14.3 Pretransplant Workup and Waiting-List Coordination

Organize the Evaluation

A pretransplant workup determines whether transplantation is appropriate and how risk can be reduced. It includes medical history, physical examination, surgical assessment, laboratory studies, infection screening, age- and risk-appropriate cancer screening and psychosocial assessment. Specific tests depend on the patient's risk and transplant-center protocol. The dialysis nurse helps assemble accurate records and supports completion rather than ordering a universal checklist for every patient.

Confirm the cause of kidney failure, prior treatment, residual function, access history, previous surgery, transfusion and transplant history. Identify medication allergies and active infection or wounds. The cause of kidney disease can affect recurrence counseling and graft planning. A chart that lists only 'ESRD' may omit a crucial inherited or recurrent disorder.

Compatibility Testing

ABO blood group is one part of donor-recipient compatibility. Human leukocyte antigen (HLA) typing describes tissue-antigen characteristics, while antibody testing identifies sensitization. Prior pregnancy, transfusion or transplantation may increase antibody exposure. A calculated panel-reactive antibody measure estimates the proportion of potential donors against whom a recipient may have relevant antibodies; it is not a measure of current kidney filtration.

A crossmatch evaluates donor-recipient immunologic compatibility through the center's laboratory method and current specimens. A negative result reduces a specific incompatibility concern but does not guarantee that rejection will never occur. Antibody specificity, donor factors and the transplant protocol matter. Do not tell a patient that matching blood type is the entire workup or that a favorable old sample remains valid indefinitely.

Medical and Surgical Assessment

Cardiac and pulmonary risk, peripheral vascular disease, functional capacity and operative anatomy are assessed according to individual risk. Review symptoms and communicate changes such as new angina, breathlessness or a recent stroke. Routine testing for every candidate is not identical, and normal past tests do not automatically establish current fitness.

Screening for infections helps plan treatment, vaccination and prevention. Hepatitis, HIV, tuberculosis risk and other infections are evaluated under the program's protocol. Some infections require treatment or specialist coordination before surgery. Vaccines are ideally updated before immunosuppression when feasible, but specific live-vaccine timing requires transplant advice; patients should not obtain a live vaccine independently close to transplantation.

Cancer screening depends on age, history and risk. A positive screen requires further workup rather than an assumed diagnosis or a fixed waiting rule. Dental, nutritional and functional issues may also need attention. The patient should understand why each requested evaluation matters so appointments do not feel like arbitrary obstacles.

Psychosocial and Practical Readiness

The psychosocial assessment explores resources and barriers as well as risk. A caregiver plan may be needed during recovery, but the center determines what support is sufficient. Do not assume a patient without a spouse is automatically ineligible. Explain the likely need for frequent early appointments and ongoing drug monitoring.

Waiting-List Status and Communication

Completion of evaluation, acceptance, active listing and receiving an offer are different milestones. A patient may be temporarily inactive because of infection, incomplete testing or another issue. Clarify the reason and the steps to return to active status. Waiting time is influenced by allocation and compatibility and cannot be promised from a simple calendar estimate.

The patient must keep contact information current and know how to respond to an organ offer. Report hospitalization, infection, transfusion, surgery and important medication or health changes to the program through the approved process. New sensitizing events may affect antibody assessment; the transplant team determines sample needs. Continuing dialysis safely while waiting remains essential.

Nursing Scenario

A patient says the evaluation is complete, but the center has not received cardiac records and the patient recently had a bloodstream infection. The nurse confirms what is outstanding, coordinates transmission with permission and communicates the infection course. The patient is taught that an old acceptance letter does not automatically mean readiness for surgery during an active illness. This prevents both avoidable delay and unsafe assumptions.

Documentation and Patient Understanding

Document actual progress rather than the single phrase 'transplant candidate.' Include referral status, center, requested tasks, patient preferences, barriers and follow-up responsibility. Use teach-back: ask the patient to explain whom to call after hospitalization and what happens when an offer arrives. Avoid treating a missed appointment as an immutable character trait; investigate what prevented attendance.

The workup is an evolving assessment. Clinical changes may require repeating or updating tests. Nursing continuity helps keep the evaluation accurate and actionable, while the transplant team makes compatibility and surgical decisions. Clear communication protects the patient from both unjustified reassurance and unnecessary exclusion.

Sources: KDIGO candidate evaluation, NIDDK transplant process.