Intended for healthcare professionals

Practice Quality Improvement Report

Bridging the gap: an integrated paediatric to adult clinical service for young adults with kidney failure

BMJ 2012; 344 doi: (Published 01 June 2012) Cite this as: BMJ 2012;344:e3718
  1. P N Harden, consultant nephrologist and transplant physician1,
  2. G Walsh, paediatric transplant nurse specialist2,
  3. N Bandler, adult transplant nurse specialist1,
  4. S Bradley, paediatric transplant nurse specialist3,
  5. D Lonsdale, youth development worker1,
  6. J Taylor, consultant paediatric nephrologist2,
  7. S D Marks, consultant paediatric nephrologist3
  1. 1Oxford Kidney Unit and Transplant Centre, Churchill Hospital, Oxford OX3 7LJ, UK
  2. 2Evelina Children’s Hospital, London, UK
  3. 3Great Ormond Street Hospital, London
  1. Correspondence to: P N Harden paul.harden{at}
  • Accepted 14 May 2012


Problem Transition from paediatric to adult care of young adults with chronic diseases is poorly coordinated, often delayed, and usually managed through a single referral letter. About 35% of young adults lose a successfully functioning kidney transplant within 36 months of transfer from paediatric to adult services.

Design Before and after study of the impact of a new integrated paediatric-adult clinical service for patients with kidney failure.

Setting Adult renal centre in Oxford and two paediatric renal centres in London.

Strategies for change An integrated paediatric-young adult joint transition clinic and care pathway was established in 2006, in conjunction with a young adult clinical service with regular community based clinics. Previously, young adult transplant recipients were transferred by a single referral letter to an adult renal consultant and managed in a conventional adult clinic.

Key measures for improvement Rates of acute rejection and loss of kidney transplants five years before and five years after the introduction of the integrated young adult care pathway.

Effects of the change Nine young adult kidney transplant recipients were transferred directly to adult care between 2000 and 2006 (group 1). From 2006 to 2010, 12 young adult transplant recipients underwent integrated transition into the new young adult service (group 2). Six transplants were lost in group 1 (67%) compared with no transplant losses in group 2.

Lessons learnt Implementing an integrated transition clinic, coupled with improving young adults’ healthcare experience through a young adult clinic, improved patient adherence to regular medication and engagement with healthcare providers, as judged by reduced transplant failure rates. This model may be applicable to other young adult populations with chronic disease transferring to adult healthcare.


  • We thank Kathy Davies for providing pharmacy support to the Oxford Young Adult Clinic and the Six Counties Kidney Patients Association and British Kidney Patients Association for providing travel grants and other support to the young adult patients. We thank Donal O’Donoghue, Beverley Matthews, and Clare Beard, from NHS Kidney Care, for establishing a national project in 2010 to study ways to enhance care pathways for teenagers and young adults with kidney disease (see film at

  • Contributors: PNH developed the new care model and designed this clinical practice study. He collected the data and performed the analysis and wrote the main draft of the manuscript. He will act as guarantor. The other authors were all involved with the design and implementation of the new care pathway. They reviewed the results and contributed to editing and writing the manuscript.

  • Funding: This project was mainly funded by local fund raising and voluntary donations to the Oxford Kidney Unit Discretionary Fund. In addition since August 2010 we have received a grant from NHS Kidney Care as part of the Supporting Young Adults with Kidney Disease initiative in England and a new grant from British Kidney Patients Association in 2012.

  • Competing interest: PNH is currently a clinical adviser to NHS Kidney Care on transition and young adult renal care in the UK. Otherwise there are no potential conflicts of interest. All other authors have completed the Unified Competing Interest forms and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work.

  • This clinical practice study did not require ethical approval.

  • Patient consent obtained.

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