CORE CURRICULUM IN NEPHROLOGY Evaluation of Adult Kidney ...


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CORE CURRICULUM IN NEPHROLOGY Evaluation of Adult Kidney ...

  1. 1. CORE CURRICULUM IN NEPHROLOGY Evaluation of Adult Kidney Transplant Candidates Suphamai Bunnapradist, MD, and Gabriel M. Danovitch, MD K idney transplantation is the treatment of choice for suitable patients with end-stage kidney disease and must be discussed with pa- into account when determining which diagnostic studies should be performed. tients with advanced chronic kidney disease WHEN TO REFER (CKD) preparing for renal replacement therapy. I. Kidney transplantation should be discussed Referral to a transplant program should be per- with all patients with irreversible advanced formed early to assess candidacy for a preemp- CKD tive transplantation. II. Patients with CKD without known contraindi- One of the main goals of the visit to the cations for transplantation should be referred transplant center is to educate patients about to a transplant program when they approach living and deceased donor transplant options. CKD stage 4 or a glomerular filtration rate Potential transplant candidates and their family (GFR) less than 30 mL/min/1.73 m2 ( 0.5 members should be encouraged to attend formal mL/s/1.73 m2) educational sessions and obtain further informa- III. Early referral will improve the chances of a tion through available literature, including center- patient receiving a preemptive transplant, specific outcomes. Potential transplant recipients especially those with a potential living do- also should be familiar with deceased donor nor; referral to a kidney transplant program organ allocation policy (Table 1). does not imply immediate transplantation Evaluation of kidney transplant candidates in- cludes an initial assessment for transplantation TRANSPLANTATION WORKUP suitability. This includes medical, surgical, immu- The purpose of the evaluation is to identify nologic, and psychosocial evaluations. The pa- contraindications for kidney transplantation and tient’s individual risks and benefits of transplan- address and correct medical and psychological tation are discussed so that he or she can make an conditions that may affect transplant outcomes. informed decision about whether to proceed with I. Comprehensive history and physical exami- transplantation. After candidates are placed on nation with emphasis on the following: the deceased donor list, a periodic reevaluation is A. Document the cause of renal disease and necessary to address new issues that may impact assess the risk of recurrence in the trans- on transplant suitability. planted kidney; this includes review of In this article, we provide guidelines for the the native kidney biopsy report, if avail- evaluation of adult kidney transplant candidates. able The workup should be tailored according to patient- B. Family history, especially kidney dis- specific conditions. Center expertise should be taken ease, hypertension, and diabetes C. Evidence of coronary heart disease, cere- brovascular disease, and peripheral vas- cular disease From the Division of Nephrology, UCLA Medical Center, D. Evidence of defects in coagulation Los Angeles, CA. E. Evidence of abnormalities of the urinary Received May 18, 2007. Accepted in revised form August 10, 2007. tract and bladder Address correspondence to Suphamai Bunnapradist, MD, F. Financial evaluation to assess ability to Director of Clinical Research, Kidney and Pancreas Trans- afford transplant medications plant Program, David Geffen School of Medicine at UCLA, G. Psychosocial evaluation in conjunction with 924 Weswood Blvd, Ste 860, Los Angeles, CA 90095. E-mail: a transplant social worker to assess support © 2007 by the National Kidney Foundation, Inc. network, determine suitability, and develop 0272-6386/07/5005-0024$32.00/0 a plan to avoid adverse posttransplantation doi:10.1053/j.ajkd.2007.08.010 psychosocial outcomes 890 American Journal of Kidney Diseases, Vol 50, No 5 (November), 2007: pp 890-898
  2. 2. Core Curriculum in Nephrology 891 H. Evaluate sensitization risks, including a Table 2. Contraindications for history of blood or platelet transfusions, Kidney Transplantation pregnancies, abortions, and previous trans- Severe uncorrectable systemic conditions with short plants expected life expectancy I. In retransplantation candidates, a de- Reversible renal failure tailed history of the prior transplantation Recent or untreatable malignancy Uncontrolled psychiatric disorders and active substance courses and cause of graft loss, medica- abuse tion compliance, and previous transplant Ongoing noncompliance complications should be obtained Chronic or ongoing active infection II. Contraindications for single-organ kidney Primary oxalosis (evaluate for combined liver-kidney transplant are listed in Table 2 transplantation) Limited irreversible rehabilitative potential III. Required laboratory tests A. Blood type (need confirmatory test by 2 laboratories) Transplant programs and referring physi- B. Complete blood count and comprehen- cians should consider which of the following sive metabolic panel tests should be performed by the transplant C. Prothrombin time (PT), partial thrombo- programs and which by referring nephrolo- plastin time (PTT) gists D. Hepatitis serological tests A. Purified protein derivative (PPD) test in those E. Venereal disease research laboratory with a history of exposure to tuberculosis, (VDRL) serological test prior residence in an endemic area, or chest F. Cytomegalovirus serological test X-ray suspicious of tuberculosis G. Tissue typing for HLA and panel-reac- B. Colonoscopy in patients older than 50 years tive antibody (PRA) C. Gynecological evaluation, including Papani- H. Identification of specific HLA antibody colaou smear in women of childbearing age should be performed in patients with D. Mammogram in women older than 40 years positive PRA E. Prostate-specific antigen (PSA) in men I. Electrocardiogram (ECG) older than 45 years J. Chest X-ray F. Serum immunoelectrophoresis in patients K. Renal ultrasound for those on dialysis older than 60 years and those with unex- therapy for more than 5 years in patients plained renal failure and anemia without recent imaging G. Stress test, echocardiogram, and cardiac IV. Optional laboratory tests as indicated angiogram (see cardiac section) H. Vascular study (see vascular section) I. Detailed coagulation study in those with Table 1. United Network for Organ Sharing Point System for Allocation of Deceased Donor Kidney history of deep venous thrombosis, spon- taneous abortion, recurrent clotting of a Factor Points Condition dialysis fistula or graft, or bleeding ten- dency Time waiting 1 Each year of waiting time Quality of HLA match 2 0-DR mismatch J. Toxoplasmosis, coccidioidomycosis, and 1 1-DR mismatch histoplasmosis titers in residents of en- Panel-reactive antibody 4 80% panel-reactive demic areas antibody and negative cross-match CARDIAC EVALUATION* Note: The 0-HLA mismatched kidneys are mandated to be I. Assessment for cardiovascular disease shared nationally. Potential recipients younger than 18 years are given priority to donors younger than 30 years and also (CVD) should be performed in all trans- receive extra points. Allocation policy is in the process of revision. Current allocation policy is available at the United Network for Organ Sharing website Nation- * Conclusive data specific to the kidney transplant popu- ally approved local variance in organ allocation policy may lation are lacking. Our recommendation is based on our take precedence over the national point system. center’s experience and published consensus reports.
  3. 3. 892 Bunnapradist and Danovitch plant candidates; patients with CKD have CEREBROVASCULAR EVALUATION a high prevalence of CVD, left ventricular I. Patients with symptoms and signs of cerebro- hypertrophy, and congestive heart failure vascular disease should be evaluated, and and therefore are at high risk of cardiovas- modifiable risk factors should be addressed cular events perioperatively and posttrans- II. In patients with seizure disorders, certain plantation anticonvulsants may interfere with the metab- II. History and physical examination to assess olism of calcineurin inhibitors; a neurology cardiovascular symptoms and signs, risk referral is recommended to assess whether factors, and physical status medications can be safely discontinued or III. ECG for all patients; abnormal results regimens with fewer drug interactions can warrant additional cardiac evaluation be substituted IV. Noninvasive screening to rule out occult PERIPHERAL VASCULAR EVALUATION CVD should be performed in patients with symptoms or clinical signs; given the high I. Vascular disease is common in patients with prevalence of occult CVD, those with end-stage renal disease (ESRD), and kidney significant CVD risk factors, including transplantation involves major vascular sur- diabetes, age older than 50 years, severe gery peripheral vascular disease, cigarette smok- II. Physical examination should focus on femo- ing history, or long-term CKD should ral and peripheral vascular arteries; Doppler undergo a stress test studies of iliac and lower-extremity vessels V. Patients with diabetes may benefit from a or other imaging study may be performed in stress test with imaging due to the low patients with symptoms and signs sugges- sensitivity of exercise ECG stress test; tive of peripheral vascular disease to evalu- type of imaging test should take into ate the feasibility of allograft placement account the transplant center’s experi- III. Angiography and computed tomography ence (CT) with intravenous contrast should be VI. Modifiable risk factors should be ad- avoided in patients with residual renal func- tion; magnetic resonance imaging (MRI) dressed and treatment should be delivered with gadolinium should be ordered with under the care of the primary nephrologist caution given the emerged association with VII. Although data are lacking, there is a nephrogenic systemic fibrosis general consensus to support repeated screening for cardiac disease; those with PULMONARY EVALUATION a normal coronary angiogram may not I. Evaluation should include assessment of need reevaluation for 3 years; new car- general anesthetic risk diac symptoms warrant immediate evalu- II. A pulmonary function test is indicated in ation patients with a significant smoking history VIII. Echocardiogram should be obtained in and those with symptoms and signs of those with suspected valvular disease or chronic lung disease, unexplained shortness congestive heart failure of breath, or exercise limitation IX. Those with inducible ischemia should be III. Isoniazid (INH) prophylaxis should be con- referred for cardiology consultation and sidered in patients with a positive tuberculin coronary angiography should be consid- skin test result or chest X-ray suggestive of ered; if CVD is detected and amenable to tuberculosis revascularization, the procedure should be IV. Smoking cessation is recommended in all performed before transplantation patients before transplantation X. Smoking cessation is recommended in all UROLOGICAL EVALUATION patients, especially those with significant CVD; referral to smoking cessation pro- I. Indications for a voiding cystourethrogram gram is recommended may include recurrent urinary tract infec-
  4. 4. Core Curriculum in Nephrology 893 tions, pyelonephritis, history of vesi- beads; without desensitizing treatment, anti- coureteral reflux, history of urinary reten- bodies to a specific antigen identify those tion, or other abnormal voiding patterns antigens as unacceptable for transplant II. Renal ultrasound or other imaging studies III. Highly sensitized patients should have been performed in all patients A. Sensitization is defined as the presence of undergoing evaluation for renal transplanta- preformed antibodies against HLA in the tion and should be available for review; spe- blood and is a major barrier to successful cific pathological conditions for which renal transplantation ultrasound is indicated include acquired cystic B. Available options include kidney paired kidney disease, suspected kidney stones, unex- donation, kidney list donation, and desen- plained hematuria, suspected renal mass, evalu- sitization treatment ation of hydronephrosis in children presenting 1. Kidney paired donation involves 2 or with CKD, and those with a significant history more pairs of incompatible living do- of urinary tract infection nors and recipients; the mutual ex- III. Urodynamic studies should be considered in change results in 2 or more compat- patients with a suspected neurogenic blad- ible transplants der and may be indicated in young patients 2. Kidney list donation involves a pair of with unexplained CKD an incompatible potential living do- IV. Patients with abnormal prostate examination nor and recipient and a waiting list findings and those with high PSA levels recipient; a waiting list recipient re- should be referred for a possible prostate ceives the organ from the living do- biopsy nor; the donor’s intended recipient is V. Patients with a history of obstructive void- given priority to receive a deceased ing symptoms and benign prostatic hyperpla- donor organ sia should have an assessment for postvoid 3. Patients with a cross-match–positive residual volume; those with high residual living donor or those on the top of the volume may need urological referral and waiting list should be referred to a further workup transplant center with expertise in desen- VI. Indications for pretransplantation native ne- sitization protocols and/or a donor ex- phrectomy change program A. Chronic pyelonephritis, infected stone, heavy proteinuria, intractable hyperten- EVALUATION OF COMORBID CONDITIONS sion, polycystic kidney disease with se- verely enlarged kidneys, recurrent bleed- I. Diabetes ing or infection, or renal mass suspicious A. In patients with type 1 diabetes with for renal cell carcinoma ESRD, early transplantation with a liv- ing donor followed by pancreas-after- ASSESSMENT FOR IMMUNOLOGIC RISK kidney transplantation usually is re- garded as the best option Screening tests to detect preformed HLA anti- B. Due to the superior outcomes of bodies include an enzyme-linked immunosor- simultaneous kidney-pancreas trans- bent assay (ELISA), flow cytometry, and cytotox- plantation compared with deceased icity test to assess PRA; positive PRA results donor kidney transplantation, this op- should be followed by specific HLA antibody tion should be discussed with pa- tests tients with type 1 diabetes, especially I. An ELISA is inexpensive and is used to those without potential living do- detect antibody against purified class I and nors; the additional risk and benefits class II antigens should be discussed thoroughly with II. Flow cytometry is more sensitive and allows patients sera to be tested against whole lymphocytes, C. Due to the high prevalence of vascular purified HLA antigens, or single antigen disease, patients should be screened
  5. 5. 894 Bunnapradist and Danovitch vigorously for peripheral and coronary therapy; data for exact risk of cancer artery disease recurrence are lacking; additional infor- II. Obesity mation can be obtained from the Israel A. Because morbid obesity is associated Penn International Tumor Registry; on- with increased risk of graft loss, delayed cology consultation may be beneficial graft function, wound complications, pro- IV. Hypercoagulable state longed hospitalization, and new-onset A. Patients with a history of spontaneous diabetes after transplantation, weight loss abortion or thrombosis, including recur- often is recommended before transplan- rent clotting of a dialysis fistula and tation, although the benefit of this inter- graft, should be screened vention is unclear; there is no specific B. Hypercoagulable states exist in up to guideline on body mass index (BMI) 15% to 20% of patients with ESRD; cutoff value, although most centers will common causes include activated pro- decline candidates when BMI is greater tein C resistance, factor V Leiden gene than 40 kg/m2 mutation, prothrombin gene mutation, III. Patients with history of cancer and antiphospholipid antibody A. Most, but not all, patients will benefit C. A hypercoagulable state is rarely a con- from waiting 2 to 5 years before trans- traindication for transplantation; patients plantation; the exception may include need to be managed with anticoagulation cancer in situ, localized nonmelanoma therapy during and after transplantation; skin cancer, and limited incidental re- anticoagulation is associated with an nal cell cancer; general guidelines are increased risk of bleeding listed in Table 3 V. Hepatitis C infection B. The optimal waiting time varies de- A. Liver biopsy should be performed to pending on type, stage, and localiza- evaluate the extent of liver damage tion of tumor, as well as response to because clinical findings and biochemi- cal markers may underestimate the Table 3. Recommendations for Minimum Tumor-Free degree of advanced liver disease in Waiting Periods for Common patients with ESRD Pretransplantation Malignancies B. Cirrhosis is a contraindication for kid- ney transplantation due to increased Tumor Type Minimal Wait Time mortality in this group; instead, liver- Renal kidney transplantation should be con- Wilm 2y sidered Renal cell carcinoma C. Consideration should be given to treatment Incidental tumors None of patients with hepatitis C before transplan- Other At least 2 years Bladder tation, especially those with a treatment- In situ None sensitive genotype (non–type 1) Invasive 2y D. The option of hepatitis C–positive donor Prostate 2y transplantation should be discussed with Uterus patients with active hepatitis C given the Cervix (in situ) None Cervical invasive 2-5 y shorter waiting time for hepatitis C de- Uterine body 2y ceased donor kidney and acceptable out- Breast 2-5 y come Colorectal 2-5 y E. Patients who are hepatitis B naïve should Lymphoma 2-5 y be vaccinated against hepatitis B Skin (local) Basal cell None VI. Hepatitis B infection Squamous cell Surveillance A. With the introduction of effective anti- Melanoma 5y viral therapy, hepatitis B infection is Note: The broad recommendations must be individual- no longer considered an absolute con- ized based on specific clinical and oncological information. traindication for transplantation
  6. 6. Core Curriculum in Nephrology 895 B. Patients with past natural infection with C. Exposure to cytotoxic agents increases detectable antibody to hepatitis B sur- the risk of bone marrow toxicity and face antigen (HBsAb) and negative hepa- posttransplantation malignancy titis B surface antigen (HBsAg) are at X. Polycystic kidney disease low risk of hepatitis B resurgence; antivi- A. Pretransplantation nephrectomy may ral prophylaxis may be beneficial be indicated in patients with recurrent C. Liver biopsy should be performed in urinary tract infections, bleeding, or patients with active hepatitis B; if large kidneys extending into the pelvis advanced liver disease is detected, pa- to make room for placement of an tients should be referred for combined allograft liver-kidney transplantation B. Extrarenal manifestations, such as aneu- rysm, valvular heart disease, and diver- D. Antiviral treatment should be initiated in ticulosis, may complicate the transplanta- patients with active viral replication tion course, and screening should be (positive hepatitis B e antigen [HBeAg] performed in suspected cases or hepatitis B virus DNA) XI. Primary oxalosis VII. Human immunodeficiency virus (HIV)- A. Primary oxalosis is a contraindication infected patients for single-organ kidney transplantation, A. HIV infection is no longer considered and patients should be referred for com- an absolute contraindication for trans- bined liver-kidney transplantation plantation XII. Blood dyscrasias B. Potential candidates should have no A. In the presence of paraproteinemia, a active acquired immunodeficiency syn- workup for myeloma is warranted; drome (AIDS)-defining illness and benign monoclonal gammopathy is a have sustained CD4 counts greater diagnosis of exclusion and serial moni- than 200 cells/mL with undetectable toring for 12 months to rule out my- serum HIV RNA on stable antiretrovi- eloma is recommended before trans- ral therapy plantation; patients should be counseled C. Coinfection with hepatitis virus is com- about the long-term risk of developing mon, and each infection should be frank myeloma addressed before transplantation B. Patients with treated myeloma may be VIII. Fabry disease cautiously considered for transplanta- A. More than 200 patients with Fabry tion; these patients remain at high risk disease have undergone transplanta- of posttransplantation infections tion in the United States; early data C. Amyloidosis is associated with poorer showed good graft and patient sur- prognosis after transplantation; however, vival; the role of enzyme replacement patients with amyloidosis with limited extrarenal manifestations can be consid- therapy before and after kidney trans- ered for kidney transplantation plantation is unclear XIII. Advanced age IX. Systemic lupus erythematosus and vasculitis A. Patients older than 60 years are at a A. Transplantation should be delayed un- greater risk of posttransplantation infec- til patients have no clinically active tion and are more susceptible to medi- disease and are on minimal immuno- cation side effects suppression; the duration of dialysis B. Appropriately evaluated and educated therapy before transplantation and se- patients in their 70s may benefit in rological status in the absence of clini- terms of life expectancy from transplan- cally active disease do not predict tation and may be considered as trans- recurrence plant candidates B. Previous treatment with steroids in- C. There are limited data on outcomes for creases the risk of bone disease patients in their late 70s and early 80s;
  7. 7. 896 Bunnapradist and Danovitch Table 4. Criteria for Expanded Criteria Donor Donor Age Categories (y) Donor Condition 10 10-39 40-49 50-59 60 CVA HTN creatinine 1.5 mg/dL X X CVA HTN X X CVA creatinine 1.5 mg/dL X X HTN creatinine 1.5 mg/dL X X CVA X HTN X Creatinine 1.5 mg/dL X None of the above X Note: Creatinine level greater than 1.5 mg/dL ( 133 mol/L). Abbreviations: X, expanded criteria donor; CVA, cardiovascular accident as the cause of death; HTN, history of hypertension at any time. most of these patients are better served tion; however, if the first graft is lost by remaining on dialysis therapy rapidly due to recurrent disease, the D. Counseling should emphasize the chance of recurrence in subsequent benefit of timely transplantation given transplants is more than 80% and a the high mortality rate of elderly living donor transplant should gener- patients on the waiting list; living ally be avoided donor transplantation should be en- XV. Patients with a previously failed graft couraged, and the option of ex- A. Referral should be made as patients panded criteria donor (ECD) listing approach stage 4 CKD should be discussed; definition of B. Patients with a failed graft are at risk ECD is listed in Table 4 of developing donor-specific antibod- E. ECD is particularly advisable for older ies, especially those with early graft patients without a living donor in whom loss due to severe rejection; screen- a prolonged wait for standard criteria ing followed by confirmation of do- donor (SCD) is anticipated nor-specific antibodies should be per- F. Age-appropriate screening for malig- formed nancy should be maintained C. Allograft nephrectomy generally is not XIV. Primary glomerular disease indicated except in those with ongoing A. Most, but not all, glomerular disease uncontrolled rejection, severe hematuria, may recur after transplantation; recur- and/or malignancy; allograft nephrec- rence of disease may result in graft loss; the rate of recurrence and risk of tomy may be associated with a resur- graft loss vary according to primary gence of donor-specific antibodies disease D. Patients with early failed grafts due to B. Primary focal sclerosis may recur in recurrent glomerulonephritis are at very 20% to 50% after kidney transplanta- high risk of subsequent recurrence; tion and lead to graft failure in up to patients with recurrent focal segmental 20% of patients after transplantation; glomerulosclerosis (FSGS) should be risk factors include younger age and considered for pretransplantation plas- rapid progression in native kidneys; mapheresis detailed counseling should be per- E. Patients with graft failure due to BK formed nephropathy can successfully undergo C. Risk of graft loss is similar in living retransplantation; allograft nephrectomy versus deceased donor transplanta- may not be necessary, especially in those tion and a living donor should be who showed clearance of viremia; vigor- considered in the first transplanta- ous monitoring of BK viremia and adjust-
  8. 8. Core Curriculum in Nephrology 897 ment of immunosuppression posttrans- SUGGESTED READINGS plantation are important 1. Abbud-Filho M, Adams PL, Alberu J, et al: A report of F. A hypercoagulable workup should be the Lisbon conference on the care of the kidney transplant recipient. Transplantation 83:S1-S22, 2007 (suppl 8) performed in patients with graft failure 2. Arndorfer JA, Meier-Kriesche HU, Ojo AO, et al: due to unexplained graft thrombosis Time to first graft loss as a risk factor for second renal G. In patients approaching CKD stage 5 allograft loss. Transplant Proc 33:1188-1199, 2001 with a potential living donor, consider- 3. Choy BY, Chan TM, Lai KN: Recurrent glomerulone- ation should be given to maintain ad- phritis after kidney transplantation. Am J Transplant 6:2535- 2542, 2006 equate immunosuppression, promptly 4. Cibrik DM, Kaplan B, Arndorfer JA, Meier-Kriesche followed by retransplantation to avoid HU: Renal allograft survival in patients with oxalosis. Trans- immune activation plantation 74:707-710, 2002 5. Danovitch GM, Hariharan S, Pirsch JD, et al: Manage- ment of the waiting list for cadaveric kidney transplants: REEVALUATION OF PATIENTS AWAITING Report of a survey and recommendations by the Clinical DECEASED DONOR KIDNEY TRANSPLANTS Practice Guidelines Committee of the American Society of Transplantation. J Am Soc Nephrol 13:528-535, 2002 I. Primary nephrologists and/or transplant can- 6. Fabrizi F, Martin P, Dixit V, Bunnapradist S, Dulai G: Hepatitis C virus antibody status and survival after renal didates on the waiting list are expected to transplantation: Meta-analysis of observational studies. Am J inform the transplant program of intercur- Transplant 5:1452-1461, 2005 rent illnesses that may affect their transplant 7. Friedman GS, Meier-Kriesche HU, Kaplan B, et al: candidacy Hypercoagulable states in renal transplant candidates: Im- II. Due to the prolonged wait time for a pact of anticoagulation upon incidence of renal allograft thrombosis. Transplantation 72:1073-1078, 2001 deceased donor transplant and the high 8. Gaston RS, Danovitch GM, Adams PL, et al: The incidence of morbidity in dialysis patients, report of a national conference on the wait list for kidney transplant candidacy needs to be reas- transplantation. Am J Transplant 3:775-785, 2003 sessed periodically 9. Gore JL, Pham PT, Danovitch GM, et al: Obesity and III. The timing, frequency, and type of testing outcome following renal transplantation. Am J Transplant 6:357-363, 2006 depend on comorbid conditions. The local 10. Jordan SC, Tyan D, Stablein D, et al: Evaluation of allocation algorithm may predict the timing of intravenous immunoglobulin as an agent to lower allosensi- transplantation and impact on the schedule of tization and improve transplantation in highly sensitized wait-list follow-up; centers that rely primarily adult patients with end-stage renal disease: Report of the NIH IG02 trial. J Am Soc Nephrol 15:3256-3262, 2004 on dialysis time may see patients when ac- 11. Marcen R: Cardiovascular risk factors in renal trans- crued time approaches expected wait time plantation—Current controversies. Nephrol Dial Transplant IV. Proper vaccination, cancer screening, and other 21:Siii3-Siii8, 2006 (suppl 3) health maintenance should be continued 12. Meier-Kriesche H, Port FK, Ojo AO, et al: Deleteri- V. During the follow-up visit, reassessment of ous effect of waiting time on renal transplant outcome. Transplant Proc 33:1204-1206, 2001 cardiovascular status is of utmost importance; 13. Meier-Kriesche HU, Arndorfer JA, Kaplan B: The routine cardiac rescreening is recommended in impact of body mass index on renal transplant outcomes: A moderate- to high-risk patients; new symp- significant independent risk factor for graft failure and toms and signs suggestive of coronary disease patient death. Transplantation 73:70-74, 2002 14. Montgomery RA, Hardy MA, Jordan SC, et al: Con- should be thoroughly evaluated sensus opinion from the antibody working group on the VI. Patients with correctable conditions should diagnosis, reporting, and risk assessment for antibody- be made temporarily unavailable until the mediated rejection and desensitization protocols. Transplan- condition is successfully corrected; those tation 78:181-185, 2004 with uncorrectable contraindication should 15. Ojo A, Meier-Kriesche HU, Friedman G, et al: Excel- lent outcome of renal transplantation in patients with Fabry’s be removed from the waiting list disease. Transplantation 69:2337-2339, 2000 16. Ramos E, Vincenti F, Lu WX, et al: Retransplantation in patients with graft loss caused by polyoma virus nephrop- ACKNOWLEDGEMENTS athy. Transplantation 77:131-133, 2004 Support: None. 17. Scandling JD: Kidney transplant candidate evalua- Financial Disclosure: None. tion. Semin Dial 18:487-494, 2005
  9. 9. 898 Bunnapradist and Danovitch 18. Shah T, Kasravi A, Huang E, et al: Risk factors for 20. Sung RS, Althoen M, Howell TA, Ojo AO, Merion development of new-onset diabetes mellitus after kidney RM: Excess risk of renal allograft loss associated with transplantation. Transplantation 82:1673-1676, 2006 cigarette smoking. Transplantation 71:1752-1771, 2001 19. Siddqi N. Hariharan S. Danovitch G: Evaluation and 21. Witczak BJ, Hartmann A, Jenssen T, Foss A, Endresen preparation of renal transplant candidates, in Danovitch GM, K: Routine coronary angiography in diabetic nephropathy pa- ed: Handbook of Kidney Transplant (ed 4). Boston, MA, tients before transplantation. Am J Transplant 6:2403-2408, Little Brown and Company, 2006, pp 169-192 2006