Candidates for renal transplantation are evaluated extensively to identify any medical or psychosocial factors that may result in an adverse outcome. Patients with ESRD often have associated comorbidities such as anemia and platelet dysfunction, bone and joint disease, gastritis, gastrointestinal bleeding, ileus, pulmonary edema, pleural effusions, hepatic disorders, and cardiovascular abnormalities. Of particular significance is the effect of ESRD on the cardiovascular system. Patients undergoing hemodialysis have a cardiovascular mortality rate 30 times that of non-uremic patients [1]. This increased risk is attributed to increased atherosclerosis, myocardial infarction, congestive heart failure, dysrhythmias, pericardial effusions, and cardiomyopathy. The presence of hypertension, hyperlipidemia, and diabetes is also common within this patient population. The purpose of the pre-transplant evaluation is to identify and treat coexisting medical problems that would increase a patient’s morbidity and mortality after transplantation. It also identifies any psychosocial factors that may have a negative effect on outcomes. These factors include any financial difficulties, uncontrolled psychological issues, lack of social support, and history of medical noncompliance.

The evaluation process begins with a thorough history of the patient’s renal disease. The etiology and pathology of ESRD can determine the risk of recurrence as well as define the associated comorbidities that will require further investigation. Other pertinent information includes dialysis status and dialysis access, urine production, any complications associated with dialysis access, thrombotic events, blood transfusions, and infections. Furthermore, it is important to determine if the patient has a history of prior transplantation, rejection episodes, allograft infections, or noncompliance. Knowing the outcome of a prior transplant may be predictive of the outcome of the subsequent transplant.

Recipient evaluation continues with an extensive review of the patient’s medical history. This is to identify further any risk factors that would predict increased morbidity and mortality as well as any contraindications to transplantation. Of particular importance are cardiopulmonary symptoms, such as angina, history of myocardial infarction, pericarditis, pericardial effusion, valve disease, and congestive heart failure. Identification of these risk factors will determine the degree of workup necessary for cardiac clearance. Cardiac testing includes an electrocardiogram, echocardiogram, stress test, and possible coronary angiogram. A history of type I diabetes would also lead to the need for an aggressive cardiac workup, given the increased risk of silent coronary disease. Furthermore, the evaluation will also include an assessment of pulmonary, neurologic, psychologic, and urologic symptoms. This information will guide the need for additional testing such as pulmonary function testing, voiding cystourethrogram, carotid duplex, and neurovascular imaging. Screening for occult malignancy and inquiring about a history of malignancy are also part of the process. An infectious disease profile is obtained to determine exposure and risk factors for tuberculosis, HIV, and hepatitis B and C. Prior surgeries, medications, allergies, and social history are also pertinent. Overall, this process serves to identify any conditions that would require further investigation.

The physical exam highlights any clinical signs that may warrant further investigation. The vital signs may reveal such symptoms as uncontrolled hypertension or orthostatic hypotension. Carotid bruits may be a marker of significant carotid stenosis. Pulmonary and cardiac findings may identify underlying disease that may not have been fully evident in the patient’s history. Abdominal exam may reveal scars of prior surgery or signs of an intra-abdominal process. Weak femoral and peripheral pulses may require additional workup to evaluate possible peripheral vascular disease. Finally, an assessment would screen for infections.

Extensive laboratory and imaging studies serve as screening tools to identify factors that will impact transplantation negatively. Not all procedures and tests are required for every patient. Rather, the need for a given study is guided by the patient’s age, history, physical exam, and inherent risk factors. Patients with a significant medical history, positive review of systems, type I diabetes, or hypertensive renal disease should undergo a complete cardiac workup including a coronary angiogram. Finding significant coronary artery disease results in a cardiologist evaluation for revascularization by coronary angioplasty with stenting or coronary artery bypass grafting prior to transplantation.

Immunologic evaluation is performed to identify factors associated with a high risk for antibody-mediated hyperacute rejection. This involves ABO blood group antigen determination, HLA typing, percent panel reactive antibody level (PRA), and donor/recipient cross-matching. ABO blood group antigens are potential targets for the recipient’s preformed cytotoxic anti-ABO antibodies. This may result in antibody-mediated hyperacute rejection in ABO-incompatible donor-recipient groups. All transplant recipients and donors are HLA typed to determine the HLA class I and class II loci. Six major and multiple minor HLA antigens are identified, and the degree of incompatibility is determined by the number of antigens that are mismatched at each loci. Better outcomes have historically been noted with a zero antigen mismatch. The PRA is used to evaluate the recipient’s sensitivity to HLA phenotypes in a given population. The recipient can become sensitized as a result of prior blood transfusions, transplants, or pregnancy. Cross-matching is used to determine if the recipient has any preformed anti-HLA antibodies specific to the prospective donor. The immunologic profile is also of particular importance with regard to organ allocation. The degree of mismatching can affect allocation of deceased donor kidneys. Organ allocation also takes into consideration individuals with a high (>95 %) PRA found to have a negative cross-match with a particular donor.

The evaluation process can be summarized by answering five basic questions:

This extensive evaluation process systematically answers these questions and identifies the patients who can be listed for kidney transplantation (see Table 19.2). It further identifies those with contraindications to transplant (see Table 19.3). The process also brings to attention those who would benefit from additional testing or intervention prior to a decision regarding transplantation.

A major limitation in kidney transplantation is deceased donor organ availability; some patients are fortunate enough to have a living donor. The major concern is the risk of subjecting a healthy patient to a nephrectomy. However, the morbidity associated with the procedure is less than 1 %, with a mortality 0.03 %. Donor life expectancy does not appear to be negatively affected and has been shown to be longer than that of the general population [3, 4].

The goal of the evaluation process for living donors is to establish that the potential donor is healthy enough to donate. As such, it is necessary to identify any underlying history that would suggest underlying renal dysfunction that would be negatively impacted by the loss of a kidney through donation (Tables 19.4, 19.5, and 19.6). Disease states such as hypertension and diabetes can affect renal function. A history of gestational diabetes is also of concern with a potential risk for type 2 diabetes later in life. In addition, the evaluation assesses a history of recurrent urinary tract infections, kidney stones, or prior renal trauma. A history of clotting disorders, deep vein thrombosis, heart disease, lung disease, or obesity serves as a possible indication of increased risk of donor morbidity and mortality.