of CKD leads to terminal loss of renal function, requiring one of three forms of renal replacement therapy: hemodialysis, peritoneal dialysis, or renal transplantation. Transplantation confers a survival advantage over dialysis and appears to improve the quality of life of most patients by providing them with a lifestyle free of dialysis constraints, minimizing their dietary restrictions and decreasing the incidence of dialysis-associated complications including cardiovascular death, progression of their renal bone disease, correcting anemia and improving the patient’s overall wellbeing. Unfortunately, renal transplantation is not a treatment alternative for all patients with End Stage Renal Disease or those with CKD Stages III and IV not yet on dialysis. In general, any patient on any type of dialysis (hemodialysis or peritoneal dialysis), or anyone with sufficient loss of kidney function to qualify, could be referred to a transplant center to determine whether or not the patient is a suitable candidate (see below). When is the best time to refer a patient to a center? As soon as it is documented that a patient’s estimated glomerular filtration rate (eGFR – a measure of renal function) has declined to 20 ml/min or less, he or she is technically eligible to be placed on a waiting list for a kidney transplant. Many transplant centers will evaluate patients early when the eGFR is less than 25-30 ml/min. What is necessary for a successful referral? A nephrologist, primary care physician, dialysis unit social worker or nurse, on behalf of the primary care physician or nephrologist, can refer a patient. Patients can also refer themselves to many transplant centers. Every transplant center has a specific referral form, which can be submitted by fax or electronically. Most centers will require the submission of the form, a recent clinical note or history and physical, the CMS-2728 form (if the patient is on dialysis already) and copy of the insurance card. Required information at the time of referral differs by transplant center, but requested information may include: CKD diagnosis, age, height, weight, BMI, type of dialysis, dialysis schedule and specifics about the need for oxygen, a wheelchair, a translator or sign language interpreter, and mode of transportation. What are the contraindications for renal transplantation? There are medical, psychological, psychosocial and financial reasons not to accept a patient as a potential transplant candidate. Some of the conditions are temporary or reversible or are considered relative contraindications. Some other conditions are permanent or irreversible and are called absolute contraindications. Further details are given below. What is a transplant evaluation? A transplant evaluation is the process by which a potential transplant recipient is evaluated by a multidisciplinary transplant team housed at a transplant center, designed to determine if the patient can be relatively safely given a transplant organ. Many centers will invite the potential candidate to attend a [KIDNEY TRANSPLANT TOOLKIT] May 13, 2019 © Copyright, Forum of ESRD Networks, 2019 Page 5 preliminary educational session, after which the patient will visit to complete the testing process. Some centers provide online education or incorporate education into the initial evaluation visit. The patient and family will be educated about the process, complications and long-term care post-transplant. Evaluations may occur in one day or more, depending on the center’s protocol and the patient’s medical conditions. Some centers take several weeks to months to complete the assessment. The patient will be evaluated and examined by a transplant surgeon, transplant nephrologist, or both depending on the center. Often Advanced Practitioners such as Physician’s Assistants or Nurse Practitioners will assist with the evaluation. Transplant Nurse Coordinators are in charge of arranging the visit and making sure the correct testing is completed; they also participate in presenting the patient’s evaluation to the transplant team in a multidisciplinary conference to determine the patient’s eligibility. Each patient is assigned an individual transplant coordinator, who is the best point of contact for communication with the transplant center to receive information on the status of a patient’s transplant evaluation. In addition, the candidate will be interviewed by the transplant financial counselor, social worker, dietitian, living donor coordinator (if applicable), and by a mental healthcare professional. The exact tests that will be ordered differ between transplant centers. A typical evaluation will include laboratory testing, electrocardiogram, cardiac echocardiogram and often cardiac stress testing, chest X-ray, and abdominal imaging which may include a CT scan, MRI scan, or abdominal ultrasound. Some patients will be scheduled to undergo pulmonary function studies or vascular studies depending on their medical condition. Most centers will include a serum drug screen, nicotine screen and sickle cell screen when appropriate. This valuable information will be necessary for the patient’s assessment by the Transplant Selection Committee. Individual transplant center protocols are reviewed and approved by the national United Network for Organ Sharing (UNOS), which is one of the government