The Pre-Transplant Evaluation Process
1. Transplant Candidate Referral
Early referral is encouraged, even before dialysis is intiated. Consults will be placed at Stage 4 of renal failure by measurement of GFR by an appropriate method and timeline for workup agreed upon.
Sanford Transplant Center will make every effort to arrange a comprehensive evaluation within 2-3 weeks of referral. The transplant surgeon, nephrologists, financial counselor, coordinator, and social worker will meet with the prospective candidate. In addition, we will also arrange for laboratory and radiological studies which may not have been done. Patients are encouraged to bring family members or friends to the Transplant Center on the day of evaluation. The referring Nephrologist can perform the history and physical and discuss the patients’ medical condition with the surgeon in the Transplant Center.
Patient Selection Criteria
End stage renal failure, Stage 5 or Creatinine Clearance < 20/mL/min.
2. Contraindications
Absolute contraindications
Disseminated malignancy
Severe disabling cardiac or pulmonary disease
Chronic infection, not responding to antibiotics
Morbid obesity (Class III)
Relative contraindications
Severe disability
Psychosocial instability
Documented noncompliance
HIV
Obesity (Class II)
Coronary Artery Disease (CAD): Cardiovascular disease is the leading cause of death after renal transplant. Most dialysis patients have one or more risk factors for CAD and understanding the extent of CAD allows not only for an assessment of peri-operative and long-term risk but also allows the opportunity for intervention to modify these risks. A prior history of myocardial infarction, angina or CHF is a major risk factor for post- transplant events and these patients should undergo stress testing and further evaluation if needed. Stress testing method to be decided by the cardiologist. A history of diabetes may be an indication for cardia cath. A comprehensive evaluation of risk factors for cardiac disease will be prepared by the transplant team with appropriate interventions. Patients will be encouraged to quit smoking and treat hyperlipidemia by diet, medication, and exercise.
We advise formal consultation with a Cardiologist for patients in renal failure and any one of these following conditions:
i. age > 50 yrs
ii. history of hypertension leading to renal failure
iii. diabetes
iv. history of CAD
Peripheral Vascular Disease: The incident of PVD in the ESRD population appears to be significant. Patients with symptomatic PVD should be evaluated and treated prior to renal transplant.
Patients in renal failure and any one of the following conditions will be evaluated for risks prior to being accepted as a transplant candidate:
- Diabetes
- History of smoking
- Age > 50 yrs
- Intermittant claudication (pain in legs while walking)
- History of DVT
Gastrointestinal Testing: A colonoscopy is required for all transplant candidates age 50 with annual fecal occult blood testing, and a repeat colonoscopy every 5-10 years. High-risk patients may require more frequent exams.
Age: There are no absolute age contraindications to renal transplantation. Each candidate is assessed regarding the surgical risk by the referring Nephrologist after appropriate investigations and consults.
Diabetes Mellitus: Diabetes is the single most common cause of ESRD in the United State and we will make referral to diabetologist for tight control of blood sugar and insulin pump if indicated. We recommend glycated hemoglobin of < 6.5.
High PRA Patients: An elevated PRA (Panel Reactive Antibody) test suggests multiple anti-human antibodies leading to unsuccessful cross-match with a potential donor. This difficulty in cross-matching can lead to prolonged waiting times. Various protocols exist to decrease antibody levels. These methods work best if there is a living donor. Finally, there is a significantly higher risk of rejection in this group of transplant patients. Patients should be specially counseled regarding this possibility, in particular, for second or third transplants.
Compliance: Traditionally, compliance behavior has been defined as the physician’s ability to influence the patients and the patient’s willingness to respond. Compliance in patients undergoing dialysis and after transplantation has become a major issue as non-compliance with medications will lead to rejection and even death. A number of instruments to assess compliance have been devised however the views of the referring Nephrologist and dialysis nurse are paramount as these professionals are in daily contact with the patient and their families. In documented cases of non-compliance, patients will be referred to the Social Worker and Psychologist for therapy. The Transplant team may also sign a “contract” with the patient to document compliance for a specific time period, after which the patient may be placed on the waiting list.
Quality of Life (QOL): A patient with a poor QOL may not be a candidate for transplant, but this will be discussed with the patient and their care-givers. Some patients may prefer to remain on dialysis rather then undergo work-up and surgery. Assessment of QOL can be performed by the Social Worker with specific tools such as the SF-6 questionnaire. However, the final decision to accept patients on the waiting list with poor QOL will remain with the primary Nephrologist.
Prostate Cancer: As the age of renal transplant candidates increases, more patients are in the age group at risk for prostate cancer. It is recommended to wait a minimum of 2 years after treatment for prostate cancer before considering renal transplantation. Patients with focal disease by biopsy may not require a 2-year waiting period if he is willing to accept a low-moderate risk of recurrence. We will request that an annual PSA be drawn for all men age 50 and above.
Preventative Guidelines in Adults: We strongly urge the referring physicians to comply with the preventative guidelines in women for breast and GYN screening making appropriate consults.
Recurrent and de novo disease after renal transplantation: This issue becomes important when patients are being considered for re-transplant to counsel them for reoccurrence. Care should be taken to document pathology of the native kidney, particularly in cases of focal segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN) and hemolytic uremic syndrome.
3. Selection Committee
All prospective transplant and kidney donor candidates will be presented by the referring Nephrologist at the selection meeting. Complex cases may require the presence of appropriate consults to be present.
Patient's suitability for transplant and a "care plan" prepared for each patient. This will be communicated to the patient and referring physicians/consults. Patients will be encouraged to contact the Transplant Center if there is a delay in obtaining consults or testing.
4. Living Donation
We strongly encourage live kidney transplants.
5. Referrals may be made to the following specialists if deemed necessary by the Transplant Team:
Endocrine
Infectious disease
Pulmonary
Urology
Cardiology/Cardiac Surgery
Neurology/Surgery
Pathology
Radiology
Gynecology
Breast diseases
Gastroenterology
Psychiatry
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