Kidney Transplant Evaluation (Case 52)

Chapter 71 Kidney Transplant Evaluation (Case 52)



Nicole D. Figueredo, MD, James Lim, MD, Francisco Badosa, MD


Case: A 46-year-old female on dialysis for 3 years with end-stage renal disease due to glomerulonephritis is referred for kidney transplant evaluation.




Speaking Intelligently


When I evaluate a patient with end-stage renal disease (ESRD) for kidney transplantation, I want to be sure the patient “sees the big picture.” By the time patients are evaluated for transplantation, most have an awareness of their problem and most have had dialysis experience. Nonetheless, I ascertain that each patient has a complete understanding of ESRD, its tx alternatives, and the realities of transplantation. Accordingly, I carefully review with them hemodialysis, peritoneal dialysis, and the possibilities of living related, unrelated, and cadaveric kidney transplants.



PATIENT CARE



Clinical Thinking


All patients with ESRD who require or are expected to require dialysis and who have a creatinine clearance of 20 mL/min or less should be referred for a kidney transplantation evaluation. To be considered for kidney transplantation, a patient must be:


• Free of absolute contraindications (see below).

• Medically fit and able to tolerate surgery and anesthesia.

• Psychosocially stable and compliant.

• Capable of understanding the risks and benefits of kidney transplantation versus dialysis.

Absolute contraindications to kidney transplantation include:


• Active infection that cannot be eliminated by medical or surgical means (i.e., HIV, hepatitis B, active tuberculosis [TB]).

• Severe advanced cardiopulmonary disease (making the patient a poor surgical candidate).

• Adverse psychosocial conditions (i.e., substance abuse or medical noncompliance).

• Recent hx of malignancy.


History



• The physician should inquire about the cause of the patient’s native renal disease: does the patient have a hx of diabetes, hypertension, recurrent UTIs/pyelonephritis, polycystic kidney disease, glomerulonephritis, or autoimmune or familial diseases?

• Investigate potential causes of HLA sensitization: hx of prior transplantation, number of pregnancies, and blood transfusions.

• Ask about comorbid conditions, specifically a hx of infectious disease (cytomegalovirus [CMV], hepatitis B/C, HIV, UTIs, TB), malignancy, cardiac, pulmonary, hematologic, or psychiatric illnesses.

• Obtain a thorough past surgical hx, including vascular or urologic surgeries, and any bleeding, clotting, or anesthesia-related complications.

• Inquire about the patient’s family hx to evaluate potential living donors.

• It is also important to know the patient’s dialysis hx, medications, and allergies.


Physical Examination



• A full physical examination should be performed.

• It is important to r/o any potential sources of infection by examining the sinuses, teeth, and catheter sites.

• Pay special attention to the lower extremity examination to r/o peripheral vascular disease as the transplanted kidney will be implanted into the iliac vessels.


Tests for Consideration


Editor’s note: Preoperative testing for kidney transplantation has four objectives:































































1. Compatibility testing
  
• ABO blood group, HLA-A, -B, -DR, panel-reactive antibody, lymphocytotoxic crossmatches $240

2. Optimizing current physiology
  
• CBC, metabolic panel, LFTs $21
• EKG (and cardiac evaluation if needed) $50 ($500)
• Dental examination (within past year) $50
• Voiding cystourethrography if GU symptoms present $250
• Ultrasonography of the kidney $185

3. Testing immune status and testing for occult infection
  
• Anergy panel, PPD, HIV test $115
• CXR $136
• Culture urine/sputum/blood to r/o infection $45
• Hepatitis panel (hepatitis B/C) $65
• HBsAg, HBsAb, and HBcAb; hepatitis C antibody; and RNA assay by PCR $65
• CMV (IgG, IgM titer) $45

4. Screening for underlying malignancy
  
• Prostate-specific antigen (men > 50 years) to r/o prostate cancer $65
• PAP smear/mammography (women > 40 years) to r/o malignancy $125
• Colonoscopy (men/women > 50 years) $625











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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Kidney Transplant Evaluation (Case 52)

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