Currently, kidney transplantation is the treatment of choice for patients with end-stage renal disease (ESRD) as it improves both patient survival and quality of life when compared to dialysis. It must be noted, however, that although the risk of death in the first year after transplantation is less than 5%, not all patients qualify for the surgery due to their unacceptably high risk for complications. The transplant evaluation process requires a comprehensive assessment of each patient's medical, surgical, and psychosocial history. A systematic approach should be used in the evaluation of potential renal transplant candidates.
The Initial Evaluation Process
Prior to the formal evaluation process, all potential transplant candidates are encouraged to attend a “patient education” session. At the meeting, patients are informed about the medical and surgical risks and benefits of renal transplantation, the necessity for frequent outpatient visits in the early postoperative period, the potential adverse effects of immunosuppression, and the importance of compliance with immunosuppressive therapy. The potential advantages and disadvantages of deceased versus living donor renal transplantation are discussed with the patients and, when possible, with their family members, significant others, and/or friends. Other issues that are addressed include the prolonged waiting time for a deceased donor transplant due to the critical shortage of donor organs and the adverse effects of waiting time on patient and graft survival. In addition, patients are forewarned that various medical and psychosocial conditions may preclude a patient from being a transplant candidate. Absolute and relative contraindications to kidney transplantation are outlined in Table 53–1.
Table 53–1. Contraindications for Renal Transplantation. |Favorite Table|Download (.pdf)
Table 53–1. Contraindications for Renal Transplantation.
Severe irreversible extrarenal disease
Life expectancy <2 years
Liver cirrhosis (unless combined liver and kidney transplant)
Poorly controlled psychiatric illnesses
Active substance abuse
Active peptic ulcer disease1
Active hepatitis B virus infection2
Positive T cell crossmatch3
The routine assessment of a renal transplant candidate includes a detailed history and a thorough physical examination. In particular, it is important to determine the cause of the original kidney disease as it can help in predicting the transplant course and outcome and the risk for disease recurrence. When available, the kidney biopsy report should be reviewed. Patients with ESRD secondary to congenital or genitourinary abnormalities should undergo a voiding cystourethrogram (VCUG) and appropriate urologic evaluation, preferably by the kidney transplant surgeon. Documentation of the patient's residual urine volume from the native kidneys is invaluable in the assessment of graft function in the posttransplant period. A history of familial or hereditary ...