The Management of Patients After Renal Transplantation

The management of the kidney transplant recipient requires knowledge of the patient’s history pre-, during, and post-transplant. Typically, a team of surgeons, nephrologists, consultants, primary care physicians, and allied health professionals all work with the patient in a multidisciplinary effort to direct transplantation efforts and administer extremely detailed care.

Selection criteria for kidney transplantation

Transplant management actually begins with the referral of the potential recipient to a transplant center. During the initial transplant evaluation, there are two essential questions that must be answered upfront. The first is to the potential recipient: Why does he/she want a transplant? The second to the referring physician: Is this patient an appropriate transplant candidate?

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Crucial to all discussions is the fact that transplantation is a treatment not a cure and requires expensive, life-long immunosuppression with multiple side effects, frequent blood draws, and long-term clinical management. The patient and referring physician need to be cognizant of this and realize the trade-offs, which for the vast majority of patients are worth it. 

An equally important consideration in the early evaluation is a patient’s prior adherence to their medical and dialysis regimens. Also, clinicians must assess whether the prospective recipient will be able to afford expensive medications, laboratory evaluations, and clinic appointments—all essential for a successful transplant.

It seems imprudent to allocate a donor organ if the patient history does not suggest the ability to maintain the allograft. Thus, early evaluation by the transplant team encompasses a comprehensive look at patient records, the full history, a thorough physical exam, and pertinent laboratory evaluations. With end-stage renal disease (ESRD) as opposed to other solid organ end-stage disease, we are fortunate, in the U.S., to have the option of dialysis, as an alternative to transplantation—a funded alternative. 

The inclusion criteria for kidney transplantation are ESRD or irreversible and progressive chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of <20 mL/min/1.73 m2. Patients with progressive kidney disease should be referred for transplant evaluation when the eGFR is <30 mL/min/1.73 m2 and before ESRD for several reasons.

First, there is a graft and patient survival advantage to receiving a kidney transplant “preemptively,” that is, before initiation of dialysis.1 Second, time on the wait list is the major determinant for receiving a kidney transplant, and especially in determining the allocation of a deceased donor kidney (which can take several years). Third, dialysis is associated with progressive complications that may lead to the exclusion of consideration for kidney transplantation.

Exclusion criteria for renal transplants are complex and involve multifaceted medical, social, and ethical considerations. The current half-life of a deceased donor kidney transplant is approximately nine years, and for a living donor transplant, it is roughly 12 years.2 The World Health Organization Ethics Statement on Transplantation, which was accepted by the United Network of Organ Sharing (UNOS), recommends that a potential recipient should not be considered for organ transplantation unless the five-year survival rate is greater than 50%.3

This precept was based on three important guiding principles: 1) patient autonomy (that transplantation will provide independence and freedom for individual patients), 2) utility (the capacity for productive post-transplant life), and 3) justice (equitable allocation of 
scant resources).

The five-year/50% life expectancy requirement seems lenient given current graft survival rates for kidney transplantation. Death with graft function (DWGF) is also the major cause of kidney transplant failure. And a primary cause of DWGF is cardiovascular disease (CVD). Among diabetic kidney transplant recipients, CVD accounts for DWGF in 81% of patients. But DWGF occurs in only 26% of transplant patients without diabetes, with the other major causes of DWGF being infection and malignancy.4

It should be noted that when there is a possibility of living donor transplant, the five-year/50% life expectancy requirement is waived—specifically when emotional and unquantifiable considerations may supersede biologic considerations.