*Purpose: Optimal management of enteric hyperoxaluria (EH) requires institution of a strict low-fat, low oxalate diet and use of oral calcium supplements as oxalate binders. Oral calcium supplements require frequent titration and careful monitoring to avoid complications and successfully achieve target plasma and urine oxalate levels. We hypothesized that a registered nurse (RN)-driven protocol could maximize the management of an EH cohort pre and post-kidney transplantation.

*Methods: We assembled a multidisciplinary team comprising transplant and kidney stone nephrologists, dieticians, and RN specialists. The group developed a protocol to adjust oral calcium carbonate dosing aligned with a structure for scheduled follow-up of serum and urine calcium and oxalate levels to achieve therapeutic targets and avoid complications. The protocol was initially developed for transplant candidates and recipients with EH but was quickly adapted for other EH patients in nephrology stone clinics.

*Results: Since the protocol depicted in Figure 1 was initiated on 11/01/2015, 90 patients (50% pre-transplant) have been enrolled with 63 patients dismissed from the protocol and 27 currently active. EH etiology was bariatric surgery in 80%. Overall, median follow-up was 0.6 (0.3-1.5) years and among active participants 1.0 (0.4-2.1) years. The most common reasons for dismissal from the protocol were noncompliance/financial difficulties (48%), management assumed by referring or local provider due to complexity or recruitment for a clinical trial (17%), and outside of protocol or oral calcium not indicated (20%).

*Conclusions: We have demonstrated the feasibility and utility of a nurse-driven protocol to manage EH patients. This protocol has reduced physician burden and cost, while improving care of this complex patient population.

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