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X=Expanded Criteria Donor; CVA=CVA was cause of death; HTN=history of hypertension at any time; Creat > 1.5 = creatinine > 1.5 mg/dl

7. The point system for kidney allocation:

A. Waiting time: (points given when creatinine clearance or calculated GFR £ 20ml/ min or initiation of dialysis)

1 point assigned to the candidate with the longest waiting time; fractions of points assigned to all other patients;

1 additional point assigned for each full year of waiting time

B. Quality of match:

2 points if there are no DR mismatches 1 point if there is 1 DR mismatch

0 points if there are 2 DR mismatches

C. Panel reactive antibody:

4 points: highly sensitized (PRA > 80% recipients with preliminary negative crossmatch)

D. Pediatric patients:

4 points: candidates <11 years old

3 points: candidates 11 to 18 years old

E. Donation status:

4 points: transplant candidate who has donated for transplantation within the U.S.

F. Medical urgency list. The majority of programs perform the evaluation in the outpatient setting and possess a relatively uniform approach to the diagnosis and treatment of the pertinent medical and psychosocial issues affecting candidacy. The absolute and relative contraindications for listing a patient for kidney transplantation, or for proceeding with transplantation at the final inpatient evaluation, are outlined in Table 6.2.

A. Pre-Existing Morbidities of the Transplant Candidate with Advanced Renal Disease

Patients being evaluated for kidney transplantation have advanced renal disease or renal failure. The scope of the conceivable organ system abnormalities affecting the patients must be appreciated in order to anticipate potential medical problems that may jeopardize the performance of a successful transplant.

Hematologic abnormalities such as anemia and platelet/hemostatic dysfunction are well recognized. The development and extensive use of recombinant human erthyropoietin has dramatically improved treatment of anemia. The use of red blood cell transfusion therapy is now unusual. However, if this has occurred, the patient is at high risk of becoming sensitized by developing anti-HLA Class I cytotoxic antibody. Bleeding disorders are recognized as serious abnormalities in patients with renal insufficiency. Dysfunction of the coagulation cascade, platelet function, and vascular endothelium contribute to the bleeding abnormalities. Augmenting the problem is the use of heparin during hemodialysis, and anti-platelet agents and coumadin to prevent vascular access thrombosis. Conversely, some patients are hypercoagulable, being discovered during work-up for arteriovenous graft thrombotic problems. This has important implications for planning the transplant procedure.

Upper and lower gastrointestinal track abnormalities are very common. In the upper gastrointestinal track there is a high frequency of gastritis and hemorrhage in ESRD patients undergoing hemodialysis. There is also an increase in mortality related to bleeding due, in part, to the bleeding abnormalities described above. Common lower gastrointestinal abnormalities in uremic patients include: diver-ticulosis, diverticulitis, spontaneous colonic perforation, and prolonged adynamic ileus (pseudo-obstruction). In patients with polycystic kidney disease, the frequency

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