Abstract: FR-PO0829
Implementation of PATHWAY GN: Cohort Characterization and Early Transitional Care Outcomes in a Registry-Enabled Glomerular Disease Program
Session Information
- Glomerular Diseases: Practice and New Concepts Shaping Modern Care
October 23, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Paulus, Amber B., Virginia Commonwealth University, Richmond, Virginia, United States
- Kidd, Jason M., Virginia Commonwealth University, Richmond, Virginia, United States
Group or Team Name
- Kidney disease and Transplant Epidemiology (KiTE) Research Consortium
Background
Patients with glomerular disease (GN) face complex care transitions including pediatric-to-adult transfer, dialysis planning, and kidney transplant referral. Existing CKD transition models do not address GN-specific factors such as variable progression, immunologic complexity, and recurrence risk. We implemented PATHWAY GN, a registry-enabled transitional care model embedded within routine nephrology practice at VCU Health.
Methods
PATHWAY GN was implemented within the Mid-Atlantic Glomerulonephritis Network (MAGNET) registry at VCU Health (IRB HM20032283). Patients with GN were identified by nephrologists during routine care and enrolled in longitudinal surveillance. Risk stratification used the Kidney Failure Risk Equation (KFRE), eGFR trends, and urine albumin-to-creatinine ratio. Three pathways were available: pediatric-to-adult transition (TRAQ 6.0), dialysis education and planning, and kidney transplant referral. Nephrology nurses operationalized pathways through education, readiness assessment, and longitudinal coordination.
Results
Sixty-two patients were enrolled between April 2025 and May 2026 (mean age 49 years, SD 19.4, range 19-82; 35 [56.5%] female). Leading diagnoses were lupus nephritis (n=17), ANCA-associated GN (n=14; MPO+ n=7, PR3+ n=7), IgA nephropathy (n=6), membranous nephropathy (n=6), FSGS (n=6), minimal change disease (n=4), and AL amyloidosis (n=3); the remainder (n=6) included C3GN, fibrillary GN, IgA vasculitis, and cryocrystalglobulinemic GN. Twenty patients (32.3%) were activated into structured PATHWAY GN workflows; 42 (67.7%) continued in registry surveillance. Activation tracked KFRE risk (90% of High Risk vs 11% of Low Risk activated). Activated patients engaged across pediatric-to-adult transition (n=3), dialysis education and planning (n=12), and kidney transplant referral (n=11). At analysis, 5 were on dialysis, 10 waitlisted, and 1 transplanted.
Conclusion
PATHWAY GN demonstrates the feasibility of a registry-enabled, risk-informed transitional care model for patients with GN. Activation of nearly one third of enrolled patients within the first year reflects the heterogeneity of GN trajectories and the model's capacity to match care intensity to clinical need. Ongoing evaluation will examine patient-centered outcomes, utilization, and clinical endpoints.
Acknowledgment
Funding Sources/Commercial Support: 2025 ANNA/Satellite Healthcare Applied Pragmatic Clinical Research Grant
Funding
- Private Foundation Support