CRN Clinical Case Review: Getting Patients through the Transplant Process

Judy Kirk MS, RDN, CDN, FNKF

With the Advancing American Kidney Health Initiative (AAKHI), launched in 2019 by the Department of Health and Human Services, preemptive referrals of chronic kidney disease (CKD) and dialysis patients to receive a kidney transplant has increased. This has led providers to more discussions about transplantation with CKD patients. As a result, this has been a contributing factor and has had a positive impact on the number of kidney transplants.

What is the process for kidney transplantation? First, the nephrologist and the patient discuss the option for kidney transplant whenever there are no definitive contraindications to receiving a transplant. If the nephrologist feels there are absolute contraindications, such as poor cardiac status, then a referral will not be made. Once a patient is referred to a transplant center, the process begins to unfold.

The patient will have a full transplant evaluation with the transplant team. The patient will meet with the physician, nursing coordinator, social worker, registered dietitian, and finance team members. A full history/physical will be completed, extensive medical testing, nutrition evaluation, assessment of social support and mental health as well as financial viability. This is all completed to assure that the patient will benefit from kidney transplantation, will not be harmed by it, and the patient has a full understanding of the transplant process. Kidney transplantation is not the end, but another treatment in the process of CKD. Upon receiving the transplant, the patient will have multiple follow up appointments with the transplant team, have ongoing diet management, and will need to be taking immunosuppressant medications for the rest of their life.

The nutrition evaluation part of the transplant evaluation process includes anthropometrics, diet history, lab reviews, medication review, diet education and identifying nutritional adequacy or malnutrition diagnosis. Weight is a variable and most transplant programs have a body mass index (BMI) cut off of 35. Bariatric surgery may be considered for patients with higher BMI. Programs will vary with their BMI criteria and exceptions can be made when the transplant candidate is reviewed by the interdisciplinary team.

Some transplant programs also include a frailty assessment. This may include factors such as weight loss, fatigue, and physical function, a walk test and handgrip test. There are several frailty scales and specifics may vary by transplant program. The frailty assessment can be predictive of outcome recovery time and patient’s length of stay after a transplant.

The process can be lengthy, especially when a patient is waiting for a cadaver kidney. If the patient has a live donor, the process is shorter. Waitlist updates are conducted on an annual basis and a patient may be on a waitlist for several years. During this time, good communication with the transplant team and compliance with medications, diet, follow-up appointments and updated testing is important.