In this post, we’ll make a thorough review of kidney transplantation as a treatment alternative for patients with ESRD.
Kidney transplantation in the treatment of CKD
Numerous studies have shown that renal transplantation is a therapy that improves long-term survival when compared with maintenance dialysis.
Transplantation in a predialysis situation is an attractive option because it improves graft survival and reduces costs. It’s associated with a 25% reduction in graft failure and 16% in mortality, compared with the recipients that are transplanted after entering dialysis; although it is not possible to do this in every case, as it will depend on the blood group of the patient and the donor supply.
An appropriate kidney transplant is, therefore, the treatment of choice for patients with terminal IRC because it offers a better evolution of the disease and due to its lower costs.
Without there being any exact rules, once the chronic nature of the process of kidney disease appears, and once the decreased renal function is established -usually when the glomerular filtration rate reaches values of about 30 ml / min-, it is necessary to present the different options renal replacement therapy (RRT) to which we must resort when kidney function values are close to being truly insufficient. At that time, the patient should be evaluated by nephrologists in specific predialysis or clinical nephrology consultations, in which the different options of TRS will be presented. Among them, the techniques of peritoneal dialysis and hemodialysis and the two types of kidney transplantation: living donor and deceased donor.
Contraindications for kidney transplantation
- Recent malignant neoplasm with metastatic activity
- Active infections
- Irreversible extrarenal disease with no rehabilitation or life expectancy of less than a year
- Psychiatric disease with loss of autonomy or competence
- Repeated therapeutic failure
- Addiction to drugs or alcohol without potential for rehabilitation
However, today, it is difficult to speak of absolute contraindications, and each patient should be assessed individually and according to their particular situation.
- Age, over 75 years
- Cardiovascular disease
- Advanced chronic liver disease
- Urinary tract abnormalities
- Previous malignancies
- Underlying disease
Risk factors linked to the recipient
There is no formal age limit for excluding a patient as a candidate for a transplant.
Age is one of the criteria that has been most relaxed by the aging of the general population and the dialysis. There are many studies that provide evidence of results in patients over 70, but those obtained in recipients over 60, are better than those that would be achieved by staying on dialysis, achieving an acceptable degree of long-term renal functions.
Elderly patients have higher morbidity with higher rates of hospitalizations for younger recipients and increased risk of cardiovascular disease, cancers, and infections, so the evaluation must be very rigorous. However, they also experience less rejection and require less aggressive immunosuppression.
Some groups consider very elderly patients as preferred to receive kidneys from cadaveric donors with criteria such as age, obtained in asystole, among others, or be double transplant recipients with this kind of donors.
Living donor transplantation in people over 65 poses special problems that must be solved with a strict respect for underlying ethical factors.
Patients with a BMI (body mass index) greater than 30 kg / m2 have a higher incidence of surgical complications, delayed healing, which leads to longer hospital stays.
There are conflicting results regarding the association of obesity with decreased graft survival. However, obesity is a risk factor for the development of diabetes, cardiovascular disease, and post-transplant hyperfiltration.
So a significant weight loss before inclusion on the waiting list is recommended.
Ischemic heart disease is the leading cause of death in transplant patients and graft loss with appropriate functions.
The risk of cardiovascular disease is higher in patients with previous cardiovascular disease, diabetes, smokers, obese (BMI over 30), carriers of classic factors of cardiovascular risk, very prolonged evolution of renal failure, and in those who have a poorly controlled hypertension and left ventricular hypertrophy.
The evaluation of ischemic heart disease is very important, especially in diabetics, in whom the coronary disease is often asymptomatic. Asymptomatic, low-risk patients should have their modifiable factors treated before including them in lists, high-risk ones (previous infarction, old age, diabetes) even if they are asymptomatic, should be tested for stress tolerance (stress tests, ultrasound with dobutamine, dipyridamole thallium scintigraphy, MRI or CAT scan). Patients with positive, noninvasive tests and those with symptoms will be studied with coronary angiography.
Patients with severe and diffuse coronary artery disease not amenable to revascularization or severe heart failure, are not good candidates for renal transplantation, and according to the case, they may be assessed for double heart / kidney transplant.
If there is a previous history or presence of risk factors for cerebrovascular disease, carotid doppler and surgery should be performed if necessary. The Doppler is also used to assess peripheral circulation in diabetic patients or patients with intermittent claudication.
Read Joe Cosgrove’s “How you can know if you will suffer from kidney failure.”