Evaluation and Management of Candidates for Kidney Transplantation

Publication Date: April 1, 2020
Last Updated: July 31, 2022

Recommendations

ACCESS TO TRANSPLANTATION

All patients with chronic kidney disease (CKD) G4-G5 (glomerular filtration rate [GFR] < 30ml/min/1.73 m2 ) who are expected to reach end-stage kidney disease (ESKD) should be informed of, educated about, and considered for kidney transplantation.
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Refer potential kidney transplant candidates for evaluation at least 6 to 12 months before anticipated dialysis initiation to facilitate identification/work-up of living donors and plan for possible pre-emptive transplantation.
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Pre-emptive transplantation with a living kidney donor is the preferred treatment for transplant-eligible CKD patients.
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AGE

Do not exclude patients from kidney transplantation because of age alone but rather consider the context of other comorbidities, including frailty, that may impact outcome when deciding about suitability for kidney transplantation.
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PEDIATRIC ISSUES

Perform neurocognitive assessment in pediatric candidates who experienced ESKD before the age of 5 years and an academic assessment of those who are experiencing difficulties at school.
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PSYCHOSOCIAL ASSESSMENT

A psychosocial assessment should be performed in all candidates by a health care professional experienced in the psychosocial aspects of kidney transplantation.
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Pre-transplant counseling and services should be offered to candidates with a diagnosable psychiatric or psychological condition, substance use disorder or nonadherence.
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ADHERENCE

Assess adherence and adherence barriers pre-transplantation. Appropriate adherence-based education, counseling pre-transplant and post-transplant surveillance should be provided.
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Candidates with a history of nonadherence from kidney transplantation should not be excluded except for those with ongoing, health-compromising nonadherent behavior despite education counseling.
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TOBACCO

Assess candidates for past and present use of tobacco products. All candidates should avoid tobacco products before and indefinitely after transplantation.
Chest computed tomography (CT) for current or former heavy tobacco users (≥ 30 pack-years) to screen for occult lung cancer is suggested and chest radiograph for other candidates.
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SURGICAL ISSUES INCLUDING OBESITY

Candidate assessment of body habitus, frailty, and medical conditions that could inhibit wound healing, should be performed. Candidates should not be excluded from transplantation solely because of obesity.
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Candidates should not be excluded because of their need for anticoagulation, antiplatelet therapy, or a history of heparin-induced thrombocytopenia.
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Assess vascular anatomy and patency for patients with significant peripheral arterial disease, prior transplant procedures, venous dialysis catheters, pelvic surgery, or deep venous thrombosis.
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Evaluate native kidney size in patients with polycystic kidney disease. Staged or simultaneous native nephrectomy and transplantation may be considered for candidates with a painful, recurrently infected, or potentially malignant polycystic kidney, or if the patient has insufficient room for a transplant.
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DIABETES

Candidates with diabetes mellitus, type 1 or type 2, should not be excluded from kidney transplantation.
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Testing for abnormal glucose metabolism by oral glucose tolerance test is suggested in candidates who are not known to have diabetes.
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CAUSE OF END-STAGE KIDNEY DISEASE

Cause of ESKD in candidates should be determined where possible to inform risks and management after kidney transplantation.
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Candidates with primary focal segmental glomerulosclerosis (FSGS), membranous nephropathy, IgA nephropathy, IgA vasculitis, immune complex-mediated membranoproliferative glomerulonephritis, C3 glomerulopathy, lupus nephritis, antiphospholipid syndrome, ANCA-associated vasculitis, anti-GBM disease, hemolytic uremic syndrome (HUS), atypical HUS, fibrillary or immunotactoid glomerulonephritis, correctable hyperoxaluria, or those with cystinosis, Fabry disease, sickle cell disease, sarcoidosis, Alport syndrome, systemic sclerosis or AA amyloidosis with no severe extrarenal disease, should not be excluded from transplantation. However, the risk of recurrence should be considered and discussed with the candidate.
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Candidates with multiple myeloma, light chain deposition disease (LCDD), heavy chain deposition disease (HCDD), light and heavy chain deposition disease (LHCDD), or AL amyloidosis should be excluded from kidney transplantation unless they have received a potentially curative treatment regimen and are in stable remission.
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INFECTIONS

Delay kidney transplantation until active infections (bacterial, fungal, viral [except HCV], parasitic) are treated.
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Asymptomatic colonization with bacterial, viral, parasitic or fungal organisms should not preclude transplantation.
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Screen all candidates for infections including human immunodeficiency virus (HIV), HCV, hepatitis B virus (HBV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus (HSV), varicella-zoster virus (VZV), measles, mumps, and rubella (MMR), human T-cell lymphotropic virus (HTLV) and syphilis. Screening for hepatitis D virus (HDV), strongyloides, Chagas disease, tuberculosis (TB), and malaria may be considered in endemic areas.
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Vaccination series recommended for the general and immunocompromised local populations should be completed prior to kidney transplantation. Live attenuated vaccines should be completed at least 4 weeks prior to transplantation.
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Vaccination can be considered for candidates who, due to age, direct exposure, residence or travel to endemic areas are at increased risk for specific diseases such as rabies, tick-borne meningoencephalitis, Japanese encephalitis (inactivated), Meningococcus, Salmonella typhi (inactivated) and yellow fever.
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MALIGNANCY

All candidates should undergo routine cancer screening, as per local guidelines for the general population.
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Candidates at increased risk for renal cell carcinoma, bladder carcinoma and hepatocelluar carcinoma should be screened.
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Candidates with active malignancy should be excluded from kidney transplantation, except for those with indolent and low-grade cancers such as prostate cancer (Gleason score ≤ 6), superficial non-melanoma skin cancer and incidentally detected renal tumors (≤ 1cm in maximum diameter), until in remission following potentially curative therapy.
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Timing of kidney transplantation after potentially curative treatment for cancer is dependent on the cancer type and stage at initial diagnosis. Decisions about transplantation for candidates in remission from cancer should be made collaboratively with oncologists, transplant nephrologists, patients, and their caregivers.
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PULMONARY DISEASE

Assess candidates with lung disease in collaboration with a pulmonary specialist to determine suitability for transplantation. Pulmonary function testing is recommended in candidates with impaired functional capacity, respiratory symptoms, or known pulmonary disease.
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All candidates should avoid tobacco products before and indefinitely after transplantation.
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Patients with irreversible, severe obstructive or restrictive lung disease should be excluded from kidney transplantation.
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CARDIAC DISEASE

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Evaluate all candidates for the presence and severity of cardiac disease with history, physical examination, and electrocardiogram. Patients with signs or symptoms of active cardiac disease should undergo assessment by a cardiologist and be managed according to current local cardiac guidelines prior to further consideration for a kidney transplant.
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Asymptomatic candidates at high risk for coronary artery disease (CAD) (eg, diabetes, previous CAD) or with poor functional capacity should undergo non-invasive CAD screening. Asymptomatic candidates who have been on dialysis for at least two years or have risk factors for pulmonary hypertension should undergo echocardiography. Cardiac imaging should be performed in patients with systemic amyloidosis to ascertain cardiac involvement and severity.
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Candidates with uncorrectable, symptomatic NYHA III/ IV heart disease [severe CAD; left ventricular dysfunction (ejection fraction < 30%); severe valvular disease] should be excluded from kidney transplantation unless there are mitigating factors.
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Candidates who have had a myocardial infarction should be assessed by a cardiologist to determine whether further testing is warranted and when they can safely proceed with kidney transplantation.
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Cardioprotective medications, including aspirin, β-blockers, and statins, should be continued during waitlisting and at time of transplantation, according to local guidance.
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PERIPHERAL ARTERIAL DISEASE

Evaluate all candidates for presence and severity of peripheral arterial disease (PAD) with history and physical examination. Those without clinically apparent PAD, but who are at high risk for PAD, should undergo non-invasive vascular testing.
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Candidates with clinically apparent PAD should be seen in consultation with a vascular surgeon. Patients with clinically apparent PAD or abnormal noninvasive testing should undergo non-contrast CT imaging of the abdomen/ pelvis to evaluate arterial calcification and improve operative planning.
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Candidates with non-healing extremity wounds with active infection should delay transplantation until the infection is resolved. Patients with severe aorto-iliac disease or distal vascular disease should not be excluded from kidney transplantation but risk of progression after transplantation should be considered and discussed with the patient.
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NEUROLOGIC DISEASE

Assess mental status in candidates with known or suspected cognitive impairment. Candidates with non-progressive intellectual, developmental, or cognitive disability should not be excluded from transplantation.
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Candidates with peripheral neuropathy should not be excluded from kidney transplantation. If such neuropathy can be attributed to uremia, urgent access to transplantation may be considered.
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A suggested waiting time of at least 6 months before kidney transplantation is advised for those who experienced a stroke and 3 months for those with a transient ischemic attack.
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We do not recommend screening asymptomatic candidates for carotid stenoses.
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Screening candidates with autosomal dominant polycystic kidney (ADPKD) disease for intracranial aneurysms may be warranted only if they are at high risk due to prior history of or a family history of subarachnoid hemorrhage.
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GASTROINTESTINAL AND LIVER DISEASE

Evaluate all candidates for the presence of gastrointestinal disease, including liver disease, with a targeted history and physical examination.
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Candidates with a history of peptic ulcer disease, diverticulitis, acute or chronic pancreatitis, asymptomatic cholelithiasis, or inflammatory bowel disease, should not be excluded from kidney transplantation. For such candidates, delay kidney transplantation until symptoms have resolved.
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Screen kidney transplant candidates for liver disease with a total bilirubin, alanine aminotransferase (ALT), international normalized ratio (INR), and albumin. In the presence of acute hepatitis of any cause, delay kidney transplantation until resolution and a long-term strategy for managing liver disease has been implemented.
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Candidates with cirrhosis or suspected cirrhosis should be referred to a specialist with expertise in combined liverkidney transplantation for evaluation. We recommend screening for hepatocellular carcinoma in candidates with cirrhosis prior to transplantation using techniques and frequency as per local guidelines.
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HEMATOLOGIC DISORDERS

Routinely screening for thrombophilia in candidates is not recommended. Screening for thrombophilia should be limited to those who have experienced a venous thromboembolic event, recurrent arteriovenous access thromboses, non-atherosclerotic arterial thrombosis, or family history of venous thromboembolism to identify candidates at higher risk of graft thrombosis.
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Testing for antiphospholipid antibodies (APLAs) may be warranted in patients with systemic lupus erythematosus (SLE) or features of antiphospholipid syndrome (APS).
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Evaluate transplant suitability of patients with significant cytopenias based on cause and severity, in consultation with a hematologist.
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Candidates with monoclonal gammopathy of undetermined significance (MGUS) or smouldering multiple myeloma should not be excluded from transplantation but a greater risk for post-transplant lymphoproliferative disease (PTLD) and transformation to multiple myeloma, respectively, should be considered and discussed with the patient.
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Patients with leukemia or lymphoma should avoid transplantation until they have received potentially curative therapy, achieved remission and remained cancer free for a period to be determined with their hematologist/oncologist.
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Decisions about kidney transplantation in patients with myelodysplasias, chronic leukemia, chronic/low-grade lymphomas, or prior history of hematological malignancy should be made after consultation with a hematologist.
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BONE AND MINERAL METABOLISM

Measure serum parathyroid hormone (PTH) at the time of transplant evaluation.
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Transplantation for patients with severe hyperparathyroidism should be delayed until they have been adequately treated as per KDIGO CKD-MBD Guideline.
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IMMUNOLOGICAL ASSESSMENT

Communicate all sensitizing events or clinical events that can impact panel reactive antibody (PRA) to the human leukocyte antigen (HLA) laboratory.
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Perform HLA antibody testing at transplant evaluation, at regular intervals prior to transplantation and after a sensitizing event or a clinical event that can impact PRA.
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HLA antibody testing should be performed using solid phase assays and HLA typing should use molecular methods, optimally at all loci. Routine testing for non-HLA or complement-binding HLA antibodies is not suggested.
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Candidates should be informed about their access to transplantation based on blood type and histocompatibility testing results.
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Recommendation Grading

Abbreviations

  • CKD: Chronic Kidney Disease
  • GFR: Glomerular Filtration Rate
  • KDIGO: Kidney Disease: Improving Global Outcomes

Overview

Title

Evaluation and Management of Candidates for Kidney Transplantation

Authoring Organizations

Kidney Disease Improving Global Outcomes

National Kidney Foundation

Publication Month/Year

April 1, 2020

Last Updated Month/Year

September 3, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center, Emergency care, Hospital, Operating and recovery room

Intended Users

Physician, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Management

Diseases/Conditions (MeSH)

D016030 - Kidney Transplantation, D007674 - Kidney Diseases

Keywords

transplantation, kidney, Kidney Dialysis, Chronic kidney Disese, dialysis

Source Citation

Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR, Segev DL, Sheerin NS, Tinckam KJ, Wong G, Knoll GA. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020 Apr;104(4S1 Suppl 1):S11-S103. doi: 10.1097/TP.0000000000003136. PMID: 32301874.

Methodology

Number of Source Documents
634
Literature Search Start Date
January 1, 1974
Literature Search End Date
May 31, 2019
Description of External Review Process
Yes - Supplement B. 7.0 The guideline had undergone external public review in October 2018.
Description of Public Comment Process
Yes - Supplement B. 7.0 Public review comments were compiled and fed back to the Work Group, which considered comments in its revision of the guideline.
Specialties Involved
Nephrology
Description of Systematic Review
Yes - Refer to Supplement B 3.1 The ERT performed systematic literature searches and organized abstract and article screening. The ERT also coordinated the methodological and analytical processes and defined and standardized the methodology for performing literature searches, data extraction, and summarizing the evidence. The Work Group took the primary role of writing and grading the recommendation statements and rationale text and retained final responsibility for their content.
List of Questions
Yes - Refer to Supplement B 2.5.3, 2.5.4, and 2.5.5. Questions of interest were formulated according to the PICOTS criteria (Population, Intervention/Predictor, Comparator, Outcome, Timing, and Study Design). Details of the PICOTS criteria are presented in Table 1. Ranking of outcomes. The Work Group ranked outcomes of interest on the basis of their importance for informing clinical decision making. (Table 2)
Description of Study Criteria
Yes - Refer to Supplement B 2.6.2, 2.6.3.
Description of Search Strategy
Yes - Refer to Supplement B 2.6.4 Systematic search strategies were developed by the ERT with input from the Work Group Co-Chairs. Modules were created for kidney transplantation, study designs, and terms for each of the systematic review topics. Separate searches were conducted for each topic (or sets of related topics). Searches were conducted in Medline (via PubMed), EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. No date or language restrictions were entered into the searches. The full literature search strategies are provided in the Supplemental Appendix A. The final searches were conducted in August 2017. The search for gammopathies was conducted in May 2019. Searches were supplemented by articles provided by Work Group members through September 2019.
Description of Study Selection
Yes - Refer to Supplement B 2.6.5, 2.6.6, and 2.6.7. Refer to Section “Literature Searches and Article Selection” starting on page S23. For selection of studies, all members of the ERT screened each set of abstracts in duplicate using an open-source, online screening program Abstrackr (http://abstrackr.cebm. brown.edu/). To establish relevance and consensus among reviewers, the entire team screened and achieved consensus on a series of initial batches of 100 abstracts. A total of 45,914 citations were screened (Figure 1). Journal articles reporting original data or systematic reviews were selected for evidence review, based on a priori criteria for eligible evidence. Of these, 762 were selected for consideration for inclusion. After review of the full-text articles, 190 were included, as enumerated in Table 3.
Description of Evidence Analysis Methods
Yes - Refer to Supplement B 2.6.8 and 2.6.9. Summary tables. Summary tables were developed for each reviewed topic. Summary tables contain outcomes of interest, relevant population characteristics, description of intervention and comparator (or predictor), results, and quality grading for each outcome. Categorical outcomes and continuous outcomes were tabulated separately. Work Group members reviewed and confirmed all summary table data and quality assessments. Summary tables are available as supplementary material at www.kisupplements.org. Evidence profiles. Evidence profiles were constructed to assess the quality and record quality grades and descriptions of effect (or association) for each outcome across studies, as well as the quality of overall evidence and description of net benefits or harms of the intervention or comparator across all outcomes. These profiles aim to make the evidence synthesis process transparent. Decisions in the evidence profiles were based on data from the primary studies listed in corresponding summary tables and on judgments of the ERT and Work Group. When the body of evidence for a particular comparison of interest consisted of 2 or fewer studies, the summary table provided the final level of synthesis and an evidence profile was not generated. Each evidence profile was initially constructed by the ERT and then reviewed, edited, and approved by the Work Group. The work products created by the ERT for summarizing the evidence base are listed in Table 3, together with the number of included studies.
Description of Evidence Grading
Yes - Refer to Supplement B 5.0. KDIGO adopted GRADE. A: High. The Work Group is confident that the true effect lies close to that of the estimate of the effect. B: Moderate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. C: Low. The true effect may be substantially different from the estimate of the effect. D: Very low. The estimate of effect is very uncertain and often will be far from the truth
Description of Recommendation Grading
Yes – Refer to Supplement B 5.0 KDIGO uses a GRADE Methodology. Level 1. Strong Recommendation: “We Recommend.” Clinicians: most patients should receive the recommended course of action. Level 2 Conditional Recommendation: “We Suggest.” Clinicians: Different choices will be appropriate for different patients. Each patient needs help to arrive at a management decision consistent with her or his values and preferences.
Description of Funding Source
Yes – Refer to Supplement B 2.0 This guideline is funded by KDIGO. Financial disclosures of Work Group members are published in Biographic and Disclosure Information section of the guideline.
Company/Author Disclosures
Yes – Refer to Supplement B 2.0. Financial disclosures of Work Group members are published in Biographic and Disclosure Information section of the guideline.
Percentage of Authors Reporting COI
100