Objective: The true burden of diabetes is likely underestimated by not considering the full range of complications associated with diabetes. Our aim was to compare cause-specific hospitalizations in adults with vs. without diabetes. Research Design and Methods: Our denominator included all adults with and without self-reported diabetes from the 2019 Behavioral Risk Factor Surveillance System Survey, weighted to reflect the U.S. population. Our numerator, age-standardized risks of ICD-10-CM-defined inpatient hospitalizations and emergency department (ED) visits, were identified from the 2019 National Inpatient Sample and National ED Sample, respectively, weighted to be representative of U.S. hospitalizations. Each cause-specific hospitalization was classified as traditional, emerging, or other. Results: For inpatient hospitalizations, the highest absolute risk difference per classification was for sepsis (traditional; 1,680 [95%CI: 1,649-1,712] hospitalizations per 100,000), pneumonia (emerging; 225 [218-232]), and respiratory failure (other; 280 [272-289]). For ED visits, the highest absolute risk difference was for abscess, furuncle, and carbuncle (traditional; 388 [352-423] visits per 100,000), complications of cardiac devices (emerging; 111 [104-118]), and disorders of the urinary system (other; 299 [252-346]). Conclusions: The causes of excess hospitalizations associated with diabetes extend well beyond traditional complications with implications for population-level planning, resource allocation, and individual diabetes management.

BACKGROUND:Suboptimal dialysis initiation is associated with adverse patient outcomes. Whether it is also associated with access to downstream transplant care is unknown. METHODS:Adults initiating dialysis treatment for kidney failure in the Southeast U.S., from 1/1/2015 to 12/31/2019 were identified from the United States Renal Data System, linked to the Early Steps to Transplant Access Registry, and followed through 12/31/2021. The primary exposure was pre-dialysis care and categorized as highly, moderately, minimally, or non-optimal based on presence of nephrology care, dialysis type (in-center or home hemodialysis, peritoneal dialysis), and vascular access vs. catheter. Primary outcomes were referral to a transplant center within 12-months of dialysis initiation and evaluation start at a transplant center within 6 months of first referral. Multivariable competing risk models quantified the association between pre-dialysis care context and referral and evaluation. RESULTS:Among 49,057 patients initiating dialysis, 28.8%, 15.5%, 31.0%, and 24.8% are highly, moderately, minimally, and non-optimal start, respectively. Patients initiating dialysis in moderately, minimally, and non-optimal ways are 28% (adjusted hazard ratio: 0.72, [95% CI: 0.69 - 0.72], 31% (0.69, [0.66 - 0.71], and 57% (0.43, [0.41 - 0.44]) less likely to be referred as compared with highly optimal starters. Those who had a non-optimal start are also 37% less likely to start the evaluation after being referred (0.63, [0.59 - 0.66]) as compared with highly optimal dialysis starters, while all other groups have a similar likelihood. CONCLUSIONS:More than half of U.S. adults with kidney failure initiate dialysis in a minimal or non-optimal way leading to reduced likelihood of transplant referral and evaluation.

Objective The epidemiology of diabetes and its complications is changing due to increasingly younger ages of diagnosis and increased life expectancy. How this changing landscape affects healthcare use, and for which conditions is unclear. We examined age-specific excess burdens of cause-specific inpatient and emergency department (ED) visits associated with diabetes. Research Design and Methods We used 2019 Behavioral Risk Factor Surveillance System, National Inpatient, and ED Sample data to derive national U.S. estimates of inpatient admissions and ED visits in adults with and without diabetes. Complications were categorized as traditional, conditions emerging as diabetes-associated, or other conditions co-occurring with diabetes. We calculated age-standardized absolute risk differences (ARD) in people with vs. without diabetes to identify leading causes of diabetes-related hospital use by age and setting. Results Traditional complications were dominated by sepsis, cardiorenal disease, acute kidney failure, myocardial infarction, and stroke with ARD ranging from 296 to 2,623 per 100,000 people with diabetes. Emerging conditions included pneumonia, device- and procedure-related complications (ARD range: 125 to 473), and schizoaffective or other mental health disorders in younger adults only (ARD range: 80-312). Other conditions included respiratory and fluid/electrolyte disorders across all ages (ARD range 100 to 363), while digestive and urinary disorders were more prominent in older adults (ARD range: 229 to 482). ED visits showed a similar pattern, with lower ARD than inpatient admissions (ARD range: 101 to 707). Conclusions Diabetes drives substantial, age-specific excess inpatient and ED use, increasingly due to nontraditional rather than classic vascular and renal complications.

Understanding regional variation in early transplant access informs tailored interventions. Two comparable surveys assessed perceived access barriers among dialysis and transplant center staff across New England, New York, U.S. Southeast, and Ohio River Valley (August 2021-October 2023). Among 630 dialysis and 34 transplant staff/centers, dialysis staff most often cited patient disinterest (48.75%), transportation challenges (44.75%), and lack of support (37.87%). Transplant staff cited lack of support (74.35%), non-adherence (52.36%), and disinterest (49.03%). Dialysis staff ranked disinterest highest in New York and Ohio River Valley, and transportation challenges highest in the Southeast and New England. Transplant staff ranked anxiety/fear about the transplant process highest in New York, and lack of support highest elsewhere. Regionally tailored strategies are needed to improve access.

Aims: This study characterizes the diabetes burden across USA-Mexico border states (1990-2021) by examining current patterns, temporal trends, binational comparisons, and demographic variations. Methods: Using Global Burden of Disease 2021 estimates, we calculated age-standardized rates for mortality, prevalence, incidence, and DALYs. We applied joinpoint regression, age-period-cohort models, and decomposition analyses to characterize trends and identify drivers of burden change, comparing border versus non-border states within and between countries. Results: Border states showed 9-14% higher burden than non-border states. Despite similar prevalence (9,010 vs 8,298 per 100,000) and incidence (435 vs 426 per 100,000), Mexican border states had nearly five times higher mortality (67.2 vs 12.0 per 100,000) and three times higher DALYs (2,355 vs 896 per 100,000) than USA counterparts. YLLs comprised 64.3% of Mexican burden versus 31.4% in USA. From 1990-2021, USA border states showed rising incidence (+3.04% annually) with declining mortality (-1.28%), while Mexican states demonstrated stable-to-declining incidence (-0.15%) with plateauing mortality post-2009. Males experienced higher mortality in both countries. Conclusions: Diabetes occurrence has converged across the border, yet outcomes remain profoundly unequal. This demands coordinated binational surveillance and policy action. Focus on prevention in the US and diabetes care management in Mexico to reduce health disparities. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The authors received no funding from an external source. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The datasets generated and analyzed during the current study are available publicly as described in methods section.

Introduction:Pretransplant access varies, but whether pretransplant steps vary regionally across dialysis facilities remains unclear. Methods:We identified 62,467 adults (aged 18-80 years) referred from 2471 dialysis facilities and 27,171 initiating transplant evaluation from 2188 facilities in New England, New York, Southeast, and Ohio River Valley within the Early Steps to Transplant Access Registry (E-STAR) (January 1, 2015-December 31, 2023), linked with US Renal Data System (USRDS) and the Scientific Registry of Transplant Recipients data, followed-up through March 2, 2024. We examined dialysis facility-level proportions of evaluation start within 6 months of referral and waitlisting within 1 year of evaluation start. Descriptive statistics using analysis of variance and chi-square tests summarized outcome distributions and baseline characteristics within tertiles of outcome proportions, overall and by region. Results:Evaluation start within 6 months across 2471 facilities varied from 0% to 100%; median within-facility proportion was 50% (interquartile range: 33.3%-64.3%), ranging from 33.3% (18.2%-50%) in the Ohio River Valley to 66.7% (50%-76.7%) in New York. Waitlisting within 1 year of evaluation start varied from 0% to 100% across 2188 facilities; median within-facility proportion was 41.2% (26.0%-60%), lowest in the Southeast (31.9% [20%-43.8%]) and similar across other regions (50%). Facilities in the lowest tertile of evaluation start proportions (< 39.13%) more often treated patients from high-poverty neighborhoods (36.8% vs. 29.2%) and were for-profit (82.4% vs. 73.5%) than the highest tertile (> 58.33%). These characteristics varied by region. Facility-level clustering explained 12.2% (95% confidence interval [CI]: 10.5%-13.5%) of variation in evaluation and 8.2% (6.7%-9.2%) in waitlisting. Conclusion:Substantial regional variation in pretransplant access across dialysis facilities reinforces the need for region-specific strategies to improve access.

Key PointsAmong incident dialysis patients, women are more likely to die from infections or withdrawal, whereas men are more likely to die from cardiovascular disease or cancer.Young women (versus young men) are more likely to die from all causes, whereas older women (versus older men) are less likely to die from all causes.Black women are more likely to die from all causes compared with Black men.BackgroundWe examined sex differences in cause-specific mortality among men and women receiving maintenance dialysis and examined potential effect modification by age and race.MethodsWe identified all adults aged 18 years or older initiating dialysis between 2000 and 2020 from the United States Renal Data System (N=2.16 million; 43.3% women). Cause-specific mortality (i.e., cardiovascular disease [CVD], withdrawal, infection, and cancer) was defined from the US Centers for Medicare and Medicaid Death Notification Form. All individuals were followed from dialysis start date until death date, transplant date, 10 years, or end of follow-up (December 31, 2021), whichever occurred first. Multivariable Cox proportional hazards models assessed the association between sex and 10-year cause-specific mortality, adjusting for demographic, clinical, and socioeconomic factors overall and stratified by age and race.ResultsOverall, 832,259 men (67.9%) and 658,043 women (70.4%) died receiving maintenance dialysis with median survival times of 2.69 (interquartile range, 1.17-5.19) and 2.72 (interquartile range, 1.16-5.21) years, respectively. CVD was the leading cause of death (38.6% women and 40.2% men), followed by withdrawal (11.1% women and 9.6% men) and infections (9.8% women and 8.6% men). Overall, women had a 9% (adjusted hazard ratio, 1.09 [95% confidence interval, 1.08 to 1.11]) and 15% (1.15 [1.14 to 1.17]) higher likelihood of infection and withdrawal-related mortality compared with men, respectively. Conversely, women had a 7% (0.93 [0.92 to 0.94]) and 10% (0.90 [0.87 to 0.92]) lower likelihood of CVD and cancer-related mortality, respectively, compared with men. By age, younger women (versus men) aged 18-44 years had higher likelihood of excess mortality across all specific causes (including a 40% increased risk of withdrawal compared with men of the same age), whereas older women (versus men) older than 75 years had a lower likelihood. By race, non-Hispanic Black women (versus men) had higher mortality across all specific causes, but for all other races, sex differences were similar to the overall population.ConclusionsA sex-specific approach that incorporates intersectionality of both age and race in the management of complications among dialysis patients may be recommended to mitigate excess mortality risks.

Introduction: Individuals who initiate dialysis for kidney failure do so with different levels of preparedness. Whether this has downstream effects for access to kidney transplant is unknown. Methods: We identified adults (aged ≥ 18 years) initiating dialysis between 2015 and 2019 from the United States Renal Data System and followed-up with them until waitlisting, death, or end of follow-up (December 31, 2021), whichever occurred first. We grouped dialysis initiation context as follows: group 1 initiated peritoneal dialysis (PD) or hemodialysis (HD) with mature arteriovenous access (AVA), group 2 initiated HD with a catheter and maturing AVA, group 3 initiated HD with a catheter and without a maturing AVA, and group 4 lacked predialysis nephrology care. Fine-Gray subdistribution hazard models were used to assess the association between dialysis initiation context and waitlisting, adjusted for clinical and nonclinical factors, and stratified by age, sex, race, and insurance status. Results: Among 541,861 adults initiating dialysis, 26.9%, 14.9%, 29.8%, and 28.4% were in groups 1, 2, 3, and 4, respectively. Compared with group 1, individuals in groups 2, 3, and 4 were 40% (adjusted hazard ratio [aHR]: 0.60; 95% confidence interval [CI]: 0.59–0.62), 45% (aHR: 0.55 [95% CI: 0.54–0.56]) and 58% (aHR: 0.42 [95% CI: 0.41–0.43]) less likely to be waitlisted. The relative impact of no predialysis nephrology care was most pronounced among older, Black, female, and Medicare insured patients. Conclusion: A large proportion (∼60%) of adults in the US initiate dialysis with no AVA or predialysis nephrology care, with detrimental consequences for downstream transplant access.

Purpose of review The 2022 National Academies of Sciences, Engineering, and Medicine report highlighted inequities in access to kidney transplantation and called for a comprehensive dashboard highlighting early transplant steps, yet data on steps such as referral and evaluation start are limited. Addressing this gap is crucial for improving equity in access to transplantation. Recent findings The Early Steps to Transplant Access Registry (E-STAR) provides a model for how prewaitlisting data can be used to inform quality improvement to drive equity in access to transplantation. E-STAR includes data from 37 transplant centers across 13 states and four regions (Southeast, New York, New England, and the Ohio River Valley), representing ∼217 000 adults with end-stage kidney disease (ESKD) treated in 4365 dialysis facilities, in addition to patients preemptively referred. Similar to the Scientific Registry of Transplant Recipients center-specific reports, the E-STAR dashboard was developed as an interactive website offering center-specific and regional insights into pretransplant access measures within and across centers with the intention to improve access to transplantation. Publicly available de-identified reports illustrate trends in referral, evaluation, and waitlisting by subgroup (e.g., race, sex, age, insurance status), while password-protected features enable transplant centers to benchmark their performance against anonymized peers. Summary The E-STAR dashboard demonstrates how centralized, standardized data collection can support transplant centers, policymakers, community partners, and regional organizations to identify disparities, drive quality improvement, and develop interventions for the advancement of equity in transplant access. This work may inform future center-specific reports once prewaitlisting data are collected nationally.

Background:Transplant center processes for determining candidacy are complex, poorly documented, ambiguous, and variable across centers. Opaque and nonstandardized transplant processes can compromise data collection and lead to inconsistent outcomes. Methods:To understand process variation and data quality in transplantation, we surveyed 8 abdominal transplant centers in an existing research consortium about their processes of care for liver, kidney, and pancreas transplants. We used the Systems Engineering Initiative for Patient Safety model to identify variation related to people, tasks, tools, environment, and processes. Results:Centers varied in their processes across phases of transplant care, including screening referral, waitlist maintenance, and posttransplant follow-up. Regarding referrals, transplant centers chose their locations for outreach to and education for referring providers based on historical density or by request (63%). Additionally, screening of referred patients for transplant evaluation varied across centers related to screening method, screening timing/attempts, and who determines eligibility. For patients declined for listing, only 25% of centers had a formal appeal process (liver only), and most centers had either an informal appeal process (liver: 50%, kidney and pancreas: 87.5%) or none (liver: 25%, kidney and pancreas: 12.5%). Conclusions:In light of increased national attention to improving data collection, processes of care, and workforce efficiency, our findings provide insight into processes that may inform effective transplant practices and identify targets for future interventions.

RATIONALE & OBJECTIVE:Women with kidney failure have reduced access to kidney transplantation compared with men. We examined trends in sex inequities in access to transplantation over time. STUDY DESIGN:Retrospective cohort study. SETTING & PARTICIPANTS:2.3 million adults identified within the US Renal Data System, aged 18-79 years, who initiated kidney replacement therapy (KRT) between 1997 and 2020. EXPOSURE:Era of KRT (1997-2000, 2001-2004, 2005-2008, 2009-2012, 2013-2016, or 2017-2020), sex (male or female). OUTCOME:Placement onto the kidney transplant waitlist, or living-donor kidney transplant (LDKT) among all individuals initiating KRT, and deceased donor kidney transplantation (DDKT) among patients on the waitlist. ANALYTICAL APPROACH:Multivariable cause-specific hazard models to analyze the association between sex and placement onto the waitlist, LDKT, and DDKT, by era, overall, and by categories of age, race, and cause of kidney failure. RESULTS:Sex inequities in waitlisting became less pronounced over time. During 1997-2000 the adjusted HR comparing men with women was 0.81 (95% CI, 0.79-0.83); by 2017-2020, it had narrowed to 0.86 (95% CI, 0.85-0.87). For the outcome of LDKT, during 1997-2000, the adjusted HR comparing men with women was 0.89 (95% CI, 0.85-0.93) and by 2017-2020 had widened to 0.79 (95% CI, 0.76-0.82). For the outcome of DDKT, during 1997-2000, the adjusted HR comparing men with women was 0.92 (95% CI, 0.89-0.95) and by 2017-2020 had widened to 1.16 (95% CI, 1.14-1.19). Sex inequities in waitlisting and LDKT were greatest in women (vs men) with diabetes (27% and 37%, respectively, in 2017-2020) and older adults 60-79 years (24% and 34%, respectively, in 2017-2020), but were broadly similar across race groups. LIMITATIONS:Residual confounding; unknown true medical eligibility for transplant. CONCLUSIONS:Since 1997, sex inequities in waitlisting have improved but remain significant, especially for women who are older and who have diabetes-attributed kidney failure. Worsening sex inequities in LDKT among women and DDKT among waitlisted men warrant further study. PLAIN-LANGUAGE SUMMARY:Women with kidney failure have historically had poorer access to kidney transplantation than men. The goal of the current study was to see whether access to transplantation, defined as placement onto the transplant waitlist or living (LDKT) or deceased donor kidney transplantation (DDKT), has changed over time using national registry data from>2.3 million adults initiating kidney replacement therapy in the United States. Overall, this study showed that since 1997 sex inequities in placement on the transplant waitlist have improved but remain significant, especially for women who are older or have diabetes. Unfortunately, sex inequities in LDKT favoring men have worsened over time while declines in DDKT appear to have impacted men more than women. These findings have implications for the design of policies and interventions to improve transplant equity.

BACKGROUND:Incidence data on pediatric chronic kidney disease (CKD) is incomplete. We developed electronic health record (EHR)-based algorithms (e-phenotypes) to identify cases and provide incidence estimates of 5 leading causes of pediatric CKD. METHODS:E-Phenotypes using common standardized clinical terminology were built and contained utilization, diagnostic, procedural, age, and time-period inclusion and exclusion criteria for autosomal dominant polycystic kidney disease (ADPKD), Alport Syndrome (AS), congenital anomalies of the kidney and urinary tract (CAKUT), lupus nephritis (LN), and primary childhood nephrotic syndrome (NS). Cases diagnosed between 2014 and 2023 were identified from a pediatric healthcare system that is the sole pediatric nephrology provider serving the Atlanta Metropolitan Statistical Area (MSA). The performance of the e-phenotypes was tested using a cohort of 1,000 pediatric patients. Cases identified were used to estimate incidences using population information from the Georgia Department of Health. RESULTS:The e-phenotypes demonstrated sensitivity ranging from 0.83 to 0.95, specificity 0.96 to 1.00, PPV 0.81 to 1.00, and NPV 0.98 to 1.00. All positive likelihood ratios (LR) were >20 and negative LR < 0.20. The 6,814 combined cases of ADPKD (n=107), AS (n=31), CAKUT (n=6,120), LN (n=161), and NS (n=395) had an annual incidence of 47.07 (95% CI 45.96-48.20) per 100,000 children. Annual incidence per 100,000 children (95% CI) for each condition was: ADPKD 0.74 (0.61- 0.89), AS 0.21 (0.15-0.30), CAKUT 42.28 (41.22-43.35), LN 1.11 (0.95-1.30), and NS 2.73 (2.47-3.01). CONCLUSIONS:Our incidence estimates suggest CKD conditions are common among children. The e-phenotypes require validation for use at other institutions but offer opportunities to examine determinants of CKD detection, management, and outcomes.