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Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
Published on: April 12, 2021
A quality improvement intervention to decrease the decline in renal function in pediatric liver transplant recipients
Irini Batsis1, Scott Elisofon2, Michael Ferguson3
1Division of Hepatology, Mount Sinai Kravis Children's Hospital, New York, New York, USA.
Insights
Quality improvement initiatives significantly reduced chronic kidney disease in pediatric liver transplant recipients. Enhanced monitoring and management plans decreased the prevalence of low estimated glomerular filtration rate (eGFR) at 12 and 24 months post-transplant.
Area of Science:
- Pediatric Nephrology
- Transplant Medicine
- Quality Improvement Science
Background:
- Chronic kidney disease (CKD) is a significant long-term complication in pediatric liver transplant (LT) recipients.
- Prevalence of estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m² was 25% at 1 year post-LT, necessitating intervention.
- A quality improvement (QI) project aimed to reduce the incidence of eGFR < 90 by at least 20% within 1 year post-LT.
Purpose of the Study:
- To implement and evaluate the effectiveness of QI interventions to decrease the prevalence of CKD in pediatric LT recipients.
- To improve the documentation of key renal parameters and management strategies post-LT.
- To assess the impact of interventions on eGFR levels at 3, 12, and 24 months post-LT.
Main Methods:
- A QI project involving three interventions was implemented starting January 2016 for pediatric patients (<19 years) undergoing LT between 2010-2018.
- Interventions included standardized documentation of blood pressure percentile (BP%) and eGFR, creation of kidney management plans for abnormal values, and pre-discharge amlodipine initiation.
- Pre- and post-intervention cohorts were compared for the prevalence of eGFR < 90 at 3, 12, and 24 months post-LT.
Main Results:
- Post-intervention, documentation rates for BP%, eGFR, and kidney management plans significantly increased from 25%, 10%, 22% to 71%, 83%, 71% respectively.
- Amlodipine initiation prior to discharge rose from 22% to 74% post-intervention.
- The prevalence of eGFR < 90 at 12 months post-LT decreased significantly from 24% to 7% (p=0.01), representing a 74% relative reduction.
Conclusions:
- QI interventions, including improved documentation and proactive management, effectively reduced the prevalence of CKD in pediatric LT recipients.
- A significant decrease in the prevalence of eGFR < 90 was observed at 12 months post-LT, exceeding the project's goal.
- Malignancy, metabolic disorders, and older age at transplant were identified as significant non-modifiable risk factors for reduced eGFR.
Background:
Chronic kidney disease (CKD) impacts long-term morbidity in pediatric liver transplant (LT) recipients. The prevalence of estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m2 (eGFR < 90) at our institution was 25% at 1 year post-LT; thus, quality improvement (QI) project was initiated, aiming to decrease the prevalence of eGFR < 90 by at least 20% at 1 year-post LT.
Methods:
Children post-LT under 19 years from 2010 to 2018 were included. Three QI interventions were implemented starting 1/2016: documentation of blood pressure percentile (BP%) and eGFR, documentation of a kidney management plan if either was abnormal, and amlodipine initiation prior to hospital discharge after LT. We compared the prevalence of eGFR < 90 at 3, 12, and 24 months after LT in the pre- and post-intervention period.
Results:
68 patients in pre- and 42 in post-intervention periods met inclusion criteria. Pre-intervention BP%, eGFR, and kidney management plan were documented at 25%, 10%, and 22%, compared to 71%, 83%, and 71% post-intervention, respectively. 22% of patients were started on amlodipine prior to discharge from LT in the pre- versus 74% in the post-intervention period. Prevalence of eGFR < 90 at 3 m post-LT was 19% in pre- versus 14% in the post-intervention period (p = .31); at 12 months 24% versus 7% (p = .01) and at 24 months 16% versus 6% (p = .13), respectively. Significant non-modifiable risk factors for eGFR < 90 were malignancy (RR = 4.5, p < .0001), metabolic disorder (RR = 2.6, p = .02), and age at transplant (7% increased risk per year of age, p = .007).
Conclusion:
By improving documentation of BP%, eGFR, and kidney management plan, the prevalence of eGFR < 90 was decreased by a relative 74% and 60% at 12 and 24 months post-LT, respectively.
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