Health care transition for adolescents with CKD-the journey from pediatric to adult care

Abstract

The design of Health Care Transition (HCT) services for adolescents and emerging adults with CKD or end-stage kidney disease (ESKD) needs to take into account patient cognition/developmental stage, family factors, and health resources within the hospital setting and community. Patient and family education is fundamental and teaching and learning tools must be literacy-accessible. Adolescents and emerging adults with CKD/ESDK have complex medical and dietary regimes, and therapeutic adherence is important for optimizing their health, quality of life, and longevity. Health providers need to identify ways of engaging them to become successful disease self-mangers. Interdisciplinary collaboration between the pediatric- and adult-focused health care teams and the services of a dedicated transition coordinator are paramount to ensure clear communication between the patient and the health professionals involved. Valid measurement tools to monitor and assess the HCT process and health outcomes need to be developed. The aims of planned HCT for adolescents and/or emerging adults with CKD/ESKD are anchored by the goals of optimizing health outcomes, health-related quality of life, and continuous quality improvement. The care of young people with CKD/ESKD can be both challenging and rewarding; we offer strategies for planned HCT services geared to these vulnerable patients.