Kidney Transplant Follow-Up Note (Pediatrics)

Date: [encounter date]

Patient: [name, age, sex]

Visit Type: [routine follow-up / problem-driven]; [clinic / telehealth]

Historian: [patient / parent-guardian / both; interpreter: yes/no]

Labs as of: [date/time of most recent results] (Note if key monitoring labs are pending or missing and plan to obtain.)

Transplant Snapshot

(Static reference block; update only when new information emerges. If safety-critical items like CMV/EBV serostatus are unknown, state explicitly. Omit noncritical unknowns.)

• Transplant date / Time since: [date; Xy Xm post-transplant]
• Donor type: [living / deceased]
• Primary kidney disease: [diagnosis]
• Maintenance immunosuppression: [agents; steroid-free / steroid-based]
• Baseline kidney function: [best creatinine and/or eGFR range]
• Rejection history: [type/date/therapy; last biopsy if relevant] (Omit line if none.)
• CMV D/R: [D+/R+ / D+/R− / D−/R+ / D−/R− / unknown]
• EBV D/R: [D+/R+ / D+/R− / D−/R+ / D−/R− / unknown]
• Significant complications: [BK viremia / CMV disease / PTLD / recurrent disease with dates] (Omit line if none.)

Interval History

(Summarize changes since last visit affecting graft risk, infection risk, growth, or medication safety. Document adherence explicitly—do not infer from stable labs.)

• Interval events: [hospitalizations, ED visits, infections, procedures, missed visits/labs]
• Graft-focused symptoms: [urine output changes, hematuria, edema, graft pain, GI symptoms]
• Immunosuppression adherence: [missed/late doses over defined period; last dose time relative to trough draw; new interacting meds]
• Prophylaxis/exposures: [prophylaxis adherence; sick contacts, travel, high-risk exposures]
• Home BP: [trend or averages if available]
• Growth/nutrition/psychosocial: [appetite, weight change, school attendance, adherence barriers]

Objective

Vitals/Growth: [BP with pediatric percentile, HR, RR, Temp, SpO2; height/weight/BMI with percentiles; head circumference if <3 years] (Note measurement context if abnormal. For telehealth, document available home vitals and limitations.)

Exam: [pertinent transplant-relevant findings: general/hydration, oral mucosa, lymphadenopathy, CV/volume status, lungs, graft site tenderness, skin lesions/warts, tremor] (Brief bullets by system. For telehealth, document observed elements and limitations.)

Labs/Data: (Present with trends relative to baseline. Note gaps and plan to obtain.)

• Renal function: [creatinine, eGFR using pediatric formula, comparison to baseline]
• Urine: [UA findings, protein quantification]
• Electrolytes/CBC: [K, Mg, Phos, HCO3; WBC/ANC, Hgb, Plt—note significant abnormalities]
• Immunosuppression levels: [agent, trough value, goal range, timing relative to last dose]
• Viral surveillance: [BK/CMV/EBV PCR results with dates and trends]
• Imaging/Biopsy: [results if obtained] (Omit line if none.)

Clinician interpretation: [one-sentence summary of overall graft stability vs concern]

Assessment & Plan

(Problem-oriented by clinical priority. Be explicit with dose changes including units, frequency, and recheck timing.)

Graft Function

[current trend vs baseline; if dysfunction, state leading concern and differential: rejection, obstruction, dehydration, infection, drug toxicity, BK]

Plan: [hydration, medication adjustments, labs, imaging, biopsy pathway with timelines]

Immunosuppression

[current regimen and doses; trough level vs goal with rationale]

Action: [continue / adjust / hold] (If adjusting: specify new dose with units and frequency, trough timing instructions, drug interactions addressed, recheck labs and timing.)

Infection Prophylaxis/Surveillance

• Viral monitoring: [BK/CMV/EBV status and next test timing]
• CMV strategy: [prophylaxis vs preemptive; stop date if applicable]
• PJP prophylaxis: [agent, adherence, duration]
• Immunizations: [due vs deferred; live vaccine considerations]

BP/Cardiovascular

[pediatric percentile classification and trend]

Plan: [medication changes with doses; lifestyle counseling]

Growth/Development

[percentiles, growth velocity, concerns]

Plan: [nutrition interventions, referrals] (Omit section if on track without concerns.)

Additional Problems

[metabolic/bone health, hematologic, psychosocial/adherence supports] (Include only if clinically relevant; otherwise omit section.)

Counseling: [red flags reviewed: fever, decreased urine, swelling, missed meds, graft pain; when to contact transplant team vs emergency care; caregiver verbalized understanding]

Follow-up

• Next labs: [date, tests, trough timing instructions]
• Next clinic visit: [timing, modality]
• Pending results: [what is pending, communication plan]
• Team coordination: [contacts made today: surgeon, ID, PCP, pharmacy, social work] (Omit if none.)