Impact of the Kidney Allocation Revision on Access to Kidney Transplantation and Outcomes in the United States.

BACKGROUND: The 2014 Kidney Allocation System (KAS) revision aimed to enhance equity in organ allocation and improve patient outcomes. This study assesses the impacts of the KAS revision on renal transplantation demographics and outcomes in the United States. METHODS: We conducted a retrospective study utilizing the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) database from 1998 to 2022. We compared recipient and donor characteristics, and outcomes (graft failure and recipient survival) pre- and post-KAS revision. RESULTS: Post-KAS, recipients were significantly older (53 vs 48, P < .001) with an increase in Medicaid beneficiaries (7.3% vs 5.5%, P < .001). Despite increased graft survival, HR = .91 (95% CI 0.80-.92, P < .001), overall recipient survival decreased, HR = 1.06 (95% CI 1.04-1.09, P < .001). KAS revision led to greater racial diversity among recipients and donors, enhancing equity in organ allocation. However, disparities persist in graft failure rates and recipient survival across racial groups. DISCUSSION: The 2014 Kidney Allocation System revision has led to important changes in the renal transplantation landscape. While progress has been made towards increasing racial equity in organ allocation, further refinements are needed to address ongoing disparities. Recognizing the changing patient profiles and socio-economic factors will be crucial in shaping future policy modifications.

Dismantling structural racism as a root cause of racial disparities in COVID-19 and transplantation.

As the United States faces unparalleled challenges due to COVID-19, racial disparities in health and healthcare have once again taken center stage. If effective interventions to address racial disparities in transplantation, including those magnified by COVID-19, are to be designed and implemented at the national level, it is first critical to understand the complex mechanisms by which structural, institutional, interpersonal, and internalized racism influence the presence of racial disparities in healthcare and transplantation. Specifically, we must deeply re-evaluate how scientists and clinicians think about race in the transplant context, and we must actively shift our efforts from merely observing disparities to acknowledging and acting on racism as a root cause underlying the vast majority of these disparities. We must do better to ensure equitable access and outcomes for all transplant patients, including within the current COVID-19 pandemic. We respectfully offer this viewpoint as a call to action to every reader to join us in working together to help dismantle racist influences and advance transplant equity.

Influence of Spirituality on Depression-Induced Inflammation and Executive Functioning in a Community Sample of African Americans.

African Americans (AAs) are disproportionately affected by cerebrovascular pathology and more likely to suffer from premature cognitive decline. Depression is a risk factor for poorer cognitive functioning, and research is needed to identify factors that serve to mitigate its negative effects. Studies have demonstrated positive influences of spirituality within the AA community. Determining whether spirituality attenuates the effects of depressive symptoms on cognitive functioning and the pathophysiological mechanisms that explain these relationships in AAs is paramount. This study examines the influence of daily spiritual experiences on the relationship between depressive symptoms and cognitive functioning, and how inflammatory markers may partially explain these associations. A sample of 212 (mean age= 45.6) participants completed the Daily Spiritual Experience Scale (DSES), Beck Depression Inventory-II (BDI-II), Trail Making Test A and B (TMT) and Stroop Color and Word Test (Stroop). Blood samples were collected to measure inflammatory mediators (IL-6, IL-1a, TNF-a). Linear regression analyses were used to evaluate associations. Higher BDI-II scores were associated with poorer psychomotor speed and visual scanning, measured by TMT A (B=1.49, P=.01). IL-6 explained a significant amount of variance in this relationship (B=.24, CI 95% [.00, .64]). IL-6 also significantly mediated the relationship between depressive symptoms and psychomotor speed and mental flexibility, measured by TMT B performance (B=.03, CI 95% [.003, .095]). Frequent spiritual experiences among AAs may ameliorate the negative influence of depressive symptoms on cognitive functioning.

Morbid obesity is an independent risk factor for postoperative renal dysfunction in young adults: a review of the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Little information exists on the acute effects of elective surgery on renal function. Our aim was to determine if obesity was an independent risk factor for postoperative renal complications (RCs). METHODS: A total of 119,142 patients aged 18 to 35 years with body mass index (BMI) ≥18 kg/m(2) obtained from American College of Surgeons National Surgical Quality Improvement Project (2005 to 2010) were classified into standard BMI categories. Association between BMI and preoperative estimated glomerular filtration rate (eGFR; calculated using modification of diet in renal disease formula) was analyzed. Postoperative changes in eGFR and RCs were measured. Multivariate regression analysis was performed adjusting for all variables. RESULTS: Postoperatively, there was a reduction in eGFR among the overweight (-3.4 mL/min/1.73 m(2), P < .001), obese class I (-3.9 mL/min/1.73 m(2), P = .001), and obese class II (-5.3 mL/min/1.73 m(2), P < .001). The odds of any postoperative RC was significantly higher in obese class III patients (odds ratio = 2.01 95% confidence interval 1.07 to 3.76, P = .029). CONCLUSIONS: Results seen in patients with BMI greater than 40 indicate that BMI can serve as an independent predictor of RCs.

Geographic Variation in Cold Ischemia Time: Kidney vs. Liver Transplantation in the United States, 2003-2011.

BACKGROUND: Regional variations in kidney and liver transplant outcomes have been reported, but their causes remain largely unknown. This study investigated variations in kidney and liver cold ischemia times (CITs) across Organ Procurement Organizations (OPO) as potential causes of variations in transplant outcomes. METHODS: This retrospective study analyzed the Standard Transplant Analysis and Research (STAR) data of deceased donor kidney (n=61,335) and liver (n=39,285) transplants performed between 2003 and 2011. CIT variations between the two types of organs were examined and compared. Factors associated with CIT were explored using multivariable regressions. Spearman's rank tests were used to associate CIT with graft failure at the OPO level. RESULTS: Significant CIT variations were found across OPOs for both organs (p < 0.05). The variation was particularly large for kidney CIT. Those OPOs with longer average kidney CIT were likely to have a lower graft survival rate (p=0.01). For liver, this association was insignificant (p=0.23). The regression analysis revealed sharp contrasts between the factors associated with kidney and liver CITs. High risk kidney transplant recipients and marginal kidneys were associated with longer average CIT. The reverse was true for liver transplants. CONCLUSIONS: Large variations in kidney CIT compared to liver CIT may indicate that there is a room to reduce kidney CIT. Reducing kidney CIT through managerial improvements could be a cost effective way to improve the current transplant system.

The Combined Influence of Psychological Factors on Biomarkers of Renal Functioning in African Americans.

OBJECTIVE: African Americans are disproportionately affected by chronic kidney disease (CKD). Recent research has documented that psychological-factors have a significant influence on the progression and treatment of CKD. However, extant evidence exists that has examined the link between psychological factors and renal function in African Americans. The purpose of the study was to determine if psychological factors were associated with several biomarkers of renal functioning in this group. PARTICIPANTS: 129 African American participants, with a mean age of 44.4 years (SD = 12.25). DESIGN AND SETTING: Data were analyzed from a cross-sectional study entitled Stress and Psychoneuroimmunological Factors in Renal Health and Disease. MAIN PREDICTOR MEASURES: Participants completed the Beck Depression Inventory-II, Cook Medley Scale, and Perceived Stress Scale-10. MAIN OUTCOME MEASURES: Systolic blood pressure, as well as blood and urine samples, were collected and served as biomarkers of renal functioning. RESULTS: Our findings indicated that psychological factors were not associated with renal functioning. Age, sex, and systolic blood pressure emerged as significant predictors of renal functioning. CONCLUSIONS: Depressive symptomatology, perceived stress, and hostility did not influence renal functioning in this sample. This unexpected finding may be attributed to the fact that this sample population was not elevated on depressive symptoms, perceived stress, or hostility. Elevated levels of these psychological factors, as well as other psychological factors associated with the CKD, may be more influential on renal functioning in African Americans.

Depressive symptomatology and respiratory sinus arrhythmia in a non-clinical sample of middle-aged African Americans.

Decreased heart rate variability and depression are both independent risk factors for cardiac mortality in clinical and non-clinical samples. The purpose of the current study is to examine the hypothesis that severity of depressive symptomatology is inversely associated with respiratory sinus arrhythmia (RSA) in a non-clinical sample of African Americans. The sample included 77 African Americans with a mean age of 48.4 (SD = 11.7). Participants completed the Beck Depression Inventory-II (BDI-II) and a 5-min resting baseline measurement of RSA was collected. The BDI-II total score was positively associated with RSA (ß = .334, p = .008). Given the unexpected direction of the association, we separated the BDI-II into cognitive and somatic affective subscales to identify which construct was driving the relationship. The somatic affective, was related to RSA (ß = .328, p = .010), but not the cognitive subscale. Given this unexpected positive result, future research should further examine the nature of the relationship between depressive symptomatology and RSA in African Americans, as the relationship may vary based on levels of depressive symptomatology.

Executive function and negative eating behaviors in severely obese African Americans.

OBJECTIVE: African Americans are disparately impacted by severe obesity. Low socioeconomic status and psychosocial risk factors help to explain this disparity; however, few studies have examined the role of negative eating behaviors or the influence of executive function on negative eating behaviors in this population. The objective was to examine the association between executive function (ie, inhibition and set shifting) and negative eating behaviors in severely obese African Americans. PARTICIPANTS: Forty-seven African Americans who met criteria for severe obesity participated. DESIGN AND SETTING: Data were analyzed from a cross-sectional study entitled Stress and Psychoneuroimmunological Factors in Renal Health and Disease. The mean age of participants was 45.7 years (SD = 10.8) and the mean educational attainment was 13 years (SD = 2.1). MAIN OUTCOME MEASURES: Participants completed the Wisconsin Card Sorting Task, the Stroop Color-Word Test, and the Eating Behavior Patterns Questionnaire. RESULTS: Correlation results suggested poorer inhibition was associated with greater self-reported emotional eating and snacking on sweets. Subsequent hierarchical regression analyses confirmed the inverse relations between inhibition, emotional eating, and snacking on sweets, after controlling for age, sex, years of education, and depression. CONCLUSIONS: Reduced inhibition may be an important risk factor for negative eating behaviors and subsequent obesity in this population. Interventions aimed at increasing inhibition and self-regulation in this at-risk group are warranted.

Dispositional depression and hostility are associated with inflammatory markers of cardiovascular disease in African Americans.

Prior research has demonstrated that state depressive symptoms and hostility can modulate inflammatory immune responses and directly contribute to cardiovascular disease (CVD) onset and development. Previous studies have not considered the contribution of dispositional depressive symptoms to the inflammatory process. They have also largely excluded African Americans, despite their disproportionate risk for CVD. The first aim of the study was to examine the impact of state and dispositional depression and hostility on CVD-associated inflammatory biomarkers interleukin-6 (IL-6) and C-reactive protein (CRP) in an African American sample. The second aim was to examine synergistic influences of hostility and state and dispositional depression on IL-6 and CRP. The final aim was to examine whether the relations between state and dispositional depression, hostility, IL-6, and CRP varied as a function of gender and education. Anthropometric measures, blood serum samples, and psychosocial data were collected from 198 African Americans from the Washington, DC metropolitan area. Hierarchical and stepwise regression analyses indicated that (1) increased levels of hostility were associated with increased levels of CRP; (2) hostility and IL-6 were more strongly associated among participants with lower educational attainment; and (3) dispositional depression and CRP were more strongly associated among participants with greater hostility and lower educational attainment. Findings suggest that enduring personality dispositions, such as dispositional depression and hostility, are critical to a thorough assessment of cardiovascular profiles in African Americans. Future studies should investigate causal pathways that link depressive and hostile personality styles to inflammatory activity for African American men and women.

Psychometric properties of the Cook Medley hostility scale and its association with inflammatory markers in African Americans.

Dispositional hostility as measured by the Cook Medley Hostility (Ho) Scale has been associated with inflammation and cardiovascular disease (CVD) risk. There is evidence that suggests that factors of hostility are more useful in predicting poor cardiovascular health outcomes than a single hostility construct. The purpose of this study was to investigate the latent factors of hostility and their association with inflammatory markers interleukin-6 (IL-6) and C-reactive protein (CRP) in an African-American community sample. This racial/ethnic group has been largely excluded from this line of research despite their disproportionate burden of CVD and its risk factors. Blood samples for plasma IL-6 and CRP were collected on the same day the Ho Scale was administered. Plasma IL-6 and CRP levels were determined using enzymatic-linked immunosorbent assay. Confirmatory factor analysis revealed three latent main factors of hostility: Neuroticism, Manichaeism and Moral Primitiveness, and seven intermediary subfactors. Of the subfactors, hostile affect was significantly associated with greater CRP levels and predatory self interest was significantly associated with greater IL-6 levels. Findings suggest that African Americans have a unique pattern of hostility and two latent subfactors are associated with a marker of CVD. Based on the findings, future studies should aim to further delineate how hostility influences health outcomes in African Americans.

The influence of coping with perceived racism and stress on lipid levels in African Americans.

BACKGROUND: Lipid dysregulation is a major contributor to cardiovascular disease (CVD) risk and is attributed to numerous biological, psychosocial, and behavioral risk factors. Psychological stress has been examined as a predictor of lipid dysregulation; however, the role of coping with perceived racism, a stressor unique to the African American experience, has not been addressed. The current study sought to determine the impact of behavioral coping responses to perceived racism and perceived daily stress on lipid levels in African Americans. METHODS: The sample consisted of 122 African American participants who resided in the Washington, DC, metropolitan area. Data were collected as part of an ongoing study entitled Stress and Psychoneuroimmunological Factors in Renal Health and Disease at Howard University Hospital. RESULTS: Through canonical analysis, distinct profiles of African American lipid function emerged with body mass index, age, and behavioral coping responses to perceived racism being associated with high-density lipoprotein cholesterol (HDL-C), triglycerides, and low-density lipoprotein cholesterol (LDL-C), respectively. Results from linear regression analyses showed that greater endorsement of behavioral coping responses to perceived racism items predicted higher levels of LDL (B = .24, p < .05). This relationship was not mediated by pathophysiological mechanisms associated with the stress response system such as cortisol, norepinephrine, epinephrine, and IL-6. CONCLUSION: The relationship between elevated levels of LDL and behavioral coping responses to perceived racism suggests that African Americans may be at increased risk for CVD due to the unique stress encountered by racism in our culture. Behavioral pathways used to counteract the negative effects of perceived discrimination may better explain this relationship. Further research is necessary to determine other biobehavioral and pathophysiological mechanisms that explain this relationship.

Coping with perceived racism: a significant factor in the development of obesity in African American women?

BACKGROUND: African American women have the highest rates of obesity in the United States. The prevalence of obesity in this group calls for the identification of psychosocial factors that increase risk. Psychological stress has been associated with obesity in women; however, there is scant literature that has explored the impact of racism on body mass index (BMI) in African American women. OBJECTIVE: The current study aimed to determine whether emotional responses and behavioral coping responses to perceived racism were associated with BMI in African American women. METHODS: A sample of 110 African American women participated in a community-based study. Height and weight measurements were taken to calculate BMI and participants completed the Perceived Racism Scale and the Perceived Stress Scale. RESULTS: Hierarchical regression analyses demonstrated a significant relationship between BMI and behavioral coping responses to perceived racism. Findings for emotional responses to perceived racism and appraisal of one's daily life as stressful were nonsignificant. Mean comparisons of BMI groups showed that obese African American women used more behavioral coping responses to perceived racism as compared to normal-weight and overweight women in the sample. CONCLUSION: Findings suggest that behavioral coping responses better explained increased risk for obesity in African American women. A biobehavioral pathway may explain this finding with a stress-response process that includes cortisol reactivity. Maladaptive behavioral coping responses may also provide insight into obesity risk. Future research is needed to determine which behavioral coping responses place African American women at greater risk for obesity.

The influence of functional social support on executive functioning in middle-aged African Americans.

Social support has a positive influence on cognitive functioning and buffers cognitive decline in older adults. This study examined the relations between social support and executive functioning in middle-aged adults. A community-based sample of African Americans completed the Interpersonal Support Evaluation List, a measure of functions of social support, and two measures of executive functioning, the Stroop Color and Word Test and the Wisconsin Card Sorting Test (WCST). Hierarchical regression analyses were used to explore the hypothesis that different facets of perceived social support influence performance on measures of executive functioning. After controlling for age, gender, and education, social support facets including belonging support, self-esteem support, appraisal support, and tangible support were significant predictors of Stroop performance. In addition, tangible support significantly predicted WCST performance. These findings add to previous literature on social support and cognition; however, findings for middle-aged adults are unique and suggest that social support has a positive influence on some executive functions in African Americans prior to old age.

A patient-centric, provider-assisted diabetes telehealth self-management intervention for urban minorities.

This article describes the design and implementation of an online diabetes self-management intervention for a sample of inner-city African Americans with diabetes. Study participants were randomly assigned to the treatment (26) and control (21) conditions. The results indicate that treatment group participants were more likely to achieve positive outcomes in terms of lowered hemoglobin A1c and body mass index measurements than were control group members. These findings support the development of telehealth interventions to promote effective chronic disease management in medically underserved communities.

Minority organ donation: the power of an educated community.

BACKGROUND: In 1978 in Washington, DC, we became aware of the scarcity of minority donors, especially African Americans. STUDY DESIGN: From then until now, 4 decades later, we have been involved in a grass roots effort emphasizing community education and empowerment combined with the use of mass media, which has increased minority donation rates exponentially. This program was initiated with a $500 grant from Howard University and was subsequently funded by National Institutes of Health grants and other funding totaling more than $10 million between 1993 and 2008. RESULTS: Between 1990 and 2008, minority donations percentages have doubled (15% to 30%). African-American organ donors per million (ODM) have quadrupled from 8 ODM to 53 ODM between 1982 and 2008. CONCLUSIONS: The investment of $10 million may seem substantial when we look at the cost-to-benefit ratio associated with the cost savings of $135,000 per donor. But it is small when compared with the more than $200 million saved by kidney donors alone, which is associated with the expected increase in the percentage of minority donors to 35% by 2010, or the equivalent of 1,750 minority donors.

Relationships among blood pressure, triglycerides and verbal learning in African Americans.

BACKGROUND: Individuals at greater risk for cardiovascular disease (CVD) display poorer cognitive functioning across various cognitive domains. This finding is particularly prevalent among older adults; however, few studies examine these relationships among younger adults or among African Americans. PURPOSE: The objective was to examine the relationships among 2 cardiovascular risk factors, elevated blood pressure and elevated triglycerides, and verbal learning in a community-based sample of African Americans. METHODS: Measurements of blood pressure and triglycerides were obtained in 121 African-American adults and compared to performance on 3 domains of the California Verbal Learning Test-II (CVLT-II). RESULTS: Blood pressure was not related to CVLT-II performance. Triglyceride levels were inversely related to CVLT-II performance. Higher triglyceride levels were associated with poorer immediate, short delay and long delay recall. CONCLUSIONS: Consistent with studies involving older participants, the current investigation shows that in a nonelderly sample of African Americans, triglyceride levels may be related to cognitive functioning. Because early detection and intervention of vascular-related cognitive impairment may have a salutary effect, future studies should include younger adults to highlight the impact of cardiovascular risk on cognition.

Perceived stress and eating behaviors in a community-based sample of African Americans.

Previous studies have reported that psychological stress is associated with greater food consumption, particularly consumption of high fat foods. We are unaware of any studies that have examined stress-induced eating among African Americans (AAs). The goals of the current study were to examine the relationship between perceived stress and high fat eating behaviors in a sample of AAs, to examine whether this relationship is stronger among overweight and obese participants, and to examine whether haphazard meal planning mediates the relationship between perceived stress and high fat eating behaviors. One hundred fifty-nine adults from a metropolitan area completed the Perceived Stress Scale (PSS-10), the Eating Behaviors Pattern Questionnaire (EBPQ), a demographic questionnaire, and body mass was assessed with BMI. Perceived stress was associated with haphazard planning and emotional eating, but not related to other high fat eating domains in the overall sample. These findings held for overweight and obese participants with the addition of snacking on sweets. High fat eating behaviors were not mediated by haphazard meal planning. These findings are consistent with other studies which demonstrate a link between stress and eating. Long-term interventions for high fat consumption and obesity should include an examination of perceived stress among AAs.