Pre-Transplant evaluation

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Pre-Transplant Assessment

For a successful kidney transplantation a pre-transplant assessment of the recipient (person who is going to receive the kidney) is imperative and is performed well in advance. The purpose of pre-transplant evaluation is to:

  • detect the primary disease that caused renal failure.
  • detect its risk of recurrence (or reappearing) after kidney transplant.
  • rule out any infections, cancer, mental problem or any other significant illness.

Hence, pre-transplant assessment helps to know whether the person is suitable for kidney transplant and prevent any post-transplant complications.

The pre-transplant assessment includes:

I. Medical, surgical and family history

  • Medical and surgical history: The doctor enquires about the original disease that led to renal failure, urologic disease, dialysis history,¬† past medical history, history of heart or blood vessel (cardiovascular) diseases, cancer or any other significant disease, pregnancy history, current medications, previous transfusions and previous transplantation.
  • The doctor also enquires about any family history of ESRD (End Stage Renal Disease), heart disease, high blood pressure, cancer, diabetes mellitus, liver disease to identify potential hereditary risk factors.

II. Physical examination includes checking for vital signs (such as temperature, pulse, respiratory rate and blood pressure) and other systemic examination. This provides information about the functioning of vital organs, signs and symptoms requiring further assessment, and need for age-appropriate health screening. All women should get a pelvic examination done.

III. Assessment of BMI (Body Mass Index): Because obesity can put the patient at an increased risk of postoperative heart problems, infections and delayed healing it is usually advisable to assess the BMI of the recipient before selecting him for kidney transplant. A BMI of less than 30 is usually required before the patient can go for further evaluations.

IV. Blood test to check your blood counts and to rule out infections such as Hepatitis B & C, Cytomegalovirus (CMV), Human Immunodeficiency virus (HIV) and Epstein-Barr virus. All active infections detected should always be treated before kidney transplantation.

V. Tuberculin skin test (or PPD test) to check for tuberculosis. Active Tuberculosis should be treated before considering kidney transplant. Previous tuberculosis can be reactivated by immunosuppression therapy, hence preventive therapy with isoniazid may be given during first year of transplantation.

VI. Urine test involves:

  • Testing urine for presence of blood, protein or sugar
  • Mid-stream urine specimen to check for urine infection. Recurrent urinary infection is common after kidney transplantation but usually easy to treat and it rarely damages the graft (i.e. transplanted kidney). Unless the infection is active it does not contraindicate transplantation.

VII. Stool test especially for occult blood (to rule out colon cancer)

VIII. Chest examination includes:

  • Chest X-ray that helps in determining the status of the lungs and lower respiratory tract.
  • Pulmonary Function test to assess how well the lungs are working and how efficiently they transfer oxygen into the blood

IX. Cardiovascular (heart & blood vessels) assessment

As there is a risk of post-operative heart attack after kidney transplant, a careful cardiovascular examination is essential. This may include:

  • ECG (Electrocardiography) to assess the functioning of the heart and detect any unknown heart damage.
  • Echocardiogram to detect any abnormalities in the heart.
  • Coronary Angiography is done in high-risk patients such as those having symptoms of Ischemic heart disease or diabetic kidney disease. In case any problem (such as blockage in the coronary arteries) is detected coronary revascularization is done before transplant operation.
  • Ultrasound with Doppler examination is done to assess the status of the iliac vessels (arteries supplying blood to abdominal wall, pelvis and legs).

X. Urinary system assessment includes:

  • Renal function test to assess kidney function. Creatinine level in the blood is used to determine functioning of kidneys.
  • Detect any existing kidney disease that may recur (reappear) and increase the risk of kidney failure after transplantation.
  • To detect any disease such as polycystic kidney tumor, stones, infection or obstruction in urinary system. In case of a large polycystic kidney disease, presence of large stone (staghorn calculi) or a potential focus of infection in kidneys nephrectomy (surgical removal of kidneys) is done before transplantation.
  • Screening of patients (especially on long-term dialysis) with kidney Ultrasonography or CT for renal carcinoma (cancer of kidney)
  1. Investigations such as endoscopy, ultrasound are carried out to examine the upper and lower gastrointestinal tract to detect any abnormalities/disease in the esophagus, stomach or the intestines. Colonoscopy is done if more than one first-degree relative has colon cancer or a history of ulcerative colitis.

XII. Liver Function test to assess liver function.

XIII. Dental examination to see whether the teeth and gums are healthy. Any infection present in the gums or teeth has to be treated before the transplant operation.

  1. Screening for cancer 
  • Mammogram is done in women over 40 years or with a family history of breast cancer
  • Pap smear test is done in all women for ruling out cervical cancer.
  • Prostate specific antigen (PSA) test should be done in men over 50 years of age

If the patient is having cancer there are chances of further hastening of cancer due to use of immunosuppressive drugs. Hence, such patients have to wait for a minimal time of 2 cancer free years from the time of last cancer treatment.

XV. Psychological assessment

  • For detecting any serious and incapacitating mental illness. Such patients are not able to comply with the treatment schedule. Hence, there is increased risk of kidney rejection.
  • For substance abuse: If the recipient smokes or takes alcohol it has to be stopped before kidney transplantation. A cigarette or alcohol free period of at least 6 months is required before receiving a new kidney.

Kidney Transplant Matching

Regardless of the type of kidney transplant you may undergo – living or cadaver, special blood tests are needed to determine the kind of blood and tissue type you have. These tests help to determine whether the available donor kidney is suitable for you or not. These tests include: