Editing Renal Transplant (section)

== Selection of kidney transplant recipients ==

* '''Diseases associated with increased risk of recurrence and secondary failure of the transplanted kidney (7): MO-SHAFF'''
*# '''Membranoproliferative glomerulonephritis'''
*# '''Primary Oxalosis'''
*# '''Sickle cell disease'''
*# '''Hemolytic-uremic syndrome'''
*# '''Amyloidosis'''
*# '''Primary Focal segmental glomerulosclerosis'''
*# '''Fabry disease'''
* '''Diseases associated with increased risk of recurrence that generally do not result in secondary failure of the transplanted kidney'''
** '''IgA nephropathy (Berger disease)'''
*** '''Commonly recurs in the transplant kidney yet rarely leads to graft failure'''
*** Most common cause of glomerular hematuria
** '''Hypertension and diabetes'''
*** '''Generally take many years to show evidence of disease in the transplant'''
* '''Diseases that do not recur in the transplanted kidney DACA'''
*# '''Renal Dysplasia'''
*# '''Autosomal dominant polycystic kidney disease (ADPKD)'''
*# '''Cystinosis'''
*# '''Alport syndrome without anti–glomerular basement membrane antibodies'''
* '''Patients with primary oxalosis and other metabolic diseases may benefit from combined kidney and liver transplant'''
* '''Absolute contraindications to transplantation (5): TICCC'''
*# '''Unsuitable conditions for Technical success'''
*# '''Active Infection'''
*# '''Comorbid (high probability of perioperative mortality)'''
*# '''Non-Compliance'''
*# '''Active Cancer'''
*#* '''5-year disease free waiting period is generally recommended'''
*#* '''Prostate cancer'''
*#** '''Low-risk'''
*#*** '''Should not be considered a contraindication to transplantation'''
*#**** '''In most cases, the morbidity and mortality of having ESRD is greater.'''
*#**** '''Patients who have low-risk disease felt to be amenable to active surveillance should be considered candidates for transplantation as long as they adhere to their surveillance regimen.'''
*#** '''Immediate or high-risk'''
*#*** '''Need to undergo definitive treatment to be considered a kidney transplant candidate.'''
*#** Patients that have undergone radical prostatectomy or radiation for prostate cancer can be evaluated for transplantation as soon as they have recovered from their treatment.
*#*** '''Waiting time after prostate cancer treatment should be dictated by the expected survival and probability of prostate cancer recurrence after treatment.'''
*#* '''Skin cancer'''
*#** '''Melanoma'''
*#*** '''Should also have a 5-year disease free period'''
*#** '''Most other skin cancers'''
*#*** '''Not a contraindication'''
*#* '''Ontario Listing Criteria§'''
*#** Most renal transplant candidates with a history of malignancy should wait a period of time between successful treatment and transplantation. '''Patients who do not meet the following waiting period criteria are not eligible for kidney transplantation.'''
*#*** '''Bladder Cancer: ≥2 years'''
*#**** '''Superficial low-grade lesions may not require any waiting time.'''
*#*** '''Renal Cell Carcinoma: ≥2 years'''
*#**** '''Small, incidental tumours may not require any waiting period.'''
*#**** '''Large or invasive or symptomatic tumours may require a waiting period of 5 years.'''
*#*** '''Testicular Cancer: ≥2 years'''
*#*** '''Wilms’ Tumour: ≥ 1 year'''
*#*** '''[Prostate Cancer not mentioned]'''
*#**** '''EAU guidelines: patients with a history of appropriately treated low stage/grade renal cell carcinoma or prostate cancer can be listed for renal transplant without additional delay; no description of wait time after intermediate/high-risk disease'''
*#*** '''Skin Cancer'''
*#**** '''Melanoma: ≥ 5 years'''
*#***** '''In situ melanoma may be considered for transplantation after waiting ≥ 2 years'''
*#**** '''Basal Cell: no waiting time required after successful removal'''
*#**** '''Squamous Cell: no firm recommendation on wait time'''
*#*** '''Breast Cancer: ≥ 5 years'''
*#**** '''Early in situ (e.g., ductal carcinoma in situ) lesions may only require a 2-year wait.'''
*#*** '''Cervical Cancer: ≥ 2 years'''
*#**** '''In situ cervical lesions may proceed with transplantation before the 2 year wait period'''
*#*** '''Colorectal Cancer: ≥ 5 years'''
*#**** '''Shorter waiting time of 2–5 years may be sufficient in patients with localized disease'''
*#*** '''Hodgkin’s Disease, Non-Hodgkin’s Lymphoma, Post-Transplant Lymphoproliferative Disorder, or Leukemia: ≥ 2 years'''
*#*** '''Lung Cancer, Thyroid Cancer: ≥ 2 years'''
* See CW11 Table 47-1 for Recommendations for Additional Urologic Studies in Renal Transplant Candidates
* '''Surgical evaluation'''
** '''Preparation of a patient for kidney transplantation requires a careful assessment of the peripheral vascular system'''
* '''Indications for pre-transplant nephrectomy (7):'''
*# '''Symptomatic renal stones not cleared by minimally invasive techniques or lithotripsy'''
*# '''High-grade solid renal tumors'''
*# '''Polycystic kidneys that are symptomatic, extend below the iliac crest, have been infected, or have solid tumors'''
*# '''Persistent anti–glomerular basement membrane antibody levels'''
*# '''Significant proteinuria not controlled with medications or angioablation'''
*# '''Recurrent pyelonephritis'''
*# '''Grade 4 or 5 vesicoureteral reflux with urinary tract infections'''
** '''Of these indications for pretransplant nephrectomy, only severe proteinuria can safely and reliably be managed by pretransplant transcatheter embolization and infarction'''.
* Even small defunctionalized bladders will frequently regain normal volume within weeks of transplantation
* A point system that has evolved in the United States for the selection of cadaver kidney transplant recipients includes the following variables: waiting time; human leukocyte antigen panel reactive antibody > 80%; age < 18; donor of kidney, liver segment, lung segment, partial pancreas, or small bowel segment; and histocompatibility. '''For most kidney transplant candidates, the most important factor in receiving an organ is time spent on the waiting list'''
* '''The best outcomes are achieved with renal transplantation immediately prior to the need for dialysis. In the United States, a patient must have documentation of a GFR < 20 mg/dL to be placed on the national waiting list for deceased donors.'''
* '''Potential recipients with a history of urolithiasis should undergo a complete metabolic stone workup.'''