**2.7. Specific gastrointestinal evaluation**

There has been no consensus on whether all asymptomatic renal transplant candidates should be screened for cholelithiasis. Screening is warranted, however, in diabetics and patients with a history of cholecystitis. Pretransplant cholecystectomy is recommended for these patients if there is evidence of cholelithiasis due to the increased risk of life-threatening cholecystitis after transplantation.

infections, voiding symptoms, or end stage renal disease secondary to congenital or genito‐ urinary abnormalities should undergo a voiding cystourethrogram (VCUG). Persistent hematuria or sterile pyuria may warrant endoscopic evaluation and/or retrograde pyelogra‐ phy. Urodynamic studies may be helpful in patients with a history of lower urinary tract dysfunction and/or urinary incontinence. Patients with bladder dysfunction secondary to neurogenic bladder or chronic infections can often be managed without urinary diversion. In continent patients with lower urinary tract dysfunction, intermittent self-catheterization is a safe and effective alternative to urinary diversion. However, a formal urologic evaluation and patient education during the initial transplant evaluation process is mandatory. Augmentation cystoplasty or urinary diversion procedures may be necessary in patients in whom simple reimplantation into a dysfunctional bladder is not an option. Male transplant candidates with sufficient urine volume and symptoms of outflow tract obstruction due to benign prostatic hypertrophy should undergo prostate resection before transplantation, whereas in anuric

Medical Evaluation of the Adult Kidney Transplant Candidate

http://dx.doi.org/10.5772/54736

17

patients, the procedure should be postponed until after a successful renal transplant.

For most patients with autosomal dominant polycystic kidney disease (ADPKD) pretransplant nephrectomy is not routinely recommended. However, unilateral or bilateral pretransplant nephrectomy(ies) may be necessary for those with massively enlarged kidneys, recurrent infection, bleeding, and/or intractable pain. Table 6 lists the special indications for pretrans‐ plant native nephrectomy. Generally, a minimum of six weeks after nephrectomy is recom‐ mended prior to transplantation. For transplant candidates who undergo preemptive transplantation from a living donor, simultaneous native nephrectomy and transplantation

**2.10. Specific urologic considerations: Pretransplant nephrectomy**

Reflux or obstructive megaureter complicated by infection or stone formation

1Indicated for massively enlarged kidneys, recurrently infected or bleeding, intractable pain

may be performed.

**Absolute indications**

Recurrent infected stones

Polycystic kidney disease1

2Should be individualized

3When there is suspicion for adenocarcinoma

**Table 6.** Indications for pretransplant native nephrectomy

Heavy proteinuria **Relative indications** Intractable hypertension2 Acquired renal cystic disease3

Chronic renal parenchymal infection

#### **2.8. Hypercoagulable states**

Thrombophilia generally does not preclude transplantation but does mandate the initiation of preventive strategies to reduce thrombotic complications and early graft loss. All transplant candidates should have routine coagulation studies performed. In high-risk candidates such as those with a previous history of thrombotic events including recurrent thrombosis of arteriovenous grafts and fistulas, positive family history of thrombosis, or history of recurrent miscarriage in female transplant candidates, a more extensive hypercoagulability profile should be performed. These may include screening for activated protein C resistance ratio or factor V Leiden mutation, factor II 20210 gene mutation, antiphospholipid antibody, lupus anticoagulation, protein C or protein S deficiency, antithrombin III deficiency, and homocys‐ teine levels. It is our center practice to screen for lupus anticoagulant and antiphospholipid antibodies in all renal transplant candidates with systemic lupus erythematosous (Pham et al., 2010). It should be noted that although a prior history of thromboembolism does not preclude transplantation, a history of extensive venous thrombosis that involve the inferior vena cava, iliac vein or both may contraindicate transplantation and warrants evaluation by the surgical transplant team.

There has been no consensus on the optimal management of recipients with abnormal hypercoagulability profile. However, unless contraindicated, perioperative and/or postoper‐ ative prophylactic anticoagulation should be considered, particularly in patients with a prior history of recurrent thrombotic events. Transplant of pediatric *en bloc* kidneys into adult recipient with a history of thrombosis should probably be avoided. The duration of anticoa‐ gulation has not been well defined, but lifelong anticoagulation should be considered in highrisk candidates (Pham et al., 2010).

#### **2.9. Urologic evaluation**

All renal transplant candidates on dialysis should be imaged with a renal ultrasound, CT, or MRI to evaluate for acquired cystic kidney disease and associated renal cell carcinoma. Although there has been no consensus on the frequency of screening for renal neoplasms in wait-listed patients, the frequency of screening should follow the guidelines set forth for dialysis patients. If there is no evidence of acquired cystic kidney disease at initial screening, repeat ultrasound can be done annually or biannually (Eitner et al., 2010). Annual screening in patients who have been on dialysis for three to five years has been advocated (Chapman et al. 2011).. Urinalysis and urine cultures should be performed in all patients with significant residual urine volume. Transplant candidates with a history of recurrent urinary tract infections, voiding symptoms, or end stage renal disease secondary to congenital or genito‐ urinary abnormalities should undergo a voiding cystourethrogram (VCUG). Persistent hematuria or sterile pyuria may warrant endoscopic evaluation and/or retrograde pyelogra‐ phy. Urodynamic studies may be helpful in patients with a history of lower urinary tract dysfunction and/or urinary incontinence. Patients with bladder dysfunction secondary to neurogenic bladder or chronic infections can often be managed without urinary diversion. In continent patients with lower urinary tract dysfunction, intermittent self-catheterization is a safe and effective alternative to urinary diversion. However, a formal urologic evaluation and patient education during the initial transplant evaluation process is mandatory. Augmentation cystoplasty or urinary diversion procedures may be necessary in patients in whom simple reimplantation into a dysfunctional bladder is not an option. Male transplant candidates with sufficient urine volume and symptoms of outflow tract obstruction due to benign prostatic hypertrophy should undergo prostate resection before transplantation, whereas in anuric patients, the procedure should be postponed until after a successful renal transplant.

#### **2.10. Specific urologic considerations: Pretransplant nephrectomy**

**2.7. Specific gastrointestinal evaluation**

16 Current Issues and Future Direction in Kidney Transplantation

transplantation.

transplant team.

risk candidates (Pham et al., 2010).

**2.9. Urologic evaluation**

**2.8. Hypercoagulable states**

There has been no consensus on whether all asymptomatic renal transplant candidates should be screened for cholelithiasis. Screening is warranted, however, in diabetics and patients with a history of cholecystitis. Pretransplant cholecystectomy is recommended for these patients if there is evidence of cholelithiasis due to the increased risk of life-threatening cholecystitis after

Thrombophilia generally does not preclude transplantation but does mandate the initiation of preventive strategies to reduce thrombotic complications and early graft loss. All transplant candidates should have routine coagulation studies performed. In high-risk candidates such as those with a previous history of thrombotic events including recurrent thrombosis of arteriovenous grafts and fistulas, positive family history of thrombosis, or history of recurrent miscarriage in female transplant candidates, a more extensive hypercoagulability profile should be performed. These may include screening for activated protein C resistance ratio or factor V Leiden mutation, factor II 20210 gene mutation, antiphospholipid antibody, lupus anticoagulation, protein C or protein S deficiency, antithrombin III deficiency, and homocys‐ teine levels. It is our center practice to screen for lupus anticoagulant and antiphospholipid antibodies in all renal transplant candidates with systemic lupus erythematosous (Pham et al., 2010). It should be noted that although a prior history of thromboembolism does not preclude transplantation, a history of extensive venous thrombosis that involve the inferior vena cava, iliac vein or both may contraindicate transplantation and warrants evaluation by the surgical

There has been no consensus on the optimal management of recipients with abnormal hypercoagulability profile. However, unless contraindicated, perioperative and/or postoper‐ ative prophylactic anticoagulation should be considered, particularly in patients with a prior history of recurrent thrombotic events. Transplant of pediatric *en bloc* kidneys into adult recipient with a history of thrombosis should probably be avoided. The duration of anticoa‐ gulation has not been well defined, but lifelong anticoagulation should be considered in high-

All renal transplant candidates on dialysis should be imaged with a renal ultrasound, CT, or MRI to evaluate for acquired cystic kidney disease and associated renal cell carcinoma. Although there has been no consensus on the frequency of screening for renal neoplasms in wait-listed patients, the frequency of screening should follow the guidelines set forth for dialysis patients. If there is no evidence of acquired cystic kidney disease at initial screening, repeat ultrasound can be done annually or biannually (Eitner et al., 2010). Annual screening in patients who have been on dialysis for three to five years has been advocated (Chapman et al. 2011).. Urinalysis and urine cultures should be performed in all patients with significant residual urine volume. Transplant candidates with a history of recurrent urinary tract For most patients with autosomal dominant polycystic kidney disease (ADPKD) pretransplant nephrectomy is not routinely recommended. However, unilateral or bilateral pretransplant nephrectomy(ies) may be necessary for those with massively enlarged kidneys, recurrent infection, bleeding, and/or intractable pain. Table 6 lists the special indications for pretrans‐ plant native nephrectomy. Generally, a minimum of six weeks after nephrectomy is recom‐ mended prior to transplantation. For transplant candidates who undergo preemptive transplantation from a living donor, simultaneous native nephrectomy and transplantation may be performed.


**Table 6.** Indications for pretransplant native nephrectomy
