14.2 Transplant Indications, Contraindications and Referral
Key Takeaways
Progressive G4–G5 patients expected to reach kidney failure should be informed about transplant and considered for referral.
Active serious infection or untreated active malignancy often delays transplantation.
Age, diabetes or obesity alone does not establish permanent ineligibility.
Referral Is an Opportunity for Assessment
Transplantation is considered for suitable patients with kidney failure and for selected patients with progressive advanced CKD before dialysis begins. KDIGO recommends informing and considering progressive G4–G5 patients expected to reach ESKD about transplantation, with timely referral so evaluation and living-donor planning can occur. Referral does not assert that the patient will be accepted; it allows the transplant team to evaluate the balance of risks and benefits.
The dialysis nurse identifies interest, explains the process and communicates relevant clinical information. Do not deny referral solely from a personal assumption about age, socioeconomic status, diagnosis or perceived motivation. The program applies its criteria and multidisciplinary judgment. If a patient is not referred or declines, document the actual reason and revisit it when circumstances change.
Temporary and Potentially Modifiable Barriers
Active serious infection can be worsened by immunosuppression and commonly requires treatment before transplantation. Active malignancy usually requires assessment and treatment, with exceptions and timing determined by cancer type and specialist guidance. Severe uncontrolled illness may make surgery unsafe at that time. These problems often mean defer and reassess rather than never transplant.
A patient recovering from a bloodstream infection needs coordination of culture results, treatment, access management and transplant readiness. A patient with a newly identified tumor needs specialist staging and individualized planning; the nurse must not invent a universal five-year waiting rule for every cancer. The key is to recognize the barrier, complete evaluation and communicate the current status.
Medical Risk Is Cumulative
Cardiovascular disease, pulmonary disease, frailty, vascular anatomy, recurrent infection and other conditions affect risk. Some patients need combined-organ evaluation or a different treatment pathway. No single condition captures the entire decision. Diabetes can create substantial vascular risk yet is not automatically a contraindication. Obesity and functional limitations require assessment and support, not a universal cutoff supplied by the dialysis nurse.
| Factor | Evaluation question |
|---|---|
| Cardiac disease | Is risk acceptable and can it be reduced? |
| Frailty or limited function | What is reversible, and what recovery support is available? |
| Infection | Is it active, controlled or resolved, and what treatment is needed? |
| Malignancy | What is the type, stage, treatment status and recurrence risk? |
| Prior transplant or sensitization | What immunologic planning is required? |
The transplant team synthesizes these risks in context. A patient can have several individually manageable problems whose combined burden changes the expected benefit. Nursing communication should provide accurate facts without turning a risk factor into a categorical rejection.
Psychosocial and Adherence Assessment
Post-transplant medication and follow-up are demanding. Assess understanding, mental health, substance use, social support and access to treatment. Previous missed dialysis or medication may reveal practical barriers that can be corrected. Explore transport, cost, literacy, side effects and competing duties. Do not equate a historical label of nonadherence with inevitable future failure.
Severe ongoing behavior that jeopardizes care may require intervention before acceptance, but the plan should identify the specific problem and support needed. Mental-health treatment, addiction care, accessible education or assistance with medicine coverage may improve readiness. The nurse helps close these gaps and documents progress. Confidentiality and respectful language remain essential.
Avoid Incorrect Absolute Rules
Chronological age alone is not a complete candidacy decision. A physiologically robust older adult may have a different risk profile from a younger patient with severe multisystem disease. HIV or treated hepatitis infection is not automatically an absolute exclusion under current transplant practice; specialist assessment and control matter. Disease recurrence risk, including some glomerular disorders, requires counseling and planning rather than unsupported reassurance or blanket denial.
Patients with cognitive impairment may require decision support and a reliable medication plan. Capacity is decision-specific and should be assessed appropriately. A patient with a disability is not presumed unable to participate. The transplant program evaluates the clinical situation, ethical issues and support arrangements.
Referral Follow-Through
Record the patient's preference, the date and destination of referral, the records sent and the outstanding evaluation tasks. Check that the center received the referral and that the patient understands the next step. A referral form filed in the dialysis chart is not proof that evaluation began. Address appointment barriers and coordinate with the program when the patient is hospitalized or clinical status changes.
A refusal or deferral should include a clear explanation and potential reassessment conditions when applicable. Continue dialysis and supportive care without implying that a patient who is unsuitable for transplant has no valuable options. A second opinion or another program's evaluation may be appropriate under the care team's process, but acceptance cannot be promised.
Scenario
A 68-year-old patient with diabetes wants transplant evaluation. The nurse explains that these characteristics warrant risk assessment but do not independently establish permanent exclusion. The team arranges referral, communicates cardiovascular history and helps with transportation. This response respects the patient's choice while leaving acceptance to the appropriate specialists.
A dialysis patient with diabetes requests transplant evaluation. What is appropriate?
Deny referral because diabetes always excludes transplant
Guarantee acceptance without evaluation
Arrange individualized candidacy assessment and address relevant risks
Tell the patient age and diagnosis never affect risk
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