Kidney Transplant Program

  • Kidney Transplantation − Quality Measures

    The Kidney Transplant Program at Cincinnati Children’s has teamed up with the James M. Anderson Center for Health Systems Excellence to deliver the highest quality care for our patients and families.  Our mission is to work collaboratively to achieve the best possible clinical outcomes. We do this through reliable, evidence-based medicine; personalized and family-centered care; state-of-the-art research and quality improvement; and seamless transition through all phases of care. 

    We have assembled dedicated teams that track a variety of measures, each aimed at improving care before and after kidney transplantation. Measures we currently report publicly include: 

      • Number of Transplants Performed Each Year
      • Patient and Graft Survival Following Kidney Transplantation
      • Median Length of Stay and Hospital Readmission Following Kidney Transplantation
      • Management  of Heart Disease Risk Factors
  • Our Performance

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    Kidney Transplant Volume

    The kidney transplant volume measure is the number of kidney transplant procedures performed each year at Cincinnati Children’s. The more procedures performed by a transplant center, the more experience the care team has with kidney transplant care. As a result, patients and families who are in need of specific procedures often seek out high-volume centers.

    Cincinnati Children’s is among the top five busiest transplant centers in the country, and in the calendar year 2013 performed more kidney transplants than any other center in the nation.

    outcomes-kidney-volume

    • The multidisciplinary kidney transplant team at Cincinnati Children’s specializes in the management of patients with complex and challenging conditions of the kidneys and lower urinary tract that lead to end-stage renal disease (ESRD) and the need for dialysis and / or kidney transplantation. These patient populations include very small children (as small as 22 pounds) and those with other organ transplants or reconstructed bladders.  As a result of our excellent outcomes and reputation, patients and families from all over the world come to Cincinnati Children’s for their kidney transplant and related care.

    Patient and Graft Survival

    The outcomes and statistics below are from the Scientific Registry of Transplant Recipients (SRTR). This national database contains information about all kidney transplants nationally and includes patient and graft survival as well as other transplant-related statistics.

    Patient Survival

    As with all major surgeries, kidney transplantation involves substantial risk.  The patient survival measure is the proportion of patients living at each time point following kidney transplantation (30 days, one year and three years).

    outcomes-kidney-patient-survival

    Note: “United States / National” data are provided for illustration only.  The numbers and rates may not be directly comparable, due to the unique mix of patients served by a transplant program, the large difference in numbers among patients transplanted at an individual program, and ALL patients transplanted across the country.

    • Patient survival following kidney transplantation at Cincinnati Children’s has consistently been excellent. For the most recent reporting period, three-year survival for our patients was 100 percent.

    Graft Survival (or Transplanted Kidney Survival)

    Survival of the transplanted kidney (also referred to as the “graft”), or graft survival, is a measure of successful kidney transplantation and care for the first three years following transplant. It represents the proportion of new kidney transplants (or grafts) that are still functioning at each time point (30 days, one year and three years) following kidney transplantation. 

    outcomes-kidney-graft-survival

    Note: Because each transplant center serves patients with varying levels of complexity, the SRTR takes into account a number of factors when calculating the “expected” survival rate for an individual center.  This calculation is called “risk adjustment” and accounts for specific patient and donor characteristics factors that are known to influence graft survival. 

    • Patients who receive their kidney transplant at Cincinnati Children’s have excellent graft survival that is equal to or above the national average.  According to the most recent data, 100 percent of new kidney transplants are still functioning at 30 days and one year following kidney transplantation and 86 percent are still functioning at three years following transplantation. 
    • In the kidney transplant program at Cincinnati Children’s, we have developed processes that help us deliver high-quality care to improve outcomes.  In fact, before every follow-up visit, we prepare an optimal and personalized plan. During this process, called pre-visit planning, we review a patient’s risk for rejecting the kidney, evaluate recent drug levels, and determine whether the patient is taking the appropriate anti-rejection medications. When every patient comes for a follow-up appointment, we are prepared with a specific plan.

    Hospital Length of Stay and Readmission

    Median Length of Stay

    The median inpatient length of stay measure illustrates how long patients can expect to be in the hospital after receiving their kidney transplant. Half of the patients will have a length of stay that is shorter than the median and half will have a stay that is longer than the median. Several factors can affect an individual’s length of stay, so it is important to remember that longer stays do not necessarily mean worse outcomes. For instance, younger patients and those with more complicated conditions typically need to stay in the hospital longer following their kidney transplant.

    outcomes-kidney-length-of-stay

    • At Cincinnati Children’s Hospital we continually assess patients’ readiness for discharge and strive to ensure that hospital stays are matched to patient needs.  If patients are discharged too soon, they may experience complications that can result in a readmission to the hospital.  Meanwhile staying too long may affect quality of life and recovery or lead to other complications. 

    30-day Hospital Readmission

    The 30-day hospital readmission rate measure reports the proportion of kidney transplant patients who are readmitted within 30 days of hospital discharge after their transplant. Our goal is for our patients to have the highest quality of life possible outside the hospital. By collaborating with our patients and families, and through the reliable implementation of our care processes, we aim to provide safe and effective care that prevents complications and the need for hospital readmission.  

    outcomes-kidney-30-day

    • Patients may experience complications that require hospital readmission. Our goal is to have a 30-day readmission rate of 0 percent. 
    • One specific improvement that has helped us reduce readmissions is what we call “perfect discharge.”  This means that before hospital discharge, we hold a meeting with each patient, family, and the entire care team. During this meeting, inpatient and outpatient providers carefully review each medication and all instructions to make sure everything is correct and everyone understands the care plan for the patient as he or she departs from the hospital. 

    Reducing Risk for Heart Disease

    For children with a kidney transplant, heart disease is the biggest threat to their long-term health1-3.  There are many reasons, including their underlying kidney disease, being on dialysis, and the medications they must take to prevent their body from rejecting their new kidney.  Cincinnati Children’s has led the way in identifying many heart disease risk factors for children who have had a kidney transplant, and we  systematically track and treat these risk factors in our patients.

    Blood Pressure Control

    High blood pressure (also called hypertension) is perhaps the most important risk factor for heart disease in kidney transplant patients.  Up to 80 percent of children with a kidney transplant have a diagnosis of hypertension4.  Even though there are many effective therapies to treat hypertension, many children with a kidney transplant have poorly controlled blood pressure5, 6.  The blood pressure control measure shows the proportion of patients under our care whose blood pressure is adequately treated according to national guidelines.

    outcomes-kidney-blood-pressure

    How We Measure

    We include all patients who have been seen in our clinic within the last six months and whose kidney transplant was at least three months before calculating each data point.  A patient’s blood pressure is considered to be adequately controlled if it is below 120 / 80 and below the 90th percentile for age, gender, and height for patients under 18 years old, or if it is below 130 / 80 for patients 18 years of age or older7, 8.

    Continuous Improvement

    • It is very important to measure blood pressure correctly or the results might be inaccurate.  Based on an extensive review of available research, we have developed a Best Evidence Statement (BESt) for the proper Blood Pressure Measurement in Children.  We have worked to implement this procedure and are happy to report that nearly 100 percent of kidney transplant patients have their blood pressure measured appropriately at each clinic visit.

    • By maintaining optimal blood pressure, a kidney transplant will last longer, the heart will be healthier and the patient will feel better.  At Cincinnati Children’s, our approach to improving blood pressure control includes several essential components including accurate measurement, planned medical care, state-of-the-art therapy (including medication management, self-management, diet and lifestyle interventions, and collaboration with the Adherence Center), and assessment of effects of high blood pressure on the heart and kidney, including echocardiography and measurement of renal function.
    • We use the latest technology to closely monitor blood pressure and ensure that it remains within optimal ranges.  In addition to thoroughly measuring blood pressure in clinic, we also ask patients to monitor blood pressure at home. This gives us additional information that can be used to develop a treatment plan tailored to each patient.
    • Before every clinic visit, we review patients’ most recent blood pressure readings and other heart disease risk factors so we are ready with a personalized plan even before patients arrive for their visit.
    • In addition to drug therapy, our treatment approach consists of diet and lifestyle counseling and follow-up with a registered dietitian.

    Cholesterol Monitoring and Control

    High cholesterol is another important heart disease risk factor for children with a kidney transplant.  Up to 80 percent of children will have or develop high cholesterol following kidney transplantation4 that may add to the risk of heart disease in the future. 

    The cholesterol monitoring within the previous 12 months measure illustrates the proportion of patients in our entire population who have had their cholesterol checked within the previous year. 

    outcomes-kidney-cholesterol

    How We Measure

    We include all patients who have been seen in our clinic within the previous 12 months and who had their transplant more than seven months earlier. 

    Continuous Improvement

    • At Cincinnati Children’s, we measure cholesterol at least once a year in all our patients and more often for patients with the highest risk for high cholesterol.  Through the use of automated reporting systems, we can identify the patients who are most at risk, and monitor their cholesterol accordingly.  

    The low density lipoprotein (LDL) cholesterol control measure illustrates the proportion of patients in our population who had LDL documented as controlled within the prior 12 months, according to national recommendations8, 9.

    outcomes-kidney-low-cholesterol

    How We Measure  

    We include all patients who have been seen in our clinic within the previous 12 months and who had their transplant more than seven months earlier.  The measure reports the proportion of all patients who had controlled LDL at their most recent check within the last 12 months.  The national recommended guideline is that LDL be below 130 mg / dl8, 9.  

    • Our approach to treating high cholesterol includes a team of providers consisting of transplant pharmacologists, nurses, registered dietitians, and the patient’s physician.  When treating high cholesterol, we use a variety of interventions including assessment of whether medications that cause high cholesterol can be stopped, counseling and regular follow-up with a registered dietitian about maintaining a heart-healthy diet and lifestyle, and consideration of medications that have been proven effective in lowering cholesterol. 
    • All of the treatment options mentioned above are considered during our pre-visit planning meetings with the treatment team. Each member of the team is trained in motivational interviewing and self-management techniques to support patients in making lifestyle changes that will lead to better health.

    References

    1. Groothoff JW, Gruppen MP, Offringa M, Hutten J, Lilien MR, Van De Kar NJ, et al. Mortality and causes of death of end-stage renal disease in children: a Dutch cohort study. Kidney Int. 2002;61(2):621-629.

    2. McDonald SP, Craig JC. Long-term survival of children with end-stage renal disease. N Engl J Med. 2004;350(26):2654-2662.

    3. Parekh RS, Carroll CE, Wolfe RA, Port FK. Cardiovascular mortality in children and young adults with end-stage kidney disease. J Pediatr. 2002;141(2):191-197.

    4. Mitsnefes MM. Cardiovascular Disease in Children with Chronic Kidney Disease. J Am Soc Nephrol. 2012.

    5. Seeman T, Simkova E, Kreisinger J, Vondrak K, Dusek J, Gilik J, et al. Control of hypertension in children after renal transplantation. Pediatr Transplant. 2006;10(3):316-322.

    6. Sinha MD, Kerecuk L, Gilg J, Reid CJ. Systemic arterial hypertension in children following renal transplantation: prevalence and risk factors. Nephrol Dial Transplant. 2012.

    7. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl 4th Report):555-576.

    8. Kavey RE, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, et al. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2006;114(24):2710-2738.

    9. Kasiske B, Cosio FG, Beto J, Bolton K, Chavers BM, Grimm R, Jr., et al. Clinical practice guidelines for managing dyslipidemias in kidney transplant patients: a report from the Managing Dyslipidemias in Chronic Kidney Disease Work Group of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Am J Transplant. 2004;4 Suppl 7:13-53.