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Appendix
Criteria for Ratings of Appropriateness for Renal Transplantation.
Ratings
Appropriate: no critical or relative contraindications
Equivocal: one or two relative contraindications
Inappropriate: one or more critical contraindications or three or more relative contraindications that, taken together, are judged as critical
Incomplete workup: one or more partial or incomplete clinical evaluations necessary for pretransplantation workup
Critical Contraindications
Active malignant condition
Active infection documented, with treatment in the past month
Active tuberculosis documented by chest film and culture
Human immunodeficiency virus infection
Life expectancy of less than 2 1/2 years
Severe functional impairment requiring level II skilled nursing
Body-mass index greater than 35
Active systemic lupus erythematosus with major clinical signs
Positive for hepatitis B surface antigen, with chronic active hepatitis on biopsy
Positive for both hepatitis B surface antigen and hepatitis B e antigen
Positive for both hepatitis B virus and hepatitis C virus
Positive for hepatitis C virus, with chronic active hepatitis on biopsy
Severe cardiac disease (e.g., left main coronary artery or three major vessels with more than 70 percent occlusion, left ventricular ejection fraction of less than 25 percent, class III or IV angina despite maximal management, New York Heart Association class III or IV congestive heart failure despite maximal management, high risk for cardiac ischemia or atherosclerotic disease according to the results of noninvasive testing, acute myocardial infarction within the past six months, or symptomatic valvular insufficiency)
Cerebral vascular accident within the past six months
Transient ischemic attack within the past six months and untreated vascular disease
Advanced atherosclerotic peripheral vascular disease, uncorrected abdominal aortic aneurysm, or major amputation due to vascular disease
Severe chronic obstructive pulmonary disease, severe pulmonary fibrosis, or severe restrictive pulmonary disease (documented forced expiratory volume in one second, less than 25 percent of the predicted value; documented partial pressure of arterial oxygen, less than 60 mm Hg at rest; exercise-induced oxygen desaturation, less than 90 percent by pulse oximetry) or four or more respiratory infections or episodes of pneumonia in the past 12 months
Chronic active hepatitis or cirrhosis
Major gastrointestinal bleeding in the past six months
Acute diverticulitis in the past six months without definitive surgical resection
Acute pancreatitis in the past six months
Acute cholecystitis and diabetes mellitus without cholecystectomy
Major psychiatric disorder (or psychosis, confusional state, or dementia) that is unstable despite maximal management
Psychiatric disorder exacerbated by steroid medications
Active substance abuse or positive result of drug screening; patient refused drug counseling or it was unsuccessful
Sickle cell disease with more than four episodes of sickle-cell crisis in the past 12 months
Oxalosis (not responsive to pyridoxine) and combined liver-kidney transplantation not planned
Anti-glomerular basement membrane disease with elevated levels of circulating anti-glomerular basement membrane antibodies
Relative Contraindications
Body-mass index of 30 to 35
Moderate coronary artery disease (e.g., untreated 50 to 70 percent occlusion of one or two vessels, but not the left main coronary artery, and a left ventricular ejection fraction of 25 to 35 percent)
Moderate chronic obstructive pulmonary disease (documented forced expiratory volume in one second, 25 to 50 percent; documented partial pressure of oxygen, 60 to 70 mm Hg at rest) or restrictive lung dis-ease or sarcoidosis with exercise-induced desaturation of at least 90 percent
Systemic lupus erythematosus without major signs for six months or less
Active tuberculosis and antituberculin treatment for six months or less
Chronic pancreatitis quiescent for 12 months or less
Acute diverticulitis more than 6 months but less than 12 months ago, without definitive surgical resection
Hepatitis B or C without chronic active hepatitis on biopsy
Cholelithiasis and diabetes mellitus without cholecystectomy
Acute cholecystitis within the past 12 months without cholecystectomy
Membranoproliferative glomerular nephritis as the cause of end-stage renal disease
Incomplete Workup
History of or multiple risk factors for coronary artery disease, cardiac symptoms (e.g., angina), or congestive heart failure and no cardiac evaluation in past 12 months
Hypertension and history of coronary artery disease without adequate cardiac evaluation (e.g., radionuclide imaging or echocardiography with analysis of systolic function and thallium or dipyridamole-thallium exercise-tolerance testing or coronary angiography)
Diabetes mellitus for more than 25 years or in a patient older than 45 years without adequate cardiac evaluation (e.g., radionuclide imaging or echocardiography with analysis of systolic function and thallium or dipyridamole-thallium exercise-tolerance testing or coronary angiography)
Report of abnormal or ischemic result on noninvasive cardiac testing and cardiac catheterization not performed
Elevated values on liver-function testing (more than twice the upper limit of the normal range) for more than two months and liver biopsy not performed
Positive for hepatitis B virus and liver-function tests or liver biopsy not performed
Positive for hepatitis C virus and liver biopsy not performed
Test for human immunodeficiency virus not performed
Active substance abuse or positive result of drug screening and inadequate or incomplete counseling
History of substance abuse and drug screening not performed
Chronic obstructive pulmonary disease and pulmonary-function testing not performed and partial pressure of arterial oxygen not determined or oximetry not performed
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