Kidney Transplant Evaluation Note (Pediatrics)

Date/Time: [Date and time of evaluation]

Location: [Clinic/Unit/Telehealth location]

Encounter Type: [inpatient / outpatient / telehealth]

Evaluator Name and Discipline: [Name, credentials, role]

Others Present: [Guardians and relationships; interpreter used and language if applicable; team members present]

Referring Clinician/Facility: [Referring provider and facility]

Primary Dialysis Facility and Modality: [Facility name, modality, and schedule] (If not on dialysis, state "Not applicable—preemptive evaluation")

Chief Concern

[Reason for pediatric kidney transplant evaluation, including ESKD etiology, dialysis status or preemptive candidacy, and duration on dialysis if applicable] (Limit to 1–2 sentences)

Sources of Information

• [Patient interview]
• [Guardian interview]
• [Outside records with source and date range]
• [Immunization registry]
• [Dialysis unit records]
• [Institutional EHR/lab systems]

Reliability/Limitations: [Complete / Limited] — [Details on missing or pending records]

Kidney Disease History

[Narrative timeline from CKD diagnosis through progression to ESKD, including onset, workup, and key milestones. Describe etiology with supporting evidence (biopsy, genetics, imaging, serologies). If etiology unknown, document workup performed and current differential.] (Include explicit dates when available)

Recurrence Risk: [Recurrence risk discussed: yes / no] — [Summary of recurrence considerations and implications for post-transplant monitoring] (Include surveillance plan if recurrence risk is relevant)

Dialysis Course: [Modality; start date; adequacy measures; access type and complications; infections with dates; residual urine output if known] (For preemptive candidates, focus on CKD trajectory and uremic symptoms; dialysis details may be minimal or omitted)

Past Medical and Surgical History

• Cardiovascular: [Hypertension; LVH; congenital heart disease; arrhythmia]
• Pulmonary: [OSA; chronic lung disease; asthma]
• Hepatic/GI: [Liver disease; hepatitis; GI disorders]
• Endocrine/Metabolic: [Diabetes; metabolic bone disease; dyslipidemia]
• Hematologic/Thrombotic: [Bleeding disorders; thrombophilia; prior clots]
• Neurologic: [Seizures; stroke; neurodevelopmental disorders]
• Malignancy: [History and treatment status]
• Prior Transplant History: [Organ, date, outcome]
• Abdominal/Urologic Surgeries: [Nephrectomy; bladder surgery; other abdominal surgeries]
• Vascular Access/Central Line History: [Type, dates, complications]

Allergies

• [Allergen] — [Reaction type] — [Severity]

(Highlight antibiotic allergies relevant to perioperative prophylaxis)

Medications

• [Medication name — dose — route — frequency]

(Include supplements, over-the-counter, and herbals if reported)

Reported Adherence: [Patient/guardian report; objective data if available including pharmacy fill records, dialysis unit observations] — [Overall adherence impression]

Growth, Development, and School Function

• Anthropometrics: Height [value] ([percentile/z-score]); Weight [value] ([percentile/z-score]); BMI [value] ([percentile/z-score]); [Growth trajectory assessment]
• Developmental History: [Normal / abnormal]; [Early intervention; therapies; IEP/504 status if applicable]
• Neurocognitive: [Concerns present / absent]; [Formal assessment status and summary if completed]
• Adolescent Transition Readiness: [Self-management skills; medication knowledge; appointment participation; readiness plan] (Include for adolescents only)

Family History

[Kidney disease; hereditary syndromes; thrombosis; autoimmune disease; other transplant-relevant conditions]. Living donor options discussed: [yes / no] (Do not document donor medical details in recipient chart)

Psychosocial Evaluation

(This section is required for all candidates; if assessment incomplete, use standardized status statements)

Guardianship and Caregiving:

• Legal guardian(s)/custody: [Details]
• Primary caregiver(s): [Names/relationship]; Backup caregiver plan: [Details]
• Transportation and distance to transplant center: [Details]

Psychosocial Functioning:

• Patient coping, anxiety/depression history, therapy supports: [Details]
• Family stressors: [Details]
• Adolescent substance use assessment: [Completed separately per confidentiality policy / Not applicable]

Adherence Assessment:

• Dialysis attendance: [On time / missed sessions with reasons]
• Diet/fluid adherence: [Assessment]
• Medication adherence: [Assessment with objective signals if available]
• Missed appointments: [Frequency/reasons]; Mitigation plan: [Details]
• Health literacy and language access needs: [Details]
• Standardized tool (if used): [Name] — Score: [Value] — Interpretation: [Details]

Social Determinants:

• Insurance coverage and medication affordability: [Details]
• Social services involvement: [Agency/active issues]

Psychosocial Impression: [Psychosocially appropriate to proceed / Proceed with conditions: (specify) / Defer listing pending (interventions)] — Recommended interventions: [Details with responsible discipline]

Immunizations and Infection Screening

Immunization Status

Vaccine	Doses Documented	Evidence of Immunity	Needed Doses/Plan	Timing Constraints
Hepatitis B	[Series status]	[HBsAb titer/date]	[Catch-up/booster plan]	[Pre-transplant timing]
MMR (live)	[# doses]	[Serology if obtained]	[Needed doses]	[≥4 weeks pre-transplant]
Varicella (live)	[# doses]	[VZV IgG/date]	[Needed doses]	[≥4 weeks pre-transplant]
Influenza	[Current season status]	N/A	[Plan if due]	[Seasonal]
COVID-19	[Primary/booster status]	N/A	[Plan if due]	[Per program policy]
Other age-appropriate vaccines	[Summary of DTaP/Tdap, IPV, Hib, PCV/PPSV, HPV, MenACWY/MenB, HepA]	[Serology if available]	[Catch-up plan]	[Timing constraints]

Overall Immunization Status: [Up to date / Catch-up required] — Schedule framework: [CDC/ACIP pediatric schedule or institutional policy]

Infection Screening

Test	Result	Date	Notes
HIV 1/2 Ag/Ab	[Result]	[Date]	[Lab/source]
HBV panel (HBsAg, anti-HBs, anti-HBc)	[Results]	[Date]	[Immunity interpretation]
HCV Ab	[Result]	[Date]	[RNA if positive]
CMV IgG	[Positive / Negative]	[Date]	[D/R risk planning]
EBV IgG	[Positive / Negative]	[Date]	[PTLD risk note]
VZV IgG	[Positive / Negative]	[Date]	[Vaccination plan if non-immune]
Syphilis	[Result]	[Date]	[Notes]
TB screening	[Result]	[Date]	[Method: IGRA / TST]
Strongyloides	[Indicated: yes / no]; [Result if done]	[Date]	[Exposure rationale]
Chagas	[Indicated: yes / no]; [Result if done]	[Date]	[Exposure rationale]
Endemic fungi	[Indicated: yes / no]; [Result if done]	[Date]	[Exposure rationale]

Exposure Counseling: [Anticipatory guidance provided regarding animals, travel, household contacts, and exposures relevant to non-immune patients]

Immunologic Risk

• ABO Blood Type: [Result] — [Date] — [Source lab] (Required before listing)
• Sensitizing Events: [Prior transplant; transfusions with dates/counts; pregnancies if applicable; major surgeries]
• HLA/Antibody Status: HLA typing: [Status]; Most recent antibody screen: [Date]; cPRA: [Value]; DSA: [Present / Absent / Details]
• Monitoring Plan: [Trigger events for repeat antibody testing]

Urologic and Surgical Readiness

(Include when CAKUT, bladder dysfunction, prior urologic surgery, or unknown anatomy; omit if anatomy confirmed normal)

• CAKUT/Bladder Function: [Diagnosis; voiding pattern; continence; UTI history; reflux]
• Required Assessments: Renal/bladder US: [Date/status]; VCUG: [Date/status / Not indicated]; Urodynamics: [Date/status / Not indicated]
• Surgical Considerations: [Prior abdominal surgeries; anticipated adhesions; need for bladder reconstruction; need for native nephrectomy; vascular access concerns]
• Surgical Impression: [Ready for transplantation / Pending additional evaluation (specify)]

Physical Examination

• Vitals: BP [value] ([percentile]); HR [value]; RR [value]; Temp [value]; SpO2 [value]
• Growth Parameters: [Height/Weight/BMI summary or reference Growth section]
• Volume Status: [Euvolemic / Hypervolemic / Hypovolemic]; [Edema assessment]
• Cardiac: [Findings]
• Pulmonary: [Findings]
• Abdomen: [Scars; hernias; organomegaly; tenderness]
• Dialysis Access: [PD catheter / HD access exam and site condition]
• Skin: [Rash; infection; lesions]
• Oral/Dental: [Findings]

Objective Data Reviewed

Labs: [Renal function trend with dates; CBC; CMP; albumin; mineral bone disease labs (Ca/Phos/PTH/Vit D); coagulation if relevant; urinalysis] (Include dates and key abnormal findings)

Imaging: [Renal/bladder ultrasound; VCUG; echocardiogram; ECG; chest imaging] (Include dates and key findings)

Consultations: [Social work; psychology; dietitian; infectious disease; cardiology; urology; anesthesia; pharmacy] (Include date and key recommendations for each)

Assessment and Plan

(Problem-oriented format ordered by transplant impact and urgency)

Problem 1: [Name/diagnosis]

• Status: [Current status with objective anchors]
• Transplant relevance: [Details]
• Plan: [Actions] — Owner: [Discipline] — Timeline: [Timeframe]

Problem 2: [Name/diagnosis]

• Status: [Current status with objective anchors]
• Transplant relevance: [Details]
• Plan: [Actions] — Owner: [Discipline] — Timeline: [Timeframe]

(Add additional problems as needed)

Risk Summary: [Brief synthesis by domain: cardiovascular, pulmonary, infectious, immunologic, psychosocial/adherence, surgical — with key risks and mitigating plans]

Preliminary Candidacy Determination: [Recommend listing active / Recommend listing inactive pending (items) / Defer evaluation pending (stabilization/further workup)]

Pre-Listing Checklist

Item	Status	Date	Owner	Notes
Administrative
Guardianship/consent verified	[Complete / Pending / Not indicated]	[Date]	[Discipline]	[Details] [LISTING BLOCKER]
Psychosocial evaluation	[Complete / Pending / Deferred]	[Date]	[Social work/psychology]	[Summary] [LISTING BLOCKER]
Blood type documented	[Complete / Pending]	[Date]	[Lab]	[Source lab] [LISTING BLOCKER]
Candidate education completed	[Complete / Pending]	[Date]	[Discipline]	[Details]
Immunologic
HLA typing	[Complete / Pending]	[Date]	[Lab]	[Details]
Antibody screen and cPRA	[Complete / Pending]	[Date]	[Lab]	[Repeat schedule] [LISTING BLOCKER]
Infectious/Immunizations
Serology panel	[Complete / Pending]	[Date]	[Lab]	[Details] [LISTING BLOCKER]
TB screening	[Complete / Pending]	[Date]	[Owner]	[Details] [LISTING BLOCKER]
Vaccine catch-up	[Complete / Pending]	[Dates]	[Pediatrics/ID]	[Live vaccine timing noted] [LISTING BLOCKER per policy]
Cardiac
Echocardiogram/ECG	[Complete / Pending]	[Date]	[Cardiology]	[Key findings]
Additional cardiac testing	[Complete / Pending / Not indicated]	[Date]	[Cardiology]	[Details]
Urology/Surgery
Renal/bladder ultrasound	[Complete / Pending]	[Date]	[Radiology]	[Findings]
VCUG/Urodynamics	[Complete / Pending / Not indicated]	[Date]	[Urology]	[Findings]
Surgical clearance	[Complete / Pending]	[Date]	[Surgery]	[Impression] [LISTING BLOCKER]
Nutrition
Dietitian assessment	[Complete / Pending]	[Date]	[Nutrition]	[Growth optimization plan]
Other Consults
[Consult name]	[Complete / Pending / Not indicated]	[Date]	[Owner]	[Recommendations]

Patient and Family Counseling

• Evaluation process and timeline reviewed
• Surgical procedure overview discussed
• Alternatives (continued dialysis, supportive care) discussed
• Risks and expected outcomes reviewed, including access to program outcomes data
• Adherence expectations and follow-up intensity discussed
• Caregiver responsibilities outlined
• Right to refuse or defer discussed

Questions answered; family verbalized understanding.

Communication and Disposition

Listing Recommendation: [List active / List inactive / Defer] — Rationale: [Brief rationale]

Status Notification: Patient/guardian informed of status [listed / not listed / pending] on [date] via [method]. [Dialysis facility notified on (date) via (method)] (Include if applicable)

Communication: Referring nephrologist contacted [date/method]; Dialysis unit notified [date/method]

Follow-up: [Timeframe for committee re-review or next evaluation steps]