Renal transplantation offers significantly better survival than dialysis. This tab covers the ESRD background, recipient selection (disease recurrence, contraindications, and cancer waiting periods), the pre-transplant surgical evaluation, deceased- and living-donor criteria, and ABO/HLA compatibility.
Background
The most common causes of ESRD, in descending order, are diabetes, hypertension, glomerulonephritis, and cystic renal disease. In children, ESRD causes growth failure, poor nutrition, and psychiatric problems. Other points:
- Nephrotic syndrome causes a hypercoagulable state from urinary loss of the natural anticoagulants antithrombin III, protein C, and protein S.
- Patients over 50 have a 20% first-year mortality on dialysis; the most common causes of death in renal failure are heart disease, sepsis, and stroke.
- Phospho-soda enemas are contraindicated in poor renal function (phosphate load), and a calcium × phosphorus product >60 mg²/dL² risks vascular calcification, arterial thrombosis, and calciphylaxis. Peritoneal dialysate containing icodextrin causes falsely high point-of-care glucose readings.
Recipient Selection
Disease recurrence in the graft:
- Recur AND cause secondary graft failure (mnemonic MO-SHAFF): Membranoproliferative GN, primary Oxalosis, Sickle cell disease, Hemolytic-uremic syndrome, Amyloidosis, primary Focal segmental glomerulosclerosis, Fabry disease.
- Recur but rarely cause failure: IgA nephropathy (Berger disease — the most common cause of glomerular hematuria), and hypertension/diabetes (which take years).
- Do NOT recur (mnemonic DACA): renal Dysplasia, ADPKD, Cystinosis, and Alport syndrome (without anti-GBM antibodies).
- Primary oxalosis and other metabolic diseases may warrant a combined kidney–liver transplant.
Absolute contraindications (mnemonic TICCC): unsuitable for Technical success, active Infection, severe Comorbidity (high perioperative mortality), non-Compliance, and active Cancer (a 5-year disease-free interval is generally recommended). Note that low-risk prostate cancer is not a contraindication (ESRD morbidity is greater) — active-surveillance candidates may be transplanted if adherent — while high-risk disease needs definitive treatment first.
Cancer waiting periods (Ontario listing criteria):
| Cancer | Waiting period |
|---|---|
| Bladder | ≥2 years (superficial low-grade: often none) |
| Renal cell | ≥2 years (small incidental: none; large/invasive: 5 years) |
| Testicular, cervical, lung, thyroid | ≥2 years |
| Wilms' tumour | ≥1 year |
| Melanoma | ≥5 years (in situ: ≥2 years) |
| Basal cell | none required |
| Breast, colorectal | ≥5 years (DCIS / localized: ~2 years) |
| Lymphoma, PTLD, leukemia | ≥2 years |
(EAU guidelines allow listing low-stage/grade RCC or prostate cancer without additional delay.)
Surgical Evaluation
Careful assessment of the peripheral vascular system is essential. Indications for pre-transplant nephrectomy: symptomatic stones not clearable by minimally invasive means; high-grade solid renal tumours; polycystic kidneys that are symptomatic, extend below the iliac crest, are infected, or harbour tumours; persistent anti-GBM antibody; uncontrolled significant proteinuria; recurrent pyelonephritis; and grade 4–5 reflux with UTIs. Only severe proteinuria can reliably be managed by transcatheter embolization instead. Even small defunctionalised bladders usually regain normal volume within weeks.
The single most important factor for receiving a deceased-donor organ is time on the waiting list. Best outcomes come from pre-emptive transplant just before dialysis is needed; in the US, a GFR <20 mL/min is required to join the national deceased-donor list.
Donor Selection
Donors are declared dead by neurologic criteria (NDD) or circulatory death (DCD). DCD kidneys face variable warm ischemia (risk of delayed graft function) but have long-term survival comparable to NDD.
- Extended-criteria donor (ECD): age ≥60, or 50–59 with ≥2 risk factors (death from stroke, hypertension, or elevated creatinine before recovery). A standard-criteria donor (SCD) is age <60 without those features. ECD organs have a 2-year graft survival of 80% vs 88% for SCD.
- ABO incompatibility — incompatible antibodies bind donor endothelial antigens, triggering complement, thrombosis, and rapid graft loss; transplant is feasible with low antibody titres using plasmapheresis/immunoadsorption (to remove antibody) plus IVIG and anti-CD20 (to prevent reformation), or via paired exchange.
- Histocompatibility — HLA class I (A, B, C) is on all nucleated cells; class II (DR, DQ, DP) is on antigen-presenting cells and endothelium. Pre-formed HLA antibodies arise from pregnancy, prior transplants, transfusions, and some infections; a patient is sensitised at antibodies to 20% of the population and highly sensitised at 80% (the panel-reactive antibody, PRA). The most sensitive test for donor-specific antibody is solid-phase single-antigen bead testing.
Living Donors
Absolute contraindications: age <18, disease that raises the donor's own risk of kidney failure, GFR <60 mL/min, active infection, ongoing substance abuse, and major psychiatric disease. Relative: obesity (ideal BMI <30) and hypertension (some centres accept single-agent-controlled). Urolithiasis is not necessarily a bar — a single small stone with a normal metabolic work-up is acceptable (donate the stone-bearing kidney), but multiple stones/episodes are a contraindication. After donor nephrectomy the donor retains ~75% of total renal function, and hyperfiltration injury has not been a problem.