Health Care Transition for Adolescents With CKD—The Journey From Pediatric to Adult Care
2011; Elsevier BV; Volume: 18; Issue: 5 Linguagem: Inglês
10.1053/j.ackd.2011.04.003
ISSN1548-5609
AutoresLorraine Bell, María Ferris, Nicole Fenton, Stephen R. Hooper,
Tópico(s)Bipolar Disorder and Treatment
ResumoThe design of Health Care Transition (HCT) services for adolescents and emerging adults with CKD or end-stage kidney disease (ESKD) needs to take into account patient cognition/developmental stage, family factors, and health resources within the hospital setting and community. Patient and family education is fundamental and teaching and learning tools must be literacy-accessible. Adolescents and emerging adults with CKD/ESDK have complex medical and dietary regimes, and therapeutic adherence is important for optimizing their health, quality of life, and longevity. Health providers need to identify ways of engaging them to become successful disease self-mangers. Interdisciplinary collaboration between the pediatric- and adult-focused health care teams and the services of a dedicated transition coordinator are paramount to ensure clear communication between the patient and the health professionals involved. Valid measurement tools to monitor and assess the HCT process and health outcomes need to be developed. The aims of planned HCT for adolescents and/or emerging adults with CKD/ESKD are anchored by the goals of optimizing health outcomes, health-related quality of life, and continuous quality improvement. The care of young people with CKD/ESKD can be both challenging and rewarding; we offer strategies for planned HCT services geared to these vulnerable patients. The design of Health Care Transition (HCT) services for adolescents and emerging adults with CKD or end-stage kidney disease (ESKD) needs to take into account patient cognition/developmental stage, family factors, and health resources within the hospital setting and community. Patient and family education is fundamental and teaching and learning tools must be literacy-accessible. Adolescents and emerging adults with CKD/ESDK have complex medical and dietary regimes, and therapeutic adherence is important for optimizing their health, quality of life, and longevity. Health providers need to identify ways of engaging them to become successful disease self-mangers. Interdisciplinary collaboration between the pediatric- and adult-focused health care teams and the services of a dedicated transition coordinator are paramount to ensure clear communication between the patient and the health professionals involved. Valid measurement tools to monitor and assess the HCT process and health outcomes need to be developed. The aims of planned HCT for adolescents and/or emerging adults with CKD/ESKD are anchored by the goals of optimizing health outcomes, health-related quality of life, and continuous quality improvement. The care of young people with CKD/ESKD can be both challenging and rewarding; we offer strategies for planned HCT services geared to these vulnerable patients. Clinical Summary•"Transition" is a deliberate, planned process that begins early and may continue beyond the transfer event.•Children with CKD need graded, supervised progressive responsibility for their own health care.•Preparation for transition is a team process encompassing the patient/family unit, interdisciplinary pediatric health care professionals, the receiving adult team, and community resources.•Evidence-based research needs include studies of effective means to facilitate the transition process of barriers and of validated outcome assessment measuresBecause the complexity and sophistication of medical and surgical care have increased over the past several decades, the prevalence of adolescents and emerging adults with chronic health conditions has increased enormously. Many have conditions that were previously fatal in childhood and seldom seen in the realm of adult medicine. These youth are reaching adulthood in ever-increasing numbers. More than 500,000 adolescents with chronic disease transfer to adult-focused health care every year in the United States alone.1Reiss J. Gibson R. Health care transition: destinations unknown.Pediatrics. 2002; 110: 1307-1314PubMed Google Scholar Some adolescents do well, but many falter or are lost to follow-up, at times with devastating consequences. Adolescents and emerging adults with CKD comprise a sizable proportion of this demographic. In the United States, the 10-year survival rate for patients with adolescent-onset end-stage kidney disease (ESKD) has increased significantly as compared with 30 years ago.2Ferris M.E. Gipson D.S. Kimmel P.L. Eggers P.W. Trends in treatment and outcomes of survival of adolescents initiating end-stage renal disease care in the United States of America.Pediatr Nephrol. 2006; 21: 1020-1026Crossref PubMed Scopus (105) Google Scholar In North America, there are an estimated 4000 kidney transplant recipients and 2000 patients on dialysis in the transition age range.3Bell L.E. Sawyer S.M. Transition of care to adult services for pediatric solid-organ transplant recipients.Pediatr Clin North Am. 2010; 57: 593-610Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 42009 World Population Data Sheet. Population Reference Bureau 2010. Available at: http://www.prb.org/Publications/Datasheets/2009/2009wpds.aspx. Accessed December 18, 2010.Google Scholar, 5Australia and New Zealand Dialysis and Transplant Registry Report 2009. Australia and New Zealand Dialysis and Transplant Registry 2010. Available at: http://www.anzdata.org.au/v1/report_2009.html. 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Accessed December 19, 2010.Google Scholar The prevalence data for adolescents and emerging adults with predialysis CKD are likely even higher. •"Transition" is a deliberate, planned process that begins early and may continue beyond the transfer event.•Children with CKD need graded, supervised progressive responsibility for their own health care.•Preparation for transition is a team process encompassing the patient/family unit, interdisciplinary pediatric health care professionals, the receiving adult team, and community resources.•Evidence-based research needs include studies of effective means to facilitate the transition process of barriers and of validated outcome assessment measures "Transfer" refers to the actual move from pediatric- to adult-focused health care services, whereas "Health Care Transition" (HCT) is a deliberate, planned, and focused process, in which adolescents and emerging adults with chronic illness assume progressively increasing responsibility for the management of their health. The goal of HCT, endorsed by leading national and international health organizations, is to maximize lifelong functioning and potential through the provision of high quality, developmentally appropriate, uninterrupted health services, as the patient moves from pediatric to adult care.7American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-American Society of Internal MedicineA consensus statement on health care transitions for young adults with special health care needs.Pediatrics. 2002; 110: 1304-1306PubMed Google Scholar, 8Rosen D.S. Blum R.W. Britto M. Sawyer S.M. Siegel D.M. Society for Adolescent MedicineTransition to adult health care for adolescents and young adults with chronic conditions: position paper of the Society for Adolescent Medicine.J Adolesc Health. 2003; 33: 309-311Abstract Full Text Full Text PDF PubMed Scopus (525) Google Scholar, 9Bell L.E. Bartosh S.M. Davis C.L. et al.Adolescent transition to adult care in solid organ transplantation: a consensus conference report.Am J Transplant. 2008; 8: 2230-2242Crossref PubMed Scopus (192) Google Scholar Although recommendations for the age of initiation of the HCT process generally range from 10 to 14 years, progressively autonomous care should be encouraged from an early age.9Bell L.E. Bartosh S.M. Davis C.L. et al.Adolescent transition to adult care in solid organ transplantation: a consensus conference report.Am J Transplant. 2008; 8: 2230-2242Crossref PubMed Scopus (192) Google Scholar, 10Kieckhefer G.M. Trahms C.M. Supporting development of children with chronic conditions: from compliance toward shared management.Pediatr Nurs. 2000; 26: 354-363PubMed Google Scholar The timing of transfer to adult care should be flexible and personalized. Although most adolescents will be ready between 16 and 21 years of age, individual cognitive, developmental, and psychosocial factors need to be considered.11Hersh A. Pang S. Curran M. Milojevic D. von Scheven E. The challenges of transferring chronic illness patients to adult care: reflections from pediatric and adult rheumatology at a US academic center.Pediatr Rheumatol. 2009; 7: 13Crossref Scopus (60) Google Scholar, 12Knauth A. Verstappen A. Reiss J. Webb G.D. Transition and transfer from pediatric to adult care of the young adult with complex congenital heart disease.Cardiol Clin. 2006; 24: 619-629Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 13Rosen D.S. Transition of young people with respiratory diseases to adult health care.Paediatr Respir Rev. 2004; 5: 124-131Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 14Weissberg-Benchell J. Wolpert H. Anderson B.J. Transitioning from pediatric to adult care.Diabetes Care. 2007; 30: 2441-2446Crossref PubMed Scopus (206) Google Scholar Site-specific regulations on patient age limits might be a limiting factor. "Emerging adulthood" refers to the age range and life cycle stage of approximately 18 to 25 years.15Arnett J.J. Emerging adulthood: a theory of development from the late teens through the twenties.Am Psychol. 2000; 55: 469-480Crossref PubMed Scopus (9468) Google Scholar Thus, it encompasses the period during which and shortly after young people with chronic illness move into the domain of adult care. It is also the phase of life when risk-taking behaviors peak.16Patton G.C. Coffey C. Sawyer S.M. et al.Global patterns of mortality in young people: a systematic analysis of population health data.Lancet. 2009; 374: 881-892Abstract Full Text Full Text PDF PubMed Scopus (829) Google Scholar, 17Park M.J. Paul Mulye T. Adams S.H. Brindis C.D. Irwin J. The health status of young adults in the United States.J Adolesc Health. 2006; 39: 305-317Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar In the developed world, the mortality rate of healthy 19 to 24-year-olds is 4 times higher than that of 10 to 14-year-olds, and the rate for 15 to 19-year-olds is between the aforementioned 2 age ranges.16Patton G.C. Coffey C. Sawyer S.M. et al.Global patterns of mortality in young people: a systematic analysis of population health data.Lancet. 2009; 374: 881-892Abstract Full Text Full Text PDF PubMed Scopus (829) Google Scholar The stakes are particularly high for adolescents burdened by chronic disease, and their risk-taking may be increased compared with the age-matched general population.3Bell L.E. Sawyer S.M. Transition of care to adult services for pediatric solid-organ transplant recipients.Pediatr Clin North Am. 2010; 57: 593-610Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 18Watson A.R. Problems and pitfalls of transition from paediatric to adult renal care.Pediatr Nephrol. 2005; 20: 113-117Crossref PubMed Scopus (109) Google Scholar, 19Suris J.C. Michaud P.A. Akre C. Sawyer S.M. Health risk behaviors in adolescents with chronic conditions.Pediatrics. 2008; 122: e1113-e1118Crossref PubMed Scopus (181) Google Scholar, 20Annunziato R.A. Emre S. Schneider B. Barton C. Dugan C.A. Shemesh E. Adherence and medical outcomes in pediatric liver transplant recipients who transition to adult services.Pediatr Transplant. 2007; 11: 608-614Crossref PubMed Scopus (277) Google Scholar Many changes occur during adolescence and emerging adulthood, such as leaving high school and childhood friends, moving away from home, job-seeking, or going away to college. Social or romantic relationships may be particularly emotional and intense. During this period some individuals experience a sense of instability or upheaval; for those with chronic illness, the need to transfer to adult-focused care may increase their vulnerability. Life can be particularly challenging for emerging adults with serious kidney disease. Many are bound to a strict routine of complex care, with little margin for acting out or for error, a difficult situation to accept when their healthy peers are enjoying increasing freedom and autonomy.21Bell L. Adolescents with renal disease in an adult world: meeting the challenge of transition of care.Nephrol Dial Transplant. 2007; 22: 988-991Crossref PubMed Scopus (45) Google Scholar During transfer to adult care, adolescents with CKD are at a risk of being overwhelmed, frightened, or lost in a system where they are vastly outnumbered by patients who are often decades older, and who may suffer from multiple serious comorbidities.22U.S. Renal Data SystemUSRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. U.S. Renal Data System, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2010http://www.usrds.org/adr.htmGoogle Scholar Additionally, chronic medical conditions can place tremendous emotional, physical, and financial stress on young adults and their families; loss of health coverage or lack of employment can add to the challenge and result in unmet health care needs.23Tew B.J. Payne H. Laurence K.M. Must a family with a handicapped child be a handicapped family?.Dev Med Child Neurol. 1974; 16: 95-98Crossref PubMed Scopus (69) Google Scholar, 24Lansky S.B. Cairns N.U. Hassanein R. Wehr J. Lowman J.T. Childhood cancer: parental discord and divorce.Pediatrics. 1978; 62: 184-188PubMed Google Scholar, 25Blum R.W. Garell D. Hodgman C.H. et al.Transition from child-centered to adult health-care systems for adolescents with chronic conditions. A position paper of the Society for Adolescent Medicine.J Adolesc Health. 1993; 14: 570-576Abstract Full Text PDF PubMed Scopus (1119) Google Scholar The need for effective HCT planning for these patients is paramount. In recent years, experts and policymakers have emphasized the importance of developing transition service models to prepare adolescents for a successful transition to adult-focused health care, but the empirical evidence targeting specific issues has only begun to be identified. When planning for successful transition of the adolescent with CKD, several factors appear to be important to consider: medical complexity, comorbidity, medical adherence, family and peers, the HCT team, and communication. The leading causes of ESKD in children are very different from those in adults. Congenital abnormalities of the kidneys and urinary tract (CAKUT) predominate, accounting for 40%, followed by hereditary disorders (14%) and focal segmental glomerulosclerosis (12%).26NAPRTCS 2008 Annual Report. North American Pediatric Renal Trials and Collaborative Studies. Available at: https://web.emmes.com/study/ped/annlrept/Annual%20Report%20–2008.pdf. Accessed December 18, 2010.Google Scholar Patients with CAKUT are at higher risk for impaired growth and short stature.27Mahan J.D. Warady B.A. Assessment and treatment of short stature in pediatric patients with chronic kidney disease: a consensus statement.Pediatr Nephrol. 2006; 21: 917-930Crossref PubMed Scopus (161) Google Scholar Impaired growth may lead to "juvenilization," lowered expectations, and not being given age-appropriate responsibility, potentially resulting in dependency and immaturity.27Mahan J.D. Warady B.A. Assessment and treatment of short stature in pediatric patients with chronic kidney disease: a consensus statement.Pediatr Nephrol. 2006; 21: 917-930Crossref PubMed Scopus (161) Google Scholar In addition, some children with CAKUT have complex genitourinary malformations requiring elaborate surgical reconstructive and corrective procedures; these may seriously affect their self-esteem, socialization, and health-related quality of life (HRQOL). After transfer, they often require ongoing urologic and gynecological follow-up for conditions with which adult practitioners may have had limited experience. Several concomitant factors can influence successful transition into adult care. These include neurocognitive functioning, special healthcare and/or educational needs, psychiatric/psychosocial status, overall quality of life, sexuality, and reproductive issues. Many children and adolescents with CKD manifest early developmental delays, impairments in overall cognitive functioning, and associated dysfunction in a variety of specific neurocognitive abilities including memory and executive functions;28Gipson D.S. Wetherington C.E. Duquette P.J. Hooper S.R. The nervous system and chronic kidney disease in children.Pediatr Nephrol. 2004; 19: 832-839Crossref PubMed Scopus (41) Google Scholar these cognitive challenges will often be carried into adulthood. Residual neuropsychological deficits and frequent hospitalizations may lead to significant long-term effects of CKD on educational attainment and/or associated vocational employment. Many children and adolescents with CKD are vulnerable for lower academic achievement across the domains of reading, writing, and mathematics;29Duquette P. Hooper S.R. Wetherington C.E. Icard P.F. Gipson D.S. Intellectual and academic functioning in pediatric chronic kidney disease.J Pediatr Psychol. 2007; 32: 1011-1017Crossref PubMed Scopus (62) Google Scholar, 30Qvist E. Pihko H. Fagerudd P. et al.Neurodevelopmental outcome in high-risk patients after renal transplantation in early childhood.Pediatr Transplant. 2002; 6: 53-62Crossref PubMed Scopus (114) Google Scholar they also face greater challenges in future attainment of more highly compensated professional careers.31Groothoff J.W. Grootenhuis M.A. Offringa M. Stronks K. Hutten G.J. Heymans H.S. Social consequences in adult life of end-stage renal disease in childhood.J Pediatr. 2005; 146: 512-517Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Similarly, individuals with CKD, including ESKD, are at risk for psychiatric and/or psychosocial difficulties and a lower HRQOL.32Goldstein S.L. Graham N. Burwinkle T. et al.Health-related quality of life in pediatric patients with ESRD.Pediatr Nephrol. 2006; 21: 846-850Crossref PubMed Scopus (186) Google Scholar As children move from late childhood to early adolescence, peer relationships begin to gain increasing significance.33Kerns K.A. Tomich P.L. Aspelmeier J.E. Contreres J.M. Attachment based assessments of parent-child relationships in middle childhood.Dev Psychol. 2000; 36: 614-626Crossref PubMed Scopus (142) Google Scholar However, at the same time, peer comparison and evaluation become particularly salient, a potential source of psychosocial difficulty for adolescents with CKD.34Duncan S.C. The role of cognitive appraisal and friendship provisions in adolescents' affect and motivation toward activity in physical education.Res Q Exerc Sport. 1993; 64: 314-323Crossref PubMed Scopus (65) Google Scholar Social functioning may be especially difficult for adolescents with CKD because of the rigidity of their medical regimen. They may be self-conscious about taking their medications in front of friends, have difficulty admitting to dietary and fluid restrictions, and embarrassed by medication side effects, such as obesity or acne. Certain patients may need to do intermittent self-catheterization or may have problems with incontinence. Some may experience fatigue or nausea and those on dialysis may be ill at ease because of the disfiguring effects of dialysis catheters or fistulas, or because of the activity restrictions imposed by different types of access. HCT goals include maximizing potential for independence, self-fulfillment, enjoyment of life and longevity, with a minimum of health complications and discomfort.3Bell L.E. Sawyer S.M. Transition of care to adult services for pediatric solid-organ transplant recipients.Pediatr Clin North Am. 2010; 57: 593-610Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Intriguingly, the HRQOL reported by many adolescents with ESKD is better than that of their parents' proxy ratings35Goldstein S. Rosburg N. Warady B. et al.Pediatric end stage renal disease health-related quality of life differs by modality: a PedsQL ESRD analysis.Pediatr Nephrol. 2009; 24: 1553-1560Crossref PubMed Scopus (75) Google Scholar; this may reflect their adaptation to chronic illness from an early age. A study from the Netherlands examined the social independence and employment achievement of adults who had experienced childhood-onset ESKD. As compared with their healthy peers, fewer had a partner and a greater proportion was still living with their parents. Their unemployment rate of 19% was twice that of the healthy age-matched population but notably, only half that of the young adult patients with adult-onset ESKD.31Groothoff J.W. Grootenhuis M.A. Offringa M. Stronks K. Hutten G.J. Heymans H.S. Social consequences in adult life of end-stage renal disease in childhood.J Pediatr. 2005; 146: 512-517Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar In terms of sexuality and reproduction, there may be health condition-associated factors or medications that diminish fertility, increase pregnancy risk, or affect the likelihood of delivering a healthy infant. Adolescents and emerging adults with CKD/ESKD related to genetic conditions need advice and discussion about potential heritability of their renal disorder for future offspring. Patients with genitourinary malformations may have elevated gestational risk, reduced fertility, or infertility (eg, cloacal or urogenital sinus disorders, Denys Drash, and Frasier syndromes). Adolescent/ emerging adult girls and women with CKD, or who are postrenal transplant recipients, need counseling on several issues including the following: (1) the potential teratogenicity of certain key medications, such as angiotensin-converting enzyme inhibitors and mycophenolate mofetil, (2) the need to plan for pregnancy in advance so that necessary medication changes can be made and time allowed for their condition to be stabilized, and (3) optimization of their prenatal care, with likely referral to a high-risk obstetric care center. It can be difficult for adolescents and emerging adults to ask questions about and discuss reproductive or other sensitive issues early after moving to adult care; time is needed for rapport to develop with their new caregivers and for a trusting relationship to be fully established. Thus, these are topics that need to be broached, both during transition preparation and after transfer to adult care. A medically adherent patient can be defined as one who follows his/her prescribed medical regimen.36Sabaté E. Adherence to Long-Term Therapies: Evidence for Action. World Health Organization, Geneva, Switzerland2003http://apps.who.int/medicinedocs/pdf/s4883e/s4883e.pdfGoogle Scholar A patient's comprehension of the medical complexities of his/her kidney disease and the associated comorbidities is essential in promoting successful transition from pediatric to adult care. However, even if these are appropriately recognized, if an individual is nonadherent to the medical regimen, his/her transition into adult care will be compromised. A 2003 World Health Organization monograph36Sabaté E. Adherence to Long-Term Therapies: Evidence for Action. World Health Organization, Geneva, Switzerland2003http://apps.who.int/medicinedocs/pdf/s4883e/s4883e.pdfGoogle Scholar addressed the worldwide implications of nonadherence and its effect on the public health burden of chronic conditions. A particular focus of this work was to emphasize the costs, both human and financial, of failed adherence. Some of the human costs of nonadherence for patients with CKD are more frequent medical complications and hospitalizations, higher health care costs, increased risk for rejection, and death.37Rapoff M.A. Adherence to Pediatric Medical Regimens.2nd ed. Springer, New York, NY2010Crossref Google Scholar Studies estimate the nonadherence rate to be approximately 50% to 55% for pediatric populations; however, it may be even higher in patients with CKD, who generally do not experience short-term consequence of nonadherence, such as pain or discomfort (eg, in contrast to some patients with inflammatory bowel disease).38La Greca A.M. Mackey E.R. Adherence to pediatric treatment regimens.in: Roberts M.C. Steele R.C. Handbook of Pediatric Psychology. 4th ed. The Guilford Press, New York, NY2009: 130-152Google Scholar The high rate of nonadherence within the pediatric population will likely increase once these individuals transition to adult-focused health care, where independence clearly is emphasized and expected.39Zelikovsky N. Schast A.P. Palmer J. Meyers K.E. Perceived barriers to adherence among adolescent renal transplant candidates.Pediatr Transplant. 2008; 12: 300-308Crossref PubMed Scopus (107) Google Scholar Understanding the competencies that pediatric patients should obtain before entering the adult health care system is central for a successful transition. When examining what competencies individuals should have to successfully adhere to their medications, 3 components seem to emerge: certain behavioral strategies, knowledge regarding one's illness, and adaptive cognitions. Programs designed to assist patients implement certain behavioral strategies and to improve knowledge regarding their illness may be targeted during regular medical appointments. A more difficult construct that affects adherence is a person's thoughts about the medication-taking process because maladaptive cognitions appear to result in worse adherence.40Simons L.E. McCormick M.L. Mee L.L. Blount R.L. Parent and patient perspectives on barriers to medication adherence in adolescent transplant recipients.Pediatr Transplant. 2009; 13: 338-347Crossref PubMed Scopus (58) Google Scholar If the HCT team can address these facets of medical regimen adherence, then the chances for a successful transition will likely be increased. CKD and ESKD can place tremendous stressors on the family and siblings of affected patients.23Tew B.J. Payne H. Laurence K.M. Must a family with a handicapped child be a handicapped family?.Dev Med Child Neurol. 1974; 16: 95-98Crossref PubMed Scopus (69) Google Scholar, 24Lansky S.B. Cairns N.U. Hassanein R. Wehr J. Lowman J.T. Childhood cancer: parental discord and divorce.Pediatrics. 1978; 62: 184-188PubMed Google Scholar, 41Groothoff J.W. Grootenhuis M. Dommerholt A. Gruppen M.P. Offringa M. Heymans H.S. Impaired cognition and schooling in adults with end stage renal disease since childhood.Arch Dis Child. 2002; 87: 380-385Crossref PubMed Scopus (89) Google Scholar A well-adjusted and supportive family can help those with CKD cope more successfully.42Soliday E. Kool E. Lande M. Family environment, child behavior, and medical indicators in children with kidney disease.Child Psychiatry Hum Dev. 2001; 31: 279-295Crossref PubMed Scopus (48) Google Scholar, 43Soliday E. Kool E. Lande M.B. Psychosocial adjustment in children with kidney disease.J Pediatr Psychol. 2000; 25: 93-103Crossref PubMed Scopus (86) Google Scholar Parents of these patients may need culturally sensitive guidance and literacy-adapted education on appropriate limit-setting, expected psychosocial and developmental milestones, and gradual empowerment of their children to manage their own medical conditions. This can be done through graded and progressively increasing responsibility throughout childhood and adolescence. Supporting young people to visit clinicians by themselves for part of a consultation helps promote health care responsibility, and a feeling of accomplishment and self-esteem.3Bell L.E. Sawyer S.M. Transition of care to adult services for pediatric solid-organ transplant recipients.Pediatr Clin North Am. 2010; 57: 593-610Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Some parents may also need to be reminded that even as their child goes through puberty and begins to look like an adult, he/she still needs supervision and support. One critical family-related factor that will affect transition is money. The financial burden associated with CKD-related care is significant and can be financially debilitating. The high costs make health insurance a necessity for individuals with kidney disease; however, emerging adults with CKD tend to have lower rates of employment and educational achievement as compared with their typical counterparts, making attaining a job with an adequate insurance policy difficult.31Groothoff J.W. Grootenhuis M.A. Offringa M. Stronks K. Hutten G.J. Heymans H.S. Social consequences in adult life of end-stage renal disease in childhood.J Pediatr. 2005; 146: 512-517Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Although many adolescents may be covered under their parents' health insurance, as they "age-out" of their parents coverage (or that of publically funded programs), the monthly premium associated with individual insurance can be cost-prohibitive. Even healthy emerging adults have difficulty with health care access.44Brindis CD, Mulye TP, Park MJ, Irwin CE Jr. Young people's health care: a national imperative NIHCM Foundation; 2006. Available at: http://nihcm.org/pdf/YoungPeoplesHCFINAL.pdf. Accessed December 20, 2010.Google Scholar, 45Callahan S.T. Cooper W.O. Changes in ambulatory health care use during the transition to young adulthood.J Adolesc Health. 2010; 46: 407-413Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 46Irwin J. 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