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Kidney transplantation

Key sources
The following summarized guidelines for the evaluation and management of kidney transplantation are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024), the European Society of Hypertension (ESH 2023), the European Association of Urology (EAU 2021), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2021; 2020), the American Society of Anesthesiologists (ASA 2021), and the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018).
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Guidelines

1.Diagnostic investigations

Matching and compatibility: as per EAU 2021 guidelines, determine the ABO blood group and the HLA A, B, C, and DR phenotypes in all candidates awaiting kidney transplantation.
A
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  • Assessment of smoking status

  • Assessment of psychosocial issues

  • Evaluation for eligibility, general principles

  • Evaluation for eligibility, age

  • Evaluation for eligibility, weight

  • Evaluation for eligibility, malignancy (hematologic)

  • Evaluation for eligibility, malignancy (solid tumors)

  • Evaluation for eligibility, viral infections (HIV)

  • Evaluation for eligibility, viral infections (HCV)

  • Evaluation for eligibility, viral infections (HBV/HDV)

  • Evaluation for eligibility, viral infections (other)

  • Evaluation for eligibility, bacterial/fungal/parasitic infections

  • Evaluation for eligibility, diabetes

  • Evaluation for eligibility, polycystic kidney disease

  • Evaluation for eligibility, glomerular diseases

  • Evaluation for eligibility, antiphospholipid syndrome

  • Evaluation for eligibility, ANCA vasculitis

  • Evaluation for eligibility, hemolytic-uremic syndrome

  • Evaluation for eligibility, systemic sclerosis

  • Evaluation for eligibility, multiple myeloma

  • Evaluation for eligibility, light/high chain deposition disease

  • Evaluation for eligibility, AL/AA amyloidosis

  • Evaluation for eligibility, hyperoxaluria

  • Evaluation for eligibility, storage diseases

  • Evaluation for eligibility, renal sarcoidosis

  • Evaluation for eligibility, Alport syndrome

  • Evaluation for eligibility, pulmonary diseases

  • Evaluation for eligibility, cardiac diseases

  • Evaluation for eligibility, PAD

  • Evaluation for eligibility, neurologic diseases

  • Evaluation for eligibility, gastrointestinal diseases

  • Evaluation for eligibility, hematologic diseases

  • Evaluation for eligibility, antithrombotic therapy

  • Evaluation for eligibility, bone and mineral metabolism disorders

  • Evaluation for eligibility, dental/periodontal diseases

  • Evaluation for eligibility, psychiatric disorders

2.Diagnostic procedures

Donor kidney biopsy: do not base decisions on the acceptance of a donor organ on histological findings alone, since this might lead to an unnecessary high rate of discarded grafts. Interpret histology in context with clinical parameters of donor and recipient including perfusion parameters where available.
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3.Medical management

Immunosuppressive therapy, indications: administer initial rejection prophylaxis with a combination of a calcineurin inhibitor (preferably tacrolimus), mycophenolate, corticosteroids, and an induction agent (either basiliximab or antithymocyte globulin).
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  • Immunosuppressive therapy (assessment of adherence)

  • Management of antithrombotics

4.Therapeutic procedures

Donor kidney preservation: use either the University of Wisconsin or histidine tryptophane ketoglutarate preservation solutions for cold storage. Use the Celsior or Marshall's solution for cold storage if the University of Wisconsin or histidine tryptophane ketoglutarate solutions are not available.
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5.Perioperative care

Pre-transplant donor kidney assessment
Assess the utility (including inspection) of the kidney for transplantation before initiating immunosuppression and inducing anesthesia for deceased donor kidney transplantation.
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Do not discard a kidney for potential transplantation based on a small renal mass alone.
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  • Preoperative hemodialysis

  • Perioperative antibiotic prophylaxis

  • Perioperative fluid management

  • Postoperative kidney protection

  • Postoperative thromboprophylaxis

6.Surgical interventions

Indications for preemptive transplantation
Offer preemptive transplantation with a living kidney donor as the preferred treatment in transplant-eligible patients with CKD.
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Offer preemptive transplantation (living or deceased donor) in adult patients with an eGFR < 10 mL/min/1.73 m² or earlier with symptoms.
B

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  • Surgical considerations for transplantation

  • Living donor nephrectomy

7.Specific circumstances

Pediatric patients: perform preemptive transplantation (living or deceased donor) in pediatric patients with an EGFR < 15 mL/min/1.73 m² or earlier with symptoms.
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8.Preventative measures

Immunizations: administer vaccination series using an accelerated schedule, if necessary, before kidney transplantation for any inactivated vaccines.
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avoid excluding candidates not completed an inactivated vaccine series from kidney transplantation.
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9.Follow-up and surveillance

Monitoring of living donors: obtain long-term follow-up in all living kidney donors.
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  • Monitoring for acute rejection

  • Monitoring for post-transplant complications

  • Management of acute rejection

  • Management of post-transplant complications (graft thrombosis)

  • Management of post-transplant complications (graft arterial stenosis)

  • Management of post-transplant complications (arteriovenous fistulae and pseudoaneurysms)

  • Management of post-transplant complications (lymphocele)

  • Management of post-transplant complications (urinary leak)

  • Management of post-transplant complications (ureteral stenosis)

  • Management of post-transplant complications (vesicoureteral reflux)

  • Management of hypertension in transplant recipients

  • Management of nephrolithiasis in transplant recipients

  • Management of prostate cancer in transplant recipients