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The first successful kidney transplant from a live donor to his identical twin brother was done in 1954. Since then, kidney transplantation has progressed from an experimental procedure to the preferred method of renal replacement therapy around the world. There are three primary reasons for the worldwide acceptance of renal transplantation: (1) transplant recipients enjoy a prolongation of survival compared with dialysis (Wolfe et al, 1999), (2) recipients report an improved quality of life (Joseph et al, 2003), and (3) it is less costly than that of dialysis (USRDS, 2010). At the end of 2010 in the United States, there were about 382,000 patients receiving dialysis therapy, with an incident rate of about 342 per million population, and over 165,000 living with a kidney transplant (USRDS, 2010). In 2010, there were 16,889 kidney transplants performed in the United States, 10,622 from deceased donors and 6277 from live donors (UNOS Web page). However, more than 88,847 patients were actively waiting for a kidney, and the gap between the number waiting and available organs widens every year (Wolfe et al, 2010). Currently, 1- and 5-year kidney graft survival ranges between 89–95% and 66–80%, depending on donor source (Figure 36–1). The major reasons leading to improved outcomes are more potent, yet selective immunosuppression, better surgical techniques, more sensitive tissue typing and crossmatching, and better prophylaxis and treatment of morbid infections. There is also an emerging consensus that preemptive transplantation, immediately prior to the need to dialysis, is advantageous, reducing much morbidity and even mortality (Kasiske et al, 2002).
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The most frequent diagnoses of renal failure for patients on the transplant waiting list are diabetes, 28% (the fastest growing); all types of glomerulonephritis/focal sclerosis, 25%; hypertension nephrosclerosis, 23%; cystic kidney diseases, 9%; interstitial/pyelonephritis, 5%; urologic diseases, 4%; and unknown causes, 7% (USRDS, 2010). Children <age 18 with renal failure often have congenital urologic conditions such as obstruction, valves, dysplasia, cystic disease reflux, prune-belly syndrome, inborn errors of metabolism (stones), or neurogenic bladders (NAPRTCS, 2009). Patients older than 65–70 years, the fastest growing recipient group, are commonly transplanted today, as physiological age is considered more important than chronological age (Flechner, 2002). Most patients with end-stage renal disease (ESRD) can be suitable transplant candidates with a few absolute contraindications. These include active infections or cancer, severe vasculopathy from atherosclerosis, and metabolic diseases likely to recur (oxalosis, cystinosis). However, all decisions must be individualized, and patients with a life expectancy of less than 3–5 years probably should be maintained on dialysis. Other factors such as psychosocial status, environment, and ability to follow a complex medical regimen are also important considerations. Prior to transplant, it is important to identify correctable conditions that may increase morbidity and diminish outcomes after the transplant (Flechner, ...