The document summarizes the evaluation of an adult kidney transplant recipient. It discusses timing transplantation based on GFR levels, screening for contraindications like infections and cardiovascular disease, evaluating immunological factors like PRA and HLA typing, and special considerations for populations like diabetics, children, and those on dialysis. The goal of the evaluation is to minimize risks and maximize outcomes for the recipient and longevity of the transplanted kidney.

1. Assessment of adult kidney
transplant recipient
Dr Sunil kumar Prajapati

2. Purpose of evaluation
• Minimize the morbidity and mortality &
maximize quality of life
• Protect living donors & scarce resource of
deceased and living donor kidneys
• Survival advantage of transplantation –
– any age, gender, ethnicity, with/without diabetic kidney
disease

3. Timing of evaluation
• If preemptively transplanted (before dialysis) - best
outcomes
• GFR ≤20 mL/min
• Rate of progression
– Patient with diabetes may progress relatively rapidly hence there is no
sense in delaying transplantation if a living donor is available
– eGFR - 30 mL/min
• Clinically uremic

4. Interested in transplantation
Yes
Preliminary screening (no
comorbidities)
No obvious C/I
ABO blood group, HLA typing
Complete medical evaluation,
history, examination & test
Relative C/I No C/I Absoluet C/I
Judge case by case Optimize medical status No transplant
If no living donor place
Proceed with living on waiting list
donor transplant if
available
Review every 2 years

5. Relative/absolute Contraindications
• Not irreversible contraindications
– life-threatening infections, cancer, unstable CVD,
noncompliance, psychatric illness
– Not expected to survive >2 years with a kidney
transplant
– ABO incompatibility, Positive T cell mismatch
– Severe obesity BMI >40

6. Cardiovascular Disease
History & examination
Low risk Medium risk (Age > 45 High risk (angina +ve)
(Age < 45 yrs, no yrs or any traditional CAG
traditional risk factors) risk factor)
Stress test
-ve +ve
Intensify conservative
Proceed with listing & Management
review every 2 yrs
Appropriate intervention

7. Cardiovascular Disease contd..
• Pre & perioperative βB reduces cardiac events in high-
risk patients
• H/o stroke or TIA should be symptom free for at least 6
m before transplantation
– Aspirin prophylaxis
– Risk of perioperative bleeding is generally outweighed by
the benefits
• History of PAD, or claudication symptoms
– examine for signs of lower extremity arterial insufficiency
– Consider USG or MR angio to image the aorta and iliac
arteries

8. Obesity
• BMI ≥ 30 kg/m2 is associated with
• death, graft failure, wound dehiscence, wound infections, HTN, ↑
risk for developing DM after transplantation
• Generally not an absolute C/I - weight loss is required
if BMI is > 40 kg/m2
• If diet is unsuccessful, bariatric surgery should be
considered for BMI ≥40 kg/m2

9. Infections
• Conditions that increases the chances of serious
post-transplant infections
– Splenectomy
– Immunosuppressive or chemotherapeutic agents
– Prior organ/BMT
– Acquired or inherited immunodeficiency syndromes
– Malnutrition
– Open wounds (including dialysis catheters), Poor
dentition
– Travel to endemic areas
– Occupational exposure

10. Infections contd..
• Immunization may be less effective in stages 4 & 5 CKD, but there is little risk &
potentially great benefit
• Asplenic patients - Hemophilus influenza & Meningococcus
• live vaccines (VZV) should not be administered immediately before transplantation

11. HIV +ve pt. may be transplant candidates if…
• Adherent to a highly active antiretroviral therapy regimen
• Undetectable virus load
• Sustained CD4 count >200/mL
• No opportunistic infections
• No life-threatening malignancies
• Appropriate expertise available

12. Infections contd..
• Hepatitis B
– HBsAg, HBe-antigen, & viral load
– Chronic active hepatitis, cirrhosis, & HCC - risks
aggravated by immunosuppression
– HBV replicator – tt. with lamividine pre & post-
transplantation

13. Infections contd..
• HCV
– liver disease & new-onset diabetes after kidney
transplantation
– Patients with HBV, HCV, chronic active hepatitis,
cirrhosis are at high risk for developing HCC -
baseline & follow-up levels of α-FP

14. Anti HCV +ve
HCV RNA -ve HCV RNA +ve
Liver Bx
Normal LFT
Normal Hepatitis Cirrhosis or precirrhosis
Antiviral Rx Defer transplant or
List fro renal transplant consider combined liver-
kidney transplant
HCV RNA -ve HCV RNA +ve
Pt by pt decision

15. Pulmonary Disease
• Smoking - 2.4 & 2.9 RR for the development
of ESRD in men and women respectively
• Quit smoking prior to transplantation
• If history of cigarette smoking and/or
shortness of breath do PFT & chest x-ray

16. Recurrent Kidney Disease
• Incidence of graft failure due to recurrent
disease is probably not high enough to
preclude transplantation in most cases
• Exceptions
– ≥2 grafts loss due to recurrent idiopathic FSGS
(Plasmapheresis)

17. Recurrent Kidney Disease

18. Genitourinary Disorders
• Asymptomatic and absent history of bladder
dysfunction do not usually require further
evaluation
• Adequate urinary drainage prior to
transplantation (at least 6wks)
• Chronic Kidney Disease Management
• Anemia
• Physiologic calcium, phosphorous, vit. D & PTH levels
• Should not have a dialysis access infection or peritonitis (if
being treated with chronic peritoneal dialysis) at the time of
transplantation.

19. Thrombophilias
• ≈ 2% allografts are lost to thrombosis
• Perioperative anticoagulation can prevent
– Screen if h/o venous thrombosis, including recurrent
hemodialysis access thromboses
– Factor V Leiden, prothrombin G20210A mutation,
Antiphospholipid antibodies
– If any of these are positive, perioperative
anticoagulation could be given
– Other indications
• Recipient is younger
• Donor is < 2 yrs age

20. Malignancies
• life-threatening - C/I
• Same cancer screening as recommended for the
general population
– Colonoscopy every 5 years for > 50 years
– Mammography for > 50 years , younger if family h/o breast
cancer
– Annual pelvic examination with cervical cytology testing
– >50 years - DRE & PSA testing for prostate cancer (controversial)
– Cystoscopy for high-risk patients screening for bladder cancer
• Analgesic nephropathy, chronic exposure to cyclophosphamide.

21. Patients with a history of prior malignancy, how long to
wait?

22. Noncompliance and Cognitive
Impairment
• Substance abuse – substance free for at least
6 months before being accepted for
transplantation.
• Patients with cognitive impairment should
probably not undergo transplantation

23. Immunologic Evaluation
• Preformed antibodies
– prior transplantations
– Pregnancies
– blood transfusions
• Test measures Ab induced lysis of a panel of lymphocytes
from different individuals in the population.
• The higher the panel reactive antibody (PRA; range 0%–100%)
titer, the more difficult it will be to find a donor, that the
potential recipient will not reject with an antibody-mediated
rejection

24. Immunologic Evaluation contd..
• The PRA is generally measured at the time of transplant evaluation
and then periodically (every 3 mth)
• PRA declines with time, especially if blood transfusions are avoided
• Still may have an anamnestic Ab response if re-exposed to an
antigen - wise to avoid
• HLA - graft survival is better with fewer mismatches (range 0-6)
• Generally, the donor and the recipient must be blood group-
compatible (Except when donor is BG A2)
• Whether a particular kidney can be transplanted is determined by a
final cross-match that measures whether the recipient has an
antibody to the donor kidney

25. Special situations…

26. Children
– Body weight > 11kg,
– Infant donors – high chances of graft thrombosis
– Best result when donor is young adult

27. Diabetic nephropathy
– Most common cause of death is MI, CHF
– Special attention to bladder emptying & foot ulcers
– Early transplant
– Combined pancreas and kidney transplant is beneficial for
nephro & neuropathy, while effect on retinopathy &
vasculopathy is unclear

28. Oxalosis
– ESRD before 30 years
– Aggressive preoperative dialysis, forced diuresis
– Pyridoxine, orthophosphates, thiazides post
transplantation
– Combined liver and kidney transplant is better
– Isolated kidney transplant in late onset form only
– Transplant when GFR – 25ml

29. Nephrectomy
• Large renal stone
• Gross abnormalities of urinary tract
• Persistent infection
• PCKD
– Persistent infection
– Very large kidney hindering graft placement
– Drug resistant HTN

30. Dialysis
• Dialysis immediately preceding
transplantation only if hyperkalemia or
unacceptable fluid overload. Increased risk of
bleeding.
• If dialysis is done than pt should be
adequately hydrated
• Pt on PD should continue dialysis until the
time of transplantation, peritoneal cavity
should be drained before surgery

31. Take home message..

32. Assesment of patient before
transplantation
• History & physical examination
– General
• Cause of CRF, duration, HTN
• Infection
• Previous transplantation
– Other disease
• CVD, malignancies(prev. or current), respiratory, GIT
• DM
– Previous operations
• Nepherectomy, splenectomy, parathyredectomy, appendectomy etc.
– Family history
– Current clinical data and tt
• Mode & duration of dialysis
• BP
• Urine – volume
• Sign & symptoms of neuropathy
• Previous BT & pregnancies
• Diet Drugs

33. Assesment of patient before
transplantation contd..
• Laboratory examinations
– Hct, TLC, DLC, absolute lecocyte count, plt. Count
– Ca, phosph, Alk phosph, PTH
– LFT
– CMV Ab, HBs Ag, HB Ab, HCV Ab, EBV Ab, HIV Ab
– Urine C/S
– Radiological exam
– CXR, USG
– Others
• ECG, Fundus, Urological exam
• Immunological exam
• Blood grouping
• Tissue typing, family typing
• Antibody screening

34. Thankyou