This document provides guidelines for evaluating and managing chronic kidney disease patients before kidney transplantation. It outlines the necessary pre-transplant medical, surgical, and immunological assessments to determine candidacy and optimize outcomes. Key points include assessing the cause of kidney failure, screening for infections/malignancies, evaluating cardiac/vascular health, and determining immunological risk through HLA typing and antibody screening. A thorough evaluation process is recommended to safely prepare both recipients and living donors for transplantation.

1. Evaluation and Management of CKD patients
before Kidney Transplantation
Osama Gheith, MD PhD
Urology and nephrology center, Mansoura University, Egypt

2. Agenda
• ACCESS TO TRANSPLANTATION
• Pre transplant assessment for surgical issues
• Pre transplant assessment for medical issues

3. ACCESS TO TRANSPLANTATION
• All CKD patients with GFR < 30ml/min/1.73 m2 should be informed, educated
about kidney transplantation.
• Refer potential KTR for evaluation at least 6 to 12 months before anticipated
dialysis for possible pre-emptive transplantation.
• Preferred treatment is pre-emptive transplantation with a living kidney .

4. • Consider diagnoses that may render transplantation futile or more dangerous
than dialysis, assessment by disease-specific experts should be sought.
Pre transplant assessment

5. • Do not exclude patients from kidney transplantation because of age alone.
• Neurocognitive assessment in pediatrics with ESKD before 5 years or those experiencing
difficulties at school.
• A psychosocial assessment should be performed in all candidates.
• Pre-transplant counseling for psychiatric or psychological condition, substance use
disorder or non-adherence.
• Non-Adherent candidates should not be excluded except:
• ongoing, health-compromising non-adherent behavior despite education counseling.
Pre transplant assessment

6. • Assess candidates for past and present use of tobacco products.
• All candidates should avoid tobacco products before after transplant.
• HRCT for current or former heavy tobacco users (≥ 30 pack-years) to screen for
occult lung cancer
• Xray chest for other candidate.
Pre transplant assessment

7. • Candidates should not be excluded because:
• Only because of obesity.
• Need for anticoagulation, antiplatelet therapy, or a history of heparin-induced
thrombocytopenia.
• Vascular assessment: Significant peripheral arterial disease, venous dialysis
catheters, pelvic surgery, or deep venous thrombosis.
Pre transplant assessment

8. • Evaluate native kidney size in patients with polycystic kidney disease.
• Staged or simultaneous native nephrectomy and transplantation:
• Painful,
• Recurrently infected,
• Potentially malignant polycystic kidney,
• For spacing.
Pre transplant assessment for surgical issues

9. Pre transplant assessment for medical issues

10. DIABETES
• Diabetic (type 1 or type 2) should not be excluded from kidney transplant.
• For abnormal glucose metabolism test for oral glucose tolerance test .

11. Original kidney disease
• Cause of ESKD should be determined if possible to inform risks or recurrence and
management post-transplant.
• Candidates with primary FSGS, MGN, IgA nephropathy, IgA vasculitis, immune
complex-mediated MPGN, C3 glomerulopathy, lupus nephritis, antiphospholipid
syndrome, ANCA-associated vasculitis, anti-GBM disease, HUS, atypical HUS,
fibrillary or immunotactoid glomerulonephritis, correctable hyperoxaluria, or
those with cystinosis, Fabry disease, sickle cell disease, sarcoidosis, Alport
syndrome, systemic sclerosis or AA amyloidosis with no severe extrarenal disease,
should not be excluded from transplantation.
• Candidates with multiple myeloma, LCDD, HCDD, LHCDD, or AL amyloidosis
should be excluded from kidney transplantation unless a potentially curative
treatment regimen was given with stable remission.

12. INFECTIONS
• Postpone kidney transplant until treating active infections (bacterial, fungal, viral
[except HCV], parasitic).
• Asymptomatic colonization should not stop transplantation.
• Screen all candidates for :
• HIV, HCV, HBV CMV,EBV,HSV, VZV,
• Measles, mumps, and rubella (MMR),
• Human T-cell lymphotropic virus (HTLV) and syphilis.
• HDV, strongyloidiasis, Chagas disease, TB, and malaria in endemic areas

13. Vaccination
• Should be completed prior to kidney transplantation.
• Live attenuated vaccines should be completed at least 4 weeks prior to
transplantation.
• Consider vaccination for endemic diseases.

14. MALIGNANCY
• Routine screening as general population(all cases).
• Risk patients: (renal cell carcinoma, bladder carcinoma and hepatocelluar carcinoma)..
• Active malignancy should be excluded, except:
• Low-grade cancers such as prostate cancer (Gleason score ≤ 6),
• Superficial non-melanoma skin cancer
• Incidentally detected renal tumors (≤ 1cm in maximum diameter).
• Timing of kidney transplantation after potentially curative treatment for cancer is
dependent on the cancer type and stage at initial diagnosis.

15. CARDIAC DISEASE
• Evaluate all cases for the presence and severity of cardiac disease
• History,
• physical examination,
• and electrocardiogram.
• Active cardiac disease should undergo assessment by a cardiologist.
• Asymptomatic candidates at high risk for CAD (e.g., diabetes, previous CAD) or
with poor functional capacity should undergo non-invasive CAD screening.

16. • Echocardiography for:
• Dialysis > 2 years
• Risk factors for pulmonary hypertension
• Systemic amyloidosis to ascertain cardiac involvement and severity.
• Continue cardioprotective medications during waitlisting and at time of
transplantation :
• aspirin, β-blockers, and statins.
Cardiac disease

17. Cardiac disease
• Cases with NYHA III/ IV heart disease should be excluded :
• Severe CAD;
• Left ventricular dysfunction (ejection fraction < 30%);
• Severe valvular disease
• Cases with history of myocardial infarction should be assessed by a cardiologist
for:
• Further investigations
• Timing of transplant

18. PERIPHERAL ARTERIAL DISEASE(PAD)
• Evaluate all cases for presence and severity of PAD:
• History
• Physical examination.
• Those at high risk for PAD--------non-invasive vascular testing.
• Clinically apparent PAD should be seen by a vascular surgeon.
• Non-contrast CT abdomen/ pelvis to evaluate arterial calcification and operative planning.

19. • Non-healing extremity wounds with active infection should delay transplantation
until the infection is resolved.
• Patients with severe aorto-iliac disease or distal vascular disease should not be
excluded from kidney transplantation but risk of progression after transplantation
should be considered and discussed with the patient
PERIPHERAL ARTERIAL DISEASE(PAD)

20. Neurological diseases
• Do not exclude cases with:
• Non-progressive intellectual, developmental, or cognitive disability.
• Peripheral neuropathy.
• Wait for 6 months before kidney transplant if recent stroke
• Wait 3 months for those with TIA.
• No need for screening asymptomatic candidates for carotid stenosis.
• Screening ADPKD for intracranial aneurysms:
• Prior history of or a family history of subarachnoid hemorrhage.

21. GASTROINTESTINAL AND LIVER DISEASE
• Evaluate all candidates for the presence of gastrointestinal disease:
• History and physical examination
• History of peptic ulcer disease, diverticulitis, acute or chronic pancreatitis,
asymptomatic cholelithiasis, or inflammatory bowel disease, should not be
excluded from kidney transplantation.

22. • Screen kidney transplant cases for liver disease with a total bilirubin, ALT, INR,
and albumin.
• Acute hepatitis : postpone until resolution and a long-term plan of management.
• Cirrhosis or suspected cirrhosis:
• Refer to a specialist for possible combined liver- kidney transplantation.
• Screening for hepatocellular carcinoma .
GASTROINTESTINAL AND LIVER DISEASE

23. HEMATOLOGIC DISORDERS
• Screening for thrombophilia should be limited to:
• Prior venous thrombo- embolic event,
• Recurrent arteriovenous access thromboses,
• non-atherosclerotic arterial thrombosis,
• or family history of venous thromboembolism .
• Testing for antiphospholipid antibodies (APLAs):
• Systemic lupus erythematosus (SLE)
• or features of antiphospholipid syndrome (APS)

24. • MGUS or smouldering multiple myeloma should not be excluded from transplantation
but a greater risk for PTLD and transformation to multiple myeloma, respectively,
should be considered and discussed.
• Patients with leukemia or lymphoma should avoid transplantation until they have
received potentially curative therapy, achieved remission and remained cancer free for
a period to be determined with their hematologist/oncologist.
• Decisions about kidney transplantation in patients with myelodysplasias, chronic
leukemia, chronic/low-grade lymphomas, or prior history of hematological malignancy
should be made after consultation with a hematologist.
HEMATOLOGIC DISORDERS

25. IMMUNOLOGICAL ASSESSMENT
• Convey all sensitizing events or clinical events that can impact PRA to the HLA
laboratory.
• Perform HLA antibody:
• At transplant evaluation,
• At regular intervals prior to transplant
• After a sensitizing event
• or a clinical event that can impact PRA.

26. • HLA antibody testing should be performed using solid phase assays and HLA
typing should use molecular methods, optimally at all loci.
• Candidates should be informed about their access to transplantation based on
blood type and histocompatibility testing results
IMMUNOLOGICAL ASSESSMENT

27. Steps of transplant preparation

28. • History and examination including counselling of the couple
• Blood grouping; urine analysis X3
• General laboratory profile of both patient and donor (chemistry, CBC, cultures, virology….)
• Immunological work up (CXM, HLA, PRA,..)
• Radiological assessment for both :
• Patient: x-ray chest, abdominal US, UTP,MCUG…
• Donor: X-ray chest, UTP, CT angiography and renogram
• Endoscopies for the recipient(FOGD, panendoscopy, colonscopy…)
• Biopsies (patient or donor)
Steps of transplant preparation

47. Conclusion
• Transplant candidate preparation will need meticulous work
up for optimization of the outcome for both donor and
recipient.