Graft failure and adaptation period to adult healthcare centers in pediatric renal transplant patients

A Socioecological Approach to Support the Transition to Adult Care for Youth With Medical Complexity: Family Perspectives and Recommendations

INTRODUCTION

The transition from paediatric to adult health care (i.e., 'health care transition') poses many challenges for youth with medical complexity (YMC) and their families. YMC need specific approaches to supporting transition, tailored to individual youth and family contexts. In this study, we examine the contextual factors influencing families' transition experiences and describe their recommendations for improving the experience.

METHODS

We conducted a qualitative explanatory case study in Ontario, Canada. We completed 21 interviews with 17 participants (11 mothers, 2 fathers, 2 YMC, 2 siblings) from 11 families of YMC. Six YMC (55%) were under 18 years of age (pre-transfer) and five (45%) were aged 18 years and older (post-transfer). Analytic approaches included reflexive thematic analysis and directed content analysis.

FINDINGS

Participants described how the interplay of personal and environmental factors impacted their transition experiences. Recommendations for health care providers focused on providing instrumental and psychological support, advocacy and care continuity. Families expressed a need for better access to information and support from primary care providers. System-level recommendations included streamlining transition processes, improving adult health care services and expanding community supports. A socioecological model is presented to guide health care providers and decision makers in assessing and tackling the challenges faced by YMC and their families during transition.

CONCLUSION

Findings highlight the complexity and scope of issues surrounding the transition to adult care for YMC in Ontario, with evidence of major gaps in services across multiple sectors and settings. Ongoing efforts are needed to move evidence into practice and advocate for more equitable and responsive care for YMC during the transition and beyond.

PATIENT OR PUBLIC CONTRIBUTION

The research team included two parent co-researchers with lived experience, who contributed to protocol refinement, funding acquisition, recruitment, findings interpretation and ongoing knowledge translation efforts.

Graft Loss in Pediatric and Young Adult Kidney Transplantation in New Zealand: Who Is at Greatest Risk and When?

BACKGROUND

Much is reported regarding the detrimental effect of transfer to adult services for adolescent and young adult (AYA) kidney transplant (KT) recipients. However, AYA recipient age independent of time post-KT, and not relating to transfer of care, is also a strong predictor of graft loss. We assessed KT graft survival if experiencing solely pediatric (PO) or adult services (AO) versus transfer from pediatric to adult services (PTA).

METHODS

A retrospective cohort analysis of all first kidney transplant recipients between birth-24 years of age, from 2000 to 2019 in New Zealand. Participant identification and data were obtained via the Australia and New Zealand Dialysis and Transplantation registry. Primary outcome was graft survival stratified by service type. Cox proportional hazard modeling assessed independent risk factors of graft loss.

RESULTS

Two hundred forty-four children and AYA with a median follow-up of 7.3 years were included. Graft survival stratified by service provision group was not different. The incidence rate of graft loss was 37, 34, and 45 per 1000 persons per year for PO, PTA, and AO respectively. Crude age-specific graft failure rates were highest for 22-24-year-olds with inferior outcomes starting from age 16, peaking at 24 years.

CONCLUSIONS

Older adolescence and young adulthood reflect a high-risk period for KT loss. Transfer to adult services was not associated with worse graft survival compared to those experiencing either AO or PO alone. Improved models of care are needed to improve graft survival in this vulnerable population within New Zealand.

Access to and Health Outcomes of Pediatric Solid Organ Transplantation for Indigenous Children in 4 Settler-colonial Countries: A Scoping Review

Solid organ transplantation (SOT) is considered the optimal treatment for children with end-stage organ failure; however, increased efforts are needed to understand the gap surrounding equitable access to and health outcomes of SOT for Indigenous children. This scoping review summarizes the literature on the characteristics of access to and health outcomes of pediatric SOT among Indigenous children in the settler-colonial states of Canada, Aotearoa New Zealand, Australia, and the United States. A search was performed on MEDLINE, EMBASE, PsycINFO, and CINAHL for studies matching preestablished eligibility criteria from inception to November 2021. A preliminary gray literature search was also conducted. Twenty-four studies published between 1996 and 2021 were included. Studies addressed Indigenous pediatric populations within the United States (n = 7), Canada (n = 6), Aotearoa New Zealand (n = 5), Australia (n = 5), and Aotearoa New Zealand and Australia combined (n = 1). Findings showed that Indigenous children experienced longer time on dialysis, lower rates of preemptive and living donor kidney transplantation, and disparities in patient and graft outcomes after kidney transplantation. There were mixed findings about access to liver transplantation for Indigenous children and comparable findings for graft and patient outcomes after liver transplantation. Social determinants of health, such as geographic remoteness, lack of living donors, and traditional spiritual beliefs, may affect SOT access and outcomes for Indigenous children. Evidence gaps emphasize the need for action-based initiatives within SOT that prioritize research with and for Indigenous pediatric populations. Future research should include community-engaged methodologies, situated within local community contexts, to inform culturally safe care for Indigenous children.

Transition of care: lessons from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) dialysis collaborative

BACKGROUND

Acknowledging the importance of preparing the pediatric dialysis patient for successful transfer to adult providers, centers from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Dialysis Collaborative developed transition tools and performed iterative implementation of a transition of care (TOC) program to gain real-life insight into drivers and barriers towards implementation of a transition program for patients receiving dialysis.

METHODS

A TOC innovation workgroup was developed in 2019 from within SCOPE Collaborative that developed nine educational modules, along with introductory letter and assessment tool to be utilized by SCOPE centers. A 4-month pilot implementation study among six centers of varying patient population (age ≥ 11 years) was performed. TOC tools were further refined, and broader implementation within the collaborative was performed. Interim assessment of TOC tool utilization and implementation success was performed among 11 centers, as a foundation towards broader discussion regarding process, barriers, and success towards TOC implementation among 26 centers.

RESULTS

Transition champion was a key driver of successful implementation, and lack of institutional support and collaboration with adult dialysis centers were important barriers towards sustainability. COVID pandemic and increased staff turnover affected longer term implementation of TOC program.

CONCLUSIONS

Successful transition and transfer of adolescents/young adults with kidney failure on dialysis remains a challenge. This study represents the experience of the largest cohort of pediatric dialysis centers, with diversity in population size and geography, towards development and implementation of a TOC program. This adds to the resources available to assist centers towards transition and transfer, with particular focus on transitioning patients on dialysis.

Transition of Kidney Care at 18: Challenges and Practical Solutions for India

Health-care transition (HCT) from pediatric-centered to adult-oriented health-care setting is more than a simple transfer of care. It is a carefully planned movement specially tailored for the needs of adolescents and young adults (AYAs). Similar to other chronic diseases, the need for HCT for AYAs with kidney disease has been well established by the International Society of Nephrology (ISN) and the International Pediatric Nephrology Association (IPNA) consensus statements since 2011. However, successful HCT in India and other low- and middle-income countries (LMICs) has been limited. Undertaking the HCT program in India requires involvement of many stakeholders, that is, AYAs, parents/caregivers, health-care providers, and the health-care system. In this article, we discuss the need for HCT, the challenges faced during the transition, and the recommended models for HCT in kidney care. We focus on the unique challenges faced in India and conclude with practical suggestions to implement HCT in our setting.

Just TRAC it! Transitioning Responsibly to Adult Care Using Smart Phone Technology

PURPOSE

There is little evidence on whether smartphone technology influences transition readiness among adolescents with heart disease. Just TRAC it! is a method of using existing smartphone features (Notes, Calendar, Contacts, Camera) to manage personal health. We evaluated the impact of Just TRAC it! on self-management skills.

METHODS

Randomized clinical trial of 16-18 year-olds with heart disease. Participants were randomly allocated 1:1 to either usual care (education session) or intervention (education session including Just TRAC it!). The primary outcome was change in TRANSITION-Q score between baseline, 3 and 6 months. Secondary outcomes were frequency of use and perceived usefulness of Just TRAC it! Analysis was intention-to-treat.

RESULTS

We enrolled 68 patients (41% female, mean age 17.3 years), 68% having previous cardiac surgery and 26% had cardiac catheterization. TRANSITION-Q scores were similar at baseline and increased over time in both groups but were not significantly different between groups. Each additional point at the baseline score brought, on average, a 0.7-point increase in TRANSITION-Q score (95% CI 0.5-0.9) at each of 3 and 6 months. The Camera, Calendar and Notes apps were reported as most useful. All intervention participants would recommend Just TRAC it! to others.

DISCUSSION

A nurse-led transition teaching with versus without Just TRAC it! improved transition readiness, with no significant difference between groups. Higher baseline TRANSITION-Q scores were associated with greater increase in scores over time. Participants had a positive reception to Just TRAC it! and would recommend it to others. Smartphone technology may be useful in transition education.

Kidney-transplanted Adolescents-Nonadherence and Graft Outcomes During the Transition Phase: A Nationwide Analysis, 2000-2020

BACKGROUND

The transition from pediatric to young adult care is a vulnerable period for the renal transplant patient. We aimed to identify medication nonadherence (noninitiation, nonimplementation, and nonpersistence) and graft loss rates among adolescents and young adults and elucidate the influence of the transition phase on transplant outcomes.

METHODS

A retrospective nationwide cohort analysis of all renal transplantations in Norway from 2000 to 2020 was performed. Data were retrieved from the Norwegian Renal Registry, and adherence data from hospital charts. Patients transplanted aged <50 y, with functioning graft at 6 mo, were included. Recipients transplanted aged <26 y were compared with recipients transplanted aged 26-50 y. Graft loss, acute rejection, and development of de novo donor-specific antibodies were assessed in relation to the transition phase, defined as 14-26 y.

RESULTS

Data from 1830 kidney recipients were included: 371 (20%) transplanted <26 y (64% male, 68% living donor) versus 1459 transplanted 26-50 y (63% male, 44% living donor). There were 298 graft losses, 78 (21%) in the <26-y group versus 220 (15%) in the 26- to 50-y group. During the transition phase, 36 grafts were lost, 29 (81%) after transfer to the adult service. Medication nonadherence was the reason for 58% (21 of 36) of the losses during the transition phase, versus 12% (27 of 220) in the 26- to 50-y group ( P < 0.001). The 5-y graft survival rate was 89% (95% confidence interval, 85%-92%) and 94% (92%-95%), respectively ( P = 0.01).

CONCLUSIONS

Nonadherence was verified as the main cause of kidney graft loss in the transition phase.

Postoperative morbidity and mortality in pediatric indigenous populations: a scoping review and meta-analysis

Mounting evidence suggests that childhood health is an important predictor of wellness as an adult. Indigenous peoples worldwide suffer worse health outcomes compared to settler populations. No study comprehensively evaluates surgical outcomes for Indigenous pediatric patients. This review evaluates inequities between Indigenous and non-Indigenous children globally for postoperative complications, morbidities, and mortality. Nine databases were searched for relevant subject headings including "pediatric", "Indigenous", "postoperative", "complications", and related terms. Main outcomes included postoperative complications, mortality, reoperations, and hospital readmission. A random-effects model was used for statistical analysis. The Newcastle Ottawa Scale was used for quality assessment. Fourteen studies were included in this review, and 12 met inclusion criteria for meta-analysis, representing 4793 Indigenous and 83,592 non-Indigenous patients. Indigenous pediatric patients had a greater than twofold overall (OR 2.0.6, 95% CI 1.23-3.46) and 30-day postoperative mortality (OR 2.23, 95% CI 1.23-4.05) than non-Indigenous populations. Surgical site infections (OR 1.05, 95% CI 0.73-1.50), reoperations (OR 0.75, 95% CI 0.51-1.11), and length of hospital stay (SMD = 0.55, 95% CI - 0.55-1.65) were similar between the two groups. There was a non-significant increase in hospital readmissions (OR 6.09, 95% CI 0.32-116.41, p = 0.23) and overall morbidity (OR 1.13, 95% CI 0.91-1.40) for Indigenous children. Indigenous children worldwide experience increased postoperative mortality. It is necessary to collaborate with Indigenous communities to promote solutions for more equitable and culturally appropriate pediatric surgical care.

Initial attendance and retention in adult healthcare as criteria for transition success among organ transplant recipients

BACKGROUND

Adolescent and young adult (AYA) solid organ transplant recipients experience worsening medical outcomes during transition to adult healthcare. Current understanding and definitions of transition success emphasize first initiation of appointment attendance in adult healthcare; however, declines in attendance over time after transfer remain possible, particularly as AYAs are further removed from their pediatric provider and assume greater independence in their care.

METHODS

The current study assessed health-care utilization, medical outcomes, and transition success among 49 AYA heart, kidney, or liver recipients recently transferred to adult healthcare. Differences in outcomes were examined along two transition success criteria: (1) initial engagement in adult healthcare within 6 or 12 months of last pediatric appointment and (2) retention in adult healthcare over 3 years following last pediatric appointment. Growth curve modeling examined change in attendance over time.

RESULTS

Successful retention in adult healthcare was significantly related to more improved clinical outcomes, including decreased number and duration of hospitalizations and greater medication adherence, as compared to initial engagement. Significant declines in appointment attendance over 3 years were noted, and individual differences in declines were not accounted for by age at transfer or time since transplant.

CONCLUSIONS

Findings underscore support for AYAs after transfer, as significant declines in attendance were noted after initiating adult care. Clinical care teams should examine transition success longitudinally to address changes in health-care utilization and medical outcomes. Attention to interventions and administrative support aimed at maintaining or increasing attendance and identifying risk factors and intervention for unsuccessful transition is warranted.

Long-Term Care of the Pediatric Kidney Transplant Recipient

Pediatric kidney transplant recipients are distinguished from adult recipients by the need for many decades of graft function, the potential effect of CKD on neurodevelopment, and the changing immune environment of a developing human. The entire life of an individual who receives a transplant as a child is colored by their status as a transplant recipient. Not only must these young recipients negotiate all of the usual challenges of emerging adulthood (transition from school to work, romantic relationships, achieving independence from parents), but they must learn to manage a life-threatening medical condition independently. Regardless of the age at transplantation, graft failure rates are higher during adolescence and young adulthood than at any other age. All pediatric transplant recipients must pass through this high-risk period. Factors contributing to the high graft failure rates in this period include poor adherence to treatment, potentially exacerbated by the transfer of care from pediatric- to adult-oriented care providers, and perhaps an increased potency of the immune response. We describe the characteristics of pediatric kidney transplant recipients, particularly those factors that may influence their care throughout their lives. We also discuss the risks associated with the transition from pediatric- to adult-oriented care and provide some suggestions to optimize the transition to adult-oriented transplant care and long-term outcomes.

Multidisciplinarity in Transition Pathways for Patients With Kidney Disease: The Current State of Play

In the field of medical care, successful transition from pediatric-centered to adult-oriented healthcare can provide a sense of continuity in the development of youth, and prepare them to accept responsibility for and manage their own chronic kidney condition in complete autonomy. The so-called transition process requires the presence of some basic aspects: a multidisciplinary team, which acts as a bridge between child and adult services; a comprehensive clinical, cognitive, psychological, and social change for the young people; the involvement of family and caregivers. Within the framework of transition and chronicity during the developmental age, we selected international papers explaining models which agreed on some important steps in the transition process, although many differences can be observed between different countries. In fact, in Europe, the situation appears to be heterogeneous as regards certain aspects: the written transition plan, the educational programmes, the timing of transfer to adult services, the presence of a transition coordinator, a dedicated off-site transition clinic. We then analyzed some studies focusing on patients with renal diseases, including the first to contain a standardized protocol for transition which was launched recently in the USA, and which seems to have already achieved important positive, although limited, results. In Italy, the issue of transition is still in its infancy, however important efforts in the management of chronic kidney disease have already been initiated in some regions, including Emila Romagna, which gives us hope for the future of many young people.

Primary care during the transition to adult care for adolescents involved with pediatric specialty services: a scoping review protocol

BACKGROUND

Of the 15-20% of youth in North America affected by a chronic health condition (e.g., type 1 diabetes, cystic fibrosis) and/or mental health or neurodevelopmental disorder (e.g., depression, eating disorder, Attention Deficit-Hyperactivity Disorder), many often require lifelong specialist healthcare services. Ongoing primary care during childhood and into young adulthood is recommended by best practice guidelines. To date, it is largely unknown if, how, and when primary care physicians (PCPs; such as family physicians) collaborate with specialists as AYAs leave pediatric-oriented services. The proposed scoping review will synthesize the available literature on the roles of PCPs for AYAs with chronic conditions leaving pediatric specialty care and identify potential benefits and challenges of maintaining PCP involvement during transition.

METHODS

Arksey and O'Malley's original scoping review framework will be utilized with guidance from Levac and colleagues and the Joanna Briggs Institute. A search of databases including MEDLINE (OVID), EMBASE, PsycINFO, and CINAHL will be conducted following the development of a strategic search strategy. Eligible studies will (i) be published in English from January 2004 onwards, (ii) focus on AYAs (ages 12-25) with a chronic condition(s) who have received specialist services during childhood, and (iii) include relevant findings about the roles of PCPs during transition to adult services. A data extraction tool will be developed and piloted on a subset of studies. Both quantitative and qualitative data will be synthesized.

DISCUSSION

Key themes about the roles of PCPs for AYAs involved with specialist services will be identified through this review. Findings will inform the development and evaluation of a primary-care based intervention to improve transition care for AYAs with chronic conditions.

Associations with kidney transplant survival and eGFR decline in children and young adults in the United Kingdom: a retrospective cohort study

Background

Although young adulthood is associated with transplant loss, many studies do not examine eGFR decline. We aimed to establish clinical risk factors to identify where early intervention might prevent subsequent adverse transplant outcomes.

Methods

Retrospective cohort study using UK Renal Registry and UK Transplant Registry data, including patients aged < 30 years transplanted 1998–2014. Associations with death-censored graft failure were investigated with multivariable Cox proportional hazards. Multivariable linear regression was used to establish associations with eGFR slope gradients calculated over the last 5 years of observation per individual.

Results

The cohort (n = 5121, of whom n = 371 received another transplant) was 61% male, 80% White and 36% had structural disease. Live donation occurred in 48%. There were 1371 graft failures and 145 deaths with a functioning graft over a 39,541-year risk period. Median follow-up was 7 years. Fifteen-year graft survival was 60.2% (95% CI 58.1, 62.3).

Risk associations observed in both graft loss and eGFR decline analyses included female sex, glomerular diseases, Black ethnicity and young adulthood (15–19-year and 20–24-year age groups, compared to 25–29 years). A higher initial eGFR was associated with less risk of graft loss but faster eGFR decline. For each additional 10 mL/min/1.73m² initial eGFR, the hazard ratio for graft loss was 0.82 (95% CI 0.79, 0.86), p < 0.0001. However, compared to < 60 mL/min/1.73m², higher initial eGFR was associated with faster eGFR decline (> 90 mL/min/1.73m²; − 3.55 mL/min/1.73m²/year (95% CI -4.37, − 2.72), p < 0.0001).

Conclusions

In conclusion, young adulthood is a key risk factor for transplant loss and eGFR decline for UK children and young adults. This study has an extended follow-up period and confirms common risk associations for graft loss and eGFR decline, including female sex, Black ethnicity and glomerular diseases. A higher initial eGFR was associated with less risk of graft loss but faster rate of eGFR decline. Identification of children at risk of faster rate of eGFR decline may enable early intervention to prolong graft survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02156-2.

Comparison of a home-based (multi) systemic intervention to promoting Medication AdheRence and Self-management among kidney transplant recipients with care-as-usual: the MARS randomized controlled trial protocol

Background

After kidney transplantation non-adherence and inadequate self-management undermine clinical outcomes and quality of life. Both have been demonstrated to be substantial in all age groups. However, interventions promoting adherence and self-management among kidney transplant recipients that have proven to be effective are scarce. In this study we aim to develop and test an intervention to optimize adherence and self-management. In this article we describe the background and design of the trial entitled ‘promoting Medication AdheRence and Self-management among kidney transplant recipients’ (MARS-trial)’.

Methods/design

This is a single-center, parallel arm randomized controlled trial. Nonadherent kidney transplant recipients aged 12 years or older are eligible for inclusion. Patients will be randomly assigned to either the experimental or a control group. The control group will receive care-as-usual. The experimental group will receive care-as-usual plus the MARS-intervention. The MARS-intervention is an outreaching intervention, based on the principles of (multi) systemic therapy which means involving the social network. A standardized intervention protocol is used for consistency but we will tailor the behavior change techniques used to the specific needs and determinants of each patient. The primary outcome of medication adherence will be measured using electronic monitoring. Secondary outcome measures regarding medication adherence and self-management are also assessed. Data is collected at baseline (T0), after a run-in period (T1), at six months post-baseline/end of treatment (T2) and after a six month follow-up period (T3).

Discussion

We combined elements of (multi) systemic therapy and evidence-based behavior change techniques to create an outreaching and highly individualized intervention. In this trial we will investigate the impact on medication adherence and self-management after kidney transplantation.

Trial registration

Netherlands Trial Register,trial number NTR7462. Registered 7th September 2018, https://www.trialregister.nl/trial/7264

Inpatient mortality in transition-aged youth with rheumatic disease: an analysis of the National Inpatient Sample

BACKGROUND

Transition from pediatric to adult care is a vulnerable time for youth with chronic diseases. In youth with rheumatic disease, studies show high rates of loss to follow up and increased disease activity. However, mortality data are lacking. In this study, we assessed whether transitional age is a risk factor for inpatient mortality.

METHODS

We analyzed the 2012-2014 National Inpatient Sample database, a representative sample of discharges in the United States. Individuals with rheumatic diseases were identified by International Statistical Classification of Disease - 9 (ICD-9) codes at time of discharge. Youth were categorized into three age groups: pre-transitional (11-17), transitional (18-24) and post transitional (25-31). We fitted univariable and multivariable logistic regression models to assess whether transitional age was a risk factor for inpatient mortality.

RESULTS

There were 30,269 hospital discharges which met our inclusion criteria of diagnosis and age. There were 195 inpatient deaths (0.7%). The most common causes of death were infection (39.5%), pulmonary disease (13.8%), and cardiac disease (11.2%). The Odds ratio for inpatient mortality of a transitional-aged individual was 1.18 compared to controls (p = 0.3). Black race (OR = 1.4), male sex (OR = 1.75), and a diagnosis of systemic sclerosis (OR = 4.81) or vasculitis (OR = 2.85) were the greatest risk factors of inpatient mortality.

CONCLUSION

Transitional age was not a risk factor for inpatient mortality in this study. We did identify other risk factors other than age. Further studies are required to assess if there is an increased risk of mortality in outpatients of the transitional age group.

Pragmatic trial evaluating the effectiveness of a patient navigator to decrease emergency room utilisation in transition age youth with chronic conditions: the Transition Navigator Trial protocol

INTRODUCTION

Transition to adult care is a challenging and complex process for youth with special healthcare needs. We aim to compare effectiveness of a patient navigator service in reducing emergency room (ER) use among adolescents with chronic health conditions transitioning to adult care.

METHODS AND ANALYSIS

Pragmatic randomised controlled trial parallel group design comparing ER visit rates between patients with access to a personalised navigator intervention compared with usual care. Unit of randomisation is the patient. Treatment assignment will not be blinded. Embedded qualitative study to understand navigator's role and cost analysis attributable to the intervention will be performed. Patients aged 16-21 years, followed within a chronic disease clinic, expected to be transferred to adult care within 12 months and residing in Alberta during study period will be recruited from three tertiary care paediatric hospitals. Sample size will be 300 in each arm. Navigator intervention over 24 months is designed to assist participants in four domains: transition preparation, health system brokering, socioeconomic determinants of health and self-management. Primary outcome is ER visit rate during observation period. Secondary outcomes are ambulatory and inpatient care utilisation measures, as well as Transition Readiness Assessment Questionnaire score, and Short-Form Health Survey 12 (SF-12) score at 6 and 18 months post-randomisation. Poisson regression will compare rates of ER/urgent care visits between navigator and control participants, using intention to treat principle. Cost analysis of the intervention will be conducted. Thematic analysis will be used to identify perceptions of stakeholders regarding the role of navigators.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Calgary Conjoint Health Research Ethics Board (REB #162561) and the University of Alberta Health Research Ethics Board (Pro00077325). Our team is composed of diverse stakeholders who are committed to improving transition of care who will assist with dissemination of results.

TRIAL REGISTRATION NUMBER

NCT03342495.

The role of resilience in healthcare transitions among adolescent kidney transplant recipients

PURPOSE

AYAs with KTs experience high rates of premature allograft loss during the HCT. There is a critical need to identify protective factors associated with stable HCT. Resilience-the ability to adapt and thrive in the setting of adversity-has known positive impact on health outcomes. This study explored the novel role of resilience constructs as protective factors in securing stable HCT among AYA with KT.

METHODS

We conducted semi-structured interviews of adolescents and young adults who transitioned from a single pediatric transplant center to multiple adult nephrology centers between 2010 and 2017. Interviews explored the role of key resilience constructs in participants' lives around the time of HCT. Participants were stratified into stable or unstable HCT groups based on biological markers of allograft function and clinical data from chart review. Content analyses of interview transcripts were reviewed and compared among HCT groups.

RESULTS

Thirty-two participants enrolled (17 stable; 15 unstable). Key resilience constructs more salient in the stable versus unstable HCT group were confidence in and connection to one's healthcare team. Reports of healthcare self-management competencies were similar across both HCT groups.

CONCLUSIONS

Confidence in and connection to one's healthcare team appear to be linked with a stable HCT among AYA with KT. This suggests that interdependence, the ability to foster connections with and elicit support from healthcare providers, as opposed to complete independence or autonomy, which is often advised in the HCT process, is a critical component of resilience linked to stable HCT.

Surgeon crossover between pediatric and adult centers is associated with decreased rate of loss to follow-up among adolescent renal transplantation recipients

The risk of adverse outcomes for pediatric renal transplant patients is highest during the transition from pediatric to adult care. While there have been many studies focus on graft failure and death, loss to follow-up likely plays a large role in patient outcomes. We hypothesize patients are lost to follow-up during this transition period and that patients transplanted at pediatric centers with a closely affiliated adult center (AFFs) are less likely to suffer from fragmentation of care and become lost to follow-up. AFFs were defined as those pediatric centers whose transplant surgeons were also on staff at an adult center and were identified using center websites. We included patients undergoing renal transplantation at <=18 years of age and had data for the entire transition period on the Scientific Registry of Transplant Recipients (n = 6,762, 92.3% in 95 AFFs). 32% of patients were lost to follow-up. On regression, patients transplanted at AFF were 33% less likely to be lost to follow-up compared with those from non-AFF (OR 0.67 CI 0.54-0.82, P < 0.01). The proportion of patients lost to follow-up during the transition period is remarkably high, but lower among recipients transplanted at AFFs. Poor follow-up may be mitigated by improving integration of care.

An Evidence Map for Interventions Addressing Transition from Pediatric to Adult Care: A Systematic Review of Systematic Reviews

PROBLEM

Adolescents and young adults with chronic illnesses continue to face barriers as they transition from pediatric to adult care. An evidence map can help to identify gaps in the transition literature to determine targets for future research.

ELIGIBILITY CRITERIA

We searched PubMed, CINAHL, PsycInfo, and Cochrane for systematic reviews published through February 2018. Eligible reviews included at least one comparative study testing a youth-focused intervention for improving transition with at least one quantitative health-related outcome reported.

SAMPLE

We identified 431 unique reviews in our search, and 37 reviews (containing 71 eligible primary studies) met inclusion criteria.

RESULTS

Most reviews (20 of 37) summarized some aspect of transition across diagnoses. Type 1 diabetes was the most common diagnosis studied (7 of 37 reviews and 24 of 71 primary studies). Only 14 of 71 primary studies focused on care after transfer to adult care.

CONCLUSIONS

The literature on interventions to improve transition to adult care has focused on a limited number of diagnoses, most commonly Type 1 diabetes. Common pediatric conditions, such as asthma, have not been studied with regard to transition. Efforts have been mainly targeted on transition preparation, with less focus on transition needs after transfer to adult care.

IMPLICATIONS

There is a need for transition research focused on common pediatric conditions and transition needs after transfer to adult care.

The effect of transfer to adult transplant care on kidney function and immunosuppressant drug level variability in pediatric kidney transplant recipients

Adolescent age at time of transplant has been recognized as a risk factor for renal allograft loss. Increased risk for graft failure may persist from adolescence to young adulthood. Transfer of care is hypothesized as a risk factor for non-adherence and graft loss. We explored whether kidney allograft function declined at an accelerated rate after transfer of care to adult transplant centers and whether coefficient of variation of tacrolimus (CV TAC) trough levels predicted allograft loss. Single-center, retrospective chart review was performed for pediatric kidney transplant recipients who received transplants between 1999 and 2011. Change in eGFR pre- and post-transfer was performed via a linear mixed-effects model. CV TAC was calculated in transplant recipients with TAC data pre- and post-transfer. t test was performed to determine the difference between means of CV TAC in subjects with and without allograft loss following transfer of care. Of the 138 subjects who transferred to adult care, 47 subjects with data pre- and post-transfer demonstrated a decrease in the rate of eGFR decline post-transfer from 8.0 mL/min/1.73 m² per year to 2.1 mL/min/1.73 m² per year, an ~80% decrease in eGFR decline post-transfer (P = 0.01). Twenty-four subjects had CV TAC data pre- and post-transfer of care. Pretransfer CV TAC for subjects with allograft loss post-transfer was significantly higher than in subjects without allograft loss (49% vs 26%, P < 0.05). Transfer of care was not independently associated with acceleration in eGFR decline. CV TAC may aid in identifying patients at risk for allograft loss post-transfer.

Impact of Paediatric Versus Adult Care Setting on Health Care Utilization in Adolescents With Inflammatory Bowel Disease

OBJECTIVE

Paediatric-onset inflammatory bowel disease (IBD) is different from adult-onset IBD with respect to disease severity and its effect on growth and development. Care of paediatric IBD patients in some countries is dispersed among paediatricians and adult care providers, which may result in different outcomes. This study aims to assess the effect of care setting (paediatric vs adult-oriented) on health care utilization in adolescent IBD patients.

METHODS

This is a Dutch population-based cohort study based on an insurance claims database covering 4.2 million insurees (approximately 25% of the Dutch population). We identified IBD patients ages 16 to 18 years and followed them until the age of 19 years or transfer to adult care, whichever came first. We categorized patients according to care setting: paediatric versus adult-oriented. We defined outcomes as corticosteroid use, IBD-related hospital admission, IBD-related surgery, and biological use. We estimated Cox proportional hazards regression models to control for confounding by indication.

RESULTS

Among 626 patients, 380 (61%) were in paediatric and 246 (39%) in adult-oriented care. In paediatric care, patients were less likely to be treated with corticosteroids (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.52-0.99) or biologicals (HR 0.57, 95% CI 0.34-0.97), and had fewer IBD-related hospital admissions (HR 0.58, 95% CI 0.37-0.92).

CONCLUSION

In a large and representative community cohort of adolescents with IBD, treatment in paediatric care setting was associated with significantly lower steroid and biological use, without increase in hospital admissions. These results might be used to optimize clinical care for adolescents with IBD.

Association of Primary Care Continuity With Outcomes Following Transition to Adult Care for Adolescents With Severe Mental Illness

IMPORTANCE

Adolescents with severe mental illness often age out of pediatric care without a clear transfer of care to adult services. The extent to which primary care provides stability during this vulnerable transition period is not known.

OBJECTIVE

To analyze the association between primary care continuity during the transition from pediatric to adult care and need for acute mental health services in young adulthood.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used linked health and demographic administrative data for all adolescents aged 12 to 16 years with severe mental illness ascertained by hospitalization for schizophrenia, eating disorder, or mood disorder between April 1, 2002, and April 1, 2014, in Ontario, Canada. Participants were followed up through March 31, 2017. Data were analyzed from July 2018 to January 2019.

EXPOSURES

Continuous primary care (same physician as baseline [age 12-16 years] always or sometimes), discontinuous primary care (visits to a primary care physician during the transition period who was not the patient's usual physician), and no primary care during the transition period (age 17-18 years).

MAIN OUTCOMES AND MEASURES

Mental health-related hospitalizations and emergency department visits in young adulthood (age 19-26 years) adjusted for sex, rurality, neighborhood income, mental illness type, and health service use before transition.

RESULTS

Among 8409 adolescents with severe mental illness (5720 [68.0%] female; mean [SD] age, 14.8 [1.2] years), 5478 (65.1%) had continuous primary care, 2391 (28.4%) had discontinuous primary care, and 540 (6.4%) had no primary care during the transition period. Youths with no primary care during transition were more likely to be male (57.2%), have lower socioeconomic status (31.5%), and have no usual primary care practitioner at baseline (25.6%). Compared with continuous care, patients with discontinuous and no primary care had an increased rate of mental health-related hospitalization in young adulthood (adjusted relative rate, 1.20; 95% CI, 1.10-1.30; and adjusted relative rate, 1.30; 95% CI, 1.08-1.56, respectively).

CONCLUSIONS AND RELEVANCE

In the context of decreasing outpatient specialist mental health visit rates following transition to adult care, ensuring adequate access to primary care during this vulnerable period may improve mental health outcomes in young adulthood.

Pediatric Heart Transplantation: Transitioning to Adult Care (TRANSIT): Feasibility of a Pilot Randomized Controlled Trial

BACKGROUND

Young-adult heart transplant recipients transferring to adult care are at risk for poor health outcomes. We conducted a pilot randomized controlled trial to determine the feasibility of and to test a transition intervention for young adults who underwent heart transplantation as children and then transferred to adult care.

METHODS

Participants were randomized to the transition intervention (4 months long, focused on heart-transplant knowledge, self-care, self-advocacy, and social support) or usual care. Self-report questionnaires and medical records data were collected at baseline and 3 and 6 months after the initial adult clinic visit. Longitudinal analyses comparing outcomes over time were performed using generalized estimating equations and linear mixed models.

RESULTS

Transfer to adult care was successful and feasible (ie, excellent participation rates). The average patient standard deviation of mean tacrolimus levels was similar over time in both study arms and < 2.5, indicating adequate adherence. There were no between-group or within-group differences in percentage of tacrolimus bioassays within target range (> 50%). Average overall adherence to treatment was similarly good in both groups. Rates of appointment keeping through 6 months after transfer declined over time in both groups.

CONCLUSIONS

The feasibility of the study was demonstrated. Our transition intervention did not improve outcomes.

Health care stakeholder perspectives regarding the role of a patient navigator during transition to adult care

BACKGROUND

Transition to adult care represents a vulnerable period for young people with special health care needs as they navigate multiple life transitions and developmental issues. Patient navigators are a promising intervention designed to facilitate the transfer from pediatric to adult care. However, consistent definitions, key tasks, roles and responsibilities are lacking in guiding the scope of practice and the implementation of patient navigators.

METHODS

Fundamental qualitative description was utilized in this study to identify perceptions from health care providers about implementing a patient navigator service for young people with special health care needs in transition to adult care. A purposive sample of health care providers with a variety of backgrounds within pediatric and adult systems in Alberta, Canada were recruited. Semi-structured interviews with participants were analyzed using thematic analysis to inductively identify perceptions regarding the role of patient navigators.

RESULTS

A total of 43 health care providers highlighted the need for a patient navigator service to encompass 4 key stages for young people with special health care needs transitioning from pediatric to adult services: (1) identification of young people with special health care needs and families requiring support, (2) preparation for transfer, (3) health system navigation and, (4) post-transfer support.

CONCLUSIONS

The results of this qualitative study provide guidance for the development of patient navigator interventions for young people with special health care needs, as well as provide support for current transition services offered across Canada.

Non-immunologic allograft loss in pediatric kidney transplant recipients

Non-immunologic risk factors are a major obstacle to realizing long-term improvements in kidney allograft survival. A standardized approach to assess donor quality has recently been introduced with the new kidney allocation system in the USA. Delayed graft function and surgical complications are important risk factors for both short- and long-term graft loss. Disease recurrence in the allograft remains a major cause of graft loss in those who fail to respond to therapy. Complications of over immunosuppression including opportunistic infections and malignancy continue to limit graft survival. Alternative immunosuppression strategies are under investigation to limit calcineurin inhibitor toxicity. Finally, recent studies have confirmed long-standing observations of the significant negative impact of a high-risk age window in late adolescence and young adulthood on long-term allograft survival.

Health Services Use during Transition from Pediatric to Adult Care for Inflammatory Bowel Disease: A Population-Based Study Using Health Administrative Data

OBJECTIVES

To evaluate the impact of the transfer from pediatric to adult care on health services use for adolescents with inflammatory bowel disease (IBD).

STUDY DESIGN

A population-based retrospective cohort study identified all children diagnosed with IBD from 1994 to 2008 and treated by pediatric gastroenterologists in Ontario, Canada, using health administrative data. Self-controlled case series analyses compared health service use in the 2 years before and 2 years after transfer with adult gastroenterologists, with a 6-month washout period at transfer. Outcomes evaluated included IBD-specific and IBD-related hospitalizations, emergency department use, outpatient visits, and laboratory use. The relative incidence (RI) in the post-transfer period was compared with pretransfer periods using Poisson regression analysis controlling for transfer starting age. Analyses were stratified by IBD type: Crohn's disease (CD) and ulcerative colitis (UC).

RESULTS

There were 536 patients included in the study (388 CD, 148 UC). Emergency department use rate was higher after transfer for both CD (RI, 2.12; 95% CI, 1.53-2.93) and UC (RI, 2.34; 95% CI, 1.09-5.03), as were outpatient visits (CD: RI, 1.56; 95% CI, 1.42-1.72; UC: RI, 1.48; 95% CI, 1.24-1.76), and laboratory investigations (CD: RI, 1.43; 95% CI, 1.26-1.63; UC: 1.38; 95% CI, 1.13-1.68). There was no change in the hospitalization rate (CD: RI, 0.70; 95% CI, 0.42-1.18; UC: RI, 2.41; 95% CI, 0.62-9.40).

CONCLUSIONS

Health services use in Canada increases after transfer from pediatric to adult care for outpatient visits, emergency department use, and laboratory tests, but not hospitalizations. This study has implications for the planning and budgeting of care for adolescents transitioning to adult care.

Why is transition between child and adult services a dangerous time for young people with chronic kidney disease? A mixed-method systematic review

Young people age 14-25 years with chronic kidney disease have been identified as generally having poor health outcomes and are a high-risk group for kidney transplant loss due in part to poor self-management. This raises a key question as to what happens during transition from child to adult services? This paper presents a mixed-method systematic review of health and social care evidence concerning young people with chronic kidney disease transitioning from child to adult health and social care services. Quantitative and qualitative evidence were synthesised in streams followed by an overarching synthesis. Literature searches (2000 to March 2017) were conducted using Pubmed, BioMed Central and Cochrane Library, grey literature sources ZETOC, .gov.uk, third sector organisations, NHS Evidence, SCIE, TRIP, Opengrey. Snowball searching was conducted in the databases Ovid, CINAHL, ISI Web of Science, Scopus and Google Scholar. Of 3,125 records screened, 60 texts were included. We found that while strategies to support transition contained consistent messages, they supported the principle of a health-dominated pathway. Well-being is mainly defined and measured in clinical terms and the transition process is often presented as a linear, one-dimensional conduit. Individual characteristics, along with social, familial and societal relationships are rarely considered. Evidence from young people and their families highlights transition as a zone of conflict between independence and dependency with young people feeling powerless on one hand and overwhelmed on the other. We found few novel interventions and fewer that had been evaluated. Studies were rarely conducted by allied health and social care professionals (e.g. renal social workers and psychologists) as part of multi-disciplinary renal teams. We conclude that there is a lack of good evidence to inform providers of health and social care services about how best to meet the needs of this small but vulnerable cohort.

A case series of perioperative variables in relation to short-term outcomes in pediatric renal transplant recipients

Multiple perioperative variables have been shown in existing literature to influence long-term outcomes of pediatric RTx, such as allograft survival. Their impact on short-term outcomes is not as well-documented. This case series aims to investigate the effects of nine perioperative variables on two short-term outcomes in pRTR: 1-week post-operative eGFR and post-operative LOS. A total of 73 pRTR transplanted over 3 years from 2012 to 2014 at a single center were studied retrospectively and statistical analyses were performed. There was higher 1-week post-operative eGFR in pRTR who received living donor transplants compared to those who received deceased donor transplants (P=.01), with mean eGFR of 135 mL/min/1.73 m² and 82 mL/min/1.73 m² , respectively. Aorta-IVC anastomosis was associated with longer LOS compared to iliac vessel anastomosis (P=.03), with median LOS of 19 and 13 days, respectively. There were no significant effects on 1-week eGFR or LOS of the seven other variables: pRTR age and gender, donor age, preoperative donor SBP, intraoperative mean CVP before graft perfusion, intraoperative median SBP z score after graft perfusion, and intraoperative fluid volume. Living donor transplants were associated with higher 1-week post-operative eGFR compared to deceased donor transplants. Aorta-IVC anastomosis was significantly associated with longer LOS compared to iliac vessel anastomosis.

Moving on: transitioning young people with chronic kidney disease to adult care

Advances in the care of children mean that adolescents with chronic kidney disease (CKD) are surviving to adulthood and requiring transition to adult care. The transition phase is well-recognised to be associated with considerable excess morbidity and graft loss, but these outcomes may be avoidable through a structured transition programme. This review will discuss the (1) challenges encountered by patients with CKD, caregivers and clinicians during transition; (2) predictors and outcomes of transition; (3) current guidelines on transition from paediatric to adult renal services; (4) interventions and research directions that may help to improve the care and outcomes for young people with CKD in transition. In spite of the substantial improvement in health gains required for this disadvantaged population, there is to date only limited evidence on the effects of current transition programmes.

Health Care Use During Transfer to Adult Care Among Youth With Chronic Conditions

OBJECTIVE

To compare health care use and costs for youth with chronic health conditions before and after transfer from pediatric to adult health care services.

METHODS

Youth born in Ontario, Canada, between April 1, 1989, and April 1, 1993, were assigned to 11 mutually exclusive, hierarchically arranged clinical groupings, including "complex" chronic conditions (CCCs), non-complex chronic conditions (N-CCCs), and chronic mental health conditions (CMHCs). Outcomes were compared between 2-year periods before and after transfer of pediatric services, the subjects' 18th birthday.

RESULTS

Among 104,497 youth, mortality was highest in those with CCCs, but did not increase after transfer (1.3% vs 1.5%, P = .55). Costs were highest among youth with CCCs and decreased after transfer (before and after median [interquartile range]: $4626 [1253-21,435] vs $3733 [950-16,841], P < .001);Costs increased slightly for N-CCCs ($569 [263-1246] vs $589 [262-1333], P < .001), and decreased for CMHCs ($1774 [659-5977] vs $1545 [529-5128], P < .001). Emergency department visits increased only among youth with N-CCCs (P < .001). High-acuity emergency department visits increased CCCs (P = .04) and N-CCCs (P < .001), but not for CMHC (P = .59), who had the highest visit rate. Among the 11 individual conditions, costs only increased in youth with asthma (P < .001), and decreased (P < .05) in those with neurologic impairment, lupus, inflammatory bowel disease, and mood/affective disorders.

CONCLUSIONS

Pediatric transfer to adult care is characterized by relatively stable short-term patterns of health service use and costs among youth with chronic conditions.

Transitional Care and Adherence of Adolescents and Young Adults After Kidney Transplantation in Germany and Austria: A Binational Observatory Census Within the TRANSNephro Trial

Transition from child to adult-oriented care is widely regarded a challenging period for young people with kidney transplants and is associated with a high risk of graft failure. We analyzed the existing transition structures in Germany and Austria using a questionnaire and retrospective data of 119 patients transferred in 2011 to 2012. Most centers (73%) confirmed agreements on the transition procedure. Patients' age at transfer was subject to regulation in 73% (18 years). Median age at transition was 18.3 years (16.5-36.7). Median serum creatinine increased from 123 to 132 μmol/L over the 12 month observation period before transfer (P = 0.002). A total of 25/119 patients showed increased creatinine ≥ 20% just before transfer. Biopsy proven rejection was found in 10/119 patients. Three patients lost their graft due to chronic graft nephropathy.Mean coefficient of variation (CoV%) of immunosuppression levels was 0.20 ± 0.1. Increased creatinine levels ≥ 20% just before transfer were less frequently seen in patients with CoV < 0.20 (P = 0.007). The majority of pediatric nephrology centers have internal agreements on transitional care. More than half of the patients had CoV of immunosuppression trough levels consistent with good adherence. Although, 20% of the patients showed increase in serum creatinine close to transfer.

Standardized multilevel transition program: Does it affect renal transplant outcome?

The transfer of renal transplant patients from pediatric to adult care is a crucial step with a high risk of subsequent graft loss. Therefore, the transition should be a thoroughly planned, well-designed and multidisciplinary process focused on the individual patient. Our pediatric nephrology department introduced a structured step-by-step transition program supported by a multidisciplinary team of health professionals. The purpose of our study was to determine the effects of the transition program on eGFR and number of ARs in comparison to a group without a transition program at one and three yr after transfer. We conducted a single-center retrospective cohort study of renal transplant patients prior to and after the introduction of the transition program. Multiple regression analysis revealed a significantly lower decline of eGFR in the group with transition program (-11.3 ± 44 mL/min/1.73 m(2) ) compared to the group without transition program (-28.4 ± 33 mL/min/1.73 m(2) ) at three yr after transfer. The number of AR episodes significantly decreased from 34.6% in the group without transition program to 9.1% in the group with transition program. The standardized multilevel transition program seems to have significant positive effects on eGFR and number of AR episodes in renal transplant patients.

Lack of significant improvements in long-term allograft survival in pediatric solid organ transplantation: A US national registry analysis

Improvements across many facets of transplantation have led to better 1-yr outcomes of transplanted organs. In this study, we assessed whether longer-term attrition rates improved in pediatric kidney (KI), liver (LI), heart (HR) and lung (LU) transplant (TX) survival. We analyzed data between 1989 and 2008 from 5747 KI, 7348 LI, 5103 HR, and 715 LU TXs (under 18 yr of age at transplant, first solitary transplant only), from the National Scientific Registry of Transplant Recipients database in the USA. Kaplan-Meier (K-M) or ordinary least square (OLS) estimates were used to calculate median and projected survival half-lives. Attrition rates, defined as percent failing within a given time period, were stratified by year of TX. Median half-lives from 1989 TX year to 2005 TX year have shown a major improvement only in LI TX, remaining unchanged in HR and KI TX, or remaining very low in LU TX. All four organ TX types have shown a dramatic drop in first-year attrition rates from 1989 to 2008. However, longer-term attrition rates (1-3, 3-5, 5-10 yr) have remained largely unchanged for all four organ TX types. Further progress in long-term survival will need targeting end-points beyond first-year rejection and survival rates.

Heightened graft failure risk during emerging adulthood and transition to adult care

Emerging adulthood, defined as the interval between 18 and 25 years of age, is a socially-defined developmental stage. Although people in this age group appear physically mature, brain maturation is not complete until the end of this period. Perhaps due to this immaturity and a resulting inferior ability to manage chronic illness emerging adults with a variety of chronic health conditions are at a high risk for adverse outcomes. In this review I will summarize evidence that emerging adulthood constitutes a high-risk period for kidney transplant recipients, and consider the possible reasons for the spike in graft failure risk during this age interval-including age-related adherence behaviour and the changes in care organization, processes and structures associated with transfer from pediatric to adult-oriented care. I will also discuss evidence showing transfer from pediatric to adult-oriented care contributes to this elevated risk, and highlight the limitations and challenges of studies examining this question. Finally, I will direct readers to resources providing guidance on the best practices for care of patients transitioning to adult care.

Transitional care in solid organ transplantation

Pediatric solid organ transplantation has become an accepted modality of treatment in the last few decades. The number of childhood recipients of solid organ transplantation surviving to adulthood is correspondingly rising. This review examines the epidemiology of pediatric solid organ transplant recipients, and the challenges faced during transition to adult services, with suggestions for improvement in collaborative and coordinated care. Transition to adulthood has been established as a vulnerable period for recipients of a solid organ transplant. Assessment of readiness for transfer, allowing sufficient time for preparation before the actual transfer, involvement of all stakeholders, and inclusion of a transition coordinator are some of the components that can facilitate successful transition to the adult transplant program. This programmatic approach improves both quality of life and long-term graft and patient survival. Moreover, the economic benefits associated with avoiding frequent hospitalizations for graft dysfunction and preventing re-transplantation more than compensate for the costs related to establishing and maintaining a robust transition program.

Usability testing of the Internet program: "Teens Taking Charge: Managing My Transplant Online"

Adolescents with SOT demonstrate high rates of medication non-adherence and higher rates of graft loss compared to all other age groups. Self-management interventions encompass information-based material designed to achieve disease-related learning and changes in the participant's knowledge and skill acquisition, while providing social support. These interventions have had some success in chronic disease populations by reducing symptoms and promoting self-efficacy and empowerment. Using findings from a needs assessment, an Internet-based self-management program, Teens Taking Charge: Managing My Transplant Online, for youth with SOT was developed. This program contains information on transplant, self-management and transition skills, and opportunities for peer support. The purpose of this study was to determine the usability and acceptability of the initial three modules (Medication and Vaccines; Diet after Transplant; and Living with a Transplant Organ) of the online program from the perspectives of youth with SOT. Participants were recruited from SOT clinics at a large pediatric tertiary care center in Canada. Three iterative cycles (seven patients per iteration) of usability testing took place to refine the Web site prototype. Study procedures involved participants finding items from a standardized list of features and talking aloud about issues they encountered, followed by a semi-structured interview to generate feedback about what they liked and disliked about the program. All 21 patients (mean age = 14.9 yr) found the Web site content to be trustworthy, they liked the picture content, and they found the videos of peer experiences to be particularly helpful. Participants had some difficulties finding information within submodules and suggested a more simplistic design with easier navigation. This web-based intervention is appealing to teenagers and may foster improved self-management with their SOT. Nine additional teen and two parent modules are being developed, and the completed Web site will undergo usability testing. In the future, a randomized control trial will determine the feasibility and effectiveness of this online self-management program on adherence, self-efficacy, and transition skills.

Loss of pediatric kidney grafts during the "high-risk age window": insights from pediatric liver and simultaneous liver-kidney recipients

Pediatric kidney transplant recipients experience a high-risk age window of increased graft loss during late adolescence and early adulthood that has been attributed primarily to sociobehavioral mechanisms such as nonadherence. An examination of how this age window affects recipients of other organs may inform the extent to which sociobehavioral mechanisms are to blame or whether kidney-specific biologic mechanisms may also exist. Graft loss risk across current recipient age was compared between pediatric kidney (n = 17,446), liver (n = 12,161) and simultaneous liver-kidney (n = 224) transplants using piecewise-constant hazard rate models. Kidney graft loss during late adolescence and early adulthood (ages 17-24 years) was significantly greater than during ages <17 (aHR = 1.79, 95%CI = 1.69-1.90, p < 0.001) and ages >24 (aHR = 1.11, 95%CI = 1.03-1.20, p = 0.005). In contrast, liver graft loss during ages 17-24 was no different than during ages <17 (aHR = 1.03, 95%CI = 0.92-1.16, p = 0.6) or ages >24 (aHR = 1.18, 95%CI = 0.98-1.42, p = 0.1). In simultaneous liver-kidney recipients, a trend towards increased kidney compared to liver graft loss was observed during ages 17-24 years. Late adolescence and early adulthood are less detrimental to pediatric liver grafts compared to kidney grafts, suggesting that sociobehavioral mechanisms alone may be insufficient to create the high-risk age window and that additional biologic mechanisms may also be required.

Adherence in Adolescent and Young Adult Kidney Transplant Recipients

Poor adherence to immunosuppressive medications may be the most important barrier to long term graft survival. An understanding of medication adherence and its determinants is critical to addressing this important problem. In this paper, we will review the different ways in which adherence may be compromised, summarize the evidence that young people constitute a particularly high risk group, and consider the consequences and impact of poor adherence. We will also review the determinants of adherence, including characteristics of the patient and family, the treatment regimen, the healthcare team and its organization, and the healthcare system. We will highlight the most common barriers to adherence identified by young people, and consider different methods of measuring adherence, along with the advantages and limitations of each. Finally, we will consider possible intervention strategies to improve adherence in young people.

Organ donation and transplantation in Canada: insights from the Canadian Organ Replacement Register

PURPOSE OF REVIEW

To provide an overview of the transplant component of the Canadian Organ Replacement Register (CORR).

FINDINGS

CORR is the national registry of organ failure in Canada. It has existed in some form since 1972 and currently houses data on patients with end-stage renal disease and solid organ transplants (kidney and/or non-kidney). The transplant component of CORR receives data on a voluntary basis from individual transplant centres and organ procurement organizations across the country. Coverage for transplant procedures is comprehensive and complete. Long-term outcomes are tracked based on follow-up reports from participating transplant centres. The longitudinal nature of CORR provides an opportunity to observe the trajectory of a patient's journey with organ failure over their life span. Research studies conducted using CORR data inform both practitioners and health policy makers alike.

IMPLICATIONS

The importance of registry data in monitoring and improving care for Canadian transplant candidates/recipients cannot be over-stated. This paper provides an overview of the transplant data in CORR including its history, data considerations, recent findings, new initiatives, and future directions.

An empirically based practice perspective on the transition to adulthood for solid organ transplant recipients

Preparing patients for transitioning to self-managed care and subsequently transferring to the adult healthcare system has become a critical process for clinicians working with pediatric transplant recipients. This paper reviews several barriers to a successful transition. These include patient barriers, caregiver barriers, and considerations within pediatric and adult centers. To date, few approaches for improving the transition process have been empirically tested. This review details studies that have examined possible models including usage of a transition coordinator and transition clinics. Recommendations are offered to promote an optimal transition including the importance and content of preparation, assessing and addressing transition readiness, insuring the involvement of all stakeholders, and finally, at minimum providing services during the transfer period. Future directions are offered aiming to advance this important area of investigation.

Medication adherence in the transition of adolescent kidney transplant recipients to the adult care

Non-adherence is common in adolescent and young adult kidney transplant recipients, leading to adverse graft outcomes. The aim of this study was to determine whether adherence to immunosuppressant medications changes during transition from a pediatric to an adult program within the same transplant center. Adherence was assessed for a period of two yr before and two yr after the transfer. Subtherapeutic trough levels of serum tacrolimus and level variability were used as measures of adherence. Twenty-five patients were transitioned between 1996 and 2011 at the median age of 22.3 [IQR 21.6-23.0] yr. Young adults 21-25 yr of age (n = 26) and non-transitioned adolescents 17-21 yr of age (currently followed in the program, n = 24 and those that lost their grafts prior to the transfer, 22) formed the comparison groups. In the transitioned group, adherence prior to the transfer was not significantly different from the adherence after the transfer (p = 0.53). The rate of non-adherence in the group of non-transitioned adolescents who lost their grafts (68%) was significantly higher than in the transitioned group (32%, p = 0.01). In the group of young adults, adherence was not significantly different from the transitioned group (p = 0.27). Thus, transition was not associated with differences in medication adherence in this single-center study. Large-scale studies are needed to evaluate the national data on medication adherence after transfer.

Recent developments in kidney transplantation in children

PURPOSE OF REVIEW

Renal transplantation in childhood is a well established procedure with excellent short-term outcomes. However, waiting times for transplantation are still relatively long if living donation cannot be performed, and long-term outcomes after transplantation have not significantly improved during the last decade.

RECENT FINDINGS

This review describes alternative modalities to improve donation rates such as en bloc kidney transplantation from young donors, ABO-incompatible transplantation and kidney paired donation. This review also deals with long-term post-transplant morbidities, such as follows: first, medication side-effects (metabolic syndrome, cardiovascular disease) and with the benefits of steroid and calcineurin inhibitor drug minimization; second, the deleterious impact of viral infections and their management and third, chronic antibody-mediated rejection, its therapeutic and prevention possibilities.

SUMMARY

Donor shortage and long-term morbidities, after transplantation, are still relevant issues in paediatric renal transplantation medicine. Significant research and efforts have been made to advance the field and create novel approaches for improvement of transplantation rates and post-transplant graft or patient survival. These modalities are to be established in the routine setting.

National trends over 25 years in pediatric kidney transplant outcomes

OBJECTIVE

To investigate changes in pediatric kidney transplant outcomes over time and potential variations in these changes between the early and late posttransplant periods and across subgroups based on recipient, donor, and transplant characteristics.

METHODS

Using multiple logistic regression and multivariable Cox models, graft and patient outcomes were analyzed in 17,446 pediatric kidney-only transplants performed in the United States between 1987 and 2012.

RESULTS

Ten-year patient and graft survival rates were 90.5% and 60.2%, respectively, after transplantation in 2001, compared with 77.6% and 46.8% after transplantation in 1987. Primary nonfunction and delayed graft function occurred in 3.3% and 5.3%, respectively, of transplants performed in 2011, compared with 15.4% and 19.7% of those performed in 1987. Adjusted for recipient, donor, and transplant characteristics, these improvements corresponded to a 5% decreased hazard of graft loss, 5% decreased hazard of death, 10% decreased odds of primary nonfunction, and 5% decreased odds of delayed graft function with each more recent year of transplantation. Graft survival improvements were lower in adolescent and female recipients, those receiving pretransplant dialysis, and those with focal segmental glomerulosclerosis. Patient survival improvements were higher in those with elevated peak panel reactive antibody. Both patient and graft survival improvements were most pronounced in the first posttransplant year.

CONCLUSIONS

Outcomes after pediatric kidney transplantation have improved dramatically over time for all recipient subgroups, especially for highly sensitized recipients. Most improvement in graft and patient survival has come in the first year after transplantation, highlighting the need for continued progress in long-term outcomes.

Avoidable hospitalizations in youth with kidney failure after transfer to or with only adult care

OBJECTIVE

Hospital admissions for ambulatory care-sensitive conditions (also called avoidable hospitalizations) are a measure of quality and access to outpatient care. We determined if young patients with end-stage renal disease (ESRD) are at increased risk of avoidable hospitalizations.

METHODS

A national organ failure registry was used to identify patients with ESRD onset at <22 years of age between April 1, 2001, and March 31, 2010, who had received care in an adult care facility after age 15 years. The cohort was linked to the national hospitalizations database to identify avoidable hospitalizations relevant for young patients with ESRD. Patients were followed up until death, loss to follow-up, or study end. Two groups were studied: (1) patients transferred from pediatric to adult care; and (2) patients receiving ESRD care exclusively in adult centers. We determined the association between overall and avoidable hospitalization rates and both age and transfer status by using Poisson regression models.

RESULTS

Our cohort included 349 patients. Among the 92 (26.4%) patients transferred to adult care during the study period, avoidable hospitalization rates were highest during the period 3 to <4 years after transfer (rate ratio: 3.19 [95% confidence interval: 1.42-7.18]) compared with the last year in pediatric care. Among the 257 (73.6%) patients who received ESRD care exclusively in adult centers, avoidable hospitalization rates increased with age.

CONCLUSIONS

Among those who were transferred to adult care, avoidable hospitalization rates increased after transfer. Avoidable hospitalization rates increased with age in ESRD patients who received care in adult centers. Young patients with ESRD are at increased risk of avoidable hospitalizations.

Different models of transition to adult care after pediatric kidney transplantation: a comparative study

Transition from pediatric to adult care is a critical and difficult step for young people with transplants and for the multidisciplinary team involved. In our retrospective study, we investigated the clinical course in a two-yr period of transition. Data from 66 teenagers were collected one yr before and after their transfer to three different adult care settings: (i) a specialized transition clinic, (ii) a general transplantation clinic, and (iii) a nephrologist. Patient survival rate was 100%. Three patients developed graft loss. GFR development was comparable in the three settings (ΔGFR 1.4 ± 8.7 vs. 3.1 ± 10.6 vs. 0.8 ± 4.4 mL/min/1.73 m2 , p = ns). Immunosuppressive therapy was stable in setting 1, whereas the number of changes increased in setting 2 and even more in setting 3. The percentage of patients with steroids increased from 36% to 38% and 52% in settings 1-3. Patient satisfaction was highest in setting 1 (100% vs. 64% and 78%, p < 0.05). Setting 1 was associated with fewer changes in therapy (13% vs. 91% and 45%, p < 0.05). The use of a specialized transition clinic is associated with fewer changes in medication and care and a higher level of patient satisfaction. This was not associated with a lower increase in GFR one yr after transition. Long-term results are awaited.

Age at graft loss after pediatric kidney transplantation: exploring the high-risk age window

BACKGROUND AND OBJECTIVE

The risk of graft loss after pediatric kidney transplantation increases during late adolescence and early adulthood, but the extent to which this phenomenon affects all recipients is unknown. This study explored interactions between recipient factors and this high-risk age window, searching for a recipient phenotype that may be less susceptible during this detrimental age interval.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

With use of Scientific Registry of Transplant Recipients data from 1987 to 2010, risk of graft loss across recipient age was quantified using a multivariable piecewise-constant hazard rate model with time-varying coefficients for recipient risk factors.

RESULTS

Among 16,266 recipients, graft loss during ages ≥17 and <24 years was greater than that for both 3-17 years (adjusted hazard ratio [aHR], 1.61; P<0.001) and ≥24 years (aHR, 1.28; P<0.001). This finding was consistent across age at transplantation, sex, race, cause of renal disease, insurance type, pretransplant dialysis history, previous transplant, peak panel-reactive antibody (PRA), and type of induction immunosuppression. The high-risk window was seen in both living-donor and deceased-donor transplant recipients, at all levels of HLA mismatch, regardless of centers' pediatric transplant volume, and consistently over time. The relationship between graft loss risk and donor type, PRA, transplant history, insurance type, and cause of renal disease was diminished upon entry into the high-risk window.

CONCLUSIONS

No recipient subgroups are exempt from the dramatic increase in graft loss during late adolescence and early adulthood, a high-risk window that modifies the relationship between typical recipient risk factors and graft loss.