regulatory bodies that oversee transplant centers. Medical contraindications account for more than half of the denials issued by transplant selection committees. Common absolute medical contraindications include: active infection, cancers under treatment or diagnosed within the last 2-5 years, depending on the type of cancer (see below), cirrhosis or advanced liver disease (unless the patient is also a candidate for a simultaneous liver transplant), severe cardiovascular disease including coronary disease non amendable to surgery or coronary artery stenting, severe or irreversible peripheral vascular disease, severe pulmonary disease including emphysema and need for home O2, and smokers who also have diabetes and are therefore at high risk for vascular complications. Absolute contraindications also include active psychiatric disorders, advanced dementia, or debilitating neurological or neuromuscular disorders. Patients who are mentally disabled, such as with Down’s Syndrome, may be candidates for kidney transplantation if they have good social support. The above partial list includes some of the most common causes for not being eligible for transplantation. The coexistence of multiple significant medical conditions will make an individual patient’s selection and acceptance less likely; in such cases the procedure and medication-related risks will outweigh the benefit of transplantation. Regarding cardiac contraindications, the reality is that a diagnosis of coronary disease, which is very prevalent among dialysis patients, is not necessarily a contraindication unless there are signs of irreversible cardiac damage including: advanced heart failure with LVEF less than 30%, recurrent coronary disease after CABG, symptomatic angina after CABG, recurrent and multiple coronary artery stenting, end stage heart disease or active cardio-pulmonary syndromes. Any active bacterial, viral, protozoan or fungal infection should be treated and eradicated before attempting transplantation with few exceptions. [KIDNEY TRANSPLANT TOOLKIT] May 13, 2019 © Copyright, Forum of ESRD Networks, 2019 Page 6 Patients are not transplant candidates if they have an active malignancy that has been recently diagnosed, is being actively treated, or has metastatic disease. Patients with non-melanoma skin cancer that is not metastatic are candidates for transplantation. Patients with cancer that is in remission who have a long enough life expectancy to benefit from transplantation (typically a minimum of about 5 years) are acceptable to be referred and may be transplant candidates. After a cancer is in remission by surgical removed, or chemotherapy, patients may become eligible to receive a kidney transplant, depending on the long-term prognosis of their cancer. Different transplant centers have different waiting periods depending on the individual patient’s clinical situation. Waiting times vary -- for instance a patient who undergoes a nephrectomy for a small renal cell carcinoma may be able to be listed for transplant immediately after recovering from surgery. However, most cancers, once treated will have a 2-5 year waiting time including: colon, prostate, cervical and lymphoma/leukemia. Breast Cancer, pancreatic cancer and ovarian cancers could have a longer surveillance waiting time that is center specific, usually between 5 to 10 years. Other cancers such as Multiple Myeloma are a contraindication unless the patient has undergone a stem cell transplant and has been in remission for several years. If the patient is interested in transplantation, it is better to refer the patient for evaluation and let the transplant center determine if the patient is a candidate at the current time. They will state when the patient can be referred back in the future. As mentioned above, patients with end stage liver disease and cirrhosis may be eligible for a combined liver and kidney transplant. Patients who have lost their kidney function due to active autoimmune diseases, such as Systemic Lupus Erythematosis or systemic vasculitis, will be asked to delay transplantation until their autoimmune disease becomes inactive. In general, unless a patient has a clear contraindication for renal transplantation, it is appropriate to refer a patient for evaluation; the transplant center will make a determination of the patient’s eligibility. Recipient weight considerations Obesity is a serious healthcare issue and its medical consequences are multiple and in certain cases lifethreatening. Obese patients have more complications post-transplant, including a higher risk of surgical wound infections and transplant rejection. Most Transplant Centers now include BMI guidelines and limits to the selection process. Typical centers will not transplant a patient with a BMI above 35 kg/m2, although many will allow a patient to be placed on the waiting list at a higher BMI, in anticipation of weight loss. There are centers that will transplant patients with higher BMI, above 35; please check with your center regarding their specific requirements before you send the referral. Psychological contraindications Patients with a psychiatric diagnosis should be referred for pre-transplant evaluation. Most centers will include a psychiatric or psychosocial evaluation as part of the initial visit. A previous psychiatric disorder doesn’t constitute by itself a