Abstract: PUB225
PATHWAYS in Glomerular Diseases: A Protocolized, Registry-Based Approach to Enhance Transitions of Care in Pediatric-to-Adult Care, Kidney Transplant Referral, and Dialysis Initiation
Session Information
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Paulus, Amber, Virginia Commonwealth University Department of Internal Medicine, Richmond, Virginia, United States
- Kidd, Jason M., Virginia Commonwealth University Department of Internal Medicine, Richmond, Virginia, United States
Background
Patients with glomerular disease (GN) experience fragmented transitions across their lifespan. The PATHWAYS Project aims to improve outcomes for these high-risk patients by standardizing three critical potential transition points: pediatric-to-adult care, kidney transplant referral, and dialysis planning. The project is embedded within the Mid-Atlantic Glomerulonephritis Network (MAGNET) registry and the VCU Kidney HEALTH platform.
Methods
Eligible patients with GN (e.g., FSGS, IgA nephropathy, lupus nephritis) were identified through MAGNET and recruited for protocolized onboarding, including informed consent and baseline biospecimen collection (blood/urine). Participants were enrolled in the PATHWAYS registry and assigned to one or more transition pathways based on clinical disposition at enrollment (Figure 1):
Pediatric-to-Adult Care: Patients aged ≥18 complete the TRAQ 6.0 at their initial adult visit. Tiered scores guide follow-up. Education includes the “READY Guide,” personalized summaries, and goal-setting tools.
Kidney Transplant Referral: Adults with eGFR ≤20 or high KFRE risk (>40%) are identified via Epic, educated with GN-specific transplant guides, and tracked for evaluation and listing.
Dialysis Planning: Patients nearing ESKD receive education on CKD, lifestyle, diet, insurance, and RRT options. Shared decision-making supports access planning and pre-initiation care.
Results
Enrollment is ongoing. Process evaluation includes protocol adherence (e.g., timely onboarding, follow-up), improvement in TRAQ scores, and timeliness of transplant or dialysis preparation. Key outcomes will be tracked via REDCap and Epic integration.
Conclusion
The PATHWAYS Project offers a scalable, protocol-driven framework to improve care transitions in GN. Integration with a registry and biospecimen bank enables longitudinal tracking and future research on outcomes and disease progression.
Figure 1. Patient Care Transition and Treatment Planning Flow for Glomerular Disease
Funding
- Private Foundation Support