Kidney Transplat
Page updated spring 2021.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used official sources or sources believe to be reliable for purpose of this webpage. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Doses need to be adjusted per manufacturer and FDA publications. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation.
Pre-emptive Transplantation
Per KDIGO guidelines, we recommend pre-emptive transplantation (living or deceased donor) in adults when the estimated glomerular filtration rate (eGFR) is < 10ml/min/1.73 m2 or earlier with symptoms .
Per KDIGO guidelines, we recommend pre-emptive transplantation (living or deceased donor) in children when the eGFR is < 15ml/min/1.73 m2 or earlier with symptoms.
Waiting Time for Candidates ≥ 18 Years
Per OPTN policies, if a kidney candidate is 18 years or older on the date the candidate is registered for a kidney, then the candidate’s waiting time is based on the earliest of the following:
1. The candidate’s registration date with a measured or calculated creatinine clearance or glomerular filtration rate (GFR) less than or equal to 20 mL/min.
2. The date after registration that a candidate’s measured or calculated creatinine clearance or GFR becomes less than or equal to 20 mL/min.
3. The date that the candidate began regularly administered dialysis as an End Stage Renal Disease (ESRD) patient in a hospital based, independent non-hospital based, or home setting.
Waiting Time for Candidates < 18 Years
Per OPTN policies, if a kidney candidate is less than 18 years old at the time of registration on the waiting list, then the candidate’s waiting time is based on the earlier of the following:
1. The date that the candidate registered on the waiting list regardless of clinical criteria.
2. The date that the candidate began regularly administered dialysis as an ESRD patient in a hospital based, independent non-hospital based, or home setting.
Medically Urgent Status
Per OPTN policies, for registered kidney candidates that also qualify for medically urgent status according to Policy 8.5.A.i, the candidate accrues time at medically urgent status while active on the waiting list, based on the date the transplant program first indicates the candidate’s qualification for medically urgent status to the OPTN.
Waiting Time for Kidney Recipients
Per OPTN policies, if a kidney recipient returns to the kidney waiting list, waiting time will be based only on the dates after the most recent kidney transplant, unless the candidate qualifies for reinstatement of waiting time according to Policy 3.6.B.i: Non-function of a Transplanted Kidney.
Eligibility Criteria for Liver-Kidney Allocation
Per OPTN policies:
1- Chronic kidney disease (CKD) with a measured or calculated glomerular filtration rate (GFR) less than or equal to 60 mL/min for greater than 90 consecutive days if the patient has begun dialysis or has had CrCl or GFR less than or equal to 30 mL/min.
2- Sustained acute kidney injury and at least one of the following, or a combination of both of the following, for the last 6 weeks:
That the candidate has been on dialysis at least once every 7 days.
That the candidate has a measured or calculated CrCl or GFR less than or equal to 25 mL/min at least once every 7 days.
Prioritization for Liver Recipients on the Kidney Waiting List
Per OPTN policies, if a kidney candidate received a liver transplant, but not a liver and kidney transplant from the same deceased donor, the candidate will be classified as a prior liver recipient. This classification gives priority to a kidney candidate if both of the following criteria are met:
1. The candidate is registered on the kidney waiting list prior to the one-year anniversary of the candidate’s most recent liver transplant date 2. On a date that is at least 60 days but not more than 365 days after the candidate’s liver transplant date, at least one of the following criteria is met: The candidate has a measured or calculated creatinine clearance (CrCl) or glomerular filtration rate (GFR) less than or equal to 20 mL/min. Or the candidate is on dialysis.
Induction Immunosuppression
Per KDIGO guidelines, we recommend starting a combination of immunosuppressive medications before, or at the time of, kidney transplantation. We recommend including induction therapy with a biologic agent .
Maintenance Immunosuppression
Per KDIGO guidelines, we recommend using a combination of immunosuppressive medications as maintenance therapy including a CNI and an antiproliferative agent, with or without corticosteroids.
Per KDIGO guidelines, we suggest that tacrolimus or Cyclosporine be started before or at the time of transplantation, rather than delayed until the onset of graft function.
Per KDIGO guidelines, we suggest that tacrolimus be the first-line CNI used.
Per KDIGO guidelines, we suggest that mycophenolate be the first-line antiproliferative agent.
CMV Prophylaxis
Per KDIGO guidelines, we recommend that kidney transplant recipient (except when donor and recipient both have negative CMV serologies) receive chemoprophylaxis for CMV infection with oral ganciclovir or valganciclovir for at least 3 months after transplantation, and for 6 weeks after treatment with a T-cell-depleting antibody.
PCP Prophylaxis
Per KDIGO guidelines, we recommend that all KTRs receive PCP prophylaxis with daily trimethoprim-sulfamethoxazole for 3–6 months after transplantation and for at least 6 weeks during and after treatment for acute rejection.
Candida prophylaxis
Per KDIGO guidelines, we suggest oral and esophageal Candida prophylaxis with oral clotrimazole lozenges, nystatin, or fluconazole for 1–3 months after transplantation, and for 1 month after treatment with an antilymphocyte antibody.
Acute Rejection
Per KDIGO guidelines, we recommend biopsy before treating acute rejection.
Acute cellular rejection
Per KDIGO guidelines, we recommend corticosteroids for the initial treatment of acute cellular rejection.
Per KDIGO guidelines, We suggest using lymphocyte-depleting antibodies for acute cellular rejections that do not respond to corticosteroids, and for recurrent acute cellular rejections.
Per KDIGO guidelines, we suggest treating subclinical and borderline acute rejection.
Antibody-mediated rejection
Per KDIGO guidelines, we suggest one or more of the following alternatives, with or without corticosteroids:
Plasma exchange
Intravenous immunoglobulin
Anti-CD20 antibody (rituximab)
Lymphocyte-depleting antibody (rabbit antithymocyte globulin, alemtuzumab)
Recurrent Kidney Disease
Per KDIGO guidelines, we suggest plasma exchange if a biopsy shows minimal change disease or FSGS in those with primary FSGS as their primary kidney disease.
Per KDIGO guidelines, we suggest high-dose corticosteroids and cyclophosphamide in patients with recurrent ANCAassociated vasculitis or anti-GBM disease.
Allocation of Kidneys by Blood Type
Per OPTN policies:
Blood Type O to Blood Type O
Blood Type AB to Blood Type AB
Blood Type A to Blood Type AB
Blood Type A to Blood Type A
Blood Type B to Blood Type B
Blood Type A, non-A1 to Blood Type B
Blood type AB, non-A1B to Blood Type B
Living Kidney Donors
Willingness and consents
Per KDIGO guidelines, the donor candidate’s willingness to donate a kidney voluntarily without undue pressure should be verified.
Consents: for evaluation and donation
Compatibility
Per KDIGO guidelines, donor candidates who are ABO blood group or HLA incompatible with their intended recipient should be informed of availability, risks, and benefits of treatment options, including kidney paired donation and incompatibility management strategies.
GFR
Per KDIGO guidelines, GFR of 90 mL/min per 1.73 m2 or greater should be considered an acceptable level of kidney function for donation.
Per KDIGO guidelines, the decision to approve donor candidates with GFR 60 to 89 mL/min per 1.73 m2 should be individualized based on demographic and health profile in relation to the transplant program’s acceptable risk threshold.
Per KDIGO guidelines, donor candidates with GFR less than 60 mL/min per 1.73 m2 should not donate.
Albuminuria
Per KDIGO guidelines, urine Albumin excretion rate less than 30 mg/d should be considered an acceptable level for donation.
Per KDIGO guidelines, the decision to approve donor candidates with AER 30 to 100 mg/d should be individualized .
Per KDIGO guidelines, candidates with urine AER greater than 100 mg/d should not donate.
Hematuria
Per KDIGO guidelines, candidates with IgA nephropathy should not donate.
Kidney stones
Per KDIGO guidelines, the acceptance of a donor candidate with prior or current kidney stones should be based on an assessment of stone recurrence risk and knowledge of the possible consequences of kidney stones after donation.
Hypertension
Per KDIGO guidelines, candidates with hypertension that can be controlled to systolic BP < 140 mm Hg and diastolic BP < 90 mm Hg using 1 or 2 antihypertensive agents, who do not have evidence of target organ damage, may be acceptable for donation.
Diabetes
Per KDIGO guidelines, candidates with type 1 diabetes mellitus should not donate.
Per KDIGO guidelines, candidates with prediabetes or type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complications.
BMI
Per KDIGO guidelines, the decision to approve candidates with BMI >30 should be individualized.
Kidney cancer and cysts
Per KDIGO guidelines, candidates with high grade Bosniak renal cysts (III or higher) or small (T1a) renal cell carcinoma curable by partial nephrectomy may be acceptable for donation on a case by-case basis.
Per KDIGO guidelines, donation of a kidney with a Bosniak II renal cyst should proceed only after assessment for the presence of solid components, septations, and calcifications on the preoperative computed tomography scan (or magnetic resonance imaging) to avoid accidental transplantation of a kidney with cystic renal cell carcinoma.
Renal artery disease
Per KDIGO guidelines, a candidate with atherosclerotic renal artery disease or fibromuscular dysplasia involving the orifices of both renal arteries should not donate.
Apolipoprotein L1 (APOL1)
Per KDIGO guidelines, having 2 APOL1 risk alleles increases the lifetime risk of kidney failure but that the precise kidney failure risk for an affected individual after donation cannot currently be quantified.
Review of Systems Questionnaire
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KDIGO Guidelines: click here.