BACKGROUND:Adolescence has been identified as a high-risk period for graft failure. However, existing knowledge on this topic is largely limited to long-term graft outcomes. The aim of this study was to examine the association between age at kidney transplantation and early graft loss, defined as graft failure within 3 years post-transplantation in the contemporary era. METHODS:This study was a retrospective analysis of 55 973 first-time kidney transplant recipients identified in the U.S. Renal Data System from January 1, 2005, to December 31, 2021. Adjusted Cox proportional hazards regression models were used to evaluate the association between age at transplantation and early graft failure including an interaction term for race/ethnicity. RESULTS:Adolescents (12 to < 18 years) and young adults (18 to < 26 years) were at the highest risk of early death-censored graft loss compared to young adults (26 to < 40 years), with hazard ratios of 1.95 (95% CI 1.74-2.17) and 2.01 (95% CI 1.86-2.17), respectively. Additionally, we found that the effect of age on early graft loss varied significantly by race, with disparities observed among Asian and Black youth. CONCLUSION:These findings highlight a persistently elevated risk in adolescents and young adults in the contemporary era.

BACKGROUND:Melanoma outcomes vary by subgroups. OBJECTIVE:Identify institutional/systemic factors contributing to outcome differences. METHODS:Retrospective cohort study of melanoma patients seen from January 1987 to May 2023 at a Veterans Affairs (VA) center and nearby tertiary care center sharing providers. Outcomes include melanoma-specific survival and mortality. RESULTS:Compared to the tertiary center (n = 9,682, 5564 males), VA patients (n = 638, 612 males) were older and had a greater proportion of melanoma in situ (P < .0001). When comparing VA males to males treated at the tertiary center, melanoma-specific survival was increased for localized melanoma (P = .003) but decreased for regional (P = .0002) and distant disease (P = .02). When comparing VA males to VA-insured males at the tertiary center, melanoma-specific survival remained increased for localized disease (P < .0001), but differences for regional or distant disease were no longer significant. Within the tertiary center, publicly insured patients had increased melanoma-specific mortality compared to privately insured (Medicare, hazard ratio [95% confidence interval]: 1.46 [1.22-1.75]; Medicaid, 1.67 [1.28-2.18]; Military/VA 1.92 [1.15-3.20]). LIMITATIONS:Smaller number of VA-insured patients. CONCLUSION:Differences in preventative screening and selective referrals may contribute to increased survival at the VA for early-stage melanoma. Insurance type within and between institutions is associated with differential mortality outcomes for advanced melanoma stages, indicating a need for additional care standardization.

Bariatric surgery has been shown to be safe in chronic kidney disease and improves access of patients to transplantation. Whether bariatric surgery after kidney transplantation is associated with improved graft or patient survival has not been examined nationally. We included adults with obesity who received a first kidney transplant according to the US Renal Data System between 2003-2019. We matched 4 controls to each case of bariatric surgery based on age at transplantation, sex, donor type, diabetes, and body mass index at transplantation. We examined the association between bariatric surgery and graft failure or death using multivariable Cox proportional hazards models and Fine-Gray models accounting for death as a competing risk. We included 770 patients, of whom 155 (20%) received bariatric surgery. Median age was 45 years and 56% were women. Receipt of bariatric surgery was associated with improved graft survival (hazard ratio [HR], 0.57; 95% CI, 0.34-0.98) in fully adjusted models, although findings did not consistently maintain statistical significance in competing risk analyses (subHR, 0.60; 95% CI, 0.35-1.02). Receipt of bariatric surgery was associated with lower risk of death (HR, 0.45; 95% CI, 0.26-0.76). In conclusion, bariatric surgery is associated with improved patient survival and potentially graft survival after kidney transplantation.

Objective: This study aims to understand environmental triggering or exacerbating factors for acne vulgaris and investigate the association of short-term exposure to wildfire-related air pollution and clinic visits for acne vulgaris.

We investigated factors that could contribute to melanoma outcome disparities by comparing outcomes at 2 different healthcare systems in the same city, staffed by shared providers. Patients at an academic center (N=6117) and a Veterans Affairs (VA) center (N=488) diagnosed between 1987 and 2022 with one melanoma were assessed retrospectively. A higher proportion of VA patients were male, older, lived further from the hospital, had average lower incomes and were diagnosed with early stage disease (p<0.0001). Melanoma specific survival (MSS) was increased for male VA AJCC stage I (p=0.046), decreased for VA stage III (p=0.0041), with no significant difference in stage II or IV (p=0.20; 0.11) patients. Within the academic center, Blacks and patients with Medicare/Medi-Cal insurance had decreased MSS (p=0.018, 0.0022, <0.0001), compared to Whites and those with private insurance respectively; race did not play a significant role in VA patients (p>0.05). There were no significant differences in MSS for patients at the academic center with military/VA insurance compared with patients seen at the VA (p>0.05). Compared to the academic center, VA patients had better MSS for stage I but worse for stage III, possibly due to inter-institutional differences in availability of clinical trials. Military/VA insured melanoma patients at the academic center had no difference in MSS compared with VA center melanoma patients. Intra-institutional differences in MSS were seen in the academic center associated with race and insurance, but not in VA patients, possibly due to the VA structure of care, which is similar to an accountable care organization.

Journal Article Accepted manuscript Access to kidney transplantation from dialysis facilities affiliated with a transplant center versus free-standing dialysis facilities in the US Get access Lucy Y Zhang, Lucy Y Zhang School of Medicine, University of California San Francisco Correspondence to: Lucy Y. Zhang; E-mail: lucy.zhang@ucsf.edu https://orcid.org/0000-0002-8293-1209 Search for other works by this author on: Oxford Academic PubMed Google Scholar Alex Dinh, Alex Dinh Department of Medicine, Division of Nephrology, University of California San Francisco Search for other works by this author on: Oxford Academic PubMed Google Scholar Kirsten L Johansen, Kirsten L Johansen Department of Medicine, Hennepin Healthcare Institute and University of Minnesota Search for other works by this author on: Oxford Academic PubMed Google Scholar Charles E McCulloch, Charles E McCulloch Department of Epidemiology and Biostatistics, University of California San Francisco Search for other works by this author on: Oxford Academic PubMed Google Scholar Barbara Grimes, Barbara Grimes Department of Epidemiology and Biostatistics, University of California San Francisco Search for other works by this author on: Oxford Academic PubMed Google Scholar Elaine Ku Elaine Ku Department of Epidemiology and Biostatistics, University of California San FranciscoDepartment of Medicine and Pediatrics, University of California San Francisco Search for other works by this author on: Oxford Academic PubMed Google Scholar Nephrology Dialysis Transplantation, gfae194, https://doi.org/10.1093/ndt/gfae194 Published: 30 August 2024

Significance Statement Serum creatinine is a product of skeletal muscle metabolism. Differences in serum creatinine concentration between Black and non-Black individuals have been attributed to differences in muscle mass but have not been thoroughly examined. Furthermore, other race and ethnic groups have not been considered. If differences in body composition explain differences in serum concentration by race or ethnicity, then estimates of body composition could be used in eGFR equations rather than race. Adjustment for intracellular water (ICW) as a proxy of muscle mass among patients with kidney failure in whom creatinine clearance should minimally influence serum concentration does not explain race- and ethnicity-dependent differences. Background Differences in serum creatinine concentration among groups defined by race and ethnicity have been ascribed to differences in muscle mass. We examined differences in serum creatinine by race and ethnicity in a cohort of patients receiving hemodialysis in whom creatinine elimination by the kidney should have little or no effect on serum creatinine concentration and considered whether these differences persisted after adjustment for proxies of muscle mass. Methods We analyzed data from 501 participants in the A Cohort Study to Investigate the Value of Exercise in ESKD/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESKD study who had been receiving hemodialysis for >1 year. We examined the independent associations among race and ethnicity (Black, Asian, non-Hispanic White, and Hispanic), serum creatinine, and ICW (L/m 2 ), a proxy for muscle mass, derived by whole-body multifrequency bioimpedance spectroscopy, using multivariable linear regression with adjustment for several demographic, clinical, and laboratory characteristics. We examined the association of race and ethnicity with serum creatinine concentration with and without adjustment for ICW. Results Black, Asian, and Hispanic patients had higher serum creatinine concentrations (+1.68 mg/dl [95% confidence interval (CI), 1.09 to 2.27], +1.61 mg/dl [95% CI, 0.90 to 2.32], and +0.83 [95% CI, 0.08 to 1.57], respectively) than non-Hispanic White patients. Overall, ICW was associated with serum creatinine concentration (0.26 mg/dl per L/m 2 ICW; 95% CI, 0.006 to 0.51) but was not statistically significantly different by race and ethnicity. Black, Asian, and Hispanic race and ethnicity remained significantly associated with serum creatinine concentration after adjustment for ICW. Conclusion Among patients receiving dialysis, serum creatinine was higher in Black, Asian, and Hispanic patients than in non-Hispanic White patients. Differences in ICW did not explain the differences in serum creatinine concentration across race groups.

Importance Patient to staff ratios vary across US dialysis facilities and have been associated with patient outcomes in older adults. Objective To determine whether patient to nurse or patient to social worker staff ratios are associated with access to kidney transplant for adolescents and young adults. Design, Setting, and Participants Retrospective cohort study including patients aged 12 to 30 years who started dialysis between 2005 and 2019 at 8490 US facilities according to the US Renal Data System, the national end-stage kidney disease registry. Exposures Time-updated quartile of patient to nurse and patient to social worker ratios at dialysis facilities. Main Outcomes and Measures Fine-Gray models were used to relate the exposure to the incidence of waitlisting and kidney transplant, accounting for the competing risk of death. Subgroup analysis by age at dialysis initiation (<22 vs >= 22 years) was performed. Follow-up was censored in January 2020. Results A total of 54 141 participants were included (median age, 25 years [IQR, 21-28]; 54.4% male; 4.3% of Asian race, 35.3% of non-Hispanic Black race). The median patient to staff ratios were 14.4 patients per nurse (IQR, 10.3-18.9) and 91.0 patients per social worker (IQR, 65.2-115.0). During a median follow-up of 2.6 years, 39.9% of patients (n = 21 598) received a transplant. In adjusted analysis, the highest (vs lowest) quartile of patient to nurse ratios was associated with 14% lower incidence of transplant (subhazard ratio [SHR], 0.86 [95% CI, 0.82-0.91]). The highest (vs lowest) quartile of patient to social worker ratios was associated with lower incidence of waitlisting (SHR, 0.95 [95% CI, 0.91-0.99]) and transplant (SHR, 0.85 [95% CI, 0.81-0.89]). For both staff ratios, there was an interaction with age at dialysis initiation, such that the association was more pronounced in patients starting dialysis at younger than 22 years (SHR, 0.71 [95% CI, 0.65-0.78] for the highest vs lowest quartile for nursing; SHR, 0.74 [95% CI, 0.68-0.80] for social work) compared with those 22 years and older (SHR, 1.00 [95% CI, 0.94-1.06] for nursing; SHR, 0.96 [95% CI, 0.91-1.02] for social work) for the outcome of transplant. Conclusions and Relevance Adolescents and young adults receiving care at dialysis facilities with higher patient to staff ratios had reduced access to waitlisting and transplant, particularly if they were younger than 22 years of age at dialysis initiation.

Background Nephrology is one of the pediatric subspecialties with the largest workforce shortage in the United States. Waitlist registration is one of the first steps toward kidney transplantation and is facilitated by pediatric nephrologists. The objective of this study was to determine whether state-level density of pediatric nephrologists is associated with access to waitlisting (primary outcome) or kidney transplantation (secondary outcome) in children with kidney failure. Methods Using Cox proportional hazards and logistic regression analyses, we studied children younger than 18 years who developed kidney failure between 2016 and 2020 according to the United States Renal Data System, the national kidney failure registry. The density of pediatric nephrologists (determined by the count of pediatric nephrologists per 100,000 children in each state) was estimated using workforce data from the American Board of Pediatrics and categorized into three groups: >1, 0.5-1, and <0.5. Results We included 4497 children, of whom 3198 (71%) were waitlisted and 2691 (60%) received transplantation. Children residing in states with pediatric nephrologist density >1 had 33% (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.07 to 1.66) and 22% (HR, 1.22; 95% CI, 1.02 to 1.45) better access to waitlisting compared with those residing in states with <0.5 pediatric nephrologist density (reference group) in unadjusted and adjusted analysis, respectively. Pediatric nephrologist density was particularly important for the odds of preemptive waitlisting comparing the highest versus lowest workforce density (adjusted odds ratio, 1.56; 95% CI, 1.02 to 2.41). The adjusted HR was 1.25 (95% CI, 1.00 to 1.55; P = 0.046) for deceased donor transplantation and 1.24 (95% CI, 0.85 to 1.82) for living donor transplantation for children residing in states with pediatric nephrologist density >1 compared with the reference group. Conclusions Children residing in states with higher pediatric nephrologist density had better access to waitlist registration, especially preemptively, and deceased donor transplantation.

Residence in rural areas is often a barrier to health care access. To date, differences in access to kidney transplantation among children who reside in rural and micropolitan areas of the US have not been explored. A retrospective cohort study of children < 18 years who developed kidney failure between 2000 and 2019 according to the United States Renal Data System (USRDS). We examined the association between rurality of patient residence and time to living and/or deceased donor kidney transplantation (primary outcomes) and waitlist registration (secondary outcome) using Fine–Gray models. We included 18,530 children, of whom 14,175 (76.5

Significance Statement Although most guidelines recommend tightly controlling BP in patients with CKD, individuals with advanced kidney disease or severe albuminuria were not well-represented in trials examining the effect of this intervention on kidney outcomes. To examine the effect of intensive BP control on the risk of kidney outcomes in patients with CKD, the authors pooled individual-level data from seven trials. They found that overall, intensive BP control was associated with a 13% lower, but not significant, risk of a kidney outcome. However, the intervention's effect on the kidney outcome differed depending on baseline eGFR. Data from this pooled analysis suggested a benefit of intensive BP control in delaying KRT onset in patients with stages 4–5 CKD, but not necessarily in those with stage 3 CKD. Background The effect of intensive BP lowering (to systolic BP of <120 mm Hg) on the risk of kidney failure requiring KRT remains unclear in patients with advanced CKD. Such patients were not well represented in trials evaluating intensive BP control. Methods To examine the effect of intensive BP lowering on KRT risk—or when not possible, trial-defined kidney outcomes—we pooled individual-level data from seven trials that included patients with eGFR<60 ml/min per 1.73 m 2 . We performed prespecified subgroup analyses to evaluate the effect of intensive BP control by baseline albuminuria and eGFR (CKD stages 4–5 versus stage 3). Results Of 5823 trial participants, 526 developed the kidney outcome and 382 died. Overall, intensive (versus usual) BP control was associated with a lower risk of kidney outcome and death in unadjusted analyses but these findings did not achieve statistical significance. However, the intervention's effect on the kidney outcome differed depending on baseline eGFR ( P interaction=0.05). By intention-to-treat analysis, intensive (versus usual) BP control was associated with a 20% lower risk of the primary kidney outcome in those with CKD GFR stages 4–5, but not in CKD GFR stage 3. There was no interaction between intensive BP control and the severity of albuminuria for kidney outcomes. Conclusions Data from this pooled analysis of seven trials suggest a benefit of intensive BP control in delaying KRT onset in patients with stages 4–5 CKD but not necessarily with stage 3 CKD. These findings suggest no evidence of harm from intensive BP control, but also point to the need for future trials of BP targets focused on populations with advanced kidney disease. Podcast This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_02_27_JASN0000000000000060.mp3

Key Points Receipt of dialysis at hospital-affiliated facilities was associated with a higher risk of mortality compared with treatment at free-standing dialysis facilities.The differential mortality risk in free-standing versus hospital-affiliated facilities was more pronounced in non-Hispanic Black and Asian patients compared with other racial/ethnic groups.

Studies have compared national SEER melanoma outcomes (for the general US population) to outcomes for US military veterans in the federal VA medical system. These studies were limited by the magnitude of healthcare system and provider heterogeneity in the US, and the lack of SEER staging granularity, such as that provided by AJCC staging. We compared melanoma outcomes at a regional veteran hospital to those at a nearby academic tertiary referral center, which share physician staffing. Our cohort study assessed melanoma outcomes using both SEER and AJCC 8th edition staging, from 1985 to 2022 and included 470 veterans and 8005 patients at the tertiary referral center. We observed no difference in overall melanoma specific survival (MSS; p=0.06). MSS stratified by SEER staging was higher for the veteran patients for localized disease (p<0.0001), but lower for regionalized (p<0.0001) and disseminated (p<0.0013) disease . When stratified by AJCC staging, MSS did not differ for in situ disease (p=0.63), or for stage I disease (p=0.14), but was lower for stage II (p=0.02), stage III (p=0.002), and stage IV (p=0.0005) disease for veterans. At the tertiary referral center, we observed an increased hazard ratio (HR) for melanoma specific mortality (MSM) for patients with federal insurance (Medicare p=0.01; Medi-Cal p<0.0001; military/VA p=0.04), compared to those with private insurance; for Black (p=0.004) and Asian (p=0.047) patients compared with white patients; and for male (p<0.0001) compared with female patients. These differences were not observed among veteran patients. Comparing melanoma outcomes for patients at institutions sharing physician staffing, we found that for SEER and AJCC early stage disease, the veteran population had higher MSS, but lower MSS for more advanced stages. There was an increased HR for MSM for subsets of patients at the tertiary care center, associated with insurance type, race and sex, which was not observed in the veteran patients.

This cross-sectional study examines whether clinic visits and online search interest for psoriasis were associated with wildfire air pollution after a delayed lag period.

Wildfires are increasingly contributing to worsening air pollution. During California wildfires, clinic visits and online search interest for atopic dermatitis and itch increased, but not for psoriasis. We assessed whether clinic visits and search interest for psoriasis were associated with wildfire air pollution after a delayed lag period. A cross-sectional time-series study was done using three metrics for air pollution: fire status, particulate matter (PM2.5), and smoke plume density. Data were collected for outpatient dermatology visits at an academic medical center in San Francisco from Oct. 2018-Feb. 2019 (including the California Camp Fire), Oct. 2015-Feb. 2016 (no fires), and Oct. 2016-Feb. 2017 (no fires). Data on psoriasis clinic visits were stratified by age group and analyzed by generalized Poisson regression. Statistical models were adjusted for temperature, humidity, age, year, and overall patient volume at clinics. Weekly online search volume interest (SVI) for 2018 in San Francisco was collected, for the term "psoriasis" from Google Trends. We analyzed 986 visits for psoriasis. An increase in adult visits occurred at week 5 after the fire [RR: 1.32 (95% CI: 1.02-1.70)] and peaked at week 8 [RR: 1.45 (95% CI: 1.13-1.86)] and week 9 [RR: 1.45 (95% CI: 1.12-1.87)]. No significant results were found for pediatric patients, likely due to limited patient numbers. Mean weekly SVI for psoriasis showed an increase starting 5 weeks after the fire, peaking at week 8. Wildfire air pollution was associated with a delayed increase in SVI and clinic visits for psoriasis.

Rojas, Gabriela Accetta; Mcculloch, Charles E.; Whelan, Adrian; Copeland, Timothy P.; Bicki, Alexandra; Giang, Sophia; Grimes, Barbara A.; Ku, Elaine Author Information

Background: Melatonin is effective for migraine prevention in adults. We hypothesized that melatonin would also be effective for migraine prevention in children and adolescents. Methods: This was a randomized, double-blind trial of melatonin (3 mg or 6 mg) versus placebo for migraine prevention in 10-17 year-olds with 4-28/ 28 headache days at baseline. Participants were recruited from the UCSF Child & Adolescent Headache Program, UCSF child neurology clinic, and social media advertisements. Migraine diagnosis was confirmed by a headache specialist. Participants completed an 8-week single-blind placebo run-in. Those meeting randomization criteria (>= 4 headache days and >= 23/28 electronic diary entries during weeks 5-8) were randomized 1:1:1 to placebo:melatonin 3 mg:melatonin 6 mg nightly for 8 weeks. The primary outcome measure was migraine days in weeks 5-8 of randomized treatment between melatonin (combined 6 mg + 3 mg) versus placebo. We aimed to enroll n = 210. Results: The study closed early due to slow enrollment (n = 72). Two participants were in the single-blind phase when the study closed, therefore the meaningful n = 70. Sixteen percent (11/70) were lost to follow-up during the single-blind phase. An additional 21% (15/70) did not meet randomization criteria (<4 headache days: n = 5, <23/28 diary days: n = 7, both: n = 3). Sixty-three percent (44/70) were eligible to randomize, of whom 42 randomized (n = 14 per arm). Taking another preventive at enrollment (OR 8.3, 95% CI 1.01 to 68.9) was the only variable associated with meeting randomization criteria. Of those randomized, 91% (38/42) provided diary data in the final 4-weeks. However, given the amount of missing data, only those with >= 21/28 diary days were analyzed-7/ 14 (50%) in the placebo group, and 20/28 (71%) in the melatonin groups combined. Median (IQR) migraine/migrainous days in weeks 5-8 of double-blind treatment was 2 (1-7) in the placebo group versus 2 (1-12) in the melatonin groups combined; the difference in medians (95% CI for the difference) was 0 days (-9 to 3). There were no differences in adverse events between groups. Conclusions: When compared to recall at enrollment, headache days decreased across the single-blind placebo phase and the double-blind phase. There was no suggestion of superiority of melatonin; however, given the substantial portion of missing data, numerically higher in the placebo arm, and underpowering, this should not be interpreted as proof of inefficacy. Melatonin was generally well tolerated with no serious adverse events. Future migraine preventive trials in this age group may find this trial helpful for anticipating enrollment needs if using a single-blind placebo run-in. Enriching for those already on a migraine preventive may improve randomization rates in future trials, though would change the generalizability of results.