Table 1.

Clinical Vignettes Highlighting Examples of Unique Transplant Patient Issues and Needs Addressed by a Team-Based Approach for the Care of Poorly Functioning Allografts With Declining Function

Patient Case	Unique Transplant Issues	Goals and Values	Hopes for Kidney Treatment	Examples of Current Needs for Team-Based Approach to Allograft Care Moving Forward
62-year-old man with a history of polycystic kidney disease, received a preemptive living kidney transplant from his wife 22 years ago. His allograft function has been slowly declining to a Cr level of 3.8 mg/dL (eGFR, 18 mL/min per 1.73 m²) most recently. He reports fatigue and not able flank pain at the site of his graft. He owns his business and lives independently. He is married with his wife of 40 years, and has two daughters and one son living faraway. He has no known living donor options.	Prior major abdominal surgeries Allograft from current wife of 40 years is now functioning poorly Prolonged allograft function of 22 years	Continue his business and active life Continue to travel readily to see his children as they build their families Not to burden his wife with his illness and treatments	He is thinking about having a transplant again, but is worried about long wait time (average, 5-6 y) and wants to hear other available options After education on retransplantation, HD, PD, and CKM, given his desire to travel, he would prefer PD as a bridge to retransplantation if needed and has residual renal function	Surgery and transplant team consideration of PD given prior surgeries and possible allograft nephrectomy Transplant team evaluation for retransplantation Pain and fatigue are greatly disrupting his quality of life. Kidney palliative care team to join nephrology for management of this as well as grief counseling for him and his wife around the loss of her graft donation
72-year-old woman with a history of systemic lupus erythematosus who received a deceased kidney transplant 16 years ago. She was on hemodialysis for 8 years before undergoing transplantation and this was a hard experience for her. She was diagnosed with ischemic heart failure a year ago and her allograft function has been declining for the past several months now with a Cr level of 4.2 mg/dL (eGFR, 14 mL/min per 1.73 m²). She was admitted to the hospital three times in the past 6 months for fluid overload, requiring intravenous diuresis. She is retired and lives with her husband. She has no children. She feels her energy level is down and is bothered by lower-leg edema.	Prior experience with KRT Previously had significant difficulties with HD and is now more chronically ill and frail	Retired, hoping to spend time at home, with her husband, quietly, reading books and enjoying the garden at their home Has really struggled with admissions for her heart failure and would like to minimize them if possible	She is not sure if she would go through another kidney transplant again, and she also had a discussion with her transplant nephrologist that having another transplant would be difficult because of her age and comorbidity She is not sure if she would try dialysis either, based on her previous experience of hemodialysis before transplantation, and is interested in learning more about CKM	Longitudinal follow-up evaluation with transplant team, nephrology, and kidney palliative care for ongoing decision making and delivery of CKM Careful consideration of how to balance management of her heart failure, fatigue, and edema with the kidney palliative care team, nephrology, and her cardiologist

Abbreviations: Cr, creatinine; eGFR, estimated glomerular filtration rate; KRT, kidney replacement therapy; HD, hemodialysis; PD, peritoneal dialysis; CKM, conservative kidney management.