Abstract: PUB217
A Multidisciplinary, Culturally Tailored Approach to Transition from Pediatric Hemodialysis to Adult Kidney Transplant in a Young Adult
Session Information
Category: Pediatric Nephrology
- 1800 Pediatric Nephrology
Authors
- Goldstein-Fuchs, D. Jordi, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, California, United States
- Wong, Cynthia, Stanford University School of Medicine, Stanford, California, United States
- Shi, Vivian, Stanford University School of Medicine, Stanford, California, United States
Introduction
This case describes a non-English speaking young adult with ESRD secondary to ANCA-associated vasculitis who initiated pediatric hemodialysis at age 17 and subsequently underwent successful deceased donor kidney transplantation through an affiliated adult transplant program using a structured, multidisciplinary transition model. Adolescence and young adulthood are recognized high-risk periods for loss to follow-up, nonadherence, and graft loss after transfer to adult care. A coordinated team including psychology, child life, dietitian, Novel Interventions in Children’s Healthcare (NICH) interventionist, and nephrology providers focused on reinforcing self-management skills, medication adherence, and disease education. At time of transplant, the patient was fully transferred to adult care services. This patient has displayed excellent post-transplant graft function, stable immunosuppression levels, and no missed appointments.
Case Description
Two unique features distinguished this transition model. First, NICH services -traditionally reserved for pediatric patients at Stanford - were extended beyond formal transfer to the adult care team. A central component of NICH is the assignment of a dedicated interventionist who serves as a liaison, available 24/7, for up to one year. Services include disease education, coordination of care, interdisciplinary team communication, and attendance at medical appointments when appropriate. NICH additionally addresses social determinants of health including housing instability, food insecurity, transportation, language access, and cultural barriers. Continued involvement of the patient’s trusted NICH interventionist provided critical continuity during adaptation to a new healthcare system, adult-care culture, and complex post-transplant regimen. Second, involvement of a combined Medicine-Pediatrics Nephrology fellow facilitated proactive transition planning, early education regarding anticipated system differences, and continuity between pediatric and adult nephrology teams.
Discussion
This extended NICH-supported model, particularly when paired with a Med-Peds or similarly trained transitional care provider, may represent a stabilizing and protective framework for young adults undergoing transfer during periods of high medical complexity, including dialysis and kidney transplantation.
Acknowledgment
We gratefully acknowledge Denise Mendoza, NICH interventionsit for their involvement in the patient's care which directly impacted the positive outcomes described in this case.