RENAL TRANSPLANTATION: AN UPDATE FOR THE GENERAL NEPHROLOGIST

Kidney Transplant Candidate Evaluation

Blackwell Publishing, Ltd.

John D. Scandling
Department of Medicine, Stanford University School of Medicine, and Stanford Hospital and Clinics, Palo Alto,
California

ABSTRACT

The practicing nephrologist is an indispensable component in offer soon after entering the wait-list, so prompt and complete
the evaluation of the candidate for kidney transplantation, from evaluation and preparation by the practicing nephrologist is
referral to the transplant center to eventual transplantation, necessary for successful early transplantation. The remaining
which now may be years later. Early referral may lead to pre- candidates require periodic review while ascending the wait-list
emptive transplantation, the ideal that has been achieved in and thorough repeat evaluation when nearing the top, as years
25% of living donor transplant cases. Annually approximately may have passed since initial evaluation. Wait-list management
30% of U.S. deceased donor kidneys are now transplanted is a major challenge faced by transplant centers, aggravated by the
under the allocation policies for zero human leukocyte antigen inexorable growth of the list. Active communication between
(HLA) mismatch kidneys and expanded criteria donor kidneys. the practicing nephrologist and the transplant center is essential
Under either of these programs, candidates may receive a kidney to maintain the candidate’s preparation for transplantation.

The evaluation of the candidate for kidney transplan- deceased donor transplantation have more than doubled
tation has been the recent subject of clinical practice over the last decade (5). Given this experience and the
guidelines published by both the European Renal prospect for little change despite the accompanying
Association–European Dialysis Transplant Association increase in living donor transplantation over the last
and the American Society of Transplantation (1,2). These decade, it is highly unlikely that a second objective of
guidelines are quite comprehensive and are valuable Healthy People 2010, to increase the proportion of
references for transplant centers. The purpose of this article dialysis patients who receive a transplant within 3 years
is to review the current general principles underlying trans- of registration on the waiting list to 30% by 2010, will be
plant evaluation, based on both clinical evidence and realized (4). In 1999 only 19% of listed patients had been
clinical practice (Table 1). While considerable variability transplanted within 3 years, down from 25% in 1991.
has been shown in the evaluation of transplant candidates Nonetheless, the superiority of transplantation as a renal
across transplant centers from a decade ago (3), the replacement therapy dictates focusing on identifying and
current breadth and extent of the variability is unknown. preparing candidates for transplantation.
Publication of the above guidelines may have led to more
uniformity. This article will present transplant evaluation
as it is practiced today at a single transplant center with Education
about 800 candidates on the wait-list and performing
about 75 transplants a year. A campaign by the National Kidney Foundation to
Healthy People 2010, a set of national health objectives, raise public awareness of chronic kidney disease (CKD)
calls for an increase in the proportion of dialysis patients is under way (6). Late presentation, recognition, and
registered on the waiting list for transplantation to increase referral of stage 5 CKD (glomerular filtration rate [GFR]
to 66% by 2010 (4). As of 2002, 16% were listed, a per- less than 15 ml/min) is a bane of the nephrologist’s
centage that has not changed since 1991. To achieve this practice and unfair to the patient. All patients with stage
goal will require the active assistance of practicing 4 CKD (GFR 15–29 ml/min) deserve referral to a neph-
nephrologists, primarily to identify and refer candidates rologist; in turn, early referral to a nephrologist may lead
to transplant centers. to early referral for transplantation and the possibility of
Meanwhile, waiting time to transplantation continues preemptive transplantation, which carries a better prognosis
to lengthen. The waiting list and median wait time for for both recipient and transplant kidney survival (7,8).
Community education by transplant centers may include
both patient education and dialysis unit staff education.
Address correspondence to: John D. Scandling, MD, 750
Welch Rd., Suite 200, Palo Alto, CA 94304-1509, or e-mail: Educating and enlisting the aid of dialysis personnel in
jscand@stanford.edu. educating patients about the option of transplantation
Seminars in Dialysis—Vol 18, No 6 (November–December) helps both the busy nephrologist and the transplant
2005 pp. 487–494 center. There are few absolute contraindications to
487
Address correspondence to: John D. Scandling, MD, 750 Welch Rd., Suite 200, Palo Alto, CA 94304-1509, or e-mail: jscand@stanford.edu.
488
TABLE 1. Principles of transplant candidate evaluation
Education
Assessment of motivation
Assessment of medical risk
Recurrent disease
Heart disease
Vascular disease
Infection
Cancer
Liver disease
Gastrointestinal disease
Obesity
Diabetes mellitus
Coagulopathy
Age
Assessment of psychosocial situation and support
transplantation and most are easily understood by dialy-
sis unit staff, but their prevalence in the CKD population
is a factor responsible for the low percentage of patients
on the wait-list (Table 2). Age alone does not preclude
transplantation, but in combination with morbid condi-
tions it may.
Transplant candidates are referred by their nephrolo-
gists or dialysis unit social workers, or on occasion self-
referred. Following clearance by their medical insurance
companies when necessary, we begin the transplant
evaluation with a mandatory education session on the
transplantation process, taught by our transplant nurse
coordinators. Failure to attend cancels a candidate’s sub-
sequent appointment to begin the individual transplant
evaluation. In our experience, patients find the class very
useful in their decision making and preparation. Family
members are encouraged to accompany the candidate to
both the transplant class and the transplant evaluation,
and usually do.
Motivation
Despite its now well-appreciated benefit (9), trans-
plantation remains elective. Some patients decide against
transplantation after attending the educational session
and end the evaluation there. Transplantation requires a
commitment of time and resources from the recipient
and the family. Transplant recipients, with family sup-
port, must commit to a schedule of frequent visits to the
transplant clinic during the first 3 months following
transplantation and to alternate-week blood testing for the
first 6 months. Thereafter the regimen eases and recipients
return to the care of their primary nephrologists, but a
commitment to ongoing follow-up at the transplant center
is expected. Transplant candidates must understand that
TABLE 2. Absolute contraindications to kidney transplantation
Active ischemic heart disease or severe cardiomyopathy
Active infection
Recent history of cancer other than nonmelanoma skin cancer
Cirrhosis or advanced liver fibrosis
Active substance abuse or dependence
Active psychosis
Incorrigible noncompliance
Scandling
transplantation entails risks and potential complications,
which may result in extended transplantation hospital-
ization, additional unscheduled clinic visits, blood tests,
and procedures, and repeat hospitalization. Recipients
who live a long distance from the transplant center are
asked to plan to stay locally for the first month following
transplantation.
In recent years we have increased our expectations of
candidates for transplantation by emphasizing a routine
of daily exercise and weight control. In some instances,
a course of physical rehabilitation is required.
Recurrent Disease
The majority of transplant candidates come to end-stage
renal disease (ESRD) with an unknown or presumed renal
diagnosis. We request the pathology report of the kidney
biopsy, if performed, and on occasion request the biopsy
slides for review by our renal pathologists if the diagno-
sis is in question. In those instances in which the diagno-
sis is known, the risk of recurrent disease is discussed
with the transplant candidate. Despite the penchant for
some kidney diseases to recur, and sometimes recur
with a vengeance, the risk rarely precludes transplanta-
tion and recurrence rarely results in transplant kidney
loss within the early years. Severe systemic amyloidosis,
light chain deposition disease (10), and hemolytic uremic
syndrome (HUS) not associated with a prodrome of
diarrhea (D− HUS) (11) may be the only circumstances
wherein the risk may preclude transplantation. Only in
the case of D− HUS, or recurrent focal segmental glome-
rulosclerosis (FSGS) in a prior transplant kidney, do we
consider advising against living donor transplantation
and specifically against living related donor transplantation
in the case of D− HUS. In any case where there is the
possibility of recurrence, but particularly in the case of
HUS or FSGS, we ask the candidates to allow us to discuss
their renal diagnoses and the risk of recurrence with any
potential living donors. In our experience this knowledge
has rarely discouraged donation.
Heart Disease
The prevalence of heart disease in the CKD popula-
tion has led us to be very aggressive in the evaluation of
coronary artery disease (12). Our concern is driven not
simply by the desire for recipient survival of transplant
surgery, but by the desire for long-term recipient survival
with a limited valuable resource, a transplant kidney,
which is highly dependent upon freedom from active
cardiovascular disease (13). The algorithms we have
followed for a dozen years for the diagnosis of coronary
artery disease in the asymptomatic candidate are shown
in Figs. 1 and 2 (14,15).
Our approach depends on the renal diagnosis and the
age of the candidate. If the renal diagnosis is diabetic
nephropathy, coronary angiography is required in any
candidate 45 years of age or older, due to the very high
prevalence of coronary artery disease in this group
(Fig. 1) (14). Coronary angiography is required because
 KIDNEY TRANSPLANT CANDIDATE EVALUATION 489
prior to transplantation (20). Noncorrectable coronary
disease is generally considered a contraindication to
transplantation.
The candidate requiring diagnostic coronary angio-
graphy who is preparing for preemptive transplantation
represents a challenge, due to the risk of precipitating
ESRD due to irreversible radiocontrast renal injury. The
risk of this injury can be greatly reduced by limiting
the radiocontrast dye quantity to less than 30 ml, which
can be achieved by using biplane cineangiography and not
performing ventriculography (21). Our experience
corroborates the published experience. The angiographic
studies have been adequate for diagnosis, and we have
had no episodes of radiocontrast injury. However, today
many revascularization procedures are catheter-based
rather than surgical and frequently require a large
radiocontrast dye load. If such intervention is necessary,
the patient risks premature ESRD or must await ESRD
before intervention. Some patients and their nephrolo-
gists may prefer to await ESRD before any procedure
requiring radiocontrast is undertaken, whether diagnostic
or therapeutic, and pass on the possibility of preemptive
transplantation.
A history of ischemic heart disease and revasculariza-
tion does not preclude transplant candidacy. An updated
cardiac evaluation is required, possibly only noninvasive
Fig. 1. Evaluation of coronary artery disease in the asymptomatic testing, but coronary angiography may be necessary.
transplant candidate with diabetic nephropathy. Adapted from Manske The presence of left ventricular dysfunction due to
et al. (14). nonischemic cardiomyopathy does not necessarily
preclude transplantation. Cardiomyopathy commonly
improves following restoration of kidney function (22).
noninvasive studies can be indeterminate or misleading
in patients with kidney failure due to diabetic nephropathy
(16–18). In the candidate with diabetic nephropathy who
is less than 45 years of age, a history of diabetes mellitus
for more than 25 years, a smoking history of more than five
pack-years, or electrocardiographic changes (nonspecific
ST-T wave abnormality) necessitates coronary angiography,
again due to the high prevalence of coronary disease in
such cases (14). In those less than 45 years of age with
none of the other three conditions, no further testing is
required, as the prevalence of coronary disease is low
(14). We have found this algorithm to be particularly
useful in defining low-risk candidates less than 45 years
of age. Through 2002, when we last analyzed outcomes
with this algorithm, there were no cardiac deaths in the
25 low-risk recipients who had undergone transplanta-
tion since we began using this algorithm in our program.
If the renal diagnosis is other than diabetic nephropathy,
only candidates 50 years of age or older are required to
undergo a stress myocardial perfusion study (Fig. 2)
(15). Candidates less than 50 years of age with a long
history of steroid exposure, a long history of ESRD, or
obesity are also asked to undergo a stress myocardial
perfusion study. Pharmacologic stress is typically required,
because many patients are unable to exercise sufficiently
to reach the target heart rate.
Despite the very limited published experience support-
ing revascularization over medical therapy (and that was
only in transplant candidates with diabetic nephropathy) Fig. 2. Evaluation of coronary artery disease in the asymptomatic
(19), if significant coronary stenosis is found, we ask the transplant candidate without diabetic nephropathy. MPS, myocardial
candidate to undergo a revascularization procedure perfusion study.
490
However, advanced cardiomyopathy, presenting as con-
gestive heart failure with modest interdialytic weight
gain or hypotension (systolic blood pressure less than
90 mmHg) in the absence of antihypertensive drug or
hypovolemia, may well preclude kidney-only transplan-
tation. Such a patient may be a candidate for combined
heart and kidney transplantation.
Vascular Disease
Neither a history of cerebral vascular disease nor a
history of peripheral vascular disease, including limb
amputation, precludes transplant candidacy. Active dis-
ease, manifested as recurrent transient ischemic attack or
ischemic limb ulcer, would preclude candidacy until
resolution, which may require surgical intervention.
In recent years we have increased our screening for
vascular disease to include testing for carotid and iliac
vessel disease in asymptomatic candidates with diabetic
nephropathy, particularly in those with a smoking history
or physical findings (carotid bruit, femoral bruit, dimin-
ished femoral or pedal pulses). We have used ultrasound
to study both the carotid and iliac vessels, although the
iliac vessel studies can be technically limited due to obe-
sity or overlying bowel gas. Thus far we have not found
any cases requiring intervention and will likely abandon
this screening.
Candidates with autosomal dominant polycystic
kidney disease (ADPKD) are asked to undergo noninva-
sive screening for intracranial aneurysm with computed
tomography (CT) or magnetic resonance angiography if
there is a family history of intracranial aneurysm. In
most instances it is not known if an aneurysm was the
cause of cerebral vascular accident, so in actuality any
candidate with ADPKD and a family history of stroke is
asked to undergo screening.
Infection
Our routine infection screening at transplant evaluation
is shown in Table 3. We screen for active and past infec-
tion that will influence transplant candidacy or guide
infection prophylaxis after transplantation. We still come
across the occasional patient with latent syphilis. In the
rare instance of a patient with human immunodeficiency
virus (HIV), we refer the individual to another transplant
center with HIV experience. Perhaps several times a year
a patient is found to have human T-cell lymphotropic
virus (HTLV) antibody. HTLV-I has been implicated in
causing adult T-cell leukemia/lymphoma and HTLV-I
associated myelopathy. HTLV-II does not have a strong
TABLE 3. Infection screening at transplant evaluation
Rapid plasma reagin (RPR)
Human immunodeficiency virus (HIV) antibody
Human T-cell leukemia virus (HTLV)-I, -II antibody
Hepatitis B surface antigen, surface antibody, core antibody
Hepatitis C antibody
Cytomegalovirus antibody
Tuberculin skin test
Scandling
disease link. Immunosuppression may be a risk for
transplant recipients with HTLV-I, but the experience is
limited (23,24). Positive HTLV serology does not pre-
clude transplant candidacy, but necessitates counseling
regarding potential risk.
Hepatitis B antigenemia does not preclude transplant
candidacy, but leads to an evaluation for liver disease
(see below). If transplantation does occur, it is done
under cover of lamivudine, to retard hepatitis B virus
replication (25,26). From 1995 to 2002, 2% or less of U.S.
kidney transplant recipients had hepatitis B antigenemia
or viremia at transplantation (4). Patients with hepatitis
B core antibody are at risk for reactivation disease under
immunosuppression, but can be transplant candidates;
indeed, between 1995 and 2002, 6–10% of U.S. transplant
recipients had hepatitis B core antibody at transplanta-
tion (although some may have represented false-positive
test results). Patients with positive hepatitis C antibody
testing undergo testing for hepatitis C viremia. Those
with viremia are evaluated for liver disease (see below)
and are considered for antiviral therapy prior to trans-
plantation. Hepatitis C viremia without significant liver
disease does not preclude transplant candidacy. From
1995 to 2002, up to 6% of U.S. transplant recipients had
hepatitis C antibody at the time of transplantation (4).
Those with hepatitis C antibody had lower patient and
transplant kidney survival than the general recipient
population, while those with hepatitis B antigenemia or
core antibody showed no difference (4). Testing for
cytomegalovirus (CMV) antibody is done to identify
candidates at high risk for CMV disease and guide
prophylaxis following transplantation.
Despite the high prevalence of anergy in ESRD
patients, this high-risk population should undergo tuber-
culin skin testing with purified protein derivative (PPD).
We ask that any patient with latent tuberculosis infection
(PPD reaction ≥ 10 mm induration in ESRD patients) be
treated with a 9-month course of isoniazid per the current
recommendations of the American Thoracic Society and
Centers for Disease Control and Prevention (27). This
treatment will not postpone transplantation, as the course
is simply continued to completion. A history of tuberculosis
does not preclude transplantation; in this situation we
administer prophylaxis after transplantation, albeit not
with complete success in preventing recurrent disease.
The presence of a hemodialysis or peritoneal dialysis
catheter obviously does not preclude transplantation,
but catheter infection would. We usually require a
minimum of 2 weeks of clinical stability following com-
pletion of a course of treatment for catheter infection
prior to transplantation.
In all potential transplant candidates, we routinely re-
commend hepatitis B and pneumococcal vaccination. We
ask that the guidelines for administration of other immu-
nizations be followed by the patients’ primary physicians.
Cancer
Cancer rates are higher after transplantation compared
to the general population, and the rates of some cancers
(nonmelanoma skin cancer, melanoma, Kaposi’s sarcoma,
 KIDNEY TRANSPLANT CANDIDATE EVALUATION 491
TABLE 4. Disease-free waiting periods before transplantation in hepatitis B is endemic. The prevalence of hepatitis C in
candidates with cancera U.S. dialysis units is variable; among our center’s trans-
Malignancy Waiting period
plant candidates, the prevalence of hepatitis C antibody
is usually about 8%.
Renal cell cancer All patients with hepatitis B antigenemia and hepatitis
Symptomatic 2 years C antibody undergo testing for viremia (32). Those with
≥ 5 cm or invasive 5 years?b viremia then undergo ultrasound of the liver, testing for
Incidental (< 5 cm) None
Wilm’s tumor 2 years alpha fetoprotein, and referral to hepatology for evalu-
Bladder 2 years ation and liver biopsy. We decline transplant candidacy
In situ or noninvasive papillomas None to patients with stage 3 or stage 4 (cirrhosis) fibrosis on
Anogenital ?b biopsy. They may be eventual candidates for combined
Cervix
Localized ≥ 2 years
liver and kidney transplantation. Patients with hepatitis
Invasive ?b C viremia without advanced fibrosis may be offered
Uterus 2 years antiviral treatment in an effort to eliminate hepatitis C
Testis 2 years replication prior to transplantation.
Thyroid 2 years
Kaposi’s and other sarcomas 2 years
Breast 5 years
Early stage 2 years?b Gastrointestinal Disease
Colorectal 5 years
Dukes A or B1 < 5 years?b Intra-abdominal infection or perforated viscus can be
Prostate 2 years
Localized None?
catastrophic in a transplant recipient. However, screen-
Liver No transplantation ing of asymptomatic patients for peptic ulcer disease,
Myeloma No transplantation cholelithiasis, and diverticulosis has been of little pre-
Lymphoma 2 years dictive value in anticipating posttransplant problems (2).
Leukemia 2 years We do not screen asymptomatic individuals. Nor do we
Melanoma 5 years
In situ or very thin 2 years screen asymptomatic potentially high-risk patients,
Nonmelanoma skin None specifically neither diabetic patients for cholelithiasis
Lung 2 years nor patients with ADPKD for colon diverticula. Patients
a
From Kasiske et al. (2). with a history of symptomatic cholelithiasis are asked to
b
?, inadequate evidence upon which to base a firm recommendation. undergo cholecystectomy, and patients with a history of
diverticulitis may be asked to undergo partial colectomy
prior to transplantation.
non-Hodgkin’s lymphoma, cancer of the mouth, and
cancer of the kidney) are higher compared to candidates
on the waiting list (28). A history of cancer in most Obesity
instances necessitates a disease-free interval before trans-
plantation. A comprehensive review of all malignancies Despite the comorbidity of obesity, transplantation
and the risk of recurrence is beyond the scope of this supersedes dialysis as the preferred treatment for ESRD
article, but the recommended disease-free waiting in the obese just as it does in the nonobese, and the obese
periods before transplantation are shown in Table 4. are being transplanted (4). In 2001–2002, at least 15% of
These waiting periods are recommended to reduce the U.S. kidney transplant recipients had a body mass index
frequency of recurrence in the early years after transplan- (BMI) of 30–35 kg/m2, and at least 6% had a BMI greater
tation. We typically adhere to these recommendations. than 35 kg/m2. Virtually all recipients gain weight fol-
Routine screening for cancer in transplant candidates, lowing transplantation, with or without corticosteroids, in
following the guidelines recommended for the general our experience. We typically refuse transplant candidacy
population based on age and gender, is now generally to individuals with a BMI greater than 40 kg/m2 and have
recommended by all transplant centers, although there is begun to recommend their consideration of gastric bypass
some debate about the utility of such screening (29,30). surgery. We will offer transplant candidacy to a patient
with a BMI greater than 35 kg/m2 with the proviso that
sufficient weight is lost to achieve a BMI of 35 kg/m2 or
Liver Disease ideally less. In the case of many obese patients, we ask
that the patient return to be seen by a transplant surgeon
Liver disease has been recognized as a late cause of to ascertain that transplant surgery is technically feasible
death in kidney transplant recipients for more than two and to ensure that we are not being too restrictive, as
decades (31). The primary cause of liver disease in trans- body habitus is also important in the determination of
plant candidates is viral hepatitis. Early death due to whether transplant surgery is possible.
fulminant hepatic failure is rare, but recipients with
chronic viral hepatitis are at increased risk for morbidity
and mortality following transplantation (32). Hepatitis Diabetes Mellitus
B is not just of historical interest in the U.S. dialysis
population, as many areas of the United States now have In 2001–2002, recipients with ESRD ascribed to dia-
immigrant populations from areas of the world where betic nephropathy comprised almost 25% of U.S. kidney
492 Scandling
transplant recipients (4). Patients with diabetes must
understand that blood glucose control will likely worsen
after transplantation, with the reestablishment of renal
insulin metabolism and the use of immunosuppressive
drugs, which may impair insulin production or sensitivity.
The true incidence of new onset diabetes after transplan-
tation is unknown, but is likely higher than generally
recognized or historically defined due to inconsistent
definition of the disorder. Defining the true incidence is
further obscured by the occurrence of cases of unrecog-
nized or subclinical diabetes in the ESRD population,
manifest only after reestablishment of kidney function.
Patients with type I diabetes mellitus are candidates
for pancreas transplantation, either combined with a
kidney from the same deceased donor or following a
kidney either from a deceased or living donor. Candidates
for pancreas transplantation must be highly motivated
and understand that pancreas transplantation carries
the risk of significant morbidity and no guarantee of
improved health and quality of life aside from freedom
from insulin. Preemptive simultaneous pancreas and
kidney transplant recipients enjoy better transplant
kidney survival (33), just as do preemptive kidney-only
transplant recipients.
All patients with diabetic nephropathy seeking trans-
plant candidacy must undergo careful cardiovascular
evaluation (see above).
Coagulopathy
A small but disturbing percentage of transplant kidneys
are lost to thrombosis early after transplantation. While
technical factors may be preeminent in this problem, it is
prudent to screen candidates at high risk for coagulation
abnormalities (34). We therefore screen patients with a
history of recurrent hemodialysis access thrombosis or
other thrombotic events and patients with systemic
lupus erythematosus (SLE) for coagulopathy. Beyond
prothrombin time and partial thromboplastin time, our
current screening includes antiphospholipid antibodies,
factor V Leiden, antithrombin III, protein C, protein S,
and homocysteine. The presence of a coagulation abnor-
mality will not preclude transplantation, but will alter the
routine of transplant surgery and postoperative care to
include anticoagulation or antiplatelet therapy.
Age
Advanced age is not a barrier to transplantation. In
2001–2002, 11.5% of deceased donor kidney recipients
and 6.6% of living donor kidney recipients were 65 years
of age or older (4). As might be anticipated, these recipients,
despite being highly selected, show an increased relative
risk of death in comparison to all younger recipient age
groups. In the words of Bill Amend, seasoned and long-
standing transplant nephrologist at the University of
California, San Francisco, patients over the age of 65
years must be WOW (well otherwise) to achieve trans-
plant candidacy. Historically we have usually followed
this admonition, but in recent years we have relaxed this
constraint somewhat and, for example, have offered
transplantation to candidates with a history of success-
fully revascularized coronary artery disease. It is impor-
tant that candidates and their families clearly understand
the increased risk of mortality relative to maintenance
dialysis in the early months after transplantation, when
recipients can be lost to acute cardiovascular events or
sepsis. Furthermore, candidates must understand that the
survival benefit of transplantation over dialysis wanes
with advancing age and that quality of life, as measured
by physical rehabilitation, may be slow to improve with
advanced age (35).
Psychosocial
The psychosocial evaluation of a transplant candidate
can be a challenge. The transplant evaluation appoint-
ment provides only a “snapshot” of the patient and his
circumstances. Therefore the transplant social worker
will typically also contact the patient’s dialysis unit
social worker to achieve a better understanding of the
candidate. Noncompliance with the dialysis prescription,
specifically treatment absenteeism, will preclude trans-
plant candidacy in our program until the patient has 3–6
months of demonstrated compliance, as spelled out in a
written contract made with the patient.
Transplant candidates will need social support at many
points along the way to achieve and maintain transplan-
tation. In some instances it may simply be someone to
help with transportation, household chores, and errands
for the first week or two following transplant surgery, but
for others the support may need to be much more sub-
stantial. While transplant centers typically have access to
interpreters to overcome language barriers, illiteracy
may be a compounding factor limiting effective commu-
nication, particularly by telephone. Therefore it is always
helpful if family members who speak English can be
available to help.
There are expenses to transplantation that must not
be forgotten in the course of transplant education. The
financial circumstances, insurance coverage, and liabil-
ity of a candidate may be much different by the time of
transplantation or at 3 years after transplantation, when
Medicare coverage expires (with the exception of those who
qualify by age or disability) and the cost of the immuno-
suppressive drugs becomes the sole responsibility of the
recipient and his medical insurance. A not uncommon
problem is lack of adequate private medical insurance cover-
age for prescription drugs, which has led some patients
to decline transplant candidacy due to the anticipated
inability to pay for the drug expenses. A quite common
problem is a lack of adequate private medical insurance
coverage after the expiration of Medicare coverage,
leaving the recipient and transplant center scrambling
to rely on the largesse of pharmaceutical companies to
provide the immunosuppressive drugs gratis to qualified
recipients.
The value of the dialysis unit as social support should
not be underestimated. After years of unemployment
during maintenance dialysis, many transplant recipients
never return to the work force, and home life may have
 KIDNEY TRANSPLANT CANDIDATE EVALUATION
TABLE 5. U.S. national median wait time to transplantation for
candidates listed in 1999a
ABO blood type Median wait time (days)
B 1815
O 1469
A 740
AB 396
a
From Danovitch et al. (5).
suffered. Transplant centers do not provide the social
support of a dialysis unit.
Entering the Wait-List
ABO blood group typing on two separate blood
samples is now required before a candidate can be listed
with the United Network for Organ Sharing (UNOS) for
deceased donor kidney transplantation. The allocation of
deceased donor kidneys in the United States follows an
algorithm based on human leukocyte antigen (HLA)
match and waiting time. The median time to transplant
for candidates listed in 1999 is shown in Table 5.
Preemptive Transplantation
The benefit of preemptive transplantation has been
identified by a number of retrospective studies (36–40).
Historically up to 25% of living donor transplant recipi-
ents and fewer than 10% of deceased donor transplant
recipients were fortunate enough to undergo preemptive
transplantation (40). Early referral and a willing,
ready, and able living donor are obviously essential to
best achieve this goal. However, there is no benefit to
transplantation when the estimated GFR still exceeds
15 ml/min (41). We typically recommend transplantation
when the estimated GFR declines to 10–12 ml/min.
The Zero Mismatch Kidney
Annually approximately 15% of U.S. deceased donor
transplant recipients continue to receive zero HLA mis-
matched kidneys (5). Because of the policy of mandatory
national sharing of these kidneys, the utility of which has
now stood a test of time, most of these recipients experi-
ence shorter waiting times and undergo transplantation
within the first 2 years of listing. A candidate must be
prepared and ready for transplantation at any time after
entering the wait-list.
The Expanded Criteria Donor (ECD) Kidney
Transplantation of ECD kidneys now accounts for
approximately 15% of yearly U.S. deceased donor trans-
plantation (5). Similar to the zero mismatch kidney
program, recipients of ECD kidneys should experience
shorter wait times to transplantation, which is anticipated
493
to be a prime advantage to candidates willing to accept these
kidneys with their shorter life expectancy. Therefore these
candidates must also be ready for transplantation at any
time after entering the wait-list. These candidates are older
than candidates awaiting non-ECD kidney transplantation
and may require more frequent review than their younger
counterparts. We offer the ECD program to all candidates
60 years of age or older and candidates 55 years of age or
older with diabetic nephropathy. Candidates for ECD
kidneys do not lose their candidacy for standard (non-
ECD) kidneys; they are listed for both types of organs.
Repeat Transplantation
About 20% of the deceased donor transplant waiting
list is now comprised of candidates awaiting repeat trans-
plantation, and a lesser but similar percentage undergoes
transplantation each year (5). The wait time for the
average candidate awaiting repeat transplantation is
approximately twice as long as that of a candidate await-
ing a first transplant, due to sensitization manifest as
panel reactive antibodies (PRA) greater than 10%. If a
repeat candidate is lucky enough to have a low level of
PRA, the wait is no longer than that of a candidate with
low PRA awaiting a first transplantation.
Managing the Wait-List
Managing the wait-list is now one of the greatest prob-
lems facing transplant centers (42,43). Some very large
transplant centers now have wait-lists with candidates
numbering in the thousands. The wait-list will continue
to grow as demand far outstrips the supply of deceased
organ donors and is now predicted to increase from
nearly 55,000 candidates at the end of 2003 to 76,000 by
2010 (5). To keep so many candidates prepared for trans-
plantation requires the assistance of the candidates’
nephrologists.
Our primary focus in wait-list management is main-
taining updated cardiac evaluations (44). All asympto-
matic candidates with documented coronary artery disease
are required to undergo annual stress myocardial perfu-
sion study. Asymptomatic candidates over the age of 50
years without coronary artery disease (and candidates
of any age with diabetic nephropathy and no coronary
artery disease) are required to undergo stress myocardial
perfusion study every 2 years. We rely on the candidates’
nephrologists to optimize treatment of coronary disease.
We also rely on the candidates’ nephrologists to maintain
routine health maintenance and cancer screening.
Our transplant coordinators maintain telephone con-
tact with their assigned candidates and request updated
medical records in the event of serious illness. These
records, and periodic candidate update forms completed
by the coordinators, are then reviewed by a transplant
nephrologist. The candidate may be asked to return for
an updated clinical evaluation with either transplant
nephrology or transplant surgery. We plan to initiate a
dedicated transplant update clinic and see all wait-listed
candidates on an annual basis.
494 Scandling
A recent change in policy has deemphasized HLA match
in the deceased donor kidney allocation algorithm, result-
ing in greater predictability in the time of transplant for
those not fortunate to receive a zero mismatch kidney (an
early event after entering the wait-list; see above) (45).
This change may enable timely preparation of these
candidates as they eventually near the top of the list in
what may be years later. Nonetheless, the size of the
wait-list and limited resources, problems common to
many transplant centers, confound efforts at optimal can-
didate management and will likely continue to do so as
the wait-list continues to grow. Thus active communica-
tion between practicing nephrologists and transplant
centers is necessary to achieve successful transplantation.
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