Transition of Care Summary (Pediatric-to-Adult Nephrology)

Document title: Transition of Care Summary – Pediatric-to-Adult Nephrology

Date of summary: [Date]

Sending clinic/institution: [Clinic/Institution name] — Primary pediatric nephrologist: [Name, credentials, phone, secure email]

Transition coordinator: [Name, role, phone, email] (Omit if not applicable)

Receiving adult practice/nephrologist: [Practice/Nephrologist name, phone, secure email] (If unknown, state "Not yet identified")

Patient: [Legal name] — DOB: [Date] — MRN: [MRN]

Preferred name/pronouns: [Preferred name/pronouns] (Omit if none specified)

Primary caregiver(s) and decision-making status: [Caregiver names/relationship; legal guardianship or supported decision-making status] (If uncertain, state "Unknown – verify at first adult visit" and add to Pending Items)

Primary renal diagnosis: [Etiology/diagnosis]

Current kidney modality: [CKD stage / HD / PD / Transplant / Preemptive listing] with [date modality started or transplant date; access type if dialysis; donor type if transplant]

Urgent flags: [Critical concerns such as high rejection risk, recent infections, access issues, insurance gaps, active safety concerns] (Keep to 1 line; front-load life/organ-threatening risks)

Executive Clinical Snapshot

(Maximum 10–12 bullets. Front-load safety-critical items. Include dates with any value that can change.)

• [Etiology of CKD/ESKD]
• [Current kidney status with date: eGFR / dialysis modality and schedule / transplant baseline creatinine]
• [Dialysis prescription headline: modality, access type, schedule, most recent adequacy with date] (Include only if on dialysis)
• [Immunosuppression regimen: agents, doses, goal troughs, last level with date] (Include only if transplanted)
• [Most recent key labs with dates: creatinine/eGFR, K, HCO3, Phos, Ca, PTH, Hgb, albumin, immunosuppressant level]
• [Major events last 6–12 months: rejection, peritonitis, access complications, hospitalizations with dates/outcomes]
• [Top active risks: adherence concerns, mental health issues, social instability, insurance/medication access gaps]
• [Time-sensitive pending items with due dates]
• [Immunization precautions and hepatitis B status]
• [Emergency contact for urgent issues until adult team assumes care]

Allergies and Precautions

• Medication allergies: [Drug — reaction type — severity — date confirmed — source] (If unknown or unconfirmed, state "Allergies: Unknown/not confirmed – verify at first visit" and add to Pending Items)
• Non-drug allergies: [Allergen — reaction] (e.g., latex, chlorhexidine, adhesives)
• Immunization contraindications: [Contraindications and precautions] (e.g., no live vaccines post-transplant)
• Special precautions: [MDRO history, difficult airway, bleeding risk, contrast precautions]

Transition Context

• Reason for transfer: [Age policy / relocation / insurance change / patient preference / other]
• Last pediatric nephrology visit: [Date] — [in-person / telehealth]
• First adult nephrology appointment: [Date/time] or [Not yet scheduled — next step]
• Dialysis unit: [Name, address, phone, schedule, primary contact] (Include only if on dialysis)
• Transplant center: [Center name, transplant coordinator name/contact] (Include only if transplanted)
• Attachments included: [List key attachments: lab trends, biopsy reports, dialysis flowsheets, transplant operative note, pathology summaries]

Active Problems and Current Management

(Use problem-oriented format. Include onset/diagnosis date, current status, current regimen, key complications, monitoring targets, and gaps/pending actions. Omit categories that do not apply to this patient.)

Primary Kidney Disease and CKD/ESKD Status

• Problem: [Diagnosis/etiology] — Onset: [Date]
• Current status: [CKD stage with eGFR and date / ESKD on HD or PD / functioning transplant with baseline creatinine and date]
• Management: [Disease-specific therapies, BP/proteinuria management, supportive care]
• Complications history: [Key complications with dates]
• Monitoring/targets: [Parameters monitored, target ranges, frequency]
• Gaps/pending: [Outstanding items and responsible party]

Disease course narrative: [6–10 sentence summary with dated anchor points covering diagnosis, progression, dialysis/transplant history, modality changes, and current trajectory] (Include only if problem list alone does not convey a coherent clinical story)

Dialysis Access and Prescription

(Include only if on dialysis)

• Access: [Type, location, creation date, revisions, current issues, last surveillance with date]
• HD prescription: [Schedule, hours, Qb/Qd, dialyzer, dialysate composition, UF profile, dry weight, anticoagulation] (Include only if on HD)
• PD prescription: [CAPD/CCPD, cycles, dwell volumes, dextrose/icodextrin, fill/drain times, daytime dwell] (Include only if on PD)
• Adequacy/metrics: [spKt/V or stdKt/V, URR, BP/volume trends, IDWG with dates]
• Complications: [Peritonitis episodes with organism/date, catheter infections, access thrombosis, intradialytic symptoms]
• Monitoring/targets: [Access surveillance schedule, adequacy targets, dry weight reassessment cadence]
• Gaps/pending: [Planned interventions, imaging, surgical referrals]

Kidney Transplant Status

(Include only if transplanted)

• Transplant date(s) and donor: [Date(s), living/deceased, ABO, HLA match]
• Immunosuppression history: [Induction agent, maintenance changes, intolerance/toxicity]
• Current immunosuppression: [Agents, dose/route/frequency, goal troughs, last level with date]
• Rejection episodes: [Type, date, treatment, outcome]
• DSA/immunologic risk: [Current DSA status with date, cPRA, sensitization events]
• Opportunistic infections: [CMV/BK/EBV history with dates, treatment, outcomes]
• Baseline function trend: [Creatinine/eGFR trend with dates, proteinuria]
• Monitoring/targets: [Drug levels, labs, biopsy/DSA surveillance cadence]
• Gaps/pending: [Upcoming labs/biopsy, PA renewals, vaccination review]

Hypertension and Cardiovascular Risk

• Status: [Home vs clinic BP trends with dates, current target]
• Regimen: [Antihypertensives with doses, sodium/fluid goals]
• Complications: [LVH, arrhythmias, hypertensive crises with dates]
• Monitoring/targets: [BP targets, ABPM if used, labs after changes]
• Gaps/pending: [Echocardiogram, ABPM, medication titration]

Anemia of CKD

• Status: [Recent Hgb with date, target range]
• Regimen: [ESA type/dose/frequency, iron regimen/route]
• Iron indices: [Ferritin, TSAT with dates]
• Monitoring/targets: [Lab frequency, hold/adjust parameters]
• Gaps/pending: [ESA/iron authorization, next dosing date]

CKD-Mineral and Bone Disorder

• Status: [Recent Ca, Phos, PTH, 25(OH)D with dates]
• Regimen: [Phosphate binders, vitamin D analogs, calcimimetics, dietary restrictions]
• Monitoring/targets: [Lab cadence and target ranges]
• Gaps/pending: [DXA if indicated, binder titration]

Urologic Conditions

(Include only if applicable)

• Diagnosis/surgeries: [Reflux, obstruction, bladder dysfunction; procedures with dates]
• Current management: [Catheterization regimen, prophylaxis, urology follow-up]
• Monitoring: [Post-void residuals, UTI surveillance, imaging cadence]

Growth/Puberty/Fertility

(Include only if relevant ongoing concerns)

• Status: [Growth percentiles, pubertal stage, fertility counseling]
• Management: [Nutrition support, endocrinology involvement, hormone therapy]

Mental Health

• Diagnoses: [Conditions with dates of diagnosis]
• Treatment: [Therapy type/frequency, medications, prescriber contact]
• Risk: [Recent crises, suicidality assessment, safety plan if applicable]

Neurodevelopmental/Self-Management Factors

(Include only if applicable)

• Conditions: [Neurodevelopmental diagnoses, cognitive considerations]
• Impact on care: [Medication organization needs, reminders, supervision requirements]

Medications

(Provide a reconciled list. For each: generic name, dose/route/frequency, indication, recent changes with dates, monitoring requirements. Flag high-risk medications. Note adherence signals and access barriers. If incomplete, state "Medication list not fully reconciled" and add to Pending Items.)

Immunosuppression (List first if transplanted)

• [Agent — dose/route/frequency — goal trough — last level with date — monitoring cadence]

Scheduled Medications

• [Medication — dose/route/frequency — indication — recent changes — monitoring — high-risk flag if applicable]

PRN and OTC/Supplements

• [Medication — dose/route/frequency — indication — cautions]

Adherence/access notes: [Refill gaps, drug level variability, specialty pharmacy requirements, prior authorization needs, copay issues, mitigation strategies in place]

Significant Events (Last 12–24 Months)

(Chronological bullets. Include remote history only if critical for ongoing management.)

• [Date — Hospitalization/ED visit — reason — interventions — outcome]
• [Date — Dialysis complication — organism/details — management — outcome]
• [Date — Transplant complication — type — treatment — outcome]
• [Date — Procedure — findings — complications]

Objective Data Trends

(Summarize trends rather than listing all values. Include most recent values with dates. Link any value driving an action to a Pending Item.)

• Blood pressure: [Home vs clinic trends, most recent with date, target]
• Weight/volume: [Recent weights with dates, dry weight if on dialysis, IDWG]
• Kidney function: [Creatinine/eGFR trend with dates, transplant baseline]
• Proteinuria: [ACR/PCR trend with dates]
• Electrolytes/acid-base: [K, HCO3 trends with dates]
• CKD-MBD labs: [Ca, Phos, PTH trends with dates]
• Anemia/iron: [Hgb, ferritin, TSAT trends with dates]
• Transplant drug levels: [Tacrolimus/cyclosporine levels with dates and variability] (Include only if transplanted)
• Imaging highlights: [Key findings from renal US, access imaging with dates]

Transition Readiness and Psychosocial Factors

• Living situation and supports: [Household members, primary supports]
• Education/work status: [School/grade or employment, accommodations]
• Cognitive/developmental factors: [Factors affecting self-management]
• Mental health treatment: [Active care, medications, therapist/psychiatry contacts]
• Substance use: [Status if known]
• Health literacy/communication: [Language, interpreter needs, learning preferences]
• Transportation/housing: [Stability, barriers]
• Insurance status: [Current plan, anticipated changes, age-out timing, medication coverage concerns]
• Transition readiness summary: [What patient can do independently: medication management, refills, scheduling, disease knowledge, symptom recognition, provider communication]

Adherence Risk Assessment

• Objective indicators: [Missed appointment %, dialysis attendance, refill gaps, drug level variability, missed labs — with rates/dates]
• Patient-reported barriers: [Transportation, reminders, side effects, understanding, cost]
• Risk categorization: [Low / Moderate / High] — Justification: [Brief rationale based on objective data]
• Mitigation strategies: [Pillbox, alarms, family supervision, pharmacy sync, simplified regimen, behavioral health support, increased monitoring post-transfer]

(If adherence is uncertain, state "Adherence unclear—insufficient data" and specify what information is missing; add information-gathering to Pending Items)

Preventive Care and Infection Status

• Vaccination summary: [Up-to-date vaccines; vaccines missing/needed] (Do not reproduce full registry)
• Hepatitis B status: [Surface antibody titer with date, vaccine series completion, booster need]
• TB screening: [Test type, date, result] (Include if locally relevant)
• Transplant infectious monitoring: [CMV/EBV serostatus, significant prior infections with dates] (Include only if transplanted)

Care Team and Emergency Contacts

• Pediatric nephrology: [Name, phone, secure email, after-hours process, support window post-transfer]
• Adult nephrology intake: [Name/clinic, phone, secure email]
• Dialysis unit: [Name, phone, charge nurse, schedule] (Include only if on dialysis)
• Transplant coordinator: [Name, phone, secure email] (Include only if transplanted)
• Specialty pharmacy: [Name, phone, PA process, delivery notes]
• Social work: [Name, contact]
• Dietitian: [Name, contact]

Emergency guidance: [Where to present for emergencies; urgent symptoms requiring immediate contact; who to notify and how]

Pending Items and Handoff Tasks

(Every item must have an assigned owner. Include labs, imaging, access surveillance, pending results, prior authorizations, vaccines, referrals, and appointments.)

Item	Reason	Due Date	Owner	Status	Notes
[Task]	[Clinical rationale]	[Date]	[Pediatric team / Adult team / Dialysis unit / Patient]	[Not started / In progress / Completed]	[Details, dependencies]

Plan by Problem

(Concise, actionable guidance for adult team. Include current status, regimen, monitoring plan, contingencies, and handoff tasks with ownership. Omit problems not applicable to this patient.)

[Problem name]

• Status: [Stable / Improving / Worsening] — [Key supporting data with dates]
• Current regimen: [Therapies, doses, devices, schedule]
• Monitoring plan: [What to check, frequency, targets]
• Contingencies: [If X occurs, consider Y]
• Handoff tasks: [Adult team vs pediatric team responsibilities with timeframes]

[Problem name]

• Status: [Summary]
• Current regimen: [Summary]
• Monitoring plan: [Summary]
• Contingencies: [Summary]
• Handoff tasks: [Summary]

(Repeat for each active problem requiring ongoing management)