Kidney Function

Pretransplant latent infections or infectious exposures can lead to a reappraisal of transplant candidacy or, subsequently, alterations in standard post-transplant management. Preexisting infectious conditions in the donor or recipient may appear in the immediate postoperative period during induction immunosuppression, in the initial weeks post-transplant during treatment of rejection episodes, or in the later months post-transplant, depending on the overall net state of immunosuppressives. Incomplete immunizations in the recipient should be corrected prior to transplantation.

General Screening
From the perspective of infectious disease and their consequences, evaluation should include eliciting a history of antibiotic allergies, valvular repairs or replacements, a dental assessment, a preoperative urine culture, and a chest radiograph to exclude active pneumonic processes and identify evidence of prior granulomatous or infectious disorders. A purified protein derivative (tuberculin) skin test with appropriate controls should be applied; however, suboptimal reactivity of skin testing in renal failure patients may lead to false-negative results. Isoniazid (INH) prophylaxis may be indicated with an abnormal chest x-ray result representing old tuberculosis despite a negative skin test. Precise recommendations for dosage an duration of therapy should adhere to the Centers for Disease Control guidelines on INH prophylaxis. Additional preoperative assessment should include a history of sexually transmitted diseases such as syphilis, HSV infection, viral hepatitis, and HIV infection.

Immunizations
Pretransplant candidates lacking standard pediatric or adult immunizations, splenectomized patients, and renal failure patients may benefit from pretransplant vaccinations with influenza, pneumococcal, and hepatitis B, diphtheria-pertussis-tetanus, inactivated polio, and measles-mumps-rubella (MMR) vaccines. Suboptimal efficacy of vaccinations in patients with renal failure must be recognized due to the effects of uremia on the immune system, however. Live vaccines should be avoided in immunocompromised patients (e.g., a renal transplant candidate with an underlying condition requiring immunosuppresive medications) and in patients who have undergone solid organ transplantation. Of particular pretransplant concern are pediatric renal failure patients with incomplete primary immunizations of live viral vaccines such as MMR. The general recommendation of avoiding live, attenuated viral vaccines in allograft recipients precludes the completion of the immunization series, thereby exposing the child to the risk of measles. Consequently, pretransplant immunization offers the opportunity to prevent the post-transplantation risks of live, attenuated viral vaccines. In this respect, measles, MMR and varicella vaccines should, ideally, be administered several months before transplantation. Pretransplant vaccination with a live, attenuated CMV vaccine has been reported to result in a reduction in the severity of CMV disease and improved graft survival in seronegative recipients of a CMV-positive allograft, the group considered to be at highest risk for CMV disease. Administration of this vaccine, however, has not been implemented.

In the past, transfusion was the only effective way to treat anemia in dialysis patients. When you receive a transfusion, you receive red blood cells from a blood donor. However, you can also be at risk of receiving an infection from the blood donor, such as hepatitis (other than Hepatitis B, which is tested for) or even AIDS (if the donor has recent infection and has not yet developed antibodies, which are the basis of the blood test done to screen out the overwhelming majority of infected donors).

Prior to the advent of human recombinant erythropoietin, anemia in these dialysis patients was treated with androgenic steroid hormones and, if necessary, transfusions of red blood cells.

Both of these treatments had important drawbacks. Androgen (male) steroids were administered by weekly injection into the muscle. Their mode of action was to stimulate cells in the bone marrow to produce more red blood cells. Unfortunately, androgens had limited effectiveness and, as a side effect, promoted the development of masculine sexual characteristics such as facial and body hair and even deepening of the voice. Blood transfusions are a more effective way of treating anemia. Their usefulness is limited by the danger of transmitting certain viral diseases, such as hepatitis. Furthermore, blood transfusions contain a large amount of iron. Some of the iron is deposited in the liver and other organs. After many units have been given, the iron may potentially cause disease of these organs.

Benefits of Treatment with Recombinant Human Erythropoietin
The most important benefit of treatment with recombinant human erythropoietin is an increase in the number of red cells in the blood. Once the number of red blood cells available to carry oxygen to all parts of the body increases, you may not require transfusions, unless you have sudden or substantial bleeding, such as from an ulcer of the stomach or intestine.

Dialysis patients with anemia who have received EPO also commonly experience improved quality of life and sense of well-being. After treatment with EPO, many patients notice an improvement in their ability to work, and their sexual performance, appetite, ability to exercise, social activity, sleep, ahir texture and skin color.

The University of New Mexico’s Center for Health Law and Ethics developed a series of questions (which the developers call a “values history“) for public guardians to sue to ask friends of solitary, incapacitated patients what this person believed or had said about their beliefs, values, health and treatment preferences in order to guide the guardian to make appropriate decisions for an incompetent individual patient who had no other surrogate. As the values history was being developed, it became clear it could be helpful to anyone, not just the person designated as the guardian, to obtain insight into or to clarify their own values, to articulate them, and preferably to record them for use by a surrogate should they become decisionally incapacitated.

Questions in the values history ask about your living environment; your family and friends; your religious background and beliefs; your attitudes toward life in general and toward independence and control, health, doctors, illness, death and dying, and finances. They ask whether you have wishes regarding specific medical procedures, such as dialysis, artificial ventilation, artificial nutrition and hydration and organ donation, and regarding a funeral, eulogy, and obituary. The questions also ask if you have any written documents, particularly advance directives.

Can I be required to have an advance directive?
According to the Patient Self-Determination Act, a federal law, you cannot be required to have an advance directive. This law specifically prohibits health care facilities or providers from conditioning admission or provision of insurance or services upon whether or not you have executed an advance directive.

Why do so few people elect to have advance directives?
Many individuals do not know what an advance directive is, or if they know, do not realize it would be appropriate for them to have. Many others do not have an advance directive because the subject raises unpleasant or frightening issues.

Why should a dialysis patient have an advance directive?
For the same reasons that everyone should have one-and for additional reasons. Dialysis is very effective in prolonging lives of those who would otherwise die of kidney failure. Fortunately, the quality of health and life for the great majority of people on dialysis acceptable and for many substantially better than that. Most people are able to work and can do most of the activities that they wish to do, but as many as 10% of chronic dialysis patients discontinue dialysis because the burdens of illness and treatment outweigh the benefits of continuing to live. Perhaps half of those who discontinue dialysis are no longer able to make decisions for themselves and the time dialysis is discontinued because of inter-current illness with altered consciousness or because of dementia.

By having an advance directive, they are assured of having their own preferences for health care respected, including the continuation of dialysis or of other life-sustaining treatment if that is their preference (or discontinuation, if that is their preference). Furthermore, it is a great relief to family members and to physicians to know a patient’s preferences and to feel secure that they are doing what this person would have wanted them to do.