**1. Introduction**

#### **1.1. Patient education**

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 advan‐ tages 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 prolonged waiting time for a deceased donor transplant due to the critical shortage of donor organ and 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 (1).

#### **1.2. General assessment**

#### *1.2.1. Medical / urological evaluation*

The routine assessment of a renal transplant candidate includes a detailed history and a thorough physical exam. In particular, it is important to search for the etiology of the original kidney disease as it can predict the transplant course and outcome and the risk for disease recurrence. When available, the kidney biopsy report should be reviewed and the risk of

© 2013 Pham et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


3Liver biopsy and pretransplant antiviral therapy recommended. Hepatology consult.

4Pretransplant desensitization protocols may allow successful transplantation across these barriers

**Table 1.** Contraindications for renal transplantation

recurrent disease should be discussed with the transplant candidate. Patients with end-stage kidney disease (ESKD) secondary to congenital or genitourinary abnormalities should undergo a voiding cystourethrogram and appropriate urological evaluation, preferably by the kidney transplant surgeon. Documentation of the patients' 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 renal disease must be obtained if living related kidney donation is an option. The patients's surgical history should be elicited with special emphasis on previous abdominal operations. The surgical evaluation of the transplant candidate is discussed elsewhere.

*1.2.2. Psychiatric evaluation*

**Table 2.** Assessment of renal transplant candidate

**Laboratory evaluation**

Urinalysis, urine culture PSA in men > 50 years of age1

Colonoscopy if > 50 years of age2

Pap smear (for women)2

**Immunologic studies** Blood group and HLA typing

tives with prostate cancer).

HLA antibodies Crossmatching

evaluation.

Cardiac evaluation (see text)

**Other evaluation**

ECG Chest x-ray

Serologies: HIV, hepatitis B and C, CMV, EBV, HSV, RPR (FTA-ABS if positive)

Immunofixation electrophoresis in candidates > 60 years of age

Abdominal ultrasound in diabetics to evaluate for gall stones Native renal ultrasound to assess for acquired cystic disease or masses

Comprehensive metabolic panel, CBC with differential and platelet count, PT/INR, PTT

Mammogram for women > 40 years of age2 or with family history of breast cancer

cin treponemal antibodies; *PSA*: prostate specific antigen; ECG: electrocardiogram

Urologic evaluation if history of bladder /voiding dysfunction, recurrent urinary tract infections (see text)

chapter.

Coexisting psychiatric disorders have been suggested to be associated with poor transplant outcomes due in part to behavioral factors such as nonadherence to medical therapy as well as physiologic factors such as modification of immunologic and stress responses (Danovitch, 2010). Patients should be inquired about mood or anxiety disorders, alterations in perceptions, morbid destructive or violent thoughts directed to self or others, medical adherence, risk taking, substance abuse, and environmental and interpersonal stressors (Danovitch, 2010). Positive prognostic factors include strong family and social support, good insight, sound spirituality, and the ability to cope with various stressors. It should also be noted that neuro‐ cognitive symptoms may masquerade as depression hence assessment of organic brain dysfunction should not be overlooked. Oftentimes, the psychiatric evaluation for transplant candidacy can be complex and would require referral to subspecialty service for diagnosis and treatment. A comprehensive discussion of psychiatric issues is beyond the scope of this

*CMV*: cytomegalovirus; *EBV*: Epstein-Barr virus; *HSV*: herpes simplex virus; *RPR*: rapid plasmin reagin; FTA-ABS: fluores‐

Medical Evaluation of the Adult Kidney Transplant Candidate

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

5

1High-risk patients should be screened at an earlier age (African-Americans, those with two or more first-degree rela‐

2Part of routine health maintenance, not required for listing unless deemed necessary by the clinician at the time of

A complete physical exam should include a careful assessment for the presence of carotid and peripheral vascular disease. Patients should preferably have a body mass index below 30-35 as obesity is associated with a higher incidence of postoperative complications. In addition to a thorough history and physical exam, patients should also undergo a number of routine laboratory testings and imaging studies as outlined in table 2.


Serologies: HIV, hepatitis B and C, CMV, EBV, HSV, RPR (FTA-ABS if positive) Comprehensive metabolic panel, CBC with differential and platelet count, PT/INR, PTT Urinalysis, urine culture PSA in men > 50 years of age1 Immunofixation electrophoresis in candidates > 60 years of age **Other evaluation** ECG Chest x-ray Colonoscopy if > 50 years of age2 Abdominal ultrasound in diabetics to evaluate for gall stones Native renal ultrasound to assess for acquired cystic disease or masses Pap smear (for women)2 Mammogram for women > 40 years of age2 or with family history of breast cancer Cardiac evaluation (see text) Urologic evaluation if history of bladder /voiding dysfunction, recurrent urinary tract infections (see text) **Immunologic studies** Blood group and HLA typing HLA antibodies Crossmatching *CMV*: cytomegalovirus; *EBV*: Epstein-Barr virus; *HSV*: herpes simplex virus; *RPR*: rapid plasmin reagin; FTA-ABS: fluores‐ cin treponemal antibodies; *PSA*: prostate specific antigen; ECG: electrocardiogram 1High-risk patients should be screened at an earlier age (African-Americans, those with two or more first-degree rela‐ tives with prostate cancer).

2Part of routine health maintenance, not required for listing unless deemed necessary by the clinician at the time of evaluation.

**Table 2.** Assessment of renal transplant candidate

#### *1.2.2. Psychiatric evaluation*

recurrent disease should be discussed with the transplant candidate. Patients with end-stage kidney disease (ESKD) secondary to congenital or genitourinary abnormalities should undergo a voiding cystourethrogram and appropriate urological evaluation, preferably by the kidney transplant surgeon. Documentation of the patients' 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 renal disease must be obtained if living related kidney donation is an option. The patients's surgical history should be elicited with special emphasis on previous abdominal operations. The surgical evaluation of the transplant candidate is

<sup>1</sup>Kidney alone transplant may be safe in end-stage kidney disease patients with compemsated HCV cirrhosis and hep‐

Post-percutaneous coronary intervention (PCI) patients. Transplant surgery not recommended:

3Liver biopsy and pretransplant antiviral therapy recommended. Hepatology consult.

4Pretransplant desensitization protocols may allow successful transplantation across these barriers

Within 4 weeks of coronary revascularization with balloon angioplasty

A complete physical exam should include a careful assessment for the presence of carotid and peripheral vascular disease. Patients should preferably have a body mass index below 30-35 as obesity is associated with a higher incidence of postoperative complications. In addition to a thorough history and physical exam, patients should also undergo a number of routine

laboratory testings and imaging studies as outlined in table 2.

discussed elsewhere.

**Absolute contraindications**

Life expectancy < 2 years

Active substance abuse Relative contraindications Active peptic ulcer disease2 Medical noncompliance Active hepatitis B virus infection3

Morbid obesity Special considerations ABO incompatibility4 Positive T cell crossmatch4

Severe irreversible extrarenal disease

Limited, irremediable rehabilitative potential Poorly controlled psychiatric illnesses

Within 3 months of bare metal stent placement Within 12 months of drug eluting stent placement

atic portal vein gradient < 10 mmHg (see text) 2Should be treated prior to transplantation

**Table 1.** Contraindications for renal transplantation

Liver cirrhosis1 (unless combined liver and kidney transplant) Primary oxalosis (unless combined liver and kidney transplant)

4 Current Issues and Future Direction in Kidney Transplantation

Active malignancy Active infection

> Coexisting psychiatric disorders have been suggested to be associated with poor transplant outcomes due in part to behavioral factors such as nonadherence to medical therapy as well as physiologic factors such as modification of immunologic and stress responses (Danovitch, 2010). Patients should be inquired about mood or anxiety disorders, alterations in perceptions, morbid destructive or violent thoughts directed to self or others, medical adherence, risk taking, substance abuse, and environmental and interpersonal stressors (Danovitch, 2010). Positive prognostic factors include strong family and social support, good insight, sound spirituality, and the ability to cope with various stressors. It should also be noted that neuro‐ cognitive symptoms may masquerade as depression hence assessment of organic brain dysfunction should not be overlooked. Oftentimes, the psychiatric evaluation for transplant candidacy can be complex and would require referral to subspecialty service for diagnosis and treatment. A comprehensive discussion of psychiatric issues is beyond the scope of this chapter.

The following section describes specific medical and urological issues that should be addressed during the transplant evaluation process.
