Comprehensive Approach to Kidney Education and Support: Transplant Outcomes

Background: The 2019 Advancing American Kidney Health Executive Order set a goal to increase the number of End-Stage Renal Disease (ESRD) patients receiving a kidney transplant. Per the USRDS 2023 Annual Data Report, only 7.9% of incident dialysis patients were preemptively transplanted or waitlisted prior to starting dialysis and 12.3% of prevalent dialysis patients were waitlisted. To help achieve high rates of preemptive transplant and waitlisting prior to dialysis, we designed a quality improvement (QI) project that provided comprehensive patient-centered nephrology care for patients at high risk of progression to ESRD. Methods: Our prospective QI project began January 2021 with analysis performed through May 2024. Patients at high risk of developing ESRD were identified via EMR registry. Inclusion criteria were GFR < 30 mL/min and 2-year KFRE score >20%. Patients were offered enhanced education and support regarding all possible ESRD modality treatment choices. Patients were seen sequentially by an experienced nephrology nurse practitioner (NP), social worker, dietician, and home dialysis nurse. Patients received an additional NP visit for ESRD decision planning and to address outstanding educational needs. Patient modality choices were documented in the EMR and communicated to the primary nephrologist. Patient progress and coordination gaps were discussed during quarterly list management meetings. Results: Our cohort included 42 patients (average age 65 years, GFR 16 ml/min, KFRE 53%), and 30 progressed to ESRD (71%). 11 ESRD patients were waitlisted (37%) with an average GFR of 16.3 mL/min at time of transplant referral. 4 waitlisted ESRD patients were transplanted (36%). Of our incident ESRD patients, 10 received a preemptive transplant or were waitlisted prior to starting dialysis (33%). Average time to transplant was 1.13 years after starting dialysis. Conclusion: Development of a multidisciplinary high-risk nephrology care clinic at our institution helped us surpass national rates of kidney transplant waitlisting, both preemptively and for patients on dialysis. By maintaining a high percentage of our high-risk patients on the waitlist, we hope to improve access to transplantation and decrease the duration of dialysis dependence.