Transplant list criteria
1 Introduction
For suitable patients renal transplantation gives better long-term survival than does dialysis and, for the majority, improves quality of life. The option of transplantation should be offered to all suitable patients, whilst recognising that the limited availability of cadaveric kidneys means that not all patients on the waiting list will receive a transplant in a timely manner.
The evaluation, selection and preparation of potential recipients is an essential stage in the process. Suitable patients should not be excluded from transplantation but nor should kidneys be used for unsuitable recipients. Best Practice Guidelines provide clinicians with evidence-based criteria by which to assess patients. However, they can never be more than guidelines and their interpretation will require clinicians to exercise judgement in the assessment of each patient.
The Kidney and Pancreas Advisory Group at UK Transplant asked the British Transplantation Society (BTS) and the Renal Association (RA) to advise on appropriate waiting list assessment protocols for adults and the British Association for Paediatric Nephrology (BAPN) to do so for paediatric patients. These Guidelines will provide UK dialysis and transplant units with a framework that ensures, as far as possible, that all patients are assessed to a uniform standard and that access to the waiting list is both appropriate and equitable.
2 Adult waiting list criteria
The Working Party took as its starting point the recently published European Best Practice Guidelines (EBPG): Evaluation, Selection and Preparation of the Potential Transplant Recipient [superscript1] A thorough review of this document led to the conclusion that, broadly, it represents a comprehensive and up to date statement of current evidence and practice and should be adopted by UK clinicians.
The Guidelines give detailed recommendations that should be read within the following framework - where the views of the Working Party differ from or add to those of the EBPG the relevant section has been referenced.
All patients with end-stage renal failure should be considered for transplantation unless there are absolute contra-indications.
The document is available in three sections in pdf format
(please note that the time taken to access these files will
be determined by the speed of operation of the website on
which they are held)
Foreword http://ndt.oupjournals.org/cgi/reprint/15/suppl_7/1.pdf (28Kb)
Preface http://ndt.oupjournals.org/cgi/reprint/15/suppl_7/2.pdf (26Kb)
SECTION I: Evaluation, selection and preparation of the potential
transplant recipient
http://ndt.oupjournals.org/cgi/reprint/15/suppl_7/3.pdf
(373Kb)
2.1 Contra-indications
2.1.1 Predicted patient survival of less than 5 years.
The Working Party felt that the EBPG (recommendation 1.4) that predicted patient survival should be at least 2 years, this is insufficiently rigorous in light of the organ shortage and the current half-life for cadaveric kidney transplants of 10-12 years.
- Malignant disease not amenable to curative treatment, or remission for greater than 5 years.
- HIV infection not treated with HAART or already progressed to AIDS. Consider transplantation for patients with preserved CD4 counts on HAART (cf EBPG 1.4).
- Cardiovascular disease - ischaemic heart disease, the prognosis of which cannot be improved by revascularisation and/or cardiac failure with a predicted risk of death greater than 50% at 5 years.
2.1.2 Predicted risk of graft loss greater than 50% at 1 year.
- Anti-GBM disease with circulating antibody.
- Anti-GBM disease in patients with Alports Syndrome following first graft failure.
- Early graft loss from recurrent FSGS is associated with reduced survival of second grafts, though the evidence is weak. Uncertainty surrounds the fate of second grafts after early first graft loss from IgA disease, membrano proliferative nephritis and other rarer primary diseases. Whilst not absolute contra-indications, these patients need careful consideration (cf EBPG 1.5.3).
2.1.3 Patients unable to comply with immunosuppressant therapy.
- A history of non-compliance, and in particular graft loss from non-compliance. Reasons for non-compliance should be investigated.
- Those with poorly controlled psychosis or regular use of Class A drugs (cf EBPG 1.2).
2.1.4 Immunosuppression predicted to cause life-threatening complications.
- Unresolved chronic bacterial infection.
- Persistent viral infection.
All the above contra-indications may require modification in circumstances that change the balance of risks between dialysis and transplantation. Two simple examples:
- Patients with severe vascular access problems could be considered for transplantation even if their overall prognosis for survival is less than 5 years.
- Patients with BMI > 30 have significantly poorer graft and patient survival after transplantation.
2.2 Pre-emptive Transplantation
Suitable patients should be eligible for the transplant waiting list if dialysis is predicted to start within 6 months - typically those with a GFR < 15 mls/min.
2.3 Assessment
Patients should be formally assessed before being placed on the waiting list, as recommended by British Transplantation Society and Renal Association Standards. The detailed assessment would follow the EBPG, although the Working Party feel that routine screening of the prostate, native kidneys and gall bladder is not required (cf EBPG 1.5). Reassessment annually is recommended - any change in the patient's condition should be reviewed according to the Guidelines for initial assessment.
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Working Party membership:
Mr C J Rudge Chairman
BTS Professor A Bradley
Dr C Newstead
RA Professor A Rees
Dr P Mason
Dr C Winearls
BAPN Working Party Dr R Postlethwaite
