Evaluation Of The Kidney Transplant Recipient 411 General Indications

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The most common conditions that lead to chronic renal failure and end-stage renal disease (ESRD) requiring dialysis and evaluation for kidney transplantation (KT) are outlined in Table 4.1. Diabetes mellitus (DM) is the most common indication for renal transplantation. This is complicated by the fact that patients with DM on dialysis have a very high mortality. Some of these patients may be candidates for a combined kidney-pancreas transplant in its different modalities, as outlined later in this chapter. Chronic glomerulonephritis from various etiologies can lead to renal failure and ultimately necessitate KT. Polycystic kidney disease (PKD), an autosomal-dominant inherited disease, is most prevalent in Caucasians. Hypertensive nephropathy with nephrosclerosis, though widely prevalent, is more commonly seen in the African American population, due to the prevalence of hypertension in this group. Other causes of renal failure are less common and need individualized evaluation for KT.

4.1.2. Contraindications

Prior to recommending KT to any given patient, the diagnosis must be secured to avoid transplanting patients with reversible renal failure, such as those

TABLE 4.1. Indications for Kidney Transplantation

Etiology

% KT l'or this indication

Diabctic nephropathy

Glomerulonephritis with renal failure

Polycystic kidney disease

Hypertensive nephropathy with renal failure

Lupus nephropathy

Interstitial nephritis

Other

35 30 10 10

y with acute tubular necrosis. Once the irreversibility of the process is clear, patients must be free of active infection (acute or chronic), active inflammatory glomerulonephritis (such as in active systemic lupus erythematosus [SLE]), active uncontrolled psychiatric disorder, and untreated malignancy). In addition, the patient must have a reasonable life expectancy after transplant and must be physiologically able to tolerate the transplant procedure. ESRD patients are prone to develop sequelae of arteriosclerosis and coronary artery disease (CAD), due in part to the higher incidence of hypertension and DM. The workup outlined here should also aim at excluding the consequences of other end-organ damage from these causes. High levels of sensitization to donor tissues also precludes transplantation due to a high incidence of hyperacute rejection and graft loss. This is further explained later in this chapter. Finally, patients must be compliant, without active addiction (alcohol and/or substance abuse), and highly motivated.

These contraindications may be absolute (e.g., intractable CAD with unstable angina), relative (e.g., hypertensive cardiomyopathy, which increases the operative risk but does not absolutely preclude transplant), or temporary (e.g., active pneumonia, which responds to therapy). All these circumstances must be properly weighed prior to considering a patient for KT.

4.1.3. Evaluation of Candidates

The evaluation and testing of the potential KT recipient follow the same general guidelines as those for the liver transplant recipient, as outlined previously, and are common also with the workup for combined kidney-pancreas transplantation. Patients must meet the previously outlined indications, be on (or about to go on) dialysis, and have irreversible ESRD. In addition, the progressive difficulty of obtaining adequate vascular access must be factored in the timing of transplantation for these individuals.

The workup starts with a detailed history and physical exam. Special em phasis is placed on the cause and evolution of the renal disease, time on dialysis, vascular access history and complications, urine production, presence of urologic issues that may complicate the future transplant (such as bladder neck obstruction or neurogenic bladder), medications, and, finally, review of systems to ascertain specific extrarenal organ system workup issues. A thorough psychosocial evaluation is undertaken at this time. Extensive laboratory, radiologic, and specialty testing then follow, as described later. When this is completed, the patient is presented for listing at a candidate selection multidisciplinary committee. If accepted, the patient is placed on the waiting list and financial clearance is established.

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