Pre-transplant evaluation

The pre-transplant evaluation begins with a careful review of the patient’s past medical history, which is solicited from the patient as well as the primary nephrologist and primary care physicians. Important information includes the age and gender of the patient and the cause of ESRD, which may predict the risk of disease recurrence.

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Additionally, important considerations are the type of dialysis used (hemodialysis versus peritoneal) and whether the patient has received a previous kidney or other organ transplant. Whether the patient makes urine or has proteinuria or hematuria may impact interpretation post-transplant. In general, proteinuria and hematuria resolve by one month after transplantation. The persistence or recurrence of hematuria after this time period should lead to investigation for such diseases as focal segmental glomerulosclerosis (FSGS) or recurrent IgA nephropathy.5

The history should provide information regarding co-morbidities such as diabetes, and cardiovascular, pulmonary, or atherosclerotic disease, which are major factors impacting both patient and graft survival. If the patient has frequent episodes of thrombosis in the dialysis access port, a history of deep venous thromboses, or early, spontaneous miscarriages, this may indicate a hypercoagulable state from antiphospholipid antibodies, factor V Leiden, prothrombin gene, methyl tetrahydrofolate reductase (MTHR) mutations, or protein C, protein S or anti-thrombin3 deficiencies that would put the graft at risk for early thrombosis. 

Endemic, occupational, or social infection risks are also important. Patients in the southwestern United States may be predisposed to coccidiomycosis, which is endemic. Patients with cats may be prone to toxoplasmosis, and patients with an outdoor dog (prone to tick bites) may develop ehrlichiosis.

A second prerequisite for management is a comprehensive pre-transplant physical examination. The cardiovascular exam is especially key here. It is important to assess the patient’s carotids and femoral and peripheral pulses. A femoral bruit from atherosclerotic disease may be mistaken for a transplant artery bruit, which is a sign of renal artery stenosis.

Much of what is used to direct our evaluation and management comes from the laboratory assessment. It is unusual to have symptoms or signs of renal disease until there is anemia, impaired metabolic homeostasis such as hyperkalemia, metabolic acidosis, hyperphosphatemia, and elevated parathyroid levels until the GFR is <40 mL/min/1.73 m2. Therefore, a comprehensive laboratory evaluation is important pre- and post-transplant (Table 1 and 2).

The transplant procedure

An understanding of the initial transplant procedure, hospitalization, and early course must be recorded in the outpatient records. Typical considerations are donor age and sex, HLA match or mismatch, the cytomegalovirus (CMV) and Epstein-Barr virus (EBV) serostatus of the donor and recipient, induction agent and dose, surgeon, placement of a urinary stent, whether there were any technical problems or delayed graft function (DGF) and elevated serum creatinine on the day of discharge, the nadir serum creatinine and the baseline serum creatinine. Below is an example of a patient record which can be used as a starting point when being queried by the fellows or coordinators for follow up.

Mr. W is a 60-year-old black man with ESRD from FSGS and who was on hemodialysis for four years using a left forearm arteriovenous fistula. 
Mr. W was under the care of Dr. S prior to receiving an expanded criteria donor kidney from a 65-year-old black man in February of 2010. This was an “import” kidney and the cold ischemia time was 16 hours.

During surgery, the artery and vein were anastomosed end-to-side to the common iliacs because of recipient atherosclerosis of the external iliac vessels. The ureter was anastomosed to the native ureter because the bladder was small and contracted. A ureteral stent was placed and subsequently removed. The HLA mismatch was a 2A, 2B, 1 DR mismatch and the CMV serostatus was D+/R+ and the EBV status D+/R+.

The patient received induction therapy with thymoglobulin 5 mg/kg over three days (100 mg/200 mg/200 mg). Maintenance therapy was with tacrolimus, enteric-coated mycophenolic acid (MPA), and a steroid taper to 5 mg by one month. The patient received 1 g of intravenous (IV) iron dextran prior to discharge. The course was complicated by slow graft function and the patient was discharged on post-operative day 5 with a serum creatinine of 4.52 mg/dL.