Deidra C. Crews

Key Points: Depressive symptoms increased modestly during the first 4 years after kidney transplant but remained below the threshold for clinical depression. Post-kidney transplant Center for Epidemiologic Studies Depression scores improved in recipients with high pre-kidney transplant depressive symptoms. Clinicians should counsel patients on the potential mental health implications of kidney transplant and individualize care decisions accordingly. Background: Depressive symptoms are common in patients with ESKD and may persist after stopping dialysis because of challenges post-kidney transplant (KT) despite clinical benefits. We sought to assess changes in depressive symptoms pre- and post-KT. Methods: We leveraged a multicenter prospective cohort of 4661 adult (aged ≥18) potential KT candidates and 1215 recipients (2008–2025). Participants reported depressive symptoms via the Center for Epidemiologic Studies Depression (CES-D) scale (range 0–60, high depressive symptoms ≥16) at evaluation, KT, and post-KT. We used linear mixed-effect models to estimate post-KT trajectories of CES-D scores overall and by characteristics at KT admission. Results: Nineteen percentage of potential candidates at evaluation and 15% of recipients at admission had depressive symptoms; 46% and 38%, respectively, were non-Hispanic Black. Over the first 4 years post-KT, depressive symptoms slightly worsened (slope=0.4 points/yr, 95% confidence interval [CI], 0.3 to 0.6) but remained below the threshold for clinical depression. Post-KT, CES-D score change differed by pre-KT high depressive symptoms score (difference=−1.2 points/yr, 95% CI, −1.8 to −0.6). Specifically, post-KT depressive symptoms were 0.7 points/yr lower (95% CI, −1.2 to −0.1) among recipients with pre-KT high depressive symptoms and 0.5 points/yr higher (95% CI, 0.3 to 0.7) among those without. CES-D score change also differed by preemptive KT status (difference=−0.6 points/yr, 95% CI, −1.0 to −0.1, non-preemptive versus preemptive). Conclusions: Depressive symptoms worsened slightly over the first 4 years post-KT but remained below the threshold for clinical depression. Notably, post-KT CES-D scores decreased in recipients with high pre-KT depressive symptoms. Clinicians should discuss the mental health impact of KT with patients and tailor care decisions to individual needs.

Background: Although technology usage is steadily increasing among older adults, adoption and confidence greatly lag behind their younger counterparts. Sociocultural and health disparities intersect with aging to present distinct structural and psychosocial barriers to the adoption of newer technologies. Digital health literacy interventions can improve task-specific skills, technological self-efficacy, and use frequency, but most do not systematically incorporate older adults’ values and goals, which are key drivers of sustained behavior change. Objective: The proposed study aims to develop and evaluate the acceptability and feasibility of a person-directed, values-based, in-home digital literacy intervention for older adults, entitled values-informed solutions for technology adoption (VISTA). Methods: VISTA begins with a values and goals discussion rather than a skills test, mapping “What Matters Most” to individualized, SMART (specific, measurable, achievable, relevant, and time-bound) technology goals. Over 8 to 12 weeks, interventionists co-developed personalized learning plans with participants, delivering up to 6 in-home biweekly visits and interim phone calls. The study provided a tablet and assistance with obtaining home internet when needed. Outcomes included digital literacy (Mobile Device Proficiency Questionnaire), technology and chronic disease self-efficacy, social networks, multimorbidity, and frailty (Fried Frailty Phenotype). Feasibility was assessed via recruitment, retention or completion, data collection rates, survey administration time, withdrawal, intervention fidelity, and per-person cost; acceptability was assessed via a postintervention satisfaction survey (Likert and open-ended items) and willingness to recommend. Results: Funding was secured in November 2023. Institutional review board approval, intervention development, and focus groups were completed throughout 2024. Recruitment and baseline assessments occurred from January 2025 to July 2025, enrolling 21 participants and randomizing 11 to immediate intervention and 10 to waitlist control (waitlist participants received the intervention after a 3-month control period). One consented participant was unable to participate early in the intervention and is not included in analyses. Inclusion criteria included being aged 65 years and older, having English proficiency, and demonstrating a willingness to improve digital literacy. Exclusion criteria involved severe cognitive impairment. At baseline, participants had a mean age of 75.7 (SD 7.74) years and were predominantly female (n=13, 65%) and Black (n=19, 95%); most reported having a low income (10/12, 83%), living alone (12/14, 85.7%), and multimorbidity (mean disease count 3.95, SD 2.46). Follow-up assessments concluded in March 2026; data cleaning and analysis are ongoing, with primary feasibility and acceptability findings anticipated for fall 2026. Conclusions: This protocol offers a unique model centering on the values and goals of older adults to improve access, use, and understanding of technology. Tapping into the motivators of older adults may provide a more beneficial way to encourage older adult technology use. VISTA could be useful in many general contexts, more specifically for older adults who are homebound or have serious illnesses, or as a preintervention for interventions involving advanced technology understanding.

Key Points: Chronic stress elevates neutrophil gelatinase-associated lipocalin and cystatin C. Chronic stress increases T helper 17 and regulatory T-cell populations in the kidney. Chronic stress could increase susceptibility to kidney diseases. Background: Chronic stress (CS) due to prolonged exposure to negative life events increases the risk of psychiatric illnesses and significantly affects physiologic processes. CS has also been linked to sustained systemic inflammation, resulting in dysregulated immune responses and organ function. We hypothesized that CS would lead to kidney inflammation and tested this in mice. Methods: Male C57BL/6J mice were subjected to CS by pair-housing them with CD-1 retired breeder mice. Kidney immune cells were isolated and evaluated by spectral flow cytometry. Cytokines were measured using a multiplex assay in kidney tissue and serum. Serum creatinine, cystatin C, and neutrophil gelatinase-associated lipocalin levels were measured. Results: Mice subjected to CS exhibited greater weight gain than the control group and had reduced fur quality. CS led to a decrease in the percentage of kidney CD4 ⁺ T cells (54.26%±0.89% versus 59.88%±1.25%, P < 0.001) and an increase in T helper 17 (2.3%±0.3% versus 0.83%±0.15%, P < 0.001) and regulatory T cells (3.42%±0.45% versus 1.53%±0.21%, P < 0.001). There was an increase in the kidney macrophage percentage in CS mice (88.33%±1.16% versus 84.26%±0.73%, P < 0.01). TNF- α levels were higher in the kidney of stressed mice (8.53±1.18 versus 3.15±1.29 pg/ml, P < 0.01). CS led to elevated levels of serum cystatin C (515.9±16.88 versus 456.6±14.79 ng/ml, P < 0.05) serum neutrophil gelatinase-associated lipocalin (833.1±282.4 versus 90.58±5.57 ng/ml, P < 0.0001). Conclusions: CS in mice led to kidney inflammation and immunologic changes. These could predispose to acute and CKDs in which inflammation plays a pathogenic role.

Key Points: In a randomized controlled trial studying outcomes of arteriovenous fistulas versus grafts, clinicians and patient participants identified multilevel barriers to patient enrollment. Pervasive biases from Fistula First emerged as a major barrier, contributing to a perceived lack of equipoise between vascular access options in older adults. Patient education on the importance of access placement, and increased clinician buy-in, may help mitigate barriers to trial enrollment. Background: People with kidney failure on chronic hemodialysis require sustainable vascular access. The Arteriovenous Vascular (AV) Access trial is a randomized controlled trial comparing clinical and patient-reported outcomes in adults 60 years or older on hemodialysis with a central venous catheter, randomized to receive either a surgical AV fistula or graft. Patient enrollment in the trial initially progressed slower than anticipated. We designed a cross-sectional qualitative substudy to identify facilitators and barriers to patient enrollment in the AV Access trial. Methods: We conducted qualitative focus groups and semistructured interviews of site investigators and providers and semistructured interviews of patients who had been approached for enrollment in the AV Access trial. We performed hybrid inductive-deductive thematic analysis of transcripts. Results: We analyzed transcripts from two focus groups (one with four vascular surgery physician investigators and one with four nephrology physician investigators) and 44 individual interviews with vascular surgery physician investigators ( n =2), nephrology physician investigators ( n =2), vascular surgery providers ( n =9), nephrology providers ( n =10), and patients ( n =21). Participants identified themes related to clinical site selection, buy-in from clinical teams, patient referral processes to vascular surgery, and processes to recruit patients to enroll in the trial. Subthemes included barriers related to patients receiving care from providers external to the study team, pervasive biases from the Fistula First initiative, limited patient knowledge of the importance of AV access, and a need for additional information provided to patients to support informed decision-making about trial participation. Conclusions: Enrollment in the AV Access trial was hindered by multilevel barriers. Some of these may be mitigated through collaborative patient education surrounding the importance of access placement, as well as provider-directed education to increase buy-in and enhance engagement. These findings can inform the design and implementation of future randomized controlled trials concerning surgical AV access outcomes. Clinical Trial registry name and registration number: The AV Access trial has been registered at ClinicalTrials.gov; NCT04646226; registration date: November 20, 2020.

UNSTRUCTURED Background: Although technology usage is steadily increasing among older adults, adoption and confidence greatly lags behind their younger counterparts. Sociocultural and health disparities intersect with aging to present distinct structural and psychosocial barriers to adoption of newer technologies. Growing evidence suggests that digital health literacy interventions may improve technology skills, increase technological self-efficacy, and increase frequency of technology use. However, these digital literacy interventions do not systematically consider participants’ values and goals, which we know are key to long term behavior change. Objective: The proposed study aims to develop and evaluate the acceptability and feasibility of a person-directed, values-based digital literacy intervention for older adults. Methods: We enrolled 20 participants in a 1:1 randomized pilot control trial with waitlist control. Inclusion criteria included aged 65 and older with English proficiency and willingness to improve digital literacy. Exclusion criteria involved severe cognitive impairment. Over the course of 8-12 weeks, participants received up to six in-home biweekly visits and interim phone calls based on their individual digital literacy needs and participant-directed goals. Each participant also received internet connectivity and a tablet if not already available. Our main outcome was digital literacy improvement. We also assessed technological self-efficacy, digital health literacy, quality of life, and measures of physical and emotional well-being. Results: - Conclusions: This protocol offers a unique model centering the values and goals of older adults to improve access, use and understanding of technology. Tapping into the motivators of older adults may offer a more beneficial way to encourage older adult technology use. VISTA could be useful in many contexts- home bound or seriously ill older adults or as a pre-intervention for interventions involving advanced technology understanding.

Key Points: Among US preemptively waitlisted patients with CKD, deceased donor transplants increased for Black and Hispanic patients, comparable with White patients. Dialysis initiation was higher for waitlisted Asian, Black, and Hispanic patients compared with White patients, mirroring lower living donor transplants. Organ Procurement and Transplantation Network wait time credit and Increasing Organ Transplant Access metric could expand preemptive transplantation. Background: Preemptive kidney transplantation (before dialysis initiation) is the optimal therapy for most transplant-eligible advanced patients with CKD. Although prior research has documented racial and ethnic disparities in preemptive referrals, less is known about distinct outcomes after preemptive waitlisting. This study examines the association between race and ethnicity and outcomes for preemptively waitlisted patients. Methods: We conducted a secondary analysis of a prospectively maintained US cohort using data from the Scientific Registry of Transplant Recipients. The study population included 98,863 adult first-time kidney transplant candidates who were preemptively waitlisted from January 1, 2009, to December 31, 2020, and followed through December 31, 2024. The exposure of interest was race and ethnicity. The primary outcome was 3-year preemptive deceased donor kidney transplantation, living donor kidney transplantation, or dialysis initiation. We used competing risk models to estimate adjusted subdistribution hazard ratios (aSHRs). Data were stratified into 3-year intervals (2009–2011, 2012–2014, 2015–2017, and 2018–2020). Results: Black and Hispanic patients received preemptive deceased donor kidney transplants as often as White patients (era 2018–2020, aSHRs [95% confidence interval (CI)]: 0.99 [95% CI, 0.92 to 1.07] and 1.02 [95% CI, 0.93 to 1.12], respectively), while Asian patients had lower rates (0.78 [95% CI, 0.69 to 0.88]). However, Asian, Black, and Hispanic patients were more likely to initiate dialysis (aSHRs: 1.50 [95% CI, 1.39 to 1.61]; 1.41 [95% CI, 1.34 to 1.49]; and 1.21 [95% CI, 1.14 to 1.29], respectively) and were less likely to receive preemptive living donor kidney transplants than White patients (era 2018–2020, aSHRs: 0.49 [95% CI, 0.44 to 0.54]; 0.31 [95% CI, 0.29 to 0.34]; and 0.61 [95% CI, 0.56 to 0.66], respectively). Conclusions: Among waitlisted patients with CKD in the United States between 2009 and 2020, rates of preemptive deceased donor kidney transplantation improved for Black and Hispanic patients and became comparable with White patients. However, Asian, Black, and Hispanic patients experienced higher rates of dialysis initiation and lower rates of preemptive living donor kidney transplantation.

Socioeconomic, environmental, and lifestyle factors shape kidney health. Among the social determinants of health, access to healthy foods is particularly significant. As a basic need, food is integral to an individual's identity, culture, and health. Dietary patterns have been shown to be strongly related to developing kidney disease, its progression, and its complications. Efforts to make more healthful the dietary patterns of people with or at risk of kidney disease, including those facing adverse social determinants of health, have emerged in recent years. In this review, we discuss evidence reported over the past decade underscoring linkages between access to healthy foods, diet quality, and the racial, ethnic, and socioeconomic disparities observed in kidney health. We examine the complex factors influencing diet quality, with a focus on food and nutrition insecurity, and their disproportionate impact on communities with greater kidney disease burden. Finally, we propose strategies that can improve diet quality for all people living with or at risk of kidney disease.