eMedicine Specialties > Transplantation > Surgery
Renal Transplantation (Medical): Differential Diagnoses & Workup
Updated: Jun 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Workup
Laboratory Studies
- Pretransplantation recipient laboratory evaluation: Emphasize identifying and treating all coexisting medical problems that may increase the morbidity and mortality rates of the surgical procedure and adversely impact the posttransplant course. In addition to a thorough medical evaluation, evaluate the social issues of the patient to determine conditions that may jeopardize the outcome of transplantation, such as financial and travel restraints or a pattern of noncompliance.
- Pertinent components include the following:
- Blood chemistries
- Liver function tests
- Complete blood count
- Coagulation profile
- Infectious profile
- Hepatitis B and C serologies
- Epstein-Barr virus serologies (immunoglobulin M [IgM] and immunoglobulin G [IgG])
- Cytomegalovirus (CMV) serologies (IgM and IgG)
- Varicella-zoster serologies (IgM and IgG)
- Rapid plasma reagin (RPR) test for syphilis
- HIV
- Purified protein derivative (PPD) - Tuberculosis skin test with anergy panel, when indicated
- Urinalysis, urine culture, and cytospin (when indicated)
Imaging Studies
- A complete cardiac workup including angiography is not necessary in every patient. However, individuals with a significant history, symptoms, type I diabetes, or hypertensive renal disease should undergo a thorough evaluation to rule out significant coronary artery disease.
- ECG (12 lead)
- Chest radiograph (posteroanterior [PA] and lateral)
- Exercise and dipyridamole thallium scintigraphy
- Two-dimensional echocardiography with Doppler (+/- dobutamine)
- Coronary arteriogram (if indicated)
- Special procedures in selected patients are dictated by findings revealed on history and physical examination.
- Upper GI endoscopy
- Colonoscopy
- Ultrasound of native kidneys
- Peripheral arterial Doppler studies
- Pulmonary function tests
- Carotid duplex studies
- Voiding cystourethrogram
- Urodynamic pressure-flow studies
Other Tests
- Recipients of kidney transplants undergo an extensive immunological evaluation that primarily serves to avoid transplants that are at risk for antibody-mediated hyperacute rejection. The immunologic evaluation consists of 4 components.
- ABO blood group determination: This test is used to determine if the patient is a potential target of recipient circulating preformed cytotoxic anti-ABO antibody. Transplantation across incompatible blood groups may result in humoral-mediated hyperacute rejection.
- Human leukocyte antigen (HLA) typing: All transplant recipients are tissue typed to determine the HLA class I and class II loci. Six HLA antigens are determined. The kidney donors also are HLA typed, and the degree of incompatibility between the donor and recipient is defined by the number of antigens that are mismatched at each of the HLA loci.
- Serum screening for antibody to HLA phenotypes
- Sensitization to histocompatibility antigens is of great concern in certain populations of transplantation candidates. This occurs when the recipient is sensitized because of receiving multiple blood transfusions, a previous kidney transplant, or from pregnancy.
- Transplantation of a kidney into a recipient who is sensitized against donor class I HLA antigens puts the recipient at high risk of developing hyperacute antibody-mediated rejection. All transplantation candidates are screened to determine the degree of humoral sensitization to HLA antigens.
- Crossmatching: This is an in vitro assay method that determines whether a potential transplant recipient has preformed anti-HLA class I antibodies against those of the kidney donor. This immunologic test is conducted prior to transplantation. A negative crossmatch must be obtained prior to accepting a kidney for transplantation.
Procedures
- The medical workup may reveal circumstances that require surgical intervention to prepare the patient for kidney transplantation.
- Pretransplant native kidney nephrectomy/nephroureterectomy: This is no longer a routine pretransplantation procedure. The native kidneys are left in place because they may still produce significant volumes of urine, secrete erythropoietin, and activate vitamin D. Nephrectomy/nephroureterectomy is reserved for specific indications, such as large polycystic kidneys, significant proteinuria, and chronic reflux disease.
- Pretransplant cholecystectomy: Ultrasonographic evidence of symptomatic or asymptomatic gallstones is an indication. The mortality and morbidity of acute cholecystitis is significant in transplant recipients who are immunosuppressed.
- Splenectomy: This is no longer a requisite pretransplantation surgical procedure. However, splenectomy may be indicated as part of a protocol for ABO-incompatible kidney transplantations.
- Multiple random blood transfusions: Once, this was associated with improved kidney transplant graft survival in the precyclosporine era. Currently, transfusion offers no clinical benefit, and the risk of sensitization is significant. In the setting of living kidney transplantation, donor-specific transfusion therapy also has been almost completely eliminated.
More on Renal Transplantation (Medical) |
| Overview: Renal Transplantation (Medical) |
 Differential Diagnoses & Workup: Renal Transplantation (Medical) |
| Treatment & Medication: Renal Transplantation (Medical) |
| Follow-up: Renal Transplantation (Medical) |
| References |
| « Previous Page | Next Page » |
References
Suthanthiran M, Strom TB. Renal transplantation. N Engl J Med. Aug 11 1994;331(6):365-76. [Medline].
Nissenson AR, Rettig RA. Medicare's end-stage renal disease program: current status and future prospects. Health Aff (Millwood). Jan-Feb 1999;18(1):161-79. [Medline].
Organ Procurement and Transplantation Network (OPTN). National Data, Kidney Graft/Patient Survival. OPTN Web site. Available at http://optn.transplant.hrsa.gov/latestData/viewDataReports.asp. Accessed June 12, 2009.
McCullough KP, Keith DS, Meyer KH, Stock PG, Brayman KL, Leichtman AB. Kidney and pancreas transplantation in the United States, 1998-2007: access for patients with diabetes and end-stage renal disease. Am J Transplant. Apr 2009;9(4 Pt 2):894-906. [Medline].
Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. Dec 2 1999;341(23):1725-30. [Medline].
Meyers CM, Kirk AD. Workshop on late renal allograft dysfunction. Am J Transplant. Jul 2005;5(7):1600-5. [Medline].
Zarifian A, Meleg-Smith S, O'Donovan R, Tesi RJ, Batuman V. Cyclosporine-associated thrombotic microangiopathy in renal allografts. Kidney Int. Jun 1999;55(6):2457-66. [Medline].
Cornell LD, Colvin RB. Chronic allograft nephropathy. Curr Opin Nephrol Hypertens. May 2005;14(3):229-34. [Medline].
Wong W, Venetz JP, Tolkoff-Rubin N, Pascual M. 2005 immunosuppressive strategies in kidney transplantation: which role for the calcineurin inhibitors?. Transplantation. Aug 15 2005;80(3):289-96. [Medline].
Further Reading
Keywords
renal transplantation, allotransplantation, kidney transplantation, kidney transplant, renal transplant, end stage renal disease, end-stage renal disease, end stage kidney disease, end-stage kidney disease, ESRD, renal replacement, diabetic nephropathy, nephrectomy, organ transplant, organ transplantation, renal disease, kidney disease, diabetes, chronic glomerulonephritis, polycystic kidney disease, PKD, nephrosclerosis, hypertensive nephrosclerosis, systemic lupus erythematosus, SLE, interstitial nephritis, renal allograft, kidney allograft
