Chapter 144: Renal Transplantation

With the advent of more potent and well-tolerated immunosuppressive regimens and further improvements in short-term graft survival, renal transplantation remains the treatment of choice for most pts with end-stage renal disease. Results are best with living-related transplantation, in part because of optimized tissue matching and in part because waiting time and ischemic time can be minimized; ideally, these pts are transplanted prior to the onset of symptomatic uremia or indications for dialysis. Transplant centers now also perform living-unrelated donor (e.g., spousal) transplants, often in “chains” involving multiple donors to optimize tissue matching. Graft survival in these cases is far superior to that observed with deceased donor transplants, although less favorable than with living-related transplants.
In 2014, there were >12,328 deceased-donor kidney transplants and 5574 living-donor transplants in the United States, with the ratio of deceased to living donors remaining stable over the last few years. As of 2015, there were 50,692 active adult candidates on the waiting list, and <18,000 pts were transplanted. This imbalance is set to worsen over the coming years with the predicted increased rates of obesity and diabetes worldwide. In an attempt to increase utilization of marginal kidneys while insuring longevity-matching, a new allocation system was developed and recently implemented. In an additional attempt to increase utilization of deceased-donor kidneys and reduce discard rates of organs, criteria for the use of so-called expanded criteria donor (ECD) kidneys and kidneys from donors after cardiac death (DCD) have been developed. ECD kidneys are usually used for older pts who are expected to fare less well on dialysis.
Factors that influence graft survival are outlined in Table 144-1. Pretransplant blood transfusion should be avoided, so as to reduce the likelihood of sensitization to incompatible HLA antigens; if transfusion is necessary, leukocyte-reduced irradiated blood is preferred. Contraindications to renal transplantation are outlined in Table 144-2. Overall, the current standard of care is that the pt should have >5 years of life expectancy to be eligible for a renal transplant, since the benefits of transplantation are only realized after a perioperative period in which the mortality rate is higher than in comparable pts on dialysis.
TABLE 144-1: Some Factors That Influence Graft Survival in Renal Transplantation
HLA mismatch↓
Presensitization (preformed antibodies)↓
Very young or older donor age↓
Female donor sex↓
African-American donor race (compared with white)↓
At-risk APOL1 donor genotype (two risk alleles for ESRD)↓
Older recipient age↑
African-American recipient race (compared with white)↓
Recipient diabetes as the cause of end-stage renal disease↓
Prolonged cold ischemia time↓
Hepatitis C infection↓
Large recipient body size↓
TABLE 144-2: Contraindications to Renal Transplantation
Absolute Contraindications
Active glomerulonephritis
Active bacterial or other infection
Active or very recent malignancy
Overt AIDSa
Active hepatitis
Severe degrees of comorbidity (e.g., advanced atherosclerotic vascular disease)
Relative Contraindications
Severe psychiatric disease
Moderately severe degrees of comorbidity
Hepatitis C infection with chronic hepatitis or cirrhosis
Noncompliance with dialysis or other medical therapy
Primary renal diseases
 Primary focal sclerosis with prior recurrence in transplant
 Multiple myeloma
 Amyloid
 Oxalosis
aMost centers consider overt AIDS a contraindication to transplantation; however, transplantation of HIV-positive pts is increasing in frequency.

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