Kidney transplant: Perspectives on optimal referral timing and its challenges

Jan. 20, 2021

Patrick G. Dean, M.D., transplant surgeon at Mayo Clinic's campus in Rochester, Minnesota, discusses the situation of patients with renal disease, including the ideal timeframe for referring patients for potential transplant, barriers to optimal referral timing and outcomes.

What would you consider optimal timing for referral for potential kidney transplant?

The best time to treat for kidney failure is preemptive, before the patient goes on dialysis. This ultimately saves money that would have been spent on dialysis before transplant, helps patients live longer and offers better quality of life with no dialysis. Currently, of the 20,000 to 23,000 kidney transplants performed annually, fewer than 20% are performed preemptively.

Dialysis is not perfect, increasing the risk of heart disease, stroke and vascular disease. We also know that the longer patients are on dialysis prior to kidney transplant, the shorter their survival time.

In early renal disease, patients sometimes have no symptoms. Is timely referral a dilemma due to this issue?

Yes. When patients' glomerular filtration rate (GFR) is in the 15 to 30 range, they don't display as many symptoms as when they measure a 10 or lower. They can show up in a physician's office very late in the progression of their kidney disease without realizing it and be diagnosed with end-stage renal disease requiring renal replacement therapy.

When a patient has a GFR of 25, it's a good time to get appropriate education on the benefits of transplantation and approach a potential living donor.

Does renal disease follow a fairly predictable trajectory, or is the course of the disease dynamic?

Though the prognosis can be different among patients, the disease usually follows a fairly predictable decline.

What are barriers to optimal referral timing?

There are patients who don't hear about transplant early in their kidney failure due to lack of access to health care or just hearing far more about dialysis than transplantation. Also, there are some misconceptions in the medical community about optimal timing.

As far as the monetary aspect, there shouldn't be any financial disincentives for the patient to being evaluated for transplant. It's pretty well covered in every center.

What are contraindications for referral for kidney transplant?

Usually with a patient who is too ill for transplant referral, comorbid conditions are present, such as severe heart disease or heart failure, coronary artery disease, significant frailty, active malignancy, or uncontrolled infections.

This all really speaks to people getting in better shape. Some important things patients can do to be eligible for transplant are to maintain a normal weight, good blood pressure and diabetic control and improve overall fitness.

What do you suggest for patients who are too ill for referral?

It's not necessarily the end of the line. Some patients who are too sick for transplant can improve with appropriate cardiac care or after they are cancer-free for a certain period of time.

Besides a preemptive approach, what else might make a more ideal scenario for kidney transplant?

The best way is with a living donor.

Do you also get referrals for dual listing for patients?

We see that pretty commonly for patients on the deceased donor list.

How have your patients done with receiving kidney transplant? What outcomes have you seen for those with end-stage kidney disease?

They generally fare quite well, especially compared with those who remain on dialysis. We reported in a 2016 issue of Transplantation that the one-year survival at Mayo Clinic's campus in Rochester, Minnesota, was 98.82%, compared with 95.89% in the entire U.S. Our three-year survival also was higher than in the rest of the country, at 92.51% versus the overall U.S. survival of 89.28%.

What is the best way to refer a patient or arrange a phone consult regarding a potential referral?

Physicians can call me directly at 507-266-6953. We work in good close partnership with nephrologists and other transplant centers, which should result in better outcomes.

For more information

Jay CL, et al. Reassessing preemptive kidney transplantation in the United States: Are we making progress? Transplantation. 2016;100:1120.