Patient Selection and Pretransplantation Care for Kidney Transplant Recipients

Referring Patients for Kidney Transplantation

Preparation for renal transplantation should begin once the nephrology specialist suspects the patients will need renal replacement therapy in the following 6 to 12 months or once the estimated glomerular filtration rate (GFR) is less than 20 mL/min (evidence support C). The process of evaluation for transplantation begins when patients are referred to the transplant center. Preemptive transplantation may generate superior graft and patient survival in renal transplant recipients. The CST and the AST recommend preemptive transplantation after maximal utilization of the patient's renal function (evidence support C).

The importance of early transplantation was illustrated in a study comparing patients undergoing early (<6 months on dialysis) versus late (>24 months on dialysis) kidney transplantation; at 60 months, graft survival was 78% versus 58% in the two groups, respectively. A further study by Ojo et al. demonstrated that the long-term risk of death can be reduced by renal transplantation compared with remaining on dialysis. Given these studies and others, there is little justification for delaying referral of patients for transplantation.

Recipient Evaluation Process

Evaluation of patients is costly, is time consuming for patients, and expends limited healthcare resources. For these reasons, the process should attempt to eliminate contraindications to transplantation early in the process. Fig. 211.1 illustrates the flow of events in evaluating potential candidates. An initial screening history is taken before the patient is scheduled for a visit to the center. Special attention is given to problems that would contraindicate transplantation ( Box 211.1 ). Patients with known contraindications should be eliminated at that point, and appropriate patients should be scheduled for a visit to the center. During the evaluation process, potential barriers to transplantation are reviewed and measures to remove them are performed if possible. If a prohibitive barrier cannot be removed, the patient should continue dialysis. The protocol for recipient evaluation is outlined in Table 211.1 . In many centers, the patients and their referring physicians are given a list of routine studies that could be performed before the visit. This may expedite transplantation, but expensive or potentially risky studies should be withheld until after the visit to the transplant center. Once the patients have been seen at the transplant center, a multidisciplinary professional approach is begun.

Detailed history and physical examinations are performed by the professional staff, looking for medical, surgical, or psychosocial problems. Patients who are unable to consistently take medications or appear for clinic visits are more likely to develop acute rejection and graft failure. Typically, compliance with therapy for 6 to 12 months is required before placement on the waiting list. Drug or alcohol abuse has been reported in 25% of patients being evaluated for renal transplantation and may indirectly jeopardize long-term graft survival. Common practice and the ATC guidelines (evidence support C) require that all patients with chemical dependence be evaluated and treated for this problem in addition to having a documented drug- or alcohol-free period of 6 months before being listed for transplantation.

Most centers obtain screening studies for viral infections and immunology studies during the clinic visit, but the general laboratory studies, other routine studies, urologic and cancer screening studies (prostate-specific antigen, mammogram, gynecology examination, Papanicolaou smear, and colonoscopy) can be performed at the patient's referring center and are performed most efficiently before the visit at the transplant center.

Evaluating Risks to Successful Transplantation

The goal of the preliminary pretransplantation evaluation is to identify risks to successful transplantation and to long-term patient and graft survival. Improvements in transplantation continue to ameliorate conditions previously considered to be absolute contraindications (see Box 211.1 ). Generally accepted contraindications include continued noncompliance, active infection, some untreated malignancies, uncontrolled psychiatric illness, and continued illicit drug abuse. Primary oxalosis without prior liver transplantation remains a contraindication in most centers. Severe uncorrectable liver failure, cardiac disease, or pulmonary disease is also a contraindication at most centers, although many centers attempt transplantation in patients with advanced but not end-stage nonrenal disease such as heart failure or liver failure. Patients with near–end-stage nonrenal organ failure may be candidates for transplantation of these organs before kidney transplantation is undertaken.

If there are no contraindications to transplantation, the remainder of the evaluations center on measures to reduce perioperative risk and to improve long-term survival of the patient and allograft.