donor navigator program fidelity.

Background: Community-level factors contribute to living donor kidney transplantation disparities but may also influence the interventions aimed to mitigate these disparities. The Living Donor Navigator Program was designed to separate the advocacy role from the patient in need of transplantation-friends/family are encouraged to participate as the patients' advocates to identify living donors, though some of the patients participate alone as self-advocates. Self-advocates have a lower living donor kidney transplantation likelihood compared to the patients with an advocate.

The Project ENABLE Cornerstone randomized controlled trial: study protocol for a lay navigator-led, early palliative care coaching intervention for African American and rural-dwelling advanced cancer family caregivers.

Background: Family caregivers play a vital, yet stressful role in managing the healthcare needs and optimizing the quality of life of patients with advanced cancer, from the time they are newly diagnosed until end of life. While early telehealth palliative care has been found to effectively support family caregivers, little work has focused on historically under-resourced populations, particularly African American and rural-dwelling individuals. To address this need, we developed and are currently testing Project ENABLE (Educate, Nurture, Advise, Before Life Ends) Cornerstone, a lay navigator-led, early palliative care coaching intervention for family caregivers of African American and rural-dwelling patients with newly diagnosed advanced cancer.

Donor-reported barriers to living kidney donor follow-up.

Background: Despite regulations mandating follow-up laboratory testing for living kidney donors, less than half of transplant centers are in compliance. We sought to understand barriers to follow-up testing from the donors' perspective.

Methods: We surveyed our center's living kidney donors.

First clinical-grade porcine kidney xenotransplant using a human decedent model.

A radical solution is needed for the organ supply crisis, and the domestic pig is a promising organ source. In preparation for a clinical trial of xenotransplantation, we developed an in vivo pre-clinical human model to test safety and feasibility tenets established in animal models. After performance of a novel, prospective compatible crossmatch, we performed bilateral native nephrectomies in a human brain-dead decedent and subsequently transplanted two kidneys from a pig genetically engineered for human xenotransplantation.

Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation.

Introduction: Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming.

Research Question: We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability.

Design: Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program.