Background Studies from several jurisdictions suggest that compared to male individuals, female individuals are less likely to get placed on the waiting list for kidney transplantation and less likely to receive a transplant. However, we poorly understand where sex disparities arise within four key steps in the pathway to kidney transplant. Objective To measure how sex influences key steps to kidney transplantation. Design We conducted a population-based cohort study using linked administrative healthcare databases. Setting Ontario, Canada. Patients The study included people with kidney failure. This group comprised patients approaching the need for dialysis and those receiving maintenance dialysis from November 1, 2017, to December 31, 2021 (with follow-up to March 31, 2023). All patients had no recorded contraindications to receiving a kidney transplant. Measurements We assessed patient access to four key steps toward kidney transplant: (1) referral to a transplant centre for assessment; (2) they had a potential living donor contact the transplant centre for evaluation; (3) addition to the deceased donor waitlist; and (4) transplantation from a living or deceased donor. We examined each step separately. Methods We compared male and female individuals on the four steps in the kidney transplant process, using the incidence rate and cumulative incidence function (95% confidence interval [CI]). We used Cox proportional hazards analysis to examine the association between sex (using male as the reference group) and each transplant step, adjusting for patient characteristics. We also examined if age (<45, 45 to <55, 55 to <65, and 65 to 75 years) changed the relationship between sex and access to transplantation. Results We included 17,993 patients with kidney failure (11,076 male and 6,917 female individuals). Of these, 15,238 entered the cohort approaching the need for dialysis, and 2,755 entered already receiving maintenance dialysis. Over follow-up, 4,945 (32.5%) patients in the approaching the need for dialysis cohort started dialysis. Female individuals had a significantly lower rate of referral to a transplant centre for assessment than male individuals (9.35 vs 10.91 referrals per 100 person-years; adjusted hazard ratio [aHR] 0.86 [95% CI: 0.81, 0.92]). The disadvantage female individuals faced in transplant referral increased with age (age 65 to 75 years, aHR 0.73 [95% CI: 0.64, 0.84]; P-value for interaction <0.001). After we adjusted for patient characteristics, we found no significant sex-based differences for any other step in the transplant process, including living donor contact, waitlisting, or transplant. For all outcomes, a significant interaction was found between age and sex (P-value for interaction < 0.001). The kidney transplant access disadvantage for female compared to male individuals was greater in older age groups (for example, aged 65 to 75 years). Limitations We could not adjust for all factors influencing transplant access (for example, frailty, smoking status, and patient preference). Conclusions Female individuals who were likely eligible for transplant were significantly less likely to be referred to a transplant centre for assessment. This disadvantage increased with age. However, we observed no significant differences between male and female individuals for other steps in the transplant process. Further research should examine possible barriers to transplant referral among female individuals.

RATIONALE & OBJECTIVE:The performance of clinical risk prediction scores for ischemic stroke and bleeding are not well established in those with chronic kidney disease (CKD) and atrial fibrillation (AF). We evaluated the performance of 3 risk scores for ischemic stroke and intracranial bleeding in patients across a broad range of kidney function. STUDY DESIGN:Retrospective study. SETTING & PARTICIPANTS:Two community-based cohorts of adults with incident AF (Kaiser Permanente and Ontario, Canada). EXPOSURE:Baseline estimated glomerular filtration rate (eGFR) was calculated using outpatient serum creatinine measures, excluding those with a kidney transplant or receiving dialysis. OUTCOME:Three risk scores for ischemic stroke (ATRIA, CHA2DS2-VASc, and R2CHADS2) and 1 for major bleeding (HAS-BLED) were calculated across eGFR categories (≥60, 45-59, 30-44, and <30 mL/min/1.73 m2). Outcomes included ischemic stroke and intracranial hemorrhage. ANALYTICAL APPROACH:C-statistics were calculated and calibration plots generated within eGFR strata. RESULTS:There were 101,360 adults with incident AF in the Kaiser Permanente cohort and 33,200 adults with incident AF in the Ontario cohort. The mean risk scores for stroke and bleeding were higher with lower eGFR across all 4 measures. The c-statistics for the stroke prediction scores were lower in those with an eGFR < 60 mL/min/1.73 m2 compared with eGFR ≥ 60 mL/min/1.73 m2 in both cohorts. The lowest discrimination for ischemic stroke was seen with the R2CHADS2 risk score (ranging from 0.53-0.61) with a C statistic of 0.57 for the eGFR < 30 mL/min/1.73 m2 category in both cohorts. The C statistic for ATRIA (range, 0.59-0.64) and CHA2DS2-VASc (range, 0.55-0.61) were also modest across lower eGFR categories compared with eGFR > 60 mL/min/1.73 m2. The discrimination for the HAS-BLED bleeding risk score for intracranial bleeding was also low in those with lower eGFR categories (ranging from 0.51 to 0.56). Calibration varied by risk score and eGFR level. LIMITATIONS:Observational study. CONCLUSIONS:Performance of clinically used stroke and bleeding risk prediction scores was modest among those with CKD, particularly at advanced CKD. More accurate risk scores are needed to improve decision making. PLAIN-LANGUAGE SUMMARY:This retrospective analysis evaluated the predictive accuracy of standard clinical risk scores for ischemic stroke (ATRIA, CHA2DS2-VASc, and R2CHADS2) and intracranial hemorrhage (HAS-BLED) in patients with atrial fibrillation (AF) and varying degrees of kidney function. Using data from 2 large cohorts, Kaiser Permanente and an Ontario-based registry, the study focused on how baseline estimated glomerular filtration rate (eGFR) influenced the discrimination and calibration of these models. The study revealed a significant inverse relationship between kidney function and model reliability. While mean risk scores were higher in patients with lower eGFR, the C statistic and calibration decreased significantly in more advanced stages of kidney disease. The results suggest that the pathophysiological complexities of advanced kidney disease limit the utility of tools to predict stroke and bleeding designed for the general population with AF. Development of kidney-specific risk models is needed to better inform anticoagulation strategies and clinical decision making.

RATIONALE & OBJECTIVE:Most living kidney donors report normal-to-high self-esteem before donation. Less is known about the longer-term effects of donation on self-esteem, whether certain pre-donation characteristics are associated with lower self-esteem after donation, or how changes in self-esteem are associated with changes in symptoms of depression and anxiety. STUDY DESIGN:Prospective cohort study. SETTING & PARTICIPANTS:Living kidney donors (n=941) were enrolled before donation from 12 Canadian and 5 Australian transplant centers between 2009 and 2014. EXPOSURE:Living kidney donation. OUTCOMES:Self-reported self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES) before donation, 3 months after donation, and then annually for 5 years or until the last follow-up visit (possible scores range from 0-30, with higher scores indicating higher self-esteem). Donors also completed the Beck Depression and Anxiety Inventories at these timepoints. ANALYTICAL APPROACH:Linear and modified Poisson regression models were used to examine whether pre-donation characteristics were associated with lower self-esteem after donation and if changes in self-esteem were associated with changes in symptoms of depression and anxiety. RESULTS:Nearly all donors (98.6%) reported normal-to-high self-esteem before donating (928/941), and only 2-4% had low self-esteem in follow-up (RSES scores <15). On average, donors had a less than 1-point decrement in average self-esteem between pre-donation and follow-up measurements; while these changes were statistically significant, they were not clinically meaningful (all mean changes <5). Donors with RSES scores ≤20 before donation had an approximate 2-point increase in self-esteem in follow-up (P <0.001). More symptoms of depression before donation were associated with lower self-esteem scores 3 months after donation (P = 0.006). An increase in self-esteem scores after donation was associated with concurrent reductions in symptoms of depression and anxiety (P <0.001). LIMITATIONS:We did not examine the association of early recipient allograft failure or death with donor self-esteem. CONCLUSIONS:In this multicenter study of living kidney donors, nearly all donors reported normal-to-high self-esteem before donation and during five years of follow-up. On average, donors with lower self-esteem before donation had a modest increase in self-esteem after donation. Increases in self-esteem after donation were accompanied by modest reductions in symptoms of depression and anxiety.

Atrial fibrillation (AF) is the most common sustained arrhythmia, with a prevalence and incidence significantly higher in adults with CKD compared with the general population. This risk increases with reduced kidney function, affecting up to 25% of all patients with CKD and 30% of those on receiving chronic dialysis. AF is associated with increased morbidity and mortality, including higher risks of stroke, heart failure, myocardial dysfunction, and progression to kidney failure. The bidirectional relationship between AF and CKD is driven by a convergence of traditional risk factors—such as hypertension and diabetes—and CKD-specific abnormalities. Key pathophysiologic mechanisms include systemic inflammation, oxidative stress, autonomic dysfunction, and disordered mineral metabolism. These factors promote structural remodeling, atrial fibrosis, and electrical instability, creating a highly arrhythmogenic substrate. Treatment options for AF include anticoagulation, rate and rhythm control medications, other cardiovascular therapies ( e.g ., sodium glucose cotransporter 2 inhibitors), and procedures aimed at normalizing rhythm and reducing stroke risk. Patients with CKD are often undertreated with AF medications and procedures, in part because of lack of robust randomized clinical trial data on efficacy and safety, particularly with advanced CKD. This narrative review summarizes key literature on the epidemiology, risk factors, mechanisms and treatment of AF in adults with CKD, and highlights critical areas for future research.

Introduction:Prepregnancy counselling is recommended for women with chronic kidney disease (CKD) to discuss potential adverse outcomes; however, no tools exist to estimate individual risk. We aimed to develop and externally validate 2 prediction models for outcomes prioritized by people with CKD and health care professionals: The primary outcome was the probability of ≥25% reduction in estimated glomerular filtration rate (eGFR) or kidney replacement therapy (KRT) within 12 months postpartum. The secondary outcome was the probability of small-for-gestational-age (SGA) (< 3rd percentile) infant and/or preterm delivery (< 34 weeks). Methods:The development cohort used linked data from the National Registry of Rare Kidney Disease (RaDar), UK Renal Registry (UKRR) and NHS Hospital Episode Statistics (HES). Individuals with eGFR < 90 ml/min per 1.73 m2 within 24 months preconception and deliveries between 1997 and 2021 were included. Validation cohorts were as follows: (i) Ontario Pregnancy Cohort (2007-2022) and (ii) 3 UK pregnancy-CKD studies (2010-2018). Candidate predictors were selected from known risk factors. Clinically relevant cut-points were determined with people with CKD. Results:The development cohort included 746 women (median prepregnancy eGFR: 58 ml/min per 1.73 m2); validation cohorts included 6974 and 380 women. Optimal cut-points of 0.15 (sensitivity: 90%, negative predictive value (NPV): 85%) and 0.10 (sensitivity: 90%, NPV: 80%) were selected for the primary and secondary outcomes. External validations demonstrated high sensitivity and NPV for the primary outcome. Although comparability is limited by differing end points, Kidney Failure Risk Equation (KFRE) predictions (2-year) were lower than our PREDICT model (1-year) (median risk 1.4% vs. 48%). Conclusion:We developed high performing models for individuals with CKD to predict coselected adverse kidney and neonatal outcomes from contemporaneous cohorts. Individualized pregnancy risk assessment tools could support future parents and health care professionals to make informed choices.

This cohort study evaluates the incidence of self-harm and suicide among individuals with hidradenitis suppurativa.

RATIONALE & OBJECTIVE:Many mortality risk prediction models for individuals with kidney failure are available; however, their development did not involve end-users during the design process, and none are widely used in clinical practice. We identified the needs and preferences of end-users to inform the development and enhance the usability of a mortality risk prediction tool for people with kidney failure. STUDY DESIGN:A half-day, online consensus workshop was conducted using a modified nominal group technique. SETTING & PARTICIPANTS:People with lived experience of kidney failure (patients with or without receipt of kidney replacement therapy and their caregivers) or kidney failure management (health care providers and policymakers) recruited from across Canada. ANALYTICAL APPROACH:Preferences were elicited in 3 topic areas: the tool's intended use, timing (prediction horizon and update frequency), and relevant predictor variables. Conventional content analysis of discussion transcripts was conducted to elaborate on the findings. RESULTS:Eighteen individuals from across 5 provinces participated in the workshop, including 7 patients, 3 caregivers, and 8 health care providers or policymakers. Participants prioritized the following: (1) tool use within clinics and in consultation with nephrologists; (2) personalization of the prediction time horizons and reassessment of risk prediction following changes in clinical condition; and (3) inclusion of coexisting conditions, kidney failure characteristics (eg, unplanned dialysis start), and frailty status as key predictor variables. Analysis of transcripts identified several factors influencing the tool's usability, including provider trust, comfort in discussing mortality risk, patient privacy, availability of follow-up and support systems, patient readiness, and feasibility of incorporating desired predictor variables. LIMITATIONS:Media-based recruitment and participation barriers may have limited the representativeness of the patient sample. CONCLUSIONS:End-users of mortality prediction tools for people with kidney failure prioritized design and use considerations. Co-design of future tools to align with end-user preferences may enhance their usability and enhance their uptake. PLAIN-LANGUAGE SUMMARY:Many calculators predict survival for people with kidney failure on dialysis, but few are used in practice, in part because they were not created with input from people who need them. To learn what users want, we conducted an online consensus workshop involving individuals living with kidney failure, caregivers, clinicians, and policymakers from across Canada. The participants discussed how and when the tool should be used and on which factors the tool should be based. They prioritized the use of the tool during clinic visits, personalizing the prediction horizon, and taking into account health conditions and frailty. The participants emphasized the importance of trust, comfort in communication, and support systems when using the tool. Involving users in tool design may enhance its usability and adoption.

Background: A significant barrier to kidney transplantation is limited knowledge about its potential benefits. To help patients who are receiving maintenance dialysis make more informed treatment decisions, a risk calculator (iChoose Kidney) was developed in the United States to provide individualized survival estimates for dialysis versus kidney transplantation. This tool was externally validated in Ontario, Canada, and was found to accurately predict mortality (Ontario version of the tool “Dialysis vs. Kidney Transplant-Estimated Survival in Ontario Risk Calculator”). The United States risk calculator has been updated to include additional variables (e.g., dialysis modality). Objective: To externally validate the updated iChoose Kidney risk calculator in patients from Ontario, Canada, with kidney failure using more recent data, removing race (race in clinical algorithms may perpetuate racial bias in medicine) and using a refined cohort definition (i.e., restricting to patients with no recorded contraindications to transplant). Design: External validation study. Setting: Linked administrative health care databases from Ontario, Canada. Patients: 24 793 patients receiving maintenance dialysis and 5398 kidney transplant recipients from January 1, 2011, to August 31, 2021. Measurements: Three-year mortality. Methods: Model discrimination was evaluated using the C-statistic. Calibration was assessed by comparing the observed versus predicted mortality risks, and further assessed by using loess-smoothed calibration plots. To address over- or under-prediction (calibration-in-the-large), intercepts were adjusted using a correction factor. In our updated model, we used logistic regression to calculate mortality risk, incorporating the following variables: sex assigned at birth (male vs female), age (continuous), cardiovascular disease, hypertension, diabetes, time on dialysis (i.e., <6 months, 6 to 12 months, >1 to 2 years, >2 to 3 years, >3 to 5 years, >5 to 7 years, >7 to 10 years, >10 to 14 years, >14 years), and dialysis modality (peritoneal dialysis, home hemodialysis, in-center dialysis). In a post-hoc analysis, we used the simplified equations from our original Canadian external validation study of the iChoose Kidney tool (i.e., age, sex, hypertension, diabetes, cardiovascular disease, time on dialysis [<6 months, 6-12 months, >12 months]), with removal of the race variable as the only modification. Results: In the dialysis cohort, over a median follow-up of 2.5 years, 30.3% of patients died. In the kidney transplant recipient cohort, over a median follow-up of 2.9 years, 7.3% died. Our updated model had moderate discrimination (C-statistic for dialysis cohort: 0.67 [95% CI: 0.67, 0.68] and C-statistic for kidney transplant cohort: 0.76 [95% CI: 0.74, 0.79]). After recalibrating the intercepts, the observed and predicted mortality were similar between the dialysis cohort and the kidney transplant cohort. Similar results were found in a post-hoc analysis using the original model with the race variable removed. Limitations: Mortality risk estimates assume that all treatment options are readily accessible to patients. However, the average waiting time for a deceased donor kidney transplant in Ontario can be several years. Conclusions: After minor modifications, the iChoose Kidney risk calculator provides reliable survival estimates in patients with kidney failure from Ontario, Canada. Given the similarity in model performance between the updated model and the original model, with race removed, we will continue to use our original simplified model, but we will remove race. Our updated Dialysis vs. Kidney Transplant-Estimated Survival in Ontario Risk Calculator can continue to be a valuable tool for healthcare professionals to use with patients who are receiving maintenance dialysis to provide individualized survival estimates for dialysis versus transplantation, supporting informed decision-making about kidney transplantation.

Likert-based scales are a popular tool in clinical trials for assessing patient-reported outcomes. A key analytical decision involves whether to treat these data as binary, continuous, or ordinal. Each approach has implications for statistical power, bias, and interpretation of the results. In this report, we examine methods for evaluating Likert scales, with a particular focus on ordinal approaches, including win probability methods and proportional odds models. We examined the use of proportional odds logistic regression, win probability estimation, dichotomisation with binary logistic regression, and linear regression for analysis of Likert scale-based outcomes. We applied these analytical approaches to patient-reported discomfort data from MyTEMP, a randomised trial comparing personalised cooler dialysate to standard-temperature dialysate in patients undergoing hemodialysis. We also conducted a simulation study to evaluate bias, coverage, and statistical power for each method under proportional and non-proportional odds scenarios across varying sample sizes and outcome distributions. In the MyTEMP trial, ordinal analyses showed patients receiving personalised cooler dialysate reported greater discomfort related to feeling cold than those receiving standard dialysate (win probability 64

Importance:Approximately 10% to 15% of patients with advanced chronic kidney disease (CKD) experience a fatal or nonfatal cardiovascular event annually. The effects of antithrombotic therapies on cardiovascular events in patients with advanced CKD are unknown. Objective:To determine whether low-dose rivaroxaban reduces rates of adverse cardiovascular events compared with placebo in patients with advanced CKD. Design, Setting, and Participants:Randomized, double-blind, placebo-controlled trial conducted at 90 centers in 12 countries. Eligible participants were adults with CKD stage 4 or 5 and patients with dialysis-dependent kidney failure. Participants had a history of either coronary artery disease; nonhemorrhagic, nonlacunar stroke; peripheral artery disease; diabetes; or were 65 years or older. Enrollment occurred between January 2021 and July 2025. The trial was stopped early on August 7, 2025, for lack of efficacy. Final follow-up occurred on October 30, 2025. Statistical analyses were conducted in February and March 2026. Interventions:Patients were randomized 1:1 to receive rivaroxaban 2.5 mg twice daily or placebo. Main Outcomes and Measures:The primary outcome was a composite of cardiovascular death, nonfatal myocardial infarction, stroke, or a peripheral artery disease event. The primary safety outcome was major bleeding. Results:Of 1458 randomized patients (mean [SD] age, 63.2 [11.6] years, 432 [29.6%] female), 1360 (93.3%) completed follow-up. During a median follow-up of 1.7 years, the primary outcome occurred in 164 patients (22.6%) in the low-dose rivaroxaban group and 151 (20.7%) in the placebo group (13.0 vs 11.8 events per 100 person-years; hazard ratio, 1.09 [95% CI, 0.87-1.36]; P = .46). Major bleeding occurred in 64 patients (8.8%) receiving low-dose rivaroxaban and 44 (6.0%) receiving placebo (5.1 vs 3.4 events per 100 person-years; hazard ratio, 1.51 [95% CI, 1.02-2.22]; P = .04). Conclusions and Relevance:In patients with advanced CKD at high cardiovascular risk, low-dose rivaroxaban did not reduce the risk of a composite cardiovascular outcome. Major bleeding rates were significantly higher in the low-dose rivaroxaban group compared with the placebo group. Trial Registration:ClinicalTrials.gov Identifier: NCT03969953.

BACKGROUND:Several case reports have linked low-dose methotrexate to serious adverse events, including death, in dialysis patients. We compared the risk of serious adverse events in dialysis patients initiating low-dose methotrexate versus hydroxychloroquine. METHODS:Using linked healthcare databases in Ontario, Canada (1997-2020), we identified 55 new users of low-dose methotrexate and 407 new users of hydroxychloroquine. The primary outcome was the 90-day risk of death or hospitalization with myelosuppression, sepsis, pneumotoxicity, or hepatotoxicity. Adjusting for age, sex, and a proxy for polypharmacy, a modified Poisson regression was used to estimate adjusted risk ratios (aRR), and a binomial regression was used to estimate adjusted risk differences (aRD). RESULTS:The median prescribed dose was 10 mg/week (IQR, 10-17.5) for methotrexate and 300 mg/day (IQR, 200-400) for hydroxychloroquine. The primary outcome occurred in 16/55 low-dose methotrexate users (29.1%) and in 29/407 hydroxychloroquine users (7.1%); aRR: 3.14 (95% CI, 1.75 to 5.63); aRD: 19.5% (95% CI, 7.5% to 31.4%). Findings were consistent across sensitivity analyses. CONCLUSION:Low-dose methotrexate should be avoided in dialysis patients whenever possible, and alternative DMARDs should be considered.

KEY POINTS:Multidisciplinary kidney care eligibility changed from eGFR ≤33.4 ml/min per 1.73 m 2 to 2-year kidney failure risk ≥10% (includes eGFR and proteinuria). After the change, we found no difference in outcomes such as dialysis initiation, preparation for dialysis, and hospitalizations. The results of this study help guide decision making with respect to the care of patients with advanced CKD. BACKGROUND:We examined the effect of a change in the eligibility criteria for multidisciplinary kidney care implemented across Ontario, Canada, on April 1, 2016 (criteria moved from an eGFR ≤33.4 ml/min per 1.73 m 2 to 2-year kidney failure risk ≥10%, which incorporates assessment of proteinuria, or an eGFR <15). METHODS:Population-based, interrupted time series analysis using administrative health care databases that included adults with an outpatient eGFR ≤33.4 ml/min per 1.73 m 2 followed by a nephrologist ( N =97,299). We examined multidisciplinary clinic and nephrologist visits, dialysis-related outcomes, hospital encounters, and mortality by monthly interval between October 1, 2013, and February 1, 2020. Autoregressive integrated moving average models were tested for level (immediate) and slope (over time) changes in outcomes after the intervention and were fit on preintervention change data for projected trends. RESULTS:After intervention, there was a significant monthly decline in the multidisciplinary clinic visit rate of 1.49 visits per 100 person-years (95% confidence interval [CI], -2.83 to -0.14) and a significant monthly increase in the proportion of patients with a referral to multidisciplinary care within 1 year before starting dialysis ( i.e ., late referral; positive slope change, 0.67%; 95%, CI, 0.06 to 1.28). The intervention was not associated with significant changes in the proportion of patients initiating dialysis, initiating dialysis with a central venous catheter or during a hospitalization, using home dialysis, or in the rate of nephrologist visits. Immediately after intervention, there were small, significant increases in mortality and hospital encounters, but importantly, there was no monthly (slope) change in mortality and a significant negative monthly change in hospital encounters (-0.24 encounters per 100 person-years; 95% CI, -0.38 to -0.09). CONCLUSIONS:Changing the eligibility criteria for multidisciplinary kidney care from an eGFR ≤33.4 ml/min per 1.73 m 2 to a 2-year kidney failure risk ≥10% or an eGFR <15 ml/min per 1.73 m 2 resulted in significantly fewer patients receiving such care without negatively affecting important clinical outcomes.

OBJECTIVE:To evaluate the improvement in vision-related quality of life, as measured by validated patient-reported outcome measures (PROMs) (NEI-VFQ-14, NEI-VFQ-25) after cataract surgery, and to explore sources of variability in outcomes. METHODS:MEDLINE, EMBASE, and CINAHL were searched, with supplementary grey‑literature screening, for primary studies reporting preoperative and postoperative PROM scores following cataract surgery. Eligible instruments were the Visual Function Index (NEI-VFQ-14), National Eye Institute Visual Function Questionnaire (NEI‑VFQ‑25/‑14), Catquest‑9SF, and related tools. Two reviewers independently performed study selection, data extraction, and risk‑of‑bias assessment using design‑specific CLARITY/U.S. National Institutes of Health frameworks. Random-effects meta-analyses pooled mean change scores for NEI-VFQ-14 and NEI-VFQ-25. Heterogeneity (τ², I²), 95% prediction intervals, small-study effects (Egger's test), and trim-and-fill were assessed. Risk of bias used design-specific CLARITY/NIH tools. RESULTS:From 3473 records, 122 studies met inclusion criteria. Forty‑seven were prospective cohorts, 9 were randomized controlled trials, and 38 were case series; 52% were judged at moderate risk of bias. Fifty-six NEI-VFQ-14 cohorts (k = 56) and 33 NEI-VFQ-25 cohorts (k = 33) were pooled. Mean improvements were +21.8 points (95% CI: 17.4-26.3; I² = 99.9%; PI: -11.3 to 54.9) for NEI-VFQ-14 and +19.3 points (95% CI: 17.0-21.6; I² = 99.4%; PI: 6.5-32.1) for NEI-VFQ-25. For NEI-VFQ-25, Egger's test suggested small-study effects (p = .002); trim-and-fill imputed 3 studies, yielding +18.2 (95% CI: 16.0-20.4). CONCLUSIONS:Cataract extraction consistently enhances patient‑perceived visual function and quality of life. Unfortunately, high heterogeneity limits precision and suggests that gains in PROM score may vary by patient and procedural factors, and small-study effects may overestimate the true benefit recorded by NEI-VFQ-25. Routine integration of validated PROMs into cataract pathways will better capture outcomes that matter to patients, given that the very high heterogeneity, standardized reporting, and longer follow‑up are priorities.

Background Many living kidney donors (LKDs) describe their evaluation process as the most difficult part of donating a kidney. The process is often lengthy, complex and inefficient, frequently requiring several months to complete. A more efficient and donor-centered evaluation may improve LKD experiences, reduce attrition, and encourage more individuals to donate. Methods We employed a Delphi approach to define and select metrics of a high-quality LKD evaluation. Four multidisciplinary working groups were created in which LKDs (n=8), healthcare professionals (n=11), and administrators (n=3) collaborated to develop evidence and experience informed recommendations. Results This work culminated in a national consensus conference held virtually in September 2024, which brought together over 100 LKDs, nurses, nephrologists, surgeons, researchers, and representatives from transplant organizations. Of the 42 recommendations evaluated through the e-Delphi process, 35 achieved consensus (≥75% agreement) across four domains. Ninety-two percent were supported by moderate-quality evidence, while 8% had no supporting evidence, reflecting the limited empirical data available for several aspects of donor evaluation processes. The recommendations clustered into four overarching themes included: (1) increasing donor numbers and evaluation efficiency (e.g., eligibility for donation determined within three to six months), (2) enhancing program resources and donor reimbursement (e.g., metrics on donor financial neutrality), (3) ensuring a donor-centered evaluation process (e.g., donor-centered metrics such as donor satisfaction), and (4) promoting consistency and evidence-based practice across programs (e.g., consistent evaluation nationally). Conclusion Collectively, these recommendations provide a framework to guide quality improvement, benchmarking, and policy development, with implications for strengthening the LKD evaluation process worldwide.

INTRODUCTION:The cause of kidney failure in kidney transplant recipients remains unknown in 20-45% of cases. Outcomes for living kidney donors (LKDs) are generally excellent, with only 8% experiencing complications post-donation. Here, we hypothesize that genetic testing could identify a genetic etiology in at least 20% of recipients and inform risk stratification in LKDs. METHODS:Genetic testing was performed in 231 transplant recipients and 46 prospective LKDs by means of exome sequencing of 409 chronic kidney disease (CKD)-associated genes. We also assessed 122 retrospective LKDs who developed adverse kidney outcomes post-donation which were defined by at least two of the three criteria: hypertension, a glomerular filtration rate under 60 mL/min/1.73m2, or a urine albumin to creatinine ratio of 3 mg/mmol or more. RESULTS:Pathogenic or likely pathogenic (P/LP) variants were identified in 23% of recipients, most commonly involving genes associated with cystic kidney disease and glomerulopathies. Among the recipients with a genetic diagnosis, there was a 37% rate of reclassification to a different phenotype post genetic testing. Among prospective LKDs, 4% had P/LP variants. In the retrospective cohort of LKDs with adverse kidney outcomes post donation, 19% carried P/LP variants. CONCLUSIONS:Genetic testing yielded a high diagnostic rate and frequently reclassified CKD etiology in transplant recipients, underscoring its diagnostic utility. Universal genetic testing of asymptomatic LKDs had a yield of 4%, although our prospective LKD cohort had limited sample size. In contrast, high proportion of LKDs with adverse kidney outcome post-donation were found to carry P/LP variants in CKD-associated genes. Our findings suggest that targeted genetic testing of high-risk donors may be a preferred over universal testing strategy to optimize donor selection in LKDs. However, further evaluation is warranted to ensure this approach appropriately balances donor safety with equitable access.

BACKGROUND:Hidradenitis suppurativa (HS) is an inflammatory skin condition that is associated with a prolonged diagnostic delay of approximately 7-10 years. The diagnostic delay can be attributed to various factors, including low awareness of diagnostic criteria among nondermatological healthcare professionals often leading to misdiagnosis. Screening questionnaires have been proposed for the diagnosis of HS. One such questionnaire has been validated and used in the Global Hidradenitis Suppurativa Atlas (GHiSA) Global Prevalence Study (GPS). OBJECTIVES:To evaluate and provide a summary of the diagnostic accuracy measures (pooled sensitivity and specificity) of the screening questionnaire employed in the GHiSA GPS. METHODS:All studies that adhered to the methodology specified by the GHiSA and provided diagnostic accuracy data were eligible for inclusion. Data on geographical location and diagnostic accuracy parameters (true positive, false positive, true negative and false negative) were extracted from the included studies and entered in duplicate into Microsoft Excel independently by two authors. The quality of the studies was assessed using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. RESULTS:Data from 25 studies carried out in 23 countries were included in the pooled analysis. The QUADAS-2 assessment revealed a high risk of bias in the domains 'reference standard' and 'patient flow'. For the applicability of the studies, there were concerns about 'patient selection'. Substantial variations in sensitivity (0.43-1.00) and specificity (0.15-1.00) values were observed globally. A bivariate random effects model showed a pooled sensitivity of 0.88 [95% confidence interval (CI) 0.80-0.94] and a pooled specificity of 0.86 (95% CI 0.78-0.91). The summary receiver operating curve revealed a clustering of studies in the upper left corner, indicating a sensitivity and specificity close to 1. The area under the curve was 0.93, suggesting excellent accuracy. CONCLUSIONS:Despite substantial variations in diagnostic estimates around the world, the pooled analysis indicated that the accuracy of the GHiSA screening questionnaire was excellent. The screening questionnaire may prove useful for triage, ensuring that only individuals fitting the criteria for HS see specialized dermatological care.