Background. The impact of revised Organ Procurement and Transplantation Network policy defining eligibility for simultaneous liver-kidney (SLK) and the safety net criteria for kidney after liver (KAL) transplantation remains insufficiently characterized. Methods. We conducted a retrospective study of adults (>18 y) evaluated for liver transplant alone (LTA), SLK, or KAL at the University of Pennsylvania from August 10, 2017, to February 28, 2023. The primary outcome was mortality among SLK and KAL recipients and those patients waitlisted for KAL. Secondary outcomes included native kidney recovery in LTA recipients, estimated glomerular filtration rate (eGFR) at 1 y post-kidney transplant, and time between liver and kidney transplants. Results. Of 1655 patients evaluated, 57 (3.4%) met SLK criteria; 49 (86%) underwent SLK and 8 (14%) received LTA. Among 1598 LTA candidates, 1010 (63%) were waitlisted and 717 (71%) received LTA. After excluding 9 early deaths (1.3%) that were unrelated to KAL delay, 67 survivors (9.5%) met KAL safety net criteria. Thirty-four (50.8%) were waitlisted (15 transplanted over a median of 220 d), 30 (44.8%) declined, and 3 (4.8%) remained under evaluation. Mortality was 4.1% after SLK and no deaths occurred after KAL >3.7 and 3.1 y of follow-up, with 3 deaths (8.8%) among KAL waitlisted patients. Of the 16 KAL waitlisted patients alive without kidney transplant at last follow-up, 2 (12.5%) were delisted after documented renal recovery and an additional 9 (56.3%) had eGFR >20 ml/min/1.73 m2 and were being considered for delisting; together, 11 (68.8%) met predefined criteria for substantial native kidney recovery. One-year median eGFR was similar (SLK 51 versus KAL 54 mL/min/1.73 m2; P = 0.6). Conclusions. Early post-LTA mortality was unrelated to delayed KAL transplantation. Recovery of native kidney function while waiting for KAL was frequent. KAL transplants occurred within a year of LTA with favorable survival and graft outcomes.

With the expansion of solid organ transplantation activities in the United States, there is a critical need for more transplant care providers and trainees to sustain and advance the field of transplantation. However, there has been a pending shortage of trainees pursuing transplant fellowship training in the United States in recent years. To address this issue, the American Society of Transplantation (AST) organized the fellows' task force, including representatives of all 4 major organs from various AST communities of practice, to understand the drivers of this pending shortage and develop strategies to increase interest in transplant specialization. The task force identified 4 areas of focus, including early and sustained exposure to transplant medicine, awareness through education, flexible fellowships and pathways to transplant, and work-life resources. Based on these focus areas, the task force developed recommendations and action items, which were compiled into a report to be implemented by individuals, institutions, communities of practice (work groups), and societies such as the AST. We hope that this report will be the first step in overcoming barriers and concerns to encourage the pursuit of specialization in transplantation in the United States.

BACKGROUND:Prior studies indicate that 1% to 4% of Epstein-Barr virus (EBV)-seronegative recipients of EBV-seropositive donor (EBV D+/R-) kidneys develop posttransplant lymphoproliferative disorder (PTLD). However, these estimates are based on limited data that lack granularity. OBJECTIVE:To determine the associations between pretransplant EBV D+/R- and recipient EBV-seropositive status (R+) and the outcomes of PTLD and graft and patient survival among adult kidney transplant recipients. DESIGN:Retrospective cohort study. SETTING:Two large U.S. transplant centers. PARTICIPANTS:Epstein-Barr virus D+/R- and EBV R+ recipients matched 1:3 on donor, recipient, and transplant characteristics between 1 January 2010 and 30 June 2022. MEASUREMENTS:Exposure was pretransplant donor and recipient EBV serostatus. The primary outcome was biopsy-proven PTLD. Secondary outcomes were all-cause graft loss (death, retransplant, or graft failure) and death. Follow-up was truncated to 3 years after transplant. RESULTS:The final cohort comprised 104 EBV D+/R- recipients matched to 312 EBV R+ recipients. The mean age was 42 years (SD, 17.1), 59% were living donor transplants, and 95% received thymoglobulin induction. Among EBV D+/R- recipients, 50 (48.1%) developed EBV DNAemia, with a median time of 198 days (IQR, 110 to 282 days) after transplantation. Posttransplant lymphoproliferative disorder occurred in 23 (22.1%) EBV D+/R- recipients at a median of 202 days (IQR, 118 to 317 days) after transplantation. Epstein-Barr virus D+/R- recipients had higher all-cause graft failure (hazard ratio, 2.21 [95% CI, 1.06 to 4.63]); mortality was higher but not statistically significant (hazard ratio, 2.19 [CI, 0.94 to 5.13]). LIMITATION:Two-center study. CONCLUSION:Compared with previous studies, this study showed that EBV D+/R- kidney recipients face a 5- to 10-fold higher cumulative incidence of PTLD. Strategies to mitigate the PTLD risk are urgently needed. PRIMARY FUNDING SOURCE:National Institutes of Health.

Rationale & Objective: The Kidney Donor Risk Index (KDRI) is widely used to rank the quality of deceased-donor kidneys and is integrated into the U.S. kidney allograft allocation system. However, the KDRI has modest predictive accuracy for allograft survival, and recent revisions to the KDRI, which removed donor race and hepatitis C virus status, also revealed model calibration problems. This study aimed to evaluate novel approaches for predicting posttransplant allograft survival. Study Design: Retrospective cohort study using Organ Procurement and Transplantation Network data from May 1, 2007, through December 31, 2021. Predictors: (1) Donor demographic and clinical variables (established predictors); (2) longitudinal laboratory data from the donor's terminal hospitalization, such as serum creatinine (new predictors); and (3) recipient clinical variables (new predictors). Setting & Participants: 75,867 adult kidney recipients at U.S. centers. Outcomes: The primary outcome was time to all-cause allograft failure over 3 years. A secondary outcome was delayed graft function, defined as dialysis in the first week after the transplant. Analytical Approach: We implemented and compared machine-learning statistical models versus traditional modeling approaches (ie, proportional hazards for the primary outcome and logistic regression of the secondary outcome) that incorporated various combinations of predictors. The performance metrics used to assess discrimination were the integrated (time-dependent) area under the curve (AUC) for allograft survival and the AUC for delayed graft function. To assess calibration, we calculated Brier scores and visually compared the predicted outcomes with the observed ones. Predictive performance was assessed in a 20% testing data split. Results: Neither machine-learning models nor the addition of longitudinal laboratory data from the donor hospitalization to traditional models improved discrimination. For the primary outcome, the final model (named the Kidney Allograft Survival Index) used a proportional hazards modeling approach. Adding recipient variables improved model discrimination (integrated AUC, 0.68) and achieved excellent calibration for the overall cohort and subgroups. The final model for delayed allograft function used logistic regression, included recipient variables, and had an AUC of 0.75 with acceptable calibration. Limitations: No external validation. Conclusions: Improving the discrimination and calibration of kidney allograft survival prediction models is achievable by including recipient characteristics. These enhanced models have potential to improve the system of kidney allocation.

A working group under the Sensitization in Transplantation: Assessment of Risk initiative was established in 2023 to develop guidelines for analytical and clinical validity of lab-based testing for donor-derived cell-free DNA (dd-cfDNA). Measurement of dd-cfDNA as a minimally invasive marker of allograft injury has become more widely used over the last few years. To date, various technical and quantitation methods have hindered the standardization and interpretation of the results, leading to variability in understanding how to best utilize cell-free DNA in transplantation. Kits are being formulated for local laboratory testing, but we lack an organized framework for laboratory quality assurance. Further, threshold values and methods of measurement have changed over time, indicating that assay sensitivity and clinical relevance are still being refined. Harmonization and reproducibility will be critical as the field moves forward to local laboratory-based testing. The goal of this work group was to review and analyze technical and biological variables and clinical settings that could contribute to disparities in results, which will ultimately influence clinical validity and utility. High-quality, standardized decentralized dd-cfDNA testing is the essential prerequisite for conducting real-world evidence-generating multicenter studies to establish the appropriate context of use for this promising assay.

The expanding number of surviving kidney transplant patients, driven in part by federal initiatives to increase transplant access for patients with advanced CKD, has strained the capacity of the existing transplant nephrology workforce to manage longer-term posttransplant recipients. As patients are living longer with working allografts, the need for effective long-term management has become very important. This can only be achieved by closer collaboration between transplant centers and referring nephrologists. There is, therefore, a great need for closer involvement of referring nephrologists in providing care for this medically complex patient population, necessitating ongoing bidirectional communication with transplant centers. The American Society of Transplantation Kidney Pancreas Community of Practice organized a Controversies Conference in October 2022 to identify major challenges and propose guidance for collaborative, safe, and standardized care transitions and longitudinal management of this population. This article summarizes the key themes, strategies, and recommendations that emerged from the conference, offering a roadmap for enhancing collaborative care models and supporting a sustainable system to manage the evolving needs of this medically complex patient population.

BACKGROUND:The 2018 revision of the adult Heart Allocation Policy (aHAP) led to a notable increase in the rate of simultaneous heart-kidney transplants (SHKT) in the United States. However, this policy has faced criticism for its inability to enhance post-transplant survival rates or decrease mortality among SHKT recipients on the waitlist, although high-quality kidneys are used. METHODS:We analyzed data from the Organ Procurement and Transplantation Network, covering 1549 SHKT cases from 2015 to 2021. The study assessed 1-y post-transplant outcomes, including all-cause heart and kidney graft failures and adverse kidney outcomes such as end-stage kidney disease, significantly reduced kidney function or the need for retransplantation. Using a propensity score-matching approach, we compared 2 cohorts: patients treated before and after the policy implementation in October 2018. RESULTS:The multivariable Cox proportional hazard models indicated a significant increase in mortality (hazard ratio [HR] 1.62; 95% confidence interval [CI], 1.10-2.37) and all-cause graft failures for both heart (HR 1.59; 95% CI, 1.08-2.33) and kidney (HR 1.39; 95% CI, 1.03-1.85) during the period after the new aHAP implementation. One year post-transplant, the incidence of adverse kidney outcomes was 6.8% under the new aHAP compared with 5.3% in the previous period among survivors ( P = 0.33). CONCLUSIONS:The suboptimal outcomes of SHKT under the new aHAP, alongside its potential impacts on kidney-alone transplant candidates, suggest a need for regular monitoring of SHKT policies. This is crucial to ensure that the intentions of the Final Rule regarding equity and utility are effectively met.

BACKGROUND:Several studies have suggested an increased risk of cytomegalovirus (CMV) viremia among Hepatitis C virus (HCV)-uninfected recipients of kidney transplants from HCV-RNA+ deceased donors (HCV D+/R-), but these studies featured small sample sizes and limited ability to address confounding variables. METHODS:We assembled a retrospective cohort of adult kidney transplant recipients at five US centers between 4/1/2015 and 12/31/2020 to determine the association between HCV D+/R- transplants and the outcomes of CMV viremia (> 1000 IU/mL), death-censored graft failure, and mortality in the first posttransplant year compared to HCV D-/R- transplants. We generated highly similar matched cohorts of HCV D+/R- and HCV D-/R- recipients based on attributes that affect the risk of CMV viremia. We matched exactly on center, CMV donor/recipient serostatus, and antibody induction therapy. RESULTS:The cohort comprised 275 HCV D+/R- recipients with a mean age of 52.5 years (SD = 10.7); 19% were CMV D+/R-, and 74% received anti-thymocyte globulin induction. With variable ratio matching, 267 HCV D+/R- recipients were matched to 996 HCV D-/R- recipients. CMV viremia occurred in 15% of HCV D+/R- and 11% of HCV D-R- recipients. In Cox regression, transplantation with an HCV-RNA+ donor kidney was not associated with a significantly higher risk of CMV viremia (HR 1.3, 95% CI 0.89-1.92) or death-censored graft loss (HR 0.61, 95% CI 0.31-1.2). CONCLUSION:The risk of CMV viremia was not significantly increased among HCV D+/R- kidney recipients. Future studies should examine associations between donor-derived HCV infection and clinical outcomes of CMV syndrome and disease.

The use of single-cell RNA sequencing in clinical and translational research is limited by the challenge of identifying cell-type-specific, targetable molecular changes in individual patients and cross-species differences. Here we created an integrated single-cell kidney atlas including over 1 million cells from 140 samples, defining more than 70 conserved cell states in human and rodent models. We developed CellSpectra, a computational tool that quantifies changes in gene expression coordination across cellular functions, which we applied to kidney and lung cancer data. This tool powers our patient-level single-cell functional profiling report, which highlights cell-type-specific changes in the coordination of pathway gene expression in individuals. Our cross-species atlas facilitates the selection of a rodent model that closely reflects the cellular and pathway-level signatures observed in patient samples, advancing the application of single-cell methodologies in clinical precision medicine. Finally, using experimental models, we demonstrate how our informatics approach can be applied for the potential selection of suitable therapeutics.

Prior studies indicate that 1% to 4% of Epstein-Barr virus (EBV)-seronegative recipients of EBV-seropositive donor (EBV D+/R-) kidneys develop posttransplant lymphoproliferative disorder (PTLD). However, these estimates are based on limited data that lack granularity. To determine the associations between pretransplant EBV D+/R- and recipient EBV-seropositive status (R+) and the outcomes of PTLD and graft and patient survival among adult kidney transplant recipients. Retrospective cohort study. Two large U.S. transplant centers. Epstein-Barr virus D+/R- and EBV R+ recipients matched 1:3 on donor, recipient, and transplant characteristics between 1 January 2010 and 30 June 2022. Exposure was pretransplant donor and recipient EBV serostatus. The primary outcome was biopsy-proven PTLD. Secondary outcomes were all-cause graft loss (death, retransplant, or graft failure) and death. Follow-up was truncated to 3 years after transplant. The final cohort comprised 104 EBV D+/R- recipients matched to 312 EBV R+ recipients. The mean age was 42 years (SD, 17.1), 59% were living donor transplants, and 95% received thymoglobulin induction. Among EBV D+/R- recipients, 50 (48.1%) developed EBV DNAemia, with a median time of 198 days (IQR, 110 to 282 days) after transplantation. Posttransplant lymphoproliferative disorder occurred in 23 (22.1%) EBV D+/R- recipients at a median of 202 days (IQR, 118 to 317 days) after transplantation. Epstein-Barr virus D+/R- recipients had higher all-cause graft failure (hazard ratio, 2.21 [95% CI, 1.06 to 4.63]); mortality was higher but not statistically significant (hazard ratio, 2.19 [CI, 0.94 to 5.13]). Two-center study. Compared with previous studies, this study showed that EBV D+/R- kidney recipients face a 5- to 10-fold higher cumulative incidence of PTLD. Strategies to mitigate the PTLD risk are urgently needed. National Institutes of Health.

Kidney transplantation improves patients' quality of life, morbidity, and mortality and reduces health care costs.1Concepcion B.P. Alasfar S. Levea S.L. Singh P. Wiseman A. The transplant nephrology workforce in the United States: current state and future directions.Adv Chronic Kidney Dis. 2020; 27: 336-343.e1https://doi.org/10.1053/j.ackd.2020.05.005Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Per the United Network of Organ Sharing, 25,000 kidney transplants were performed in 2022 in the United States. Announced in 2019, the Advancing American Kidney Health Initiative aims to double kidney transplants over the subsequent 10 years.2US Department of Health and Human ServicesAdvancing American Kidney Health.https://aspe.hhs.gov/system/files/pdf/262046/AdvancingAmericanKidneyHealth.pdfDate accessed: February 28, 2023Google Scholar With the expected increase in transplant volumes and increasing medical complexity of kidney candidates and recipients, we are faced with the continuing challenge of training highly qualified and competent transplant nephrologists. There has been an anecdotal, poorly understood decline in kidney transplant fellowship (KTF) applications over the last several years. To assess the characteristics of KTF applications from 2017 to 2022, an anonymous survey was sent to program directors of 62 of the 63 AST-accredited US KTF programs, excluding our own (Item S1). Two reminder emails were sent, and responses were collected over a 5-week period. This study was approved by the University of Pennsylvania Institutional Review Board (IRB# 852753). Responses were received from 54% of training programs surveyed (n = 34). Of these, 65% were from established programs (>10 years old, n = 22), 58% were large-volume transplant centers (>200 kidney transplants annually, n = 20). Respondents were distributed in the Northeast (n = 7), Midwest (n = 9), West Coast (n = 8), and South/Southeast (n = 9) (Fig S1). Most (74%, n = 25) have 1 fellowship position annually; the remainder have 2. Between 2017 and 2022, most respondents (62%, n = 21) did not fill their fellowship spot(s) at least once, while 31% (n = 14) did not fill at least twice (Table 1). There was no clear relationship between programs sponsoring fellow training visas and unfilled spots, though 9 of these programs started sponsorship within 2017-2022. Two programs exclusively accepted fellows who were US medical graduates; both went unfilled at least twice in the last 5 years. This is unsurprising, as 55%-65% of all matched nephrology fellows (and thus potential KTF candidates) in the last few years are international medical graduates.3Pivert K.A. 2021. AY 2022 Match.https://data.asn-online.org/posts/ay_2022_matchDate accessed: February 28, 2023Google Scholar Funding for KTFs was most frequently provided by the hospital's transplant program (50%, n = 17); other sources included some combination of renal division support, revenue generated from transplant fellows' being hired as instructors and billing for their services, philanthropy, and industry/grants.Table 1Program Characteristics and Frequency of Unfilled Positions From 2017 to 2022Always FilledDid Not Fill OnceDid Not Fill TwiceDid Not Fill >2×Geographic area Northeast4210 Midwest2142 West Coast2221 South/Southeast2240Age of program <5 years2010 5-9 years1151 10-15 years2510 >15 years4042Size of program One fellowship spot7493 Two fellowship spots2320Visa acceptance Accepts J1 only4100 Accepts J1 and H1B2572 No visas offered3131Programs accepting US grads only0011Total respondents = 34. (Note that 5 respondents did not answer the survey question regarding number of unfilled positions in the last 5 years.) Open table in a new tab Total respondents = 34. (Note that 5 respondents did not answer the survey question regarding number of unfilled positions in the last 5 years.) Figure 1 and Table S1 show survey respondents' ranking of strategies to increase interest in transplant fellowship. Respondents frequently cited that there needs to be an increased transplant exposure in medical school education and developing 3- or 4-year early pathway programs for those with early interests in transplant. Although prior surveys to transplant nephrologists have shown that they feel financially undercompensated,4Chonchol M. Gutierrez O.M. Rahman M. Charytan D.M. Rosner M. Transplant nephrology.Clin J Am Soc Nephrol. 2022; 17: 1272-1274https://doi.org/10.2215/CJN.08710722Crossref PubMed Scopus (1) Google Scholar, 5Singh N. Doshi M.D. Schold J.D. et al.Survey of salary and job satisfaction of transplant nephrologists in the United States.Clin J Am Soc Nephrol. 2022; 17: 1372-1381https://doi.org/10.2215/CJN.03490322Crossref PubMed Scopus (3) Google Scholar, 6Heher E.C. Hricik D.E. Brennan D.C. Securing the future of kidney transplantation by addressing the challenges of transplant nephrology.Am J Transplant. 2021; 21: 37-43https://doi.org/10.1111/ajt.16264Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar our survey showed a bimodal distribution in how important respondents think increasing compensation would be in building KTF interest: 38% (n = 13) of respondents deemed it 1 of the 2 most important strategies, while 41% (n = 14) deemed it 1 of the 2 least important strategies. This warrants further investigation, especially given the discrepancy from prior survey results. It may be that practicing transplant nephrologists feel overall undercompensated, but that program directors are split on whether this impacts recruitment efforts and interest in the field. Respondents could provide free-text comments regarding strategies to promote interest in transplant fellowships. Some suggested that before interest in transplant nephrology can be built, an increased interest in general nephrology needs to be fostered. Since the field joined the National Resident Matching Program in 2009, there has been a precipitous decline in the number of general nephrology fellowship applications, with the number of filled nephrology fellowship positions dropping by >30% in 2016, though this has since shown a reversing trend.3Pivert K.A. 2021. AY 2022 Match.https://data.asn-online.org/posts/ay_2022_matchDate accessed: February 28, 2023Google Scholar,7Cheng S.C. Pivert K.A. Sozio S.M. "Make me a match": all-in and other trends in the nephrology match.Clin J Am Soc Nephrol. 2022; 17: 1691-1693https://doi.org/10.2215/CJN.04450422Crossref PubMed Scopus (1) Google Scholar,8Moe S.M. Brennan D.C. Doshi M.D. et al.The importance of transplant nephrology to a successful kidney transplant program.Clin J Am Soc Nephrol. 2022; 17: 1403-1406https://doi.org/10.2215/CJN.02000222Crossref PubMed Scopus (4) Google Scholar One respondent felt the salary for the fellowship year itself should be increased; another thought KTF should be ACGME (Accreditation Council for Graduate Medical Education) accredited. There may be advantages to ACGME accreditation, including a tracking mechanism for KTF applications, standardization of KTF training and assessment, and, possibly, a pathway for government funding similar to other graduate medical education programs. There are limitations to our study. First, despite a 50% response rate from programs representing all regions of the country, our sample size remained small, precluding us from performing statistical comparisons. Second, although transplant nephrology fellowship program directors offer unique and invaluable insights to declining KTF interest, understanding the perspective of nephrology fellows and general medicine residents would be just as, if not more, important. Despite these limitations, this is a first step in trying to understand the decline in KTF applications in an area where no data exist. With the current shortage of transplant nephrologists6Heher E.C. Hricik D.E. Brennan D.C. Securing the future of kidney transplantation by addressing the challenges of transplant nephrology.Am J Transplant. 2021; 21: 37-43https://doi.org/10.1111/ajt.16264Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,8Moe S.M. Brennan D.C. Doshi M.D. et al.The importance of transplant nephrology to a successful kidney transplant program.Clin J Am Soc Nephrol. 2022; 17: 1403-1406https://doi.org/10.2215/CJN.02000222Crossref PubMed Scopus (4) Google Scholar and the rising number of evaluations, waitlistings, and kidney transplants, we may be facing a crisis in the very near future. It may behoove the American Society of Transplantation and the American Society of Nephrology to create a combined task force to understand the root cause of the decline in applications, explore strategies to increase interest, and investigate the benefits and feasibility of ACGME accreditation for transplant nephrology. Survey design: all authors. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual's own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature if appropriate. None. Dr Potluri is supported by a Career Development Award from the National Institute of Diabetes, Digestive and Kidney Diseases (K08 DK127250). Dr Bloom receives research support from Veloxis, CSL Behring, CareDx, and Natera. He receives royalties from UpToDate, serves as an advisor for Paladin and Nephrosant, and serves as a consultant for Veloxis. The other authors declare that they have no relevant financial interests. RB is on the editorial board of AJKD. Received April 26, 2023. Evaluated by 3 external peer reviewers, with editorial input from an Acting Editor-in-Chief (Editorial Board Member Michelle M. Estrella, MD). Accepted in revised form June 30, 2023. The involvement of an Acting Editor-in-Chief to handle the peer-review and decision-making processes was to comply with AJKD's procedures for potential conflicts of interest for editors, described in the Information for Authors & Journal Policies. Download .pdf (.25 MB) Help with pdf files Supplementary File (PDF)Figure S1, Item S1, Table S1.

Introduction: Medication education and adherence assessments are integral to kidney transplant success. This program evaluation aimed to describe candidate-reported findings using a standardized medication adherence assessment in candidates undergoing living-donor kidney transplantation. Design: This was a single-center retrospective description of medication adherence on adult HIV-negative living-donor candidates from July 1, 2018 to December 1, 2018 who had ≥6 months post-operative follow-up. Medication adherence assessments were performed by a pharmacist at the pre-operative visit within 2 weeks prior to transplant. Candidates were considered to (a) have adherence concerns if they reported missed/late medications within 2 weeks of assessment or ever stopped a medication without medical advice and (b) considered using adherence strategies if they reported active use of pill box, method to keep track of refills/auto-refill use, medication list, or medication reminder(s). Missed medication data were collected at 3- and 6-months posttransplant. Results: Among 181 candidates included, 81 (45%) had adherence concerns and 169 (93%) reported using adherence strategies. There were no significant differences with adherence concerns by age ≤ 29 years, sex, race, prior transplant/dialysis, or less than a high school education. More candidates with greater than a high school education used adherence strategies (96% vs 86%, P = .002). Too few candidates had documentation on missing medications at 3 and 6 months. Conclusions: Over 40% of candidates reported characteristics concerning medication nonadherence despite over 90% reporting adherence strategies used. Medication adherence assessments can assist with identification of medication nonadherence and education individualization.

BACKGROUND AND OBJECTIVES:We conducted a national survey to assess the opinions and experiences of transplant center staff related to processes of care graduation. METHODS:Following IRB approval, medical staff at U.S. adult kidney transplant programs were surveyed using the Qualtrics survey platform (4/5/2022-10/05/2022). Respondents were invited via email and listservs of professional societies. If > 1 survey was submitted for a program, a selection hierarchy was utilized (e.g., prioritizing nephrologists' responses). RESULTS:Respondents provided data from 46.7% of active programs (N = 92), representing 67% of the national kidney transplant volume. Most respondents (70%) were nephrologists. Full graduation to referring nephrologists was reported by 39% of transplant programs, with an additional 48% reporting partial graduation with ongoing co-management. Rationales for graduation were multifactorial, most commonly including patient travel distance (64%), maintenance of referral base (58%), continuity of care (58%), and center and/or patient burden (54%). Common reasons cited by programs for postgraduation return of care to the transplant center included worsening renal function (82%), malignancy (66%), opportunistic infection (63%), limited local nephrologist availability (60%), and pregnancy planning (57%). Additional coordinators and clinic staff were cited as needed to make transplant center perpetual care feasible by 78% of programs, with 71% stating that more clinicians are needed, while half thought more physical space or telemedicine are required. CONCLUSIONS:Graduation of kidney transplant patients is common, with half of programs using a joint-care approach and another third reporting full return of care to the referring nephrologist. Expanded opportunities related to transplant care for the broad nephrology community are essential.