RENAL TRANSPLANTATION: INTRODUCTION
The purpose of this chapter is to provide the general urologist and the urologist-in-training with an overview of renal transplantation. It is meant to be practical.
The incidence of end-stage renal disease (ESRD) in the United States is approximately 380 per million population per year, and it increases with age (United States Renal Data System, 2017). One-half of ESRD patients in the United States are over 65 years old. Diabetes mellitus, glomerulonephritis, hypertension, and cystic kidney diseases are, in descending order, the four main causes of ESRD. Patients treated with renal replacement therapy have decreased life expectancies when compared with the general population, and the annual mortality from ESRD is greater than that for either breast or prostate cancer (United States Renal Data System, 2017; Seigel et al, 2018). When dialysis and transplantation are compared, better patient survival, quality of life, and healthcare cost savings are reported for kidney transplant recipients (Wolfe et al, 1999; Grams et al, 2010). There are about 90,000 dialysis patients awaiting kidney transplantation, half of whom are on the active waiting list, a list that remains nearly three times larger than the supply of donor kidneys (United States Renal Data System, 2017).
Two-thirds of the nearly 20,000 kidneys transplanted in the United States each year are from deceased donors, and a quality-matched deceased donor kidney allocation system has been implemented to decrease unrealized life-years of recipients, reduce wastage of marginal kidneys, and decrease access disparities. A Kidney Donor Profile Index (KDPI) based on 10 donor factors (age, height, weight, ethnicity, history of hypertension, history of diabetes, cause of death, serum creatinine, hepatitis C status, and donation after cardiac death status) was developed to replace the binary categories of standard criteria (SCD) and extended criteria donors (ECD) that incorporated only four factors (United States Renal Data System, 2017). A deceased donor with a KDPI of 85% is about the same as an ECD. An expected posttransplant survival (EPTS) score is developed for kidney transplant candidates. The EPTS is based on age, time on dialysis, prior transplantation of any organ, and the presence of diabetes. Low scores are good scores, and there is preferential allocation of donor kidneys with EPTS scores of 20% or less to candidates with EPTS scores of 20% or less. KDPI and EPTS calculators can be found at optn.transplant.hsra.gov/resources/allocation-calculators.
The rates for 10-year deceased donor kidney transplant graft and patient survivals are 48% and 64%, respectively. The 10-year living donor kidney graft and patient survivals are 62% and 78%, respectively (United States Renal Data System, 2017).
For decades, kidney transplantation has provided examples of (1) a multidisciplinary approach to complex, expensive patient care; (2) the advantages of a mandatory national registry; (3) the use of antibody therapy; and (4) the rewards and frustrations of dealing with a complex national healthcare system with a major single payer and multiple private healthcare insurers ...