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B. Pretransplant Evaluation

The pertinent components of a complete pretransplant recipient medical evaluation are outlined in Table 6.3. The emphasis of the evaluation should be to identify and treat all coexisting medical problems that may increase the morbidity and mortality rates of the surgical procedure and adversely impact on the posttransplant course. In addition to a thorough medical evaluation, the social issues of the patient should be evaluated to determine conditions that may jeopardize the outcome of transplantation such as financial and travel restraints and a pattern of noncompliance.

1. History of Renal Disease

There is a diverse array of diseases that destroy renal function afflicting the newborn to the aged. The overall rate of end-stage renal disease is approximately 750 persons/million population. Table 6.4 depicts the most common etiologies of renal disease leading to kidney transplantation.5 It is important to understand the etiology of renal disease, since the primary renal pathology may influence outcome based on the propensity for recurrence of disease and the association of comorbidities. For example, patients with autosomal dominant polycystic kidney disease may have other medical problems such as intracerebral aneurysm and di-verticulosis. Patients with SLE nephritis may have a lupus anticoagulant. Other valuable pieces of information derived from the history would include the clinical course on dialysis with respect to the need for blood transfusions, the occurrence of thrombotic problems with AV grafts/fistulas and control venous dialysis catheters, and the infection rate from peritoneal dialysis catheters (peritonitis) and central venous catheters. Noting the amount of urine production daily is helpful in assessing the early function of kidney allograft. A history of previous kidney transplantation is important for obtaining insight into risk of rejection, infection,

Table 6.3. Pretransplant recipient medical evaluation

1. History

A. Etiology of renal disease

B. Dialysis status

C. Urine production

D. Urologic problems

E. Previous transplant, including complications after transplant

F. Blood transfusions

G. Allergies

2. Review of Systems

3. Past Medical/Surgical History

4. Physical Examination

A. Vital signs, height, weight

B. Abdominal pain, previous abdominal surgery, heme positive stool

C. Vascular: carotid bruit, peripheral pulses

D. Infection

5. Gynecologic evaluation (Pap smear)

6. Mammography (family history of, > 40years of age)

7. Dental Evaluation

8. Laboratory Studies

A. Complete blood count, blood chemistries (including calcium, phosphorous, magnesium) liver function tests, coagulation profile, PTH level

B. Infectious profile: CMV serologies (IgM/IgG) Epstein-Barr virus serologies (IgM/ IgG), varicella-zoster serologies, Hepatitis B and C serologies, HIV, RPR (syphilis), PPD (Tuberculosis skin test with anergy panel when indicated)

C. Urinalysis, urine culture, and cytospin

D. Immunological profile, blood type (ABO), panel reactive antibody (PRA), HLA typing

9. Chest x-ray (PA and lateral)

11. Special procedures in selected patients

A. Upper GI endoscopy

B. Colonoscopy

C. Gallbladder ultrasound

D. Ultrasound of native kidneys

E. Peripheral arterial Doppler studies

F. Pulmonary function tests

G. Abdominal x-ray

H. Carotid Duplex study

12. Complete cardiac work-up

A. Electrocardiogram

B. Exercise/dipyridamole thallium scintigraphy

C. 2D-echocardiography with Doppler (+/- dobutamine)

D. Coronary arteriogram (if indicated)

13. Urologic assessment (in select patients)

A. Voiding cystourethrogram

B. Urodynamic pressure-flow studies

C. Cystoscopy

14. Psychosocial evaluation

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