Recipient Evaluation & Candidacy

The contract between this chapter and the reader.

1. 1. State the purpose of recipient evaluation.
2. 2. Conduct the systematic pre-transplant workup.
3. 3. Screen for latent infection and vaccinate before transplant.
4. 4. Apply cancer screening and the cancer-free interval.
5. 5. Identify absolute and relative contraindications.
6. 6. Stratify cardiac, immunologic, and surgical risk.
7. 7. Decide candidacy as a benefit-over-dialysis judgement.
8. 8. Recognise when dialysis or conservative care may be preferable.
9. 9. Re-evaluate the candidate while waiting.

A sixty-second reading. Each bullet stands alone.

• Recipient evaluation confirms that transplantation will help and is safe, and identifies treatable risks and absolute contraindications.
• Cardiovascular disease is the leading cause of death, so cardiac risk is assessed and optimised before listing.
• Latent infections — tuberculosis, hepatitis B and C, HIV, CMV and EBV — are screened because immunosuppression can reactivate them.
• Vaccinations, including live vaccines, are given before transplant, not after.
• Age-appropriate cancer screening is performed, and a cancer-free interval is observed after a treated malignancy.
• Absolute contraindications include active untreated malignancy or infection, irreversible non-renal organ failure, and substance misuse precluding adherence.
• Age and obesity are relative, not absolute, contraindications.
• Risk is stratified across cardiac, immunologic, infectious, surgical, and psychosocial domains.
• Candidacy is a judgement of whether transplant offers a realistic benefit over remaining on dialysis.
• For very frail or high-risk patients, dialysis or conservative care may be the better path.
• The recipient's understanding, adherence, and support are part of the evaluation.
• The primary renal disease's recurrence risk is considered.
• Candidates are re-evaluated while waiting, as their condition changes.

The medical core. An expert should agree recipient evaluation and candidacy are fully covered here.

Why it matters at the bedside

Transplantation offers most patients longer, better life than dialysis — but it front-loads risk: major surgery and lifelong immunosuppression. Evaluation is how we make sure the bargain is a good one for this patient: that the graft will help, that hidden problems are found and fixed first, and that nothing makes the transplant unsafe or doomed.

The purpose of evaluation

• Recipient evaluation answers three questions: will transplantation benefit this patient, is it safe, and can the patient sustain it? It finds and treats conditions that raise peri-operative and post-transplant risk, detects absolute contraindications, and confirms the understanding, adherence, and support a transplant demands.

Cardiovascular assessment

• Cardiovascular disease is the leading cause of death in this population, so cardiac evaluation is central: functional status, coronary risk, and, in higher-risk candidates, stress testing or further cardiac assessment. Significant disease is optimised before listing, because the peri-operative period is a stress test the heart must pass.

Infection screening and vaccination

• Immunosuppression reactivates latent infection, so candidates are screened for tuberculosis, hepatitis B and C, HIV, and CMV and EBV serostatus (which guides later prophylaxis), among others, and treated where needed — hepatitis C is now curable, and controlled HIV is not a contraindication. Vaccinations, crucially including live vaccines, are completed before transplant, since live vaccines cannot be given once a patient is immunosuppressed.

Malignancy screening and the cancer-free interval

• Because immunosuppression can accelerate cancer, candidates undergo age-appropriate screening, and a patient with a previously treated malignancy observes a cancer-free interval before transplant to reduce the risk of recurrence under immunosuppression. The interval depends on the tumour type and stage.

Urologic, anatomic, and immunologic workup

• The lower urinary tract and pelvic vasculature are assessed for the implant: bladder function, the need for native nephrectomy (for example, very large polycystic kidneys, chronic infection, or severe reflux), and the iliac vessels. The immunologic workup — HLA typing and antibody screening with cPRA — is detailed in the histocompatibility chapter.

Obesity, frailty, and psychosocial factors

• Several factors temper rather than forbid transplantation. Obesity raises surgical risk (thresholds vary and weight optimisation is encouraged), frailty predicts worse outcomes, and the psychosocial assessment — adherence history, social support, substance use, and mental health — matters because non-adherence is a leading, preventable cause of late graft loss. Nutrition and the recurrence risk of the primary renal disease are also weighed.

Contraindications

• Some conditions are absolute contraindications until resolved: active untreated malignancy, active untreated infection, irreversible non-renal organ failure (unless a combined transplant is planned), substance misuse that precludes adherence, and a very short life expectancy. Most other factors — age, obesity, frailty, comorbidity, treatable infection — are relative, to be weighed rather than to bar listing outright.

Risk stratification

• The evaluation aggregates into a risk profile across cardiac, immunologic, infectious, surgical, and psychosocial domains. Higher risk prompts more workup and optimisation, sometimes combined-organ consideration, and occasionally the conclusion that the risks outweigh the benefit — which leads to the candidacy decision.

The candidacy decision

• Candidacy is not a checklist verdict but a judgement: does transplantation offer this patient a realistic benefit over remaining on dialysis, given their comorbidity, frailty, and goals? For most it does. For some — the very frail, those with limited life expectancy or prohibitive surgical risk — dialysis or conservative care may serve them better, and that is a values-laden decision made with the patient, not imposed on them.

Re-evaluation while waiting

• Candidacy is not decided once. Waits can be long, and patients change — a new cardiac event, a malignancy, weight change, or rising sensitization — so candidates are re-evaluated periodically while listed, and a patient who was a good candidate at listing may need reassessment before a kidney is accepted.

Five fully-built tables.

Table A — The evaluation domains

Table B — Infection screening and vaccination

Table C — Contraindications

Table D — Risk domains

Table E — Candidacy considerations

Visualise & Map

Numbered rules. These numbers are the cross-reference handle for the cases and flowcharts.

Clinical Reasoning

Five cases. Each stops you at a decision before it answers it.

Exhaustive. Every rule in the chapter is here.

Safety & Evidence

Panel A — Red flags

Panel B — NEVER DO

Anti-patterns clinicians fall into. Each becomes a Level 22 distractor.

The grade reflects strength of evidence, not importance.

Patient Decisions

Outcomes as natural frequencies. Figures are representative; the direction of effect is given where precise numbers are uncertain.

Decisions where the right answer depends on the patient's values and situation, not the evaluation alone.

Effective-care decisions (not preference-sensitive)

• Screening for and treating latent infection before transplant — standard of care.
• Completing vaccination, including live vaccines, before transplant — timing dictates it.
• Observing a cancer-free interval after malignancy — evidence-based.
• Optimising significant cardiac disease before listing — safety dictates it.

The conversation rehearsed as a skill. Numbers trace to Level 14.

Apply & Test

Copy-paste chart notes that map to the real decisions in this chapter.

Template 1 — Transplant evaluation summary / candidacy note

• Cardiac: risk, testing, optimisation status ___.
• Infection: TB / hepatitis B-C / HIV / CMV-EBV serology; vaccinations (incl. live) ___.
• Malignancy: screening; cancer-free interval (if applicable) ___.
• Urologic/anatomic, immunologic (HLA, cPRA), psychosocial (adherence/support) ___.
• Contraindications: absolute (none / ___) ; relative (age/obesity/frailty) ___.
• Candidacy decision: list / optimise then reassess / decline; rationale ___.

Template 2 — Waitlist re-evaluation note

• Interval changes: new cardiac event / malignancy / weight / sensitization ___.
• Updated cardiac and immunologic (cPRA / DSA) status ___.
• Still a suitable candidate? yes / optimise / suspend / remove.
• Updated patient goals/values ___.
• Plan and next review date ___.

Pre-rounds compression. Rules only.

Active recall. At least one card per objective.

Micro-teaching for rounds. Two scenarios, five steps each.

Metacognition anchored to this chapter's tensions. No answers provided.

1. 1. Evaluation is also gatekeeping; how do you protect a scarce organ's chance of success without unfairly excluding the patients who most need one?
2. 2. Transplant trades upfront surgical risk for later benefit; how do you help a frightened patient weigh a near-term danger against a distant gain?
3. 3. Non-adherence predicts graft loss, yet judging ‘adherence’ risks bias; how do you assess it fairly rather than as a proxy for social disadvantage?
4. 4. For a very frail patient, listing may feel kinder than declining; how do you tell the difference between offering hope and offering harm?
5. 5. ‘Relative’ contraindications invite inconsistency between programmes; how do you keep your own thresholds principled rather than arbitrary?

Nine items, each anchored in this chapter. At least one per objective.