contraindication, as long as the patient’s condition is stable and free of acute episodes, appropriately treated, and the patient is compliant with the treatment and pharmacologic regime as documented by the treating or supervising mental health professional. Patients with active Bipolar Disorder, Schizoaffective Disorders, Schizophrenia or severe anxiety or depression disorders will need appropriate care before they could be accepted as candidates and will need close psychiatric or psychological follow up post-transplant. Financial, support and transportation requirements Besides the obvious medical and psychological contraindications, there are other serious considerations that could negatively impact the longevity and wellbeing of the transplanted organ and the patient. The social worker and the financial transplant coordinators will discuss in detail the insurance coverage, [KIDNEY TRANSPLANT TOOLKIT] May 13, 2019 © Copyright, Forum of ESRD Networks, 2019 Page 7 patient’s deductibles and patient’s financial responsibilities. Depending on an individual patient’s financial situation, many patients will be required by the transplant center to set money aside to cover the out-ofpocket expenses and copayments related to the transplant episode; different centers have different requirements. In addition, given the imperative need to follow the patient often in clinic, particularly in the first post-transplant year, a reliable transportation plan and family support plan should be available as a prerequisite for acceptance. Medication adherence is critical for the success of the transplant, and plans will be required to ensure that the patient will be able to afford the medication deductibles. Recreational drug use Most renal and pancreas programs will accept patient who consume alcohol in moderation, as long as the patient has no evidence of liver disease or a diagnosis of alcoholism. All other recreational drugs are usually prohibited by most centers, although some centers do not consider casual marijuana use to be a contraindication. During the initial screening, a comprehensive drug screen will be performed and that patient with a positive test for cocaine, other illegal drugs, and narcotics not prescribed by a physician won’t be accepted until the agent in use is discontinued and proof of cessation, rehabilitation, and relapse prevention is completed and certified by a mental health professional or drug rehabilitation program. Drug use is associated with an increased risk of medication non-adherence, increased risk of rejection, increased risk of some infections and subsequent multi-substance abuse. Medication and medical care non-adherence Every member of the transplant selection team will assess the patient’s history of compliance with physician visits, medications, dietary restrictions, and the dialysis prescription. Lack of compliance as demonstrated by poor attendance to dialysis sessions, or early termination of the sessions as per patient request, could be seen as lack of compliance and poor insight; both adherence to a complicated medical regimen and insight into a patient’s own medical condition are necessary for a successful transplant outcome. Such patients will with all likelihood be viewed unfavorably as a transplant candidate by the transplant selection committee. Age limitations, physical performance, and candidacy Chronological age is not by itself a contraindication to transplant. However, an elderly patient with multiple medical conditions who has poor physical capacity, or is in a frail state, is likely to be denied listing. Patients who are 75 years old or older may receive extra scrutiny to be sure they have the physical stamina to undergo the transplant procedure, and tolerate common post-transplant complications, such as infection or rejection. The expected waiting time until transplant must be considered: a 75-year-old patient who does not have a living donor is likely to be 80 years old or older when they receive a transplant offer and is likely to be in a worse medical condition than when they were first listed. Patients over age 80 may not experience a survival advantage from a renal transplant; however, every patient must be evaluated as an individual. It is important to see elderly patients back at the transplant center on a regular basis, typically yearly, to assess their current state of health, and to decide if the patient should be removed from the waitlist. Re-transplantation after prior transplant 20% of the ESRD patients listed in the UNOS Renal Wait List have a history of a previously failed graft. The reasons for transplant loss vary, but three common reasons are: 1. Chronic allograft dysfunction resulting in kidney failure, especially after many years of chronic immunosuppression use; 2. Failed graft secondary to medication non-adherence; 3. Recurrence of the primary renal disease, or occurrence of a new kidney disease such as a glomerulopathy [KIDNEY TRANSPLANT TOOLKIT] May 13, 2019 © Copyright, Forum of ESRD Networks, 2019 Page 8 There is no absolute contraindication for a referral for re-transplant, as long as the patient meets the same medical and psychosocial criteria of any patient being considered for a renal transplant. If the patient has lost a graft due to non-adherence with medications, or poor and follow up with the transplant center, they may or may not be a candidate for