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Pre-Transplant Evaluation

Who gets a transplant?

• Indications: ESRD, CKD 5, and CKD 4 with GFR ≤ 20
• Absolute contraindications: severe/advanced vascular or pulmonary disease, active/untreated infections, intermediate/high stage malignancy in past 3 years, major psychiatric illness
• Relative contraindications: life expectancy < 5yrs independent of renal disease, medical nonadherence, substance use, BMI > 40, poor functional status

Transplant evaluation

• History: cause of ESRD, hx ESRD management, comorbidities
• Exam: assess for vascular disease, abdominopelvic surgical scars
• Lab: CBC, CMP, coags, UA, urine P/C ratio, HCG, infectious workup (CMV, EBV, VZV, HBV, HCV, HIV, syphilis, TB)
• Tissue matching: assess ABO, HLA
• Imaging: abdominopelvic CT/US to assess for disease, anastomotic sites, and surgical complicating factors
• Cardiac workup: EKG, CXR, consider stress test if multiple cardiovascular risk factors
• Malignancy eval: screen per guidelines, wait 1yr after treatment of localized or low stage disease, 5yrs for intermediate/high stage disease
• Donor eval: history, physical, lab/infectious workup, renal assessment (left kidney preferred for donation due to vessel length)

Urologic "clearance" for transplant

• LUTS: does not need to be worked up or treated prior to transplant unless underlying cause of ESRD (BPH/VUR/NGB), recurrent UTIs, or prior interventions
• Interventions can result in scar tissue (stricture/BNC) in patients with minimal urine output
• Delay BPH interventions 1-2mo after transplant to decrease infectious complications
• Stones: do not need to treat if asymptomatic, treat if causing infections
• Decreased bladder capacity: usually improves post-transplant, does not require workup or augmentation

Complications

Hematuria

• Acute: usually resolves within days and rarely requires irrigation, usually from anastomosis
• Post-biopsy: can be development of fistula, 70% spontaneously resolve, otherwise can embolize
• Other: follow normal hematuria workup, consider cytology and urine BK titers

Anastomotic issues

• Retained stent: 0-6%, encrustation does not cause symptoms due to lack of innervation
• Urine leak: 1-9%, usually due to distal ureteral ischemia, follow drain and urine output, drain will have elevated creatinine, place foley + PCN, may improve with diversion alone (36-87%) but stenosis may develop and require individualized repair
• Ureteral stricture: 1-9%, usually due to distal ureteral ischemia, consider when renal failure and hydronephrosis occur, hydronephrosis may be less than expected due to perirenal fibrosis, provide drainage and assess for obstruction, repair endoscopically or with open/lap technique
• Vesicoureteral reflux: 50-86%, symptomatic in < 1%, may increase HTN/sepsis risk, confirm with VCUG, improve voiding pressures, can consider deflux vs reimplant

GU Cancer

• Kidney: manage both native and transplant kidneys per guidelines (do not partial nephrectomize native kidneys), no benefit in screening unless preexisting risk factors
• Bladder: 3x increased risk, can use BCG even if immunocompromised, otherwise manage per guidelines
• Prostate: no need to screen as part of pretransplant workup, active surveillance underutilized

Other post-transplant issues

• Lymphocele: 0.6-33%, symptomatic in 0.03-26%, usually diagnosed within 6mo, confirm with imaging and drainage, most resolve spontaneously (< 15% will require treatment), can aspirate +/- sclerotherapy, drainage, decortication/marsupialization
• Infections: treat for 7-10 days if transplanted within 6mo, otherwise 5-7 days, 14-21 days for pyelonephritis/sepsis, treatment of asymptomatic bacteruria not recommended
• Kidney stones: 1%, can observe nonobstructing stones < 4mm, otherwise treat per stone algorithms
• LUTS: may be undiagnosed due to oliguria/anuria, normal voiding should improve with bladder filling, preoperative management of small bladder not required, delay TURP until 3 weeks post-transplant (high risk for sepsis/death)