Structured Multidisciplinary Care for Clinically Complex Kidney Transplant Recipients: A 12-Month Single-Center...

Kidney transplant recipients with high clinical complexity often face persistent symptom burden, emotional distress, and reduced quality of life despite stable graft function. Evidence for structured multidisciplinary programs tailored to this population remains scarce.

We conducted a 12-month, single-center implementation cohort study including 73 kidney transplant recipients classified as complex using NECPAL criteria or presenting significant emotional distress. Participants were enrolled in a coordinated, person-centered multidisciplinary program integrating nephrology, psychology, palliative care, nutrition, rehabilitation, nursing, and social work. Outcomes were assessed at baseline and Months 1, 3, 6, 9, and 12 using validated instruments: ESAS-r (symptom burden), DME (emotional distress), GES (spiritual well-being), and SF-12 (health-related quality of life). Global adaptation was defined as improvement in ≥ 2 of 3 domains (symptom burden, emotional distress, and spirituality). Qualitative data from open-ended responses were thematically analyzed.

Over follow-up, participants showed reductions in symptom burden (ESAS-r: 35.27 to 18.60), emotional distress (DME: 12.53 to 6.57), and increases in spiritual well-being (GES: 17.21-20.12), with improvements in SF-12 general health, emotional health, and social functioning. Global adaptation was achieved by 43.9% of patients, most within 3 months. Patients with ≥ 4 NECPAL criteria exhibited the most pronounced multidimensional gains. Emotional coping emerged as the strongest predictor of improvement. Qualitative analysis revealed unreported symptoms, resilience strategies, and existential reframing.

Implementation of a structured multidisciplinary model, combined with early complexity screening, was feasible and associated with longitudinal improvements across physical, emotional, spiritual, and functional domains in complex kidney transplant recipients. These preliminary findings suggest potential benefit-particularly for those with highest baseline vulnerability-and support the need for validation in multicenter, controlled studies.