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Evaluation of Prospective Donors and Recipients

Evaluation of Prospective Donors and Recipients

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Published by arlindodascrot2011
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Published by: arlindodascrot2011 on Oct 30, 2010
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05/22/2012

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1
Evaluation of ProspectiveDonors and Recipients
A
ll patients should be considered for transplantation when it isdetermined that renal replacement therapy will someday berequired. In some cases, the evaluation can be completed and thepatient can receive transplantation before initiating chronic maintenancedialysis. Prospective candidates for transplantation must be carefullyscreened for potentially fatal cancers and infections that are made worseby immunosuppression. Hepatic, pulmonary, cardiovascular, and gas-trointestinal disorders all may increase the risks of surgery and chronicimmunosuppression. Patients must be carefully screened for these disor-ders. In many cases, intervention before transplantation may help reducethe recipient’s risks of transplantation. Detailed guidelines have beenestablished to evaluate prospective candidates for transplantation [1].Living donors offer the recipient optimal graft survival, reduced wait-ing time, and an opportunity for preemptive transplantation (
ie,
beforeinitiating dialysis). The evaluation of prospective living donors mustensure that the donation is safe for both donor and recipient. However,the primary focus of this evaluation must always be on protecting thewell-being of the prospective donor. Both the short-term surgical risksand the long-term risks of having a single kidney must be carefullydefined. The evaluation also must ensure the donor has no disease thatcould be transmitted with the kidney. Guidelines have been developedfor the evaluation of living prospective donors [2].When no suitable living donors are available, the prospective recipientcan be placed on the waiting list for a cadaveric kidney. Unfortunately,because the number of patients needing cadaveric kidneys has grownmuch faster than has the number of available kidneys, the medianwaiting time is now over 2 years. This shortage has led many trans-plantation centers to use cadaveric kidneys, which are associated withreduced graft survival. In particular, graft survival is affected by theage of the kidney donor. Many centers are expanding the age limits of acceptability to reduce waiting times. A detailed discussion of theselection, retrieval, preservation, and allocation of cadaveric kidneysis beyond the scope of this review.
Bertram L. Kasiske 
C H A PT ER
 
12.2
Transplantation as Treatment of End-Stage Renal Disease
Evaluation of Prospective Transplantation Recipients
Irreversiblerenal failureCurrently ondialysis?Monitor rateGFRdeclineDialysis likely in6 months?Prospectiveliving donor?Evaluate potentialrecipientEvaluate prospectiveliving donorYesYesYesNoNoNoInitial evaluation of recipients
FIGURE 12-1
Initiating the evaluation. Before transplantation it must be clearlyestablished that renal failure in the patient is irreversible. When theprospective recipient is not already on chronic maintenance dialysis,however, preemptive transplantation (
ie,
transplantation beforeinitiating dialysis) should be considered. Because the waiting timefor a cadaveric kidney is generally long, preemptive transplantationusually is possible only when a prospective living donor is available.In any case, the rate of decline in the glomerular filtration rate (GFR)must be monitored closely in patients with progressive renal disease.The evaluation process should begin when it is anticipated thattransplantation may be required within 6 months. (
From
Kasiskeand coworkers. [1]; with permission.)
Screen for cancerCurrent or pastevidence of cancer?Appropriatedisease-freeinterval?Proceed withevaluationYesNoCancer screening in recipients
FIGURE 12-2
Screening for cancer. An active malignancy is an absolute contraindication to transplantation.Effective screening measures for patients at risk include chest radiograph, mammogram,PAP test, stool Hemoccult, digital rectal examination, and flexible sigmoidoscopy exami-nation. Patients who have had a life-threatening malignancy but are potentially cured maybe candidates for transplantation when there has been an appropriate disease-free interval.This interval generally is at least 2 years, and longer in the case of some malignancies.(
From
Kasiske and coworkers [1].)
 
12.3
Evaluation of Prospective Donors and Recipients
Active infection?Appropriate treatmentand disease-free intervalHIV positive?Discourage transplantationHistory of TB orpositive PPDwithout adequatetherapy?Consider prophylactictreatmentAssess risk forother infectionsYesYesYesNoNoNoScreening for infection in recipients0123401020304050607080901005
   G  r  a   f   t  s  u  r  v   i  v  a   l ,
   %
nn/n 4670n/p 5970p/n 7299p/p 11,257Years after transplantationCMV r/d
FIGURE 12-3
Screening for infection. An active potentially life-threatening infectionis a contraindication to transplantation. Patients with human immun-odeficiency virus (HIV) are usually not candidates for transplantation.Patients with a history of tuberculosis (TB) or a positive purifiedprotein derivative (PPD) skin test who have not been adequatelytreated should generally receive prophylactic therapy. (
From
Kasiske and coworkers [1].)
FIGURE 12-4
Assessing the risks of cytomegalovirus (CMV) infection after trans-plantation. CMV is a major cause of morbidity and mortality aftertransplantation. The incidence and severity of CMV are associatedwith the serologic status of the donor (d) and recipient (r), the risksgenerally being the following: recipient negative–donor negativeless than recipient positive–donor negative less than recipient negative–donor positive less than recipient positive–donor positive. As shownin these data from the United Network for Organ Sharing ScientificRegistry, the rate of graft survival tends to be less in recipients of kidneys from donors who test positive for CMV infection. Theserologic status of both the donor and recipient is often used todetermine which patients are candidates for prophylactic or pre-emptive anti-CMV therapy after transplantation. (
From
Cecka [3];with permission.)
Renal diseasewith potentialto recur?Proceed withevaluationWait untilquiescentRisk acceptable?AvoidtransplantationYesYesNoNoAssessment for recurrent renaldisease in recipients
FIGURE 12-5
Assessing the risk of renal disease recurrence. Although the risk for recurrence of theunderlying renal disease is rarely great enough to preclude transplantation, patients andphysicians must be aware of this risk. In some cases it may be prudent to delay transplan-tation until the underlying disease is quiescent. (
From
Kasiske and coworkers [1].)

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