The Evaluation Process
In order to determine if you are a candidate for a kidney transplant, you will need to have a thorough evaluation. Before you come for your evaluation appointment, we will ask your doctor’s office for records of your medical history.
On the day of your evaluation, the following will take place:
● You will be taught about transplantation by a transplant nurse coordinator. This will provide an overview of the evaluation and transplant process as well as what to expect after the transplant. Please bring a support person with you, and anyone who may wish to be a living donor.
● You will be seen by a transplant social worker for a one-on-one psychosocial interview. The social worker will explore such things as who will help you after transplant for care and transportation. She will also talk to you about how you might cope with the challenges you may face as a transplant recipient. Some outreach clinic visits may not include the social worker evaluation. If you are not seen by a social worker in an outreach clinic, this will be done in Sacramento at another time during your evaluation testing phase.
● You will be seen by a transplant doctor who will perform a physical examination and discuss your medical history with you. The doctor will discuss the advantages, disadvantages, and risks of transplantation and answer any questions you may have.
● You may see a dietitian during your visit. The need for this is based on your weight or other nutritional problems you may have.
After completing the physical and reviewing your medical and surgical history, the doctor may send you for laboratory tests, a chest x ray and EKG if your insurance allows. Next, the doctor will present your case to the transplant selection committee. The committee consists of nephrologists, surgeons, social workers, nurses, and a psychiatrist. The committee meets weekly and will determine if you are a candidate for transplant.
Patient selection for transplantation is a complex process, but the criteria for acceptance are standardized as much as possible. The selection criteria for our program are outlined below.
1. Advanced kidney disease: Regulations for listing for transplantation state that candidates must either be on dialysis or have near loss of kidney function with a creatinine clearance < 20cc/min (normal is >80).
2. Adequate urinary tract: The bladder must be an adequate reservoir for drainage of urine from the transplanted kidney. Some candidates may require removal of the native (own) kidneys in cases of chronic infection, severe hypertension, tumors, or polycystic kidneys that are too large, painful, or bleeding.
3. Acceptable cardiovascular function: Heart problems are the most frequent significant complications after transplantation. Pre-transplant heart evaluation is aimed at minimizing this risk and the specific tests will depend on the candidate’s medical history. Contraindications to transplantation include significant un-correctible coronary artery disease and/or poor cardiac pump function.
4. Acceptable vascular system: Since the kidney is attached to the blood vessels that also supply the lower extremities, candidates must have adequate circulation in the legs. Additional testing may be required for candidates with signs of poor circulation. A significant history of stroke, or risk for stroke, might also contraindicate transplantation.
5. Acceptable lung function: Smokers may be declined until they are able to quit (based on age and medical history). All smokers must go through a 6 week smoking cessation program before listing and document completion.
6. Acceptable liver function: Any evidence of liver disease, including previous hepatitis B or C infection, will be investigated, possibly including liver biopsy. If liver disease is too advanced, kidney transplantation alone is not an option. These candidates may be referred for consideration for combined kidney-liver transplant.
7. Active significant fungal or bacterial infection is a contraindication to transplantation.
8. Cancer screening: Appropriate for age tests will be necessary including colonoscopy (age>50yo), prostatic specific antigen (males >50), PAP smear and mammogram (female >40). Candidates who have had previously treated malignancies will be evaluated individually to assess the risk of recurrence.
9. Obesity: Candidates must have a body mass index (BMI, weight/body surface area) of <40. In many cases, due to an unfavorable heavy distribution of weight in the abdomen, the team may require weight loss to a much lower BMI. Suitability for transplantation is assessed on an individual basis.
10. Functional status: Candidates must be able to walk short distances and perform activities of daily living without assistance.
11. Psychosocial status: Candidates must be motivated, have demonstrated compliance with medical and dialysis regimens, not suffer from psychosis, live in a stable environment capable of supporting compliance with the transplant regimen including transportation, and not be an active substance abuser, (including marijuana in any form). Candidates with drug and/or alcohol history may be required to sign a contract, attend a treatment program and/or undergo random drug/alcohol screening.
12. Financial considerations: Transplantation is an expensive treatment option due to the medications and intense monitoring of the recipient’s organ function. Candidates with an inability to fund transplant care due to lack of adequate insurance coverage may not be eligible for transplant. The transplant financial coordinator will work with transplant candidates to provide information regarding potential sources of financial support.
You and your nephrologist will be notified about your candidacy for transplant by letter. If you are accepted for transplant, the letter will include information about any additional tests need to be done to complete your evaluation.
Some of those tests might be:
● Cardiac tests such as an echocardiogram, a stress test or cardiac catheterization to make sure your heart is healthy enough for you to have transplant surgery.
● Pulmonary function tests to check the function of your lungs.
● A colonoscopy to screen for colon cancer.
● A test to make sure your lower urinary tract is normal - This test is called a VCUG.
● A dental exam to check for cavities or infection
Occasionally, the doctor recommends that a person have their own kidneys removed before their transplant because they are causing:
● Severe high blood pressure
● Chronic infection or bleeding from the kidneys
● Overcrowding in the abdomen
Once your medical evaluation is complete, the results will be reviewed by the transplant team and final insurance authorization will be obtained for listing. You will be notified by letter when you are listed.