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April 2020 ■ Volume 104 ■ Number 4S
Official Journal of
The Transplantation Society &
International Liver Transplantation Society
THE TRANSPLANTATION SOCIETY, INC.
1966
[Non-Text]
Transplantation®
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation
[Non-Text]
Wolters Kluwer
www.transplantjournal.com
April 2020 ■ Volume 104 ■ Number 4S
Official Journal of
The Transplantation Society &
International Liver Transplantation Society
International Liver Transplantation Society
1966
International Liver Transplantation Society
Transplantation®
Contents
Disclaimer.... S1
KDIGO Executive Committee .... S2
Work Group Membership .... S3
Preface .... S4
Reference Keys.... S6
KDIGO CKD Nomenclature .... S7
Conversion Factors .... S8
Abbreviations and Acronyms.... S9
KDIGO Clinical Practice Guideline on the Evaluation and Management of
Candidates for Kidney Transplantation.... S11
Summary of Recommendation Statements .... S11
Methods for Guideline Development .... S22
Section 1: Access to Transplantation.... S33
Section 2: Age S35
Section 3: Pediatric Issues.... S36
Section 4: Psychosocial Assessment .... S37
Section 5: Adherence .... S39
Section 6: Tobacco.... S41
Section 7: Surgical Issues including Obesity.... S43
Section 8: Diabetes.... S46
Section 9: Cause of End-Stage Kidney Disease (ESKD) .... S47
Section 10: Infections.... S55
Section 11: Malignancy S63
Section 12: Pulmonary Disease S67
Section 13: Cardiac Disease S68
Section 14: Peripheral Arterial Disease (PAD) S72
Section 15: Neurologic Disease S73
Section 16: Gastronintestinal and Liver Disease S75
Section 17: Hematologic Disorders S77
Section 18: Bone and Mineral Metabolism S79
Section 19: Immunological Assessment S80
Acknowledgments S83
References.... S84
Appendix: Biographic and Disclosure Information.... S98
April 2020 ■ Volume 104 ■ Number 4S
Official Journal of
The Transplantation Society &
THE JOURNAL OF TRANSPLANTATION SCIENCE • 1966
1975
Transplantation®
Contents
Table 1. Systematic review topics and screening criteria .... S24
Table 2. Hierarchy of outcomes .... S27
Table 3. Work products for the guideline .... S28
Table 4. Classification of study quality .... S29
Table 5. GRADE system for grading quality of evidence .... S29
Table 6. Final grade for overall quality of evidence .... S30
Table 7. Balance of benefits and harms .... S30
Table 8. KDIGO nomenclature and description for grading recommendations .... S30
Table 9. Determinants of strength of recommendation .... S31
Table 10. The Conference on Guideline Standardization (COGS) checklist for reporting clinical practice guidelines .... S31
Table 11. Recommendations for initial and follow-up screening of viral and non-viral pathogens in kidney transplant candidates .... S57
Table 12. Summary of routine vaccinations for kidney transplant candidates .... S62
Table 13. Recommendations for cancer screening in the general population and potential transplant candidates .... S64
Table 14. Recommended waiting times between cancer remission and kidney transplantation .... S65
Figure 1. Search yield .... S28
Figure 2. Reevaluation protocol after graft loss to nonadherence .... S42
Figure 3. Algorithm for the evaluation of kidney transplant candidates with HCV .... S58
© 2020 Wolters Kluwer
S1
DISCLAIMER
SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE
This Clinical Practice Guideline document is based upon systematic literature searches last conducted in August 2017 supplemented with additional evidence review through May 2019. It is designed to assist decision making. It is not intended to define a standard of care, and should not be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when considering the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Healthcare professionals using these recommendations should decide how to apply them to their own clinical practice.
SECTION II: DISCLOSURE
Kidney Disease: Improving Global Outcomes (KDIGO) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise from an outside relationship or a personal, professional, or business interest of a member of the Work Group. All members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived as or are actual conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information is published in its entirety at the end of the document and is kept on file at KDIGO.
Copyright © 2020 by KDIGO. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without explicit permission in writing from KDIGO. Details on how to seek reprints, permission for reproduction or translation, and further information about KDIGO's permissions policies can be obtained by contacting Danielle Green, Executive Director at: danielle.green@kdigo.org. To the fullest extent of the law, neither KDIGO, Transplantation Supplements, nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
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Transplantation ■ April 2020 ■ Volume 104 ■ Number 4S
www.transplantjournal.com
KDIGO EXECUTIVE COMMITTEE
Garabed Eknoyan, MD
Norbert Lameire, MD, PhD
Founding KDIGO Co-Chairs
David C. Wheeler, MD, FRCP Immediate Past Co-Chair
Michel Jadoul, MD
KDIGO Co-Chair
Mustafa Arici, MD
Tara I. Chang, MD, MS
Jennifer E. Flythe, MD, MPH
Masafumi Fukagawa, MD, PhD
Morgan E. Grams, MD, MHS, PhD
Fan Fan Hou, MD, PhD
Meg J. Jardine, MBBS, PhD
Markus Ketteler, MD
Magdalena Madero, MD
Wolfgang C. Winkelmayer, MD, MPH, ScD
KDIGO Co-Chair
Jolanta Małyszko, MD, PhD
Ikechi G. Okpechi, MBBS, FWACP, PhD
Rukshana Shroff, MD, FRCPCH, PhD
Laura Sola, MD
Paul E. Stevens, MB, FRCP
Sydney C.W. Tang MBBS, MD, PhD, FRCP
(L,E,G), FHKCP, FHKAM
Marcello A. Tonelli, MD, SM, FRCPC
Christina M. Wyatt, MD, MSc
KDIGO Staff
John Davis, Chief Executive Officer
Danielle Green, Executive Director
Michael Cheung, Chief Scientific Officer
Melissa Thompson, Chief Operating Officer
Tanya Green, Events Director
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
© 2020 Wolters Kluwer
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WORK GROUP MEMBERSHIP
Work Group Co-Chairs
Steven J. Chadban, BMed (hons), PhD, FAAHMS, FRACP
Royal Prince Alfred Hospital and Charles Perkins Centre, University of Sydney
Sydney, Australia
Gregory A. Knoll, MD, MSc, FRCPC
Department of Medicine
The Ottawa Hospital and Ottawa Hospital
Research Institute
Ottawa, Canada
Work Group
Curie Ahn, MD, PhD
Seoul National University
Seoul, South Korea
David A. Axelrod, MD, MBA, FACS
University of Iowa
Iowa City, IA, USA
Bethany J. Foster, MD, MSCE
The Montreal Children's Hospital
McGill University Health Centre
Montreal, Canada
Bertram L. Kasiske, MD, FACP
Hennepin County Medical Center
Minneapolis, MN, USA
Vijay Kher, MD, DM, FAMS, FRCPE, FIMAS
Medanta Kidney and Urology Institute
Haryana, India
Deepali Kumar, MD, MSc, FRCPC, FAST
University Health Network
University of Toronto
Toronto, Canada
Rainer Oberbauer, MD, PhD
Medical University of Vienna
Vienna, Austria
Julio Pascual, MD, PhD
Hospital del Mar
Barcelona, Spain
Helen L. Pilmore, MD, FRACP
Auckland City Hospital
Auckland, New Zealand
James R. Rodrigue, PhD, FAST
Beth Israel Deaconess Medical Center
Boston, MA, USA
Dorry L. Segev, MD, PhD
Johns Hopkins University
Baltimore, MD, USA
Neil S. Sheerin, BSc, PhD, FRCP
Newcastle University
Newcastle, United Kingdom
Kathryn J. Tinckam, MD, MMSc, FRCPC, FAST
University Health Network
University of Toronto
Toronto, Canada
Germaine Wong, MD, PhD
University of Sydney
Sydney, Australia
Evidence Review Team
Center for Evidence Synthesis in Health, Brown University School of Public Health
Providence, RI, USA
Ethan M. Balk, MD, MPH, Project Director, Evidence Review Team Director
Craig E. Gordon, MD, MS, Assistant Project Director, Evidence Review Team Associate Director
Amy Earley, BS, Research Associate
Valerie Rofeberg, ScM, Research Associate
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PREFACE
INTRODUCTION
Transplantation is the kidney replacement therapy of choice for suitable patients with end-stage kidney disease (ESKD). However, not all patients are suitable candidates for transplantation, and suitability is often determined by the perceived risks of transplantation relative to the risks of not receiving a transplant. Estimation of risk is therefore a key part of the transplant candidate evaluation. Should a decision to proceed to transplantation be made, consideration of how to minimize risks and maximize the chances of a successful outcome are additional aspects of the candidate evaluation process.
This guideline systematically examines current evidence concerning the risks of transplantation associated with specific conditions and provides recommendations as to how clinicians may wish to deal with specific risk factors in isolation. In practice, patients are frequently complex and exhibit multiple risk factors for poor transplant outcomes. Ultimately the clinician will be required to synthesize the total risk burden that each candidate presents in deciding on suitability for transplantation.
SCOPE
This guideline addresses the evaluation and management of possible candidates for kidney transplantation alone, from either a deceased or living donor. It covers the time period from the first consideration of the need for kidney replacement therapy to kidney transplant surgery. It considers adult and pediatric candidates. Education of the candidate and their family is beyond the scope of this guideline; however, we do wish to highlight the essential role of patient education in parallel with the evaluation process, as it is required to enable shared-decision making and consent regarding the decision to proceed to transplantation or not. This guideline does not address candidates for combined transplantation of a kidney and another organ but we have attempted to be as comprehensive as possible in addressing all clinically relevant conditions that may impact transplant candidacy. However, given the breadth of conditions relevant to transplantation and the rapidly evolving nature of data in medicine, it is likely that we may have omitted some issues and in other instances will have cited data that will be superceded. Please consult Methods for Guideline Development for further details.
TARGET AUDIENCE
This guideline is intended for caregivers who refer and/or evaluate patients for possible kidney transplantation.
BACKGROUND AND PRINCIPLES UNDERPINNING THE GUIDELINE
Ethics
Kidney transplantation, using organs obtained from either living or deceased donors, should be conducted in accordance with the Declaration of Istanbul, \( ^{1} \) which provides clear guidelines on ethical practice in this area.
Local considerations
As a global guideline, Kidney Disease: Improving Global Outcomes (KDIGO) necessarily seeks and considers all available evidence in producing guidelines which are of global relevance. However, the fact that the practice and outcomes of transplantation vary enormously across the globe—between continents, countries and even jurisdictions—requires the reader to consider their local practices and outcomes in interpreting and implementing the guideline. In particular, considerations should include:
1. Superiority of transplantation over dialysis for the provision of kidney replacement therapy. Existing data clearly demonstrate that on average, transplantation achieves superior medical outcomes (i.e., survival and quality of life) at lower cost as compared to dialysis, and transplantation is therefore considered to be the medically desirable and economically
© 2020 Wolters Kluwer
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dominant therapy. However, this conclusion is based upon data from high income countries with good access to both transplantation and dialysis. \( ^{2} \) This conclusion is likely to hold true for low- and middle-income countries from a medical perspective, though whether transplantation is cheaper than dialysis in this context is less certain and remains to be proven.
2. Access to dialysis and transplantation. In some areas, access to dialysis and/or transplantation may be restricted or absent. This may be due to the lack (or absence) of necessary infrastructure or services, cost of services to the patient, geographical inaccessibility, or other factors. Thus, access must be considered when interpreting these guidelines.
3. Outcomes of dialysis and transplantation. The decision to pursue transplantation in preference to dialysis for any given patient is based upon an expectation of superior outcomes following transplantation. To make this decision, knowledge of expected outcomes from dialysis and transplantation, at a local level, is required. For example, if local transplant outcomes yield a 60% patient survival at 2 years, whereas dialysis yields 70% survival, then transplantation may not be justified for an average patient with ESKD. In the absence of local data describing the outcomes of dialysis and transplantation, the decision to transplant or not must be made by adaptation of available data to the local context.
4. Local risks involved in transplantation. Regional and geographical variation in risk is evident following transplantation and should be considered in implementing the Guideline. The risk of infection after transplantation exhibits marked regional variation in type, frequency and severity. For example, the risk of post-transplant reactivation of latent tuberculosis (TB) is high among those from endemic areas, yet profoundly low among those from temperate climates. Cancer incidence is also affected by geography, genetics and lifestyle. For example, skin cancer is a common cause of death among Caucasian kidney transplant recipients in Australia, particularly among those residents with high sun exposure, yet skin cancers are far less common and are a rare cause of death in other areas of the world. Thus, local knowledge and understanding of likely risks and benefits are required to place the recommendations made within this Guideline into local context.
We thank the Work Group Co-Chairs, Drs. Greg Knoll and Steve Chadban, along with all the Work Group members who volunteered countless hours of their time to develop this guideline. We also thank the Evidence Review Team at the Brown University School of Public Health, KDIGO staff, and The Transplantation Society for their support which made this project possible.
Michel Jadoul, MD
Wolfgang C. Winkelmayer, MD, MPH, ScD
KDIGO Co-Chairs
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REFERENCE KEYS
KDIGO NOMENCLATURE AND DESCRIPTION FOR GRADING GUIDELINE RECOMMENDATIONS
Within each recommendation, the strength of recommendation is indicated as Level 1, Level 2, or Not Graded, and the quality of the supporting evidence is shown as A, B, C, or D.
<table><tr><td rowspan="2">Grade*</td><td rowspan="2">Patients</td><td colspan="2">Implications</td></tr><tr><td>Clinicians</td><td>Policy</td></tr><tr><td>Level 1“We recommend”</td><td>Most people in your situation would want the recommended course of action and only a small proportion would not</td><td>Most patients should receive the recommended course of action</td><td>The recommendation can be evaluated as a candidate for developing a policy or a performance measure</td></tr><tr><td>Level 2“We suggest”</td><td>The majority of people in your situation would want the recommended course of action, but many would not</td><td>Different choices will be appropriate for different patients. Each patient needs help to arrive at a management decision consistent with her or his values and preferences</td><td>The recommendation is likely to require substantial debate and involvement of stakeholders before policy can be determined</td></tr></table>
*The additional category “Not Graded” is used, typically, to provide guidance based on common sense or where the topic does not allow adequate application of evidence. The most common examples include recommendations regarding monitoring intervals, counseling, and referral to other clinical specialists. Ungraded recommendations are generally written as simple declarative statements, but not meant to be interpreted as being stronger recommendations than Level 1 or 2 recommendations.
<table><tr><td>Grade</td><td>Quality of Evidence</td><td>Meaning</td></tr><tr><td>A</td><td>High</td><td>We are confident that the true effect lies close to that of the estimate of the effect</td></tr><tr><td>B</td><td>Moderate</td><td>The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different</td></tr><tr><td>C</td><td>Low</td><td>The true effect may be substantially different from the estimate of the effect</td></tr><tr><td>D</td><td>Very low</td><td>The estimate of effect is very uncertain, and often will be far from the truth</td></tr></table>
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CURRENT CHRONIC KIDNEY DISEASE (CKD) NOMENCLATURE USED BY KDIGO
CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health. CKD is classified based on Cause, GFR category (G1-G5), and Albuminuria category (A1-A3), abbreviated as CGA.
Prognosis of CKD by GFR and albuminuria category \( ^{3} \)
Prognosis of CKD by GFR and albuminuria categories: KDIGO 2012
<table><tr><td colspan="3">Persistent albuminuria categories Description and range</td></tr><tr><td>A1</td><td>A2</td><td>A3</td></tr><tr><td>Normal to mildly increased</td><td>Moderately increased</td><td>Severely increased</td></tr><tr><td><30 mg/g<3 mg/mmol</td><td>30-300 mg/g3-30 mg/mmol</td><td>>300 mg/g>30 mg/mmol</td></tr></table>
<table><tr><td rowspan="6">GFR categories (ml/min/1.73 m2) Description and range</td><td>G1</td><td>Normal or high</td><td>≥90</td><td></td><td></td><td></td></tr><tr><td>G2</td><td>Mildly decreased</td><td>60-89</td><td></td><td></td><td></td></tr><tr><td>G3a</td><td>Mildly to moderately decreased</td><td>45-59</td><td></td><td></td><td></td></tr><tr><td>G3b</td><td>Moderately to severely decreased</td><td>30-44</td><td></td><td></td><td></td></tr><tr><td>G4</td><td>Severely decreased</td><td>15-29</td><td></td><td></td><td></td></tr><tr><td>G5</td><td>Kidney failure</td><td><15</td><td></td><td></td><td></td></tr></table>
Green: low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red, very high risk.
ALBUMINURIA CATEGORIES IN CKD \( ^{3} \)
<table><tr><td rowspan="2">Category</td><td rowspan="2">AER (mg/24 hours)</td><td colspan="2">ACR (approximate equivalent)</td><td rowspan="2">Terms</td></tr><tr><td>(mg/mmol)</td><td>(mg/g)</td></tr><tr><td>A1</td><td>< 30</td><td>< 3</td><td>< 30</td><td>Normal to mildly increased</td></tr><tr><td>A2</td><td>30-300</td><td>3-30</td><td>30-300</td><td>Moderately increased*</td></tr><tr><td>A3</td><td>>300</td><td>>30</td><td>>300</td><td>Severely increased**</td></tr></table>
ACR, albumin-to-creatinine ratio; AER, albumin excretion rate; CKD, chronic kidney disease
*Relative to young adult level
**Including nephrotic syndrome (albumin excretion usually > 2200 mg/24 hours [ACR > 2200 mg/g; > 220 mg/mmol])
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CONVERSION FACTORS OF CONVENTIONAL UNITS TO SI UNITS
<table><tr><td></td><td>Conventional Unit</td><td>Conversion Factor</td><td>SI Unit</td></tr><tr><td>Creatinine</td><td>mg/dl</td><td>88.4</td><td>μmol/l</td></tr></table>
Note: Conventional unit x conversion factor = SI unit
© 2020 Wolters Kluwer
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ABBREVIATIONS AND ACRONYMS
<table><tr><td>ACC</td><td>American College of Cardiology</td></tr><tr><td>ADPKD</td><td>Autosomal dominant polycystic kidney disease</td></tr><tr><td>AGREE</td><td>Appraisal of Guidelines for Research and Evaluation</td></tr><tr><td>AHA</td><td>American Heart Association</td></tr><tr><td>aHUS</td><td>Atypical hemolytic uremic syndrome</td></tr><tr><td>ANCA</td><td>Anti-neutrophil cytoplasmic antibody</td></tr><tr><td>Anti-GBM</td><td>Anti-glomerular basement membrane</td></tr><tr><td>Anti-HBc</td><td>Antibody to hepatitis B core antigen</td></tr><tr><td>Anti-HBs</td><td>Antibody to hepatitis B surface antigen</td></tr><tr><td>ANZDATA</td><td>Australia and New Zealand Dialysis and Transplant</td></tr><tr><td>APLA</td><td>Antiphospholipid antibody</td></tr><tr><td>APS</td><td>Antiphospholipid syndrome</td></tr><tr><td>ASHI</td><td>American Society for Histocompatibility and Immunogenetics</td></tr><tr><td>AST</td><td>American Society of Transplantation</td></tr><tr><td>BMD</td><td>Bone mineral density</td></tr><tr><td>BMI</td><td>Body mass index</td></tr><tr><td>C3G</td><td>C3 glomerulopathy</td></tr><tr><td>C3GN</td><td>C3 glomerulonephritis</td></tr><tr><td>CAD</td><td>Coronary artery disease</td></tr><tr><td>CFB</td><td>Complement Factor B</td></tr><tr><td>CFH</td><td>Complement Factor H</td></tr><tr><td>CFI</td><td>Complement Factor I</td></tr><tr><td>CI</td><td>Confidence interval</td></tr><tr><td>CKD</td><td>Chronic kidney disease</td></tr><tr><td>CKD G4, CKD G5</td><td>Chronic kidney disease GFR category 4; chronic kidney disease GFR category 5</td></tr><tr><td>CKD-MBD</td><td>Chronic kidney disease-mineral and bone disorder</td></tr><tr><td>CMV</td><td>Cytomegalovirus</td></tr><tr><td>COGS</td><td>Conference on Guideline Standardization</td></tr><tr><td>cPRA</td><td>Calculated panel reactive antibody</td></tr><tr><td>CST</td><td>Canadian Society of Transplantation</td></tr><tr><td>CT</td><td>Computed tomography</td></tr><tr><td>CVD</td><td>Cardiovascular disease</td></tr><tr><td>DAA</td><td>Direct-acting antiviral</td></tr><tr><td>DDD</td><td>Dense deposit disease</td></tr><tr><td>DM</td><td>Diabetes mellitus</td></tr><tr><td>DOAC</td><td>Direct oral anticoagulant</td></tr><tr><td>DSA</td><td>Donor-specific antibody</td></tr><tr><td>EBNA</td><td>EBV nuclear antigen</td></tr><tr><td>EBV</td><td>Epstein-Barr virus</td></tr><tr><td>ECD</td><td>Expanded-criteria donor</td></tr><tr><td>ECG</td><td>Electrocardiogram</td></tr><tr><td>EDS</td><td>Ehlers-Danlos Syndrome</td></tr><tr><td>eGFR</td><td>Estimated glomerular filtration rate</td></tr><tr><td>EGD</td><td>Esophagogastroduodenoscopy</td></tr><tr><td>ERA-EDTA</td><td>European Renal Association-European Dialysis and Transplantation Association</td></tr><tr><td>ERT</td><td>Evidence Review Team</td></tr><tr><td>ESC</td><td>European Society of Cardiology</td></tr><tr><td>ESKD</td><td>End-stage kidney disease</td></tr><tr><td>FI</td><td>Frailty Index</td></tr><tr><td>FSGS</td><td>Focal segmental glomerulosclerosis</td></tr><tr><td>FVL</td><td>Factor V Leiden</td></tr><tr><td>GFR</td><td>Glomerular filtration rate</td></tr><tr><td>GRADE</td><td>Grades of Recommendation, Assessment, Development and Evaluation</td></tr><tr><td>\( HbA_{1c} \)</td><td>Glycated hemoglobin</td></tr><tr><td>HBsAg</td><td>Hepatitis B surface antigen</td></tr><tr><td>HBV</td><td>Hepatitis B virus</td></tr></table>
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Transplantation ■ April 2020 ■ Volume 104 ■ Number 4S
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<table><tr><td>HCDD</td><td>Heavy chain deposition disease</td></tr><tr><td>HCV</td><td>Hepatitis C virus</td></tr><tr><td>HDV</td><td>Hepatitis D virus</td></tr><tr><td>HIT</td><td>Heparin-induced thrombocytopenia</td></tr><tr><td>HIV</td><td>Human immunodeficiency virus</td></tr><tr><td>HLA</td><td>Human leukocyte antigen</td></tr><tr><td>HR</td><td>Hazard ratio</td></tr><tr><td>HSV</td><td>Herpes simplex virus</td></tr><tr><td>HTLV</td><td>Human T-cell lymphotropic virus</td></tr><tr><td>HUS</td><td>Hemolytic uremic syndrome</td></tr><tr><td>ICA</td><td>Intracranial aneurysm</td></tr><tr><td>IC-MPGN</td><td>Immune complex-mediated MPGN</td></tr><tr><td>IgAN</td><td>IgA nephropathy</td></tr><tr><td>IU</td><td>International unit</td></tr><tr><td>KDIGO</td><td>Kidney Disease: Improving Global Outcomes</td></tr><tr><td>KDOQI</td><td>Kidney Disease Outcomes Quality Initiative</td></tr><tr><td>KHA-CARI</td><td>Kidney Health Australia-Caring for Australasians with Renal Impairment</td></tr><tr><td>LCDD</td><td>Light chain deposition disease</td></tr><tr><td>LHCDD</td><td>Light and heavy chain deposition disease</td></tr><tr><td>LN</td><td>Lupus nephritis</td></tr><tr><td>LVEF</td><td>Left ventricular ejection fraction</td></tr><tr><td>MDRO</td><td>Multidrug resistant organisms</td></tr><tr><td>MET</td><td>Metabolic equivalent</td></tr><tr><td>MGUS</td><td>Monoclonal gammopathy of undetermined significance</td></tr><tr><td>MI</td><td>Myocardial infarction</td></tr><tr><td>MIDD</td><td>Monoclonal immunoglobulin deposition disease</td></tr><tr><td>MMR</td><td>Measles, mumps, or rubella</td></tr><tr><td>MN</td><td>Membranous nephropathy</td></tr><tr><td>MPGN</td><td>Membranoproliferative glomerulonephritis</td></tr><tr><td>NAT</td><td>Nucleic acid test(ing)</td></tr><tr><td>NODAT</td><td>New-onset diabetes after transplantation</td></tr><tr><td>NYHA</td><td>New York Heart Association</td></tr><tr><td>OR</td><td>Odds ratio</td></tr><tr><td>PAD</td><td>Peripheral arterial disease</td></tr><tr><td>PASP</td><td>Pulmonary artery systolic pressure</td></tr><tr><td>PCD</td><td>Plasma cell dyscrasia</td></tr><tr><td>PLA2R</td><td>Phospholipase A2 receptor</td></tr><tr><td>PPD</td><td>Purified protein derivative</td></tr><tr><td>PRA</td><td>Panel-reactive antibody</td></tr><tr><td>PTH</td><td>Parathyroid hormone</td></tr><tr><td>RCT</td><td>Randomized controlled trial</td></tr><tr><td>RR</td><td>Relative risk</td></tr><tr><td>siRNA</td><td>small interfering RNA</td></tr><tr><td>STEC-HUS</td><td>Shiga toxin-associated hemolytic uremic syndrome</td></tr><tr><td>TB</td><td>Tuberculosis</td></tr><tr><td>TIA</td><td>Transient ischemic attack</td></tr><tr><td>TSANZ</td><td>Transplantation Society of Australia and New Zealand</td></tr><tr><td>UK</td><td>United Kingdom</td></tr><tr><td>UNOS</td><td>United Network for Organ Sharing</td></tr><tr><td>US</td><td>United States</td></tr><tr><td>UTI</td><td>Urinary tract infection</td></tr><tr><td>VCA</td><td>Viral capsid antigen</td></tr><tr><td>VZV</td><td>Varicella-zoster virus</td></tr></table>
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Supplement
THE TRANSPLANTATION SOCIETY • 1966
SOCIETÉ DE TRANSPLANTATION • 1966
OPEN
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation
Steven J. Chadban, BMed, PhD, \( ^{1*} \) Curie Ahn, MD, PhD, \( ^{2} \) David A. Axelrod, MD, MBA, \( ^{3} \) Bethany J. Foster, MD, MSCE, \( ^{4} \) Bertram L. Kasiske, MD, \( ^{5} \) Vijay Kher, MD, DM, \( ^{6} \) Deepali Kumar, MD, MSc, \( ^{7} \) Rainer Oberbauer, MD, PhD, \( ^{8} \) Julio Pascual, MD, PhD, \( ^{9} \) Helen L. Pilmore, MD, \( ^{10} \) James R. Rodrigue, PhD, \( ^{11} \) Dorry L. Segev, MD, PhD, \( ^{12} \) Neil S. Sheerin, BSc, PhD, \( ^{13} \) Kathryn J. Tinckam, MD, MMSc, \( ^{7} \) Germaine Wong, MD, PhD, \( ^{14} \) and Gregory A. Knoll, MD, MSc, \( ^{15\star} \)
Abstract: The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
Keywords: albuminuria; adherence; bone and mineral metabolism; candidates; CKD-MBD; clinical practice guideline; cancer; cardiac disease; compatibility; diabetes mellitus; end-stage kidney disease; evidence-based recommendation; gastrointestinal disease; genetic kidney disease; hematuria; hematological disorders; HLA; immunological assessment; infectious diseases; KDIGO; kidney transplantation; liver disease; malignancy; mineral and bone disorder; neurologic disease; obesity; pediatric; perioperative; peripheral arterial disease; pulmonary disease; psychosocial; systematic review; tobacco
(Transplantation 2020;104: S1–S103)
In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Kidney Transplant Candidate Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020;104: S1–S103.
Received 6 January 2020
\( ^{1} \) Royal Prince Alfred Hospital and Charles Perkins Centre, University of Sydney, Sydney, Australia.
\( ^{2} \) Seoul National University, Seoul, South Korea.
\( ^{3} \) University of Iowa, Iowa City, IA.
\( ^{4} \) The Montreal Children’s Hospital, McGill University Health Centre, Montreal, Canada.
\( ^{5} \) Hennepin County Medical Center, Minneapolis, MN.
\( ^{6} \) Medanta Kidney and Urology Institute, Haryana, India.
\( ^{7} \) University Health Network, University of Toronto, Toronto, Canada.
\( ^{8} \) Medical University of Vienna, Vienna, Austria.
\( ^{9} \) Hospital del Mar, Barcelona, Spain.
\( ^{10} \) Auckland City Hospital, Auckland, New Zealand.
\( ^{11} \) Beth Israel Deaconess Medical Center, Boston, MA.
\( ^{12} \) Johns Hopkins University School of Medicine, Baltimore, MD.
\( ^{13} \) Newcastle University, Newcastle, United Kingdom.
ISSN: 0041-1337/20/1044S-S1
DOI: 10.1097/TP.0000000000003136
14 University of Sydney, Sydney, Australia.
15 The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada.
*Guideline Work Group Co-Chairs
Copyright © 2020 KDIGO. Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
SUMMARY OF RECOMMENDATION STATEMENTS
SECTION 1: ACCESS TO TRANSPLANTATION
1.1: We recommend that all patients with chronic kidney disease (CKD) G4-G5 (glomerular filtration rate [GFR] < 30 ml/min/1.73 m\( ^{2} \)) who are expected to reach end-stage kidney disease (ESKD) (excluding those listed in Rec 1.1.3) be informed of, educated about, and considered for kidney transplantation regardless of socioeconomic status, sex, gender identity, or race/ethnicity (1D).
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1.1.1: Refer potential kidney transplant candidates for evaluation at least 6 to 12 months before anticipated dialysis initiation to facilitate identification/work-up of living donors and plan for possible pre-emptive transplantation (Not Graded).
1.1.2: Refer potential candidates already on dialysis when medically stable and kidney failure deemed irreversible (Not Graded).
1.1.3: We recommend not referring patients for kidney alone transplant evaluation with the following conditions (1D):
- Multiple myeloma (Rec 9.13.1.1), light chain deposition disease (Rec 9.13.2.1, 9.13.2.2 and 9.13.2.3) unless they have received a potentially curative treatment regimen and are in stable remission;
- AL amyloidosis with significant extrarenal involvement (Recs 9.13.3.1 and 13.8);
- Decompensated cirrhosis (consider for combined liver-kidney transplant; Recs 10.5.2.4.2, 16.7.2);
- Severe irreversible obstructive or restrictive lung disease (Rec 12.5);
- Severe uncorrectable and symptomatic cardiac disease that is deemed by a cardiologist to preclude transplantation (Rec 13.7);
- Progressive central neurodegenerative disease (Rec 15.4).
1.1.3.1: Document the reason(s) for not referring patients for transplant evaluation (Not Graded).
1.1.3.2: Inform patients about the reason(s) for not referring for transplant evaluation (Not Graded).
1.1.4 We recommend delaying transplant evaluation in patients with the following conditions until properly managed (1D):
- An unstable psychiatric disorder that affects decision-making or puts the candidate at an unacceptable level of post-transplant risk (Rec 4.2);
- Ongoing substance use disorder that affects decision-making or puts the candidate at an unacceptable level of post-transplant risk (Rec 4.3);
- Ongoing, health-compromising nonadherent behavior despite education and adherence-based counseling (Rec 5.4);
- Active infection (excluding hepatitis C virus infection) that is not properly treated (Rec 10.1.1);
- Active malignancy except for those with indolent and low-grade cancers such as prostate cancer (Gleason score \(\leq 6\)), and incidentally detected renal tumors (\(\leq 1\) cm in maximum diameter) (Rec 11.2.1);
- Active symptomatic cardiac disease (eg, angina, arrhythmia, heart failure, valvular heart disease) that has not been evaluated by a cardiologist (Rec 13.2);
- Active symptomatic peripheral arterial disease (Rec 14.5);
- Recent stroke or transient ischemic attack (Rec 15.1);
- Active symptomatic: peptic ulcer disease (Rec 16.2.2); diverticulitis (Rec 16.3.1), acute pancreatitis (Rec 16.4.1), gallstone/ gallbladder disease (16.5.1), inflammatory bowel disease (Rec 16.6.1);
• Acute hepatitis (Rec 16.7.2);
• Severe hyperparathyroidism (Rec 18.2).
1.2: Use a multidisciplinary team, which includes at a minimum a transplant physician, transplant surgeon and a health care professional experienced in the psychosocial aspects of transplantation, to evaluate and decide about suitability for kidney transplantation (Not Graded).
1.3: Approve patients for kidney transplantation that have an estimated survival which is acceptable according to national standards (Not Graded).
1.3.1: Inform patients of their option to seek a second opinion from another transplant center if they are declined (Not Graded).
1.4: We recommend pre-emptive transplantation with a living kidney donor as the preferred treatment for transplant-eligible CKD patients (1A).
1.4.1: We recommend pre-emptive transplantation (living or deceased donor) in adults when the estimated glomerular filtration rate (eGFR) is < 10 ml/min/1.73 m \( ^{2} \) or earlier with symptoms (1D).
1.4.2: We recommend pre-emptive transplantation (living or deceased donor) in children when the eGFR is < 15 ml/min/1.73 m \( ^{2} \) or earlier with symptoms (1D).
SECTION 2: AGE
2.1: Consider age in the context of other comorbidities, including frailty, that may impact outcome when deciding about suitability for kidney transplantation (Not Graded).
2.1.1: We recommend not excluding patients from kidney transplantation because of age alone (1A).
SECTION 3: PEDIATRIC ISSUES
3.1: We suggest performing a neurocognitive assessment in pediatric candidates who experienced end-stage kidney disease before the age of 5 years (2D).
3.2: We suggest performing an academic assessment in pediatric candidates of school age who are experiencing academic difficulties (2D).
SECTION 4: PSYCHOSOCIAL ASSESSMENT
4.1: We suggest performing a psychosocial assessment in all candidates (2D).
4.1.1: Refer candidates to a health care professional experienced in the psychosocial aspects of kidney transplantation (eg, social worker, psychologist, psychiatrist, psychiatric nurse/nurse practitioner) to perform this assessment (Not Graded).
4.1.2: Use measurement tools completed by the patient and/or evaluating clinician to supplement the assessment (Not Graded).
4.1.2.1: We suggest not using measurement tools in isolation to determine transplant candidacy (2D).
4.1.3: Refer candidates with a diagnosable psychiatric or psychological condition, substance use disorder or nonadherence for pre-transplant counseling and services to enhance the likelihood of a favorable post-transplant outcome (Not Graded).
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4.2: We recommend not transplanting patients with an unstable psychiatric disorder that affects decision-making or puts the candidate at an unacceptable level of post-transplant risk (1C).
4.3: We recommend not transplanting patients with ongoing substance use disorder that affects decision-making or puts the candidate at an unacceptable level of post-transplant risk (1C).
4.4: We suggest that patients without current social support be considered for kidney transplantation if they are able to care for themselves and have an identified support plan in place prior to transplantation (2D).
SECTION 5: ADHERENCE
5.1: Assess adherence and adherence barriers pre-transplantation to allow for appropriate education, counseling and post-transplant surveillance (Not Graded).
5.2: Refer candidates with a history of health-compromising nonadherent behavior or identified adherence barriers for adherence-based education and counseling pre-transplant (Not Graded).
5.3: We suggest that candidates with a history of graft loss due to nonadherence undergo adherence-based counseling prior to re-transplantation (2D).
5.4: We recommend that candidates with a history of nonadherence be considered for transplantation unless there is ongoing, health-compromising non-adherent behavior (1D).
SECTION 6: TOBACCO
6.1: Assess past and present use of tobacco products by candidates at transplant evaluation and while on the waiting list (Not Graded).
6.2: We recommend counseling all candidates to avoid tobacco products before and indefinitely after transplantation (1B).
6.3: We recommend offering a tobacco cessation program to candidates who are using tobacco products (1B).
6.4: We recommend that candidates abstain from tobacco use, at a minimum 1 month prior to wait-listing or living donor transplantation (1B).
6.5: We suggest chest computed tomography (CT) for current or former heavy tobacco users ( \( \geq \) 30 pack-years) as per local guidelines to screen for occult lung cancer (2C).
SECTION 7: SURGICAL ISSUES INCLUDING OBESITY
7.1: We recommend candidates to have their body habitus examined by a transplant surgeon at the time of evaluation and while on the waiting list (1B).
7.1.1: We suggest that candidates not be excluded from transplantation because of obesity (as defined by body mass index or waist-to-hip ratio) (2B).
7.1.2: We suggest weight loss interventions be offered to candidates with obesity prior to transplantation (2D).
7.2: We suggest that candidates be assessed for frailty at the time of evaluation and while on the waitlist to inform post-transplant risk and enable optimization strategies, such as pre-operative rehabilitation (2C).
7.3: We suggest that candidates be assessed for medical conditions that inhibit wound healing, including obesity, undernutrition, tobacco use, and prior abdominal surgeries, to inform risks of delayed wound healing and hernia formation (2B).
7.4: Candidates should not be excluded from consideration for kidney transplantation because of their need for anticoagulation, antiplatelet therapy or a history of heparin-induced thrombocytopenia (HIT) (Not Graded).
7.4.1: Single antiplatelet agents (eg, aspirin, clopidrogel, ticagrelor) can be continued while waiting for deceased donor transplant (Not Graded).
7.4.2: Delay transplantation for the mandated period of treatment with dual antiplatelet therapy (eg, aspirin plus clopidogrel) when the risk of stopping medication (eg, stent thrombosis) or operating while on treatment (eg, surgical bleeding) exceeds the anticipated benefit of transplantation (Not Graded).
7.4.2.1: Antiplatelet agents (except aspirin) should be stopped 5 days prior to living donor transplantation (unless cessation is contraindicated) and during the perioperative period for deceased donor transplantation (Not Graded).
7.4.3: Do not transplant patients on direct-acting oral anticoagulants (DOACs; eg, apixaban, rivaroxaban) except when there is specific expertise using DOACs perioperatively and access to DOAC reversal agents (Not Graded).
7.4.3.1: Switch to an alternative anticoagulant (eg, warfarin) prior to waitlisting or living donor transplantation if recommended by a thrombosis expert/hematologist or if there is no expertise using DOACs perioperatively or access to DOAC reversal agents (Not Graded).
7.4.4: Use non-heparin based agents for perioperative anticoagulation in candidates with a history of HIT (Not Graded).
7.5: Assess vascular anatomy and patency for patients with significant peripheral arterial disease (Section 14), prior transplant procedures, venous dialysis catheters, pelvic surgery, or deep venous thrombosis (Not Graded).
7.6: Evaluate native kidney size in patients with polycystic kidney disease (Not Graded).
7.6.1: We suggest staged or simultaneous native nephrectomy and transplantation for candidates with polycystic kidney disease that is symptomatic (eg, recurrent pain, recurrent infection), a suspicion of malignancy, or if the patient has insufficient room for a transplant (2D).
7.7: Refer to a urologist experienced in transplant issues for patients at increased risk for or those with a history of urologic malignancy, recurrent urinary tract infections, dysfunctional voiding, prior bladder augmentation/division, an ileal conduit, significant structural anomalies of the kidneys or urinary tract, or nephrolithiasis (Not Graded).
7.7.1: We suggest cystoscopy to screen for bladder carcinoma in candidates at increased risk, such as those with high-level exposure to cyclophosphamide or heavy smoking ( \( \geq \) 30 pack-years) (2D).
7.7.2: We suggest that pre-transplant unilateral or bilateral nephrectomy be considered for pediatric candidates with high urine volumes (>2.5 ml/kg/hour) or heavy proteinuria associated with hypoalbuminemia (2D).
SECTION 8: DIABETES
8.1: We recommend that candidates with type 1 or type 2 diabetes mellitus (DM) be considered for kidney transplantation (1B).
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8.1.1: We suggest candidates with ESKD and type 1 DM be considered for simultaneous pancreas-kidney transplantation in regions where this procedure is available (2A).
8.2: We suggest testing for abnormal glucose metabolism by oral glucose tolerance test in candidates who are not known to have diabetes (2A).
SECTION 9: CAUSE OF END-STAGE KIDNEY DISEASE (ESKD)
9.1 Cause of ESKD and kidney transplantation
9.1.1: We recommend that the cause of ESKD in candidates be determined, where possible, to inform risks and management after kidney transplantation (1A).
9.1.2: Advise candidates about the disease-specific risk of recurrence and resultant risk of graft loss (Not Graded).
9.2 Focal segmental glomerulosclerosis (FSGS)
9.2.1: We recommend not excluding candidates with primary FSGS from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.2.1.1: Loss of a prior graft due to recurrent FSGS indicates a high risk of recurrence upon subsequent transplantation and this factor should be a major consideration in determining candidacy (Not Graded).
9.2.2: We suggest genetic testing (eg, for podocin and nephrin gene mutations, among others) be performed in children and young adults with a clinical course consistent with genetic FSGS to inform the risk of recurrence (2C).
9.2.3: We suggest avoiding routine use of pre-transplant plasma exchange or rituximab to reduce the risk of recurrent FSGS (2D).
9.3 Membranous nephropathy (MN)
9.3.1: We recommend not excluding candidates with MN from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.3.1.1: We suggest not excluding candidates with prior graft loss due to MN; however, the risk of recurrence should be considered and discussed with the candidate (2D).
9.3.2: We suggest that autoantibodies to phospholipase A2 receptor (PLA2R) be measured pre-transplant to inform the risk of recurrence in patients with MN (2C).
9.3.3: We suggest not routinely using rituximab or alkylating agents to reduce the risk of recurrent MN (2D).
9.4 IgA nephropathy (IgAN)
9.4.1: We recommend not excluding candidates with IgAN from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.5 IgA vasculitis
9.5.1: We recommend not excluding candidates with IgA vasculitis from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.6 Immune complex-mediated membranoproliferative glomerulonephritis (IC-MPGN) and C3 glomerulopathy (C3G)
9.6.1 IC-MPGN
9.6.1.1: We recommend not excluding candidates with IC-MPGN from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.6.1.2: We recommend investigation for an infective, autoimmune, or paraprotein-mediated cause of IC-MPGN prior to transplantation to guide treatment and inform risk of recurrence (1C).
9.6.1.3: We suggest that, when possible, the cause of the IC-MPGN be treated prior to transplantation (2C).
9.6.2 C3G, including dense deposit disease (DDD) and C3 glomerulonephritis (C3GN)
9.6.2.1: We recommend not excluding candidates with C3G from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.6.2.2: We suggest that candidates with C3G be screened for genetic or acquired causes for the dysregulation of the complement alternative pathway to guide treatment and inform risk of recurrence (2C).
9.6.2.3: Loss of a prior graft due to recurrent C3G indicates a high risk of recurrence upon subsequent transplantation and this factor should be a major consideration in determining candidacy (Not Graded).
9.7 Lupus nephritis (LN)
9.7.1: We recommend not excluding candidates with LN from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.7.2: We recommend that lupus activity should be clinically quiescent on no or minimal immunosuppression prior to transplantation (1D).
9.7.3: We recommend evaluation for secondary antiphospholipid antibodies prior to transplantation to inform perioperative management (1C).
9.8 Antiphospholipid syndrome (APS)
9.8.1: We recommend not excluding candidates with APS from kidney transplantation; however, the risks of post-transplant thrombosis and perioperative anticoagulant therapies should be considered and discussed with the candidate (1B).
9.8.2: We suggest that APS should be clinically quiescent prior to transplantation (2D).
9.8.3: Continue anticoagulation (eg aspirin, warfarin) at the time of activation on the transplant waitlist (Not Graded).
9.9 Anti-neutral cell cytoplasmic antibody (ANCA)-associated vasculitis
9.9.1: We recommend not excluding candidates with ANCA-associated vasculitis from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.9.2: We suggest that ANCA-vasculitis should be clinically quiescent prior to transplantation (2D).
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9.10 Anti-glomerular basement membrane (anti-GBM) disease
9.10.1: We recommend not excluding candidates with anti-GBM disease from kidney transplantation (1B).
9.10.2: We recommend that anti-GBM antibody titers be measured in candidates and that transplantation is only performed when antibodies are undetectable (1D).
9.11 Hemolytic uremic syndrome (HUS)
9.11.1: We recommend not excluding candidates with HUS due to infection with a Shiga-toxin producing organism, usually E. coli (STEC-HUS), from kidney transplantation (1A).
9.11.2: We recommend assessment of candidates with suspected atypical HUS (aHUS) for a genetic or acquired defect in complement regulation or other genetic causes of aHUS to inform risk of recurrence (1B).
9.11.3: We recommend not excluding candidates with aHUS from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1B).
9.11.3.1: We recommend that if the candidate has an abnormality in complement regulation placing them at high risk of recurrence, kidney transplantation should not proceed unless a complement inhibitor can be administered or combined liver-kidney transplant can be performed (1B).
9.12 Systemic sclerosis
9.12.1: We recommend not excluding candidates with systemic sclerosis from kidney transplantation in the absence of severe pulmonary, gastrointestinal, or other life-threatening extrarenal disease (1C).
9.13 Plasma cell dyscrasias (PCDs)
Please consult Section 17.6 Hematologic Disorders for recommendations related to monoclonal gammopathy of undetermined significance (MGUS)
9.13.1 Multiple myeloma
9.13.1.1: We suggest that candidates with multiple myeloma be excluded from kidney transplantation unless they have received a potentially curative treatment regimen and are in stable remission (2D).
9.13.2 Monoclonal immunoglobulin deposition disease (MIDD)
9.13.2.1: We suggest that candidates with light chain deposition disease (LCDD) be excluded from kidney transplantation unless they have received a potentially curative treatment regimen and are in stable remission (2D).
9.13.2.2: We suggest that candidates with heavy chain deposition disease (HCDD) be excluded from kidney transplantation unless they have received a potentially curative treatment regimen and are in stable remission (2D).
9.13.2.3: We suggest that candidates with light and heavy chain deposition disease (LHCDD) be excluded from kidney transplantation
unless they have received a potentially curative treatment regimen and are in stable remission (2D).
9.13.3 AL amyloidosis
9.13.3.1: We suggest that candidates with AL amyloidosis be excluded from kidney transplantation unless they have minimal extrarenal disease (eg, cardiac amyloid), have received a potentially curative treatment regimen and are in stable remission (2D).
9.14 AA amyloidosis
9.14.1: We recommend not excluding candidates with AA amyloidosis from kidney transplantation after adequate treatment of the underlying cause and in the absence of severe extrarenal organ involvement (1D).
9.15 Fibrillary/immunotactoid glomerulonephritis
9.15.1: We recommend not excluding candidates with fibrillary or immunotactoid glomerulonephritis from kidney transplantation; however, the risk of recurrence should be considered and discussed with the candidate (1D).
9.16 Hyperoxaluria (oxalosis), primary and secondary
9.16.1: We suggest that candidates with primary hyperoxaluria type 1 be considered for combined or sequential liver-kidney transplantation (2C).
9.16.2: We suggest genetic testing to identify the cause of primary hyperoxaluria to inform treatment decisions (2C).
9.16.3: We suggest not excluding candidates with correctable hyperoxaluria—pyridoxine-responsive or secondary—from kidney transplantation alone; however, the risk of recurrence should be considered and discussed with the candidate (2D).
9.16.4: We recommend the use of strategies to lower total body oxalate burden prior to transplantation in patients with hyperoxaluria, including intensive dialysis, diet modification, and pyridoxine treatment as appropriate on a case-by-case basis (1D).
9.17 Cystinosis
9.17.1: We recommend not excluding candidates with cystinosis from kidney transplantation in the absence of severe extrarenal manifestations (1C).
9.18 Fabry disease
9.18.1: We recommend not excluding candidates with Fabry disease from kidney transplantation in the absence of severe cardiac or other systemic extrarenal organ involvement (1C).
9.19 Sickle cell disease
9.19.1: We recommend not excluding candidates with sickle cell disease from kidney transplantation in the absence of active, severe extrarenal sickle cell disease (1C).
9.20 Sarcoidosis
9.20.1: We recommend not excluding candidates with renal sarcoidosis from kidney transplantation in the absence of severe extrarenal disease (1C).
9.21 Alport syndrome
9.21.1: We recommend not excluding candidates with Alport syndrome from kidney transplantation (1C).
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SECTION 10: INFECTIONS
10.1 Active infections
10.1.1: We recommend that kidney transplantation be delayed until active infections (bacterial, fungal, viral [except hepatitis C], parasitic) are treated (1C).
10.2 Colonization
10.2.1: Follow local protocols for detection and management of colonization with drug-resistant organisms (Not Graded).
10.2.2: We recommend not excluding patients from kidney transplantation with asymptomatic bacterial, parasitic or fungal colonization (1C).
10.3 Specific Infections
10.3.1 Urinary tract infections (UTIs)
10.3.1.1: We recommend treating symptomatic UTIs prior to kidney transplantation (1B).
10.3.1.2: We suggest not routinely performing prophylactic nephrectomy for recurrent pyelonephritis or cyst infections (2D).
10.3.2 Tuberculosis (TB)
10.3.2.1: We suggest complete treatment of active TB prior to kidney transplantation, as per World Health Organization or local guidelines (2C).
10.3.2.2: We recommend screening for latent TB at the time of candidate evaluation in low TB prevalence areas with a chest radiograph along with a purified protein derivative (PPD) skin test or interferon-gamma release assay (1C).
10.3.2.3: We suggest starting treatment of latent TB prior to or immediately following kidney transplantation in low TB prevalence areas (2C).
10.3.2.4: We suggest screening for latent TB at the time of candidate evaluation as per local guidelines in intermediate and high TB prevalence areas with post-transplantation vigilance for active TB (2C).
10.4 Screening for periodontal disease
10.4.1: We suggest dental evaluation, as per local general population guidelines, to screen for dental/periodontal disease prior to kidney transplantation (2C).
10.5 Screening for viral infections (see Table 11)
10.5.1 Human immunodeficiency virus (HIV)
10.5.1.1: We recommend screening all patients for HIV infection, using HIV serology (1A).
10.5.1.2: We recommend not excluding patients with controlled HIV infection from kidney transplantation (1C).
10.5.1.3: Kidney transplant candidates with HIV should be managed in a center with experience in this area (Not Graded).
10.5.2 Hepatitis C virus (HCV) [This section is adapted from 2018 KDIGO HCV Guideline]
10.5.2.1: We recommend screening all patients for HCV infection (1A). (KDIGO HCV Guideline Recommendation 1.1.4)
10.5.2.2: We recommend using an immunoassay followed by nucleic acid testing (NAT) if immunoassay is positive (1A). (KDIGO HCV Guideline Recommendation 1.1.1.1)
10.5.2.3: We recommend kidney transplantation as the best therapeutic option for patients with CKD G5 irrespective of presence of HCV infection (1A). (KDIGO HCV Guideline Recommendation 4.1.1)
10.5.2.4: We suggest that all candidates with HCV infection be evaluated for severity of liver disease and presence of portal hypertension (if indicated) prior to acceptance for kidney transplantation (Figure 3) (2D). (KDIGO HCV Guideline Recommendation 4.1.2)
10.5.2.4.1: We recommend that patients with HCV and compensated cirrhosis (without portal hypertension) undergo isolated kidney transplantation (1B). (KDIGO HCV Guideline Recommendation 4.1.2.1)
10.5.2.4.2: We recommend referring patients with HCV and decompensated cirrhosis for combined liver-kidney transplantation (1B) and deferring HCV treatment until after transplantation (1D). (KDIGO HCV Guideline Recommendation 4.1.2.2)
10.5.2.5: Timing of HCV treatment in relation to kidney transplantation (before vs. after) should be based on donor type (living vs. deceased donor), waitlist times by donor type, center-specific policies governing the use of kidneys from HCV-infected deceased donors, HCV genotype, and severity of liver fibrosis (Not Graded). (KDIGO HCV Guideline Recommendation 4.1.3)
10.5.2.5.1: We recommend that all patients with HCV who are candidates for kidney transplantation be considered for direct-acting antiviral (DAA) therapy, either before or after transplantation (1A). (KDIGO HCV Guideline Recommendation 4.1.3.1)
10.5.2.5.2: We suggest that candidates with HCV with a living kidney donor can be considered for treatment before or after transplantation according to HCV genotype
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and anticipated timing of transplantation (2B). (KDIGO HCV Guideline Recommendation 4.1.3.2)
10.5.2.5.3: We suggest that if receiving a kidney from an HCV-positive donor improves the chances for transplantation, the HCV NAT-positive patient can undergo transplantation with an HCV-positive kidney and be treated for HCV infection after transplantation (2B). (KDIGO HCV Guideline Recommendation 4.1.3.3)
10.5.3 Hepatitis B virus (HBV) [See Section 10.7 for related recommendations on HBV vaccinations]
10.5.3.1: We recommend screening for HBV infection with HBsAg, anti-HBs, and anti-HBc (1A).
10.5.3.2: We recommend screening with HBV DNA for patients with a positive HBsAg or anti-HBc (1A).
10.5.3.3: We recommend that patients from hepatitis D virus (HDV) endemic areas be screened with HDV serology if they are positive for HBsAg or anti-HBc (1A).
10.5.3.4: We recommend that HBsAg positive and/or HBV DNA positive candidates be referred to a specialist with expertise in the management of liver disease and HBV infection to determine appropriate antiviral treatment (1D).
10.5.3.4.1: We recommend that HBsAg positive and/or HBV DNA positive candidates undergo isolated kidney transplantation if they do not have decompensated cirrhosis and are stable on antiviral therapy after specialist evaluation (1B).
10.5.3.5: We recommend not excluding anti-HBc antibody positive (HBsAg negative) patients from kidney transplantation (1C).
10.5.3.5.1: We recommend that anti-HBc antibody positive (HBsAg negative) patients not receive antivir
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