For patients with chronic kidney disease, transitions of care can be challenging, stressful times. Some transitions of care and changes of providers are inevitable, such as when pediatric patients with chronic kidney disease (CKD) transition to adult nephrology care. Other transitions of care are more unexpected, such as when adults with CKD may have to change providers due to relocation or changes in insurance. For both anticipated and unanticipated transitions, there are things to keep in mind which can help facilitate smooth transfers of care.
Pediatric patients with CKD transition to adult nephrology care around 18 to 21 years of age. However, it is recommended that the preparation for transfer of
care begin earlier, at around 11
to 14 years of age. Longer, more thorough preparation for transfer to adult care can ensure a more seamless transition and help prepare young people for full autonomy
with medical visits.
As noted in the 2024 KDIGO (Kidney Disease Improving Global Outcomes) CKD guidelines, several resources are available to help guide the transition from pediatric to adult care, and to help assess readiness to do so: TRxANSITION; Youth Quiz from the On Trac program; Transition Readiness Assessment Questionnaire (TRAQ); Readiness for Transition Questionnaire (RTQ); and Got Transition tools (http://www.gottransition.org).
For pediatric nephrologists, seeing adolescent patients without caregivers for at least part of the clinic visit can help young people practice interacting with healthcare providers independently. Doing so also provides privacy for the discussion of sensitive topics. Also, allowing older adolescent patients to visit the adult clinic prior to transfer of care can be helpful.
For adult nephrologists caring for young adult patients, it is important to recognize that patients under 25 years of age with CKD are a unique population at high risk of adverse outcomes. This is at least in part due to physiologic incomplete brain maturation, as the prefrontal cortex, responsible for planning and organization, is not fully developed until approximately that age. Healthcare transitions per se are associated with adverse outcomes, including loss of follow-up, but may be even higher risk in the young adult population. Therefore, it is recommended that young adults be seen in-clinic more frequently than older adults with the same stage of CKD.
For healthcare providers, it is important to understand that adolescent and young adult patients are navigating not only a transition of care and change of healthcare providers, but also the larger transition from childhood to adulthood. Keeping this in mind, and framing clinical interactions accordingly, can help to optimize this critically important time of transition.
In addition to the pediatric-to-adult transfer of care, healthcare transitions can also occur for adults. They may also need to change nephrologists in the context of a relocation or change in insurance.
When meeting with the new nephrologist, knowing and communicating key aspects of medical history (e.g. etiology and duration of CKD, other medical conditions, etc.) is important. Additionally, knowing prescribed medications, their dosages, and why they were prescribed helps to maintain optimal care while transitioning to a new nephrologist. Especially useful to the new healthcare team is an updated, printed list of medications, medication dosages, medication indications, drug allergies, and medical conditions. Having an up-to-date list can help to avoid sub-optimal care during a healthcare transition, as communication between the transferring and receiving care teams may not always be comprehensive or thorough.
Additionally, when meeting with a new nephrologist, it is important to discuss logistics, routes of communication, and clinical expectations. How often should in-person clinic visits occur? Are telehealth video visits an option? Who should be contacted for scheduling, re-scheduling, or cancelling appointments? How are medication refills handled? What is the best way to contact a member of the healthcare team? Is there an app used by the clinical team that can help facilitate patient-provider communication? In what time frame should a response to a phone message or app-based text message be expected?
Good communication, understanding, involvement, and preparation among healthcare providers, patients, and caregivers is paramount to facilitating seamless transitions of care for those with CKD.
Dr. Hanudel was born and raised in Roanoke Rapids, North Carolina. He completed his undergraduate studies at Yale University in 2003, earning a degree in Molecular, Cellular, and Developmental Biology. He received his medical degree from Harvard Medical School in 2008. Dr. Hanudel then came to UCLA, where he completed his pediatric residency and completed his pediatric nephrology fellowship, and earned a Master of Science in Clinical Research degree. He joined the UCLA Department of Pediatrics faculty in 2016. He also serves on the RSN Board.
Web ID 4084
