I would first like to commend Harden et al on their quality improvement report titled, “Bridging the gap: an integrated paediatric to adult clinical service for young adults with kidney failure” (1). The authors highlight an important issue for adolescents worldwide, however I believe the methodology is flawed and paints a misleading picture for the reader.

This study compared two groups: pre-integrated care (2000-2005) and post-integrated care (2006-2011). In the pre-integrated care group the median follow-up time was 40 months versus 26 months in the post-integrated care group. Though only median figures, without more detailed reporting on follow-up times it can only be assumed that the post-integrated care group were not given ample opportunity to exhibit transplant failure relative to the pre-integrated care group and this directly implicates the reliability of these results.

Secondly, the authors mention correctly that a major component of transplant loss in adolescents is treatment adherence, and this can present as acute rejection after six months post-transplant. In the pre-treatment group the authors show that one transplant was rejected within one month which clearly indicates an issue aside from adherence. The authors should have removed this patient from their analysis and given the low number of patients assessed in this study this would have dropped the pre-integrated care group transplant rejection rate from 67% (6/9) as reported by the authors to 62.5% (5/8). Without further reporting on time to rejection a reader must question whether there were further cases like this (i.e. less than six months to rejection) that are causing confounding.

Lastly, the authors report that one patient in the pre-treatment group died from miliary tuberculosis however there is no mention to if and/or how this could have implicated a renal transplant. Tuberculosis is known to be implicated in renal transplant rejection (2).

Aside from what is formerly mentioned I believe that Harden et al should be commended for their contribution to the British Medical Journal and I look forward to their future publications.

1. Harden PN, Walsh G, Bandler N, et al. Bridging the gap: an integrated paediatric to adult clinical service for young adults with kidney failure. BMJ 2012;344:e3718.

2. Dowdy L, Ramgopal M, Hoffman T, et al. Genitourinary tuberculosis after renal transplantation: report of 3 cases and review. Clin Infect Dis 2001;32:662-6.

Competing interests: None declared