The finding:
De novo MDD (major depressive disorder) occurred in 4.3% of individuals in Korea, with a statistically significantly lower graft survival rate at 1, 3, and 5 years (89.5%, 75.3%, and 66.5%) compared to matched controls. MDD was found to be an independent risk factor for reduced graft survival, with additional risk factors including female sex, alcoholic liver disease, pretransplant encephalopathy, and lower hemoglobin levels. In the MDD group, the leading cause of death was graft failure (33.3%), followed by infection (26.7%), and alcohol recidivism (18.8%). Furthermore, graft survival did not differ significantly with antidepressant use.

Strengths and weaknesses:
The nested case-control design with 1:5 matching effectively controlled for immortal time bias, enhancing the reliability of survival analysis by aligning follow-up periods and accounting for the variable timing of MDD onset. The sample size was large and spanned an extended period to capture the relatively rare outcome of de novo MDD. Multivariable Cox regression ensured the identification of independent risk factors by adjusting for confounders such as age, sex, and other comorbidities. Weaknesses include the retrospective nature of the study, which leaves gaps in historical data such as medication adherence and physical activity, which were not directly measured. As this was a single-center study, its generalizability is limited. Furthermore, subclinical depression may have been missed, given the use of MDD definitions strictly according to DSM-4 and DSM-5. Variables not explored include socioeconomic status, treatment adherence, and lifestyle factors. Subgroup differences cannot be determined due to there being only 58 MDD cases, thus lacking enough statistical power.

Relevance:
The median onset of MDD at 316 days underscores the importance of long-term post-transplant follow-up. This study further emphasizes the need for prioritizing multidisciplinary care that includes mental health services. Interestingly, the inverse association observed between hemoglobin levels and MDD suggests that correcting anemia post-liver transplant (LT) plays a significant role. This study provides compelling evidence that de novo MDD is a significant post-LT complication with actionable implications for clinical management.

The Finding:
The Kidney Transplant Fast Track (KTFT) intervention streamlines the pretransplant evaluation process by allowing patients to complete nearly all necessary tests during their initial clinic visit, unlike the historical control (HC) group where patients were given a list of tests to complete independently. Over a 7-year period, findings show that the KTFT group (n=1118) had an increased likelihood of being added to the active kidney transplant (KT) waitlist compared with the HC group (n=1152). Furthermore, once on the waitlist, patients in the KTFT group were also more likely to actually receive a KT. Both Black and White patients had higher chances of being waitlisted in the KTFT group. However, the improvement in likelihood of receiving a transplant was statistically significant only among Black patients when comparing the KTFT with the HC group. Notably, the KTFT intervention eliminated the disparity in waitlisting between Black and White patients—a disparity that persisted in the HC group, where Black patients were less likely to be waitlisted. This indicates that the KTFT intervention not only accelerates the overall transplant process but also addresses racial disparities in access to kidney transplants.

Strengths and weaknesses:
Strengths of the study include its prospective design with a historical control within the same center, which effectively avoids institutional differences that can be difficult to account for. Moreover, the research boasted a large sample size endowed with sufficient power needed to detect variances in waitlisting and KT rates, with detailed subgroup analyses by race/ethnicity. The use of Fine-Gray competing risk models was instrumental in accounting for death as a competing event while adjusting for confounders. Importantly, the study explicitly addressed racial/ethnic disparities, a critical issue in KT access, and effectively demonstrated inequities, particularly for Black patients. Weaknesses consist of the study’s nonrandomized nature, which potentially introduces confounders due to temporal changes such as policy shifts, staff turnover, and other structural changes. Conducted at a single well-resourced center, it is unclear whether the results can be generalized to lower-resourced centers. Furthermore, the KTFT had 170 eligible patients excluded for not attending their evaluation, while the HC group had no exclusions; this differential in criteria introduces significant bias into the findings. Additionally, the study’s scope was limited concerning other races/ethnicities, possibly overlooking broader demographic impacts.

Relevance:
This study provides compelling evidence that a streamlined, system-facilitated KT evaluation process like KTFT can enhance waitlisting and KT rates while reducing racial disparities, particularly for Black patients. Despite limitations from its nonrandomized, single-center design, its findings advocate for broader implementation in transplant centers to optimize access and equity in ESKD treatment.