Selection of patients for transplantation

Selection of patients for transplantation

• Potential transplant recipients undergo a rigorous work-up process to identify major comorbidities that would preclude transplant surgery . Age per se is not a contraindication to renal transplantation and it is now common to transplant patients in their seventies as long as they have the necessary cardiovascular fitness. Uncontrolled infection and most malignancies are contraindications to transplantation. Patients with ESRD have a greatly increased risk of cardiovascular disease and require a chest radiograph, electrocardiogram (ECG) and, if indicated, an echocardiogram. Patients with a history of diabetes or isch - aemic heart disease should undergo a stress echocardiogram and sometimes coronary angiography . There are a number of technical considerations before a patient is deemed suitable for transplanta tion. The iliac blood vessels must be suitable for anastomosis and there must be a means of draining the transplant ureter. In patients with a history of vascular disease or deep venous thrombosis, the iliac arterial and venous system should be assessed by Doppler ultrasound scanning and possibly also MRA or CT angiography . Patients who have been anuric for a number - of years may have a small non-compliant bladder and this should be assessed by urodynamics. In patients with polycystic kidney disease, the size of the native kidneys should be assessed clinically to make sure that there is su ffi cient room for a kidney transplant in at least one iliac fossa. If there is inadequate space on both sides, then a pretransplant native nephrectomy will be necessary ( Figure 88.11 ). With the exclusion of non-melanotic skin cancer, patients who have had a malignant disease should be deferred for a disease-free period of at least 2 /uni00A0 years. Where possible patients should be listed for transplantation pre-emptively when they are within 6 months of requiring dialysis. This equates to an estimated glomerular filtration rate 2 (eGFR) of 10–15 /uni00A0 mL/min/1.73m .

Figure 88.11 Computed tomography scan of a patient with very large polycystic kidneys that extend well into both iliac fossae. The patient requires removal of one of the polycystic kidneys to make room for a subsequent renal transplant. Nephrectomy should be performed several weeks before transplantation.