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Kidney transplant recipients require meticulous clinical and laboratory surveillance to monitor allograft health. Conventional biomarkers, including serum creatinine and proteinuria, are lagging indicators of allograft injury, often rising only after significant and potentially irreversible damage has occurred. Immunosuppressive medication levels can be followed, but their utility is largely limited to guiding dosing changes or assessing adherence. Kidney biopsy, the criterion standard for the diagnosis and characterization of injury, is invasive and thus poorly suited for frequent surveillance. Donor-derived cell-free DNA (dd-cfDNA) is a sensitive, noninvasive, leading indicator of allograft injury, which offers the opportunity for expedited intervention and can improve long-term allograft outcomes. This article describes the clinical rationale for a routine testing schedule utilizing dd-cfDNA surveillance at months 1, 2, 3, 4, 6, 9, and 12 during the first year following kidney transplantation and quarterly thereafter. These time points coincide with major immunologic transition points after transplantation and provide clinicians with molecular information to help inform decision making.

Introduction: Limited health literacy has been associated with poor health outcomes in the general population, but there have been few studies investigating the association between functional health literacy and kidney transplant listing. The primary objective of this study was to determine if functional health literacy was associated with kidney transplant listing after controlling for demographic, psychosocial, and medical variables, which were secondarily examined for correlation with transplant listing. Design: We retrospectively reviewed 423 kidney transplant candidates who were prospectively administered the Test of Functional Health Literacy in Adults during their transplant evaluation. Results: The functional health literacy scores were found to correlate with transplant listing (P = 0.013). Unexpectedly, a subset of patients (n = 14 out of 36) who had scores < 59 was still able to obtain approval for listing. The probability of approval decreased when functional health literacy scores ranged from 0 to 59 and increased when functional health literacy scores varied between 60 to 100. Multivariable analysis found transplant listing to also be associated with substance use (OR = 0.15, P < 0.001), ESKD etiology other than diabetes or hypertension (OR = 2.62, P < 0.001), time on dialysis (P = 0.012), and pace of transplant evaluation (P < 0.001). Conclusion: Functional health literacy was associated with kidney transplant listing. Programmatic interventions that can help overcome the impact of functional health literacy and improve access to transplantation should be explored.