Bridging the Pediatric-to-Adult Gap in Kidney Transplantation: Rethinking Transitions Through Structured Parallel Care and IM-Peds Nephrology

The transition of pediatric kidney transplant (KT) recipients into adult nephrology care remains a significant challenge in India, often leading to fragmented follow-ups, poor adherence, and adverse graft outcomes.^1-2 While transition models have been explored globally, India’s healthcare system lacks structured pathways to ensure smooth handovers between pediatric and adult care, especially for transplantation.

A parallel care model for transplant recipients, beginning in mid-adolescence (ages 16-18), offers a potential solution. In this model, adolescents would follow-up jointly with pediatric and adult nephrologists, ideally continuing this shared care until the age of 20. This strategy allows patients and their families to gradually adapt to adult care expectations while maintaining continuity in the pediatric care setting. The introduction of adult nephrology services in a phased manner, alongside pediatric nephrology, fosters better communication, builds trust, and encourages patient autonomy, improving the transition process.

Additionally, independent self-attended visits during late adolescence, once the child is accustomed to the concept of adult nephrology, can ease the transition and empower the patient. A structured approach to educating adolescents about their transplant, medication adherence, and navigating healthcare logistics is essential for ensuring that patients are not overwhelmed when they officially transition to adult care.

One long-term solution could be a 4-year dual MD program in Internal Medicine and Pediatrics (IM-Peds), similar to the Med-Peds residency program in the United States, but adapted for the Indian postgraduate system. Such a program would allow for comprehensive training across the lifespan, enabling graduates to deliver age-bridging care to adolescents and young adults with chronic conditions, including KTs. Those wishing to specialize further, such as in nephrology, could then pursue a DM or DNB super-specialization in combined adult-pediatric nephrology, in addition to adult or pediatric nephrology alone. This model would help address the current lack of formalized transitional care and ensure continuity, especially in centers that already have both pediatric and adult nephrology units. As Girimaji et al. noted, the success of transitional clinics in India depends heavily on the presence of both adult and pediatric services and their coordination,³ an IM–Peds trained nephrologist could serve as a unique link between these domains, minimizing fragmentation and supporting a structured, patient-centered transition, without needing both pediatric and adult nephrology cares under the same roof.

However, implementing such a dual-training model in India may face systemic and logistical barriers. Currently, there is no regulatory framework under the National Medical Commission (NMC) to support dual IM-Peds MD programs. Transition practices across centers remain informal and are often driven by individual clinician interest rather than institutional protocols or mandates.³ Existing departmental boundaries can limit interdisciplinary collaboration, making integrated training difficult. Moreover, there is a gap in formal training among nephrologists, both pediatric and adult, in addressing the needs of adolescent and young adult patients.³ Career trajectories for dual-trained graduates remain undefined in academic and hospital systems, and smaller centers may lack the infrastructure for such models. Addressing these barriers requires policy-level engagement, curriculum development, and the implementation of pilot programs.

These ideas are particularly relevant in the Indian context, where the transition process is often too abrupt, and pediatric transplant patients are left to navigate the adult care system without support.

Despite challenges, certain factors enhance the feasibility of implementing an IM-Peds program in India. First, many tertiary-care teaching hospitals already have well-established departments in both IM and Peds, enabling shared training infrastructure. Second, the rising burden of chronic pediatric conditions, including CKD, diabetes, and congenital heart disease, has created a clear demand for clinicians who can provide age-spanning, holistic care. Third, initiatives like NMC’s push toward competency-based medical education (CBME) may provide a framework for piloting integrated programs. Additionally, recent awareness of transitional care needs, as highlighted in Indian publications and nephrology forums, signals growing academic and clinical interest in bridging this care gap. Institutional willingness to innovate, alongside support from professional societies, could enable early pilot models and eventual policy-level consideration.

This viewpoint presents a unique and practical approach to bridging the pediatric-to-adult care gap. While existing guidelines from international bodies such as the American Society of Transplantation⁴ advocate for structured transition clinics, implementation in India may not be immediately feasible due to resource constraints.³ However, the parallel care model and IM-Peds specialization are adaptable and scalable within the Indian healthcare system, providing a sustainable and cost-effective solution.

As transplant medicine continues to evolve, Indian academic institutions and healthcare policymakers should consider adopting these strategies to ensure that the care continuum remains intact as pediatric transplant recipients transition to adulthood. Through these changes, we can improve the quality of life for patients with chronic diseases, including KT recipients.