CHAPTER 12: Kidney Transplant Recipient Evaluation: Outcome-Based Approach

INTRODUCTION

Kidney transplantation offers improved survival and better quality of life for patients with end-stage renal disease (ESRD). However, this is dependent on a successful transplantation, without immediate complications. A carefully completed pretransplant recipient evaluation will address modifiable risk factors (for resolution) and nonmodifiable risk factors (for informed consent or exclusion of candidates). Factors that could potentially affect both immediate perioperative as well as long-term posttransplant outcomes should be thoroughly addressed in order to optimize the benefits of kidney transplantation as a treatment option.

FACTORS AFFECTING PERIOPERATIVE MORTALITY

• Fatal cardiovascular event due to:

  • Myocardial infarction

  • Cardiac arrhythmias

  • Congestive heart failure

  • Valvular disorders with hemodynamic impact

  • Pericardial disease

• Coagulopathy causing bleeding

• Hypercoagulable states causing blood clots and fatal pulmonary embolism

• Severe preexisting lung disease and respiratory failure

• Fatal gastrointestinal bleeding

• Fatal cerebrovascular event

• Preexisting infection that leads to postoperative sepsis

• Postoperative infection causing sepsis

FACTORS AFFECTING PERIOPERATIVE MORBIDITY AND PROLONGED HOSPITAL STAY

• Nonfatal acute coronary event

• Deep vein thrombosis

• Postoperative bleeding at the operative site or gastrointestinal bleeding requiring transfusion

• Lung disease leading to prolonged intubation and intensive care unit (ICU) stay and complications related to it

• Postoperative pneumonia causing respiratory failure

• Postoperative urinary infection causing sepsis

• Mechanical complications related to surgery:

  • Arterial or venous thrombosis

  • Ureteric obstruction or leak

  • Urinary bladder injury

  • Visceral (bowel) injury

  • Vascular compromise of the lower extremity

• Poor preoperative functional status

• Obesity predisposing to perioperative complications

• Psychosocial issues

FACTORS AFFECTING MORBIDITY AND MORTALITY IN THE DELAYED POSTTRANSPLANT PERIOD

• Cardiovascular complications, e.g., acute coronary event, heart failure, stroke

• Poor adherence with medications

• Progression of comorbid conditions:

  • Chronic hepatitis

• New opportunistic infections:

  • Pneumocystis jirovecii pneumonia

  • Cytomegalovirus (CMV) infection

  • BK virus infection

  • Parvovirus B19 infection

  • Opportunistic fungal infections

  • Mycobacterium tuberculosis infection

• Recurrent kidney disease:

  • Primary focal and segmental glomerulosclerosis (FSGS)

  • Immunoglobulin A (IgA) nephropathy

  • Membranoproliferative glomerulonephritis (MPGN)

  • Lupus nephritis

  • Thrombotic microangiopathy

• Posttransplant malignancies:

  • Lymphoma

  • Skin malignancies

  • Native kidney neoplasm

• Psychological disorders

OUTCOME-BASED APPROACH TO RECIPIENT EVALUATION

(See Table 12-1.)