Abstract:
Problem/Situation: In 2021, a review of our waitlist population indicated that 18% of our patients had a BMI > 35, putting them at a higher risk of cardiovascular events post-transplant. 2% had a BMI > 40, making them ineligible for transplant. If these patients took part in weight management services prior to organ transplant they could have better outcomes during their post-transplant course. The objective of this program was to make transplant an option for patients whose BMI would have made them ineligible for transplant. Additionally, it would address risk factors, specifically obesity, to optimize post-transplant outcomes for patients that have a BMI between 35 and 40.
These patients are less likely to complete a traditional bariatric program due to management of complicated chronic conditions involving multiple medical appointments and ongoing coordination. For the patient to be successful, it was critical to have a nurse coordinator develop a process that would guide the patient through a bariatric program specific for the kidney transplant patient.
Methods/Practices/Interventions: Mayo Clinic Rochester Transplant Center has specific BMI listing limits for kidney transplants. Our focus for this program is Kidney Transplant patients with a BMI of 35-40. This program had been using Endocrinology to address obesity needs in the past, however they were treating the general population rather than focusing on the transplant-specific patient population. Bringing this service into the Transplant Center provided us a greater opportunity to prepare for and coordinate specific weight loss efforts for transplant patients and to properly follow up for kidney transplant surgery. The initial team developed for the new program consisted of the transplant bariatric surgeon, Nephrologist, Endocrinologist (consulting), Psychiatry (consulting), and an RN credentialed Operations Manager. It also involved a dietitian.
The program is a multidisciplinary approach that touches on dietary changes, activity, psychological and behavioral therapies, medication therapies, and surgical procedures that can be used to facilitate weight loss prior to being listed for Transplant. The process begins with a pre-transplant patient referred by the pre-transplant coordinator or a provider. If the patient has a BMI greater than 35 and based on the patient’s needs and eligible benefits, the bariatric nurse coordinator will enter orders for Endocrinology and Psychology (a panel), an initial visit with the transplant bariatric surgeon, and an initial visit with Transplant Nutrition. After all visits are completed, the patient can proceed to a pre-surgical assessment with the transplant bariatric surgeon. Once evaluated, a case request for surgery is created which ensures a holding place for surgery and sends a prior authorization. Once the prior authorization is approved, a surgery date can be scheduled, PAME orders are placed, and all required post-surgery visits are scheduled.
Findings/Solutions/Conclusions: The newly developed bariatric nurse coordinator role has been instrumental in coordinating patient care and facilitating the removal of barriers to optimize the patient’s outcomes. They are the focal point for the practice and the patient. The success of this new program is largely due to the creation of the bariatric nurse coordinator role. The results show that we have performed 65 sleeve gastrectomies on pre-kidney transplant patients. 36 of them have gone on to receive a kidney transplant. 10 of them are actively waiting for a transplant. 3 of them have been made inactive because their kidney function improved post-sleeve and they are no longer eligible for a transplant, as they are too well. Overall, this indicates a 75% success rate as 49/65 patients who have received a sleeve through our program have gone on to either receive a kidney, are currently awaiting a kidney, or are too well to be listed.??
Implications/Relevance: The opportunity for the number of obese patients receiving Kidney organ transplants has increased through this program. The unique needs of the transplant patient were also identified and addressed enabling better outcomes. The scope of the program and lessons learned can be broadly used with other organ groups, not just within our center but across other organ transplant programs.
