Contraindications to kidney transplantation: uneven grounds?

Determining eligibility for a kidney transplant is an important decision. Practice guidelines define contraindications to transplantation; however many are not evidence based. Canadian guidelines recommend that patients unlikely to survive the wait period not be evaluated. The purpose of this study was to evaluate what proportion of patients with a contraindication would survive the wait time.

Consecutive incident dialysis patients (January 2006 to December 2012) with a contraindication, defined using Canadian guidelines, were studied. Mortality rates were determined for each individual contraindication. Theoretical survival to the median wait time to transplantation was calculated.

Of 746 incident patients, 435 (58 %) were deemed to have a contraindication at dialysis start. Nearly 80 % had a contraindication with a high mortality rate (dementia, multisystem disease, etc.). Patients with high mortality rates were less likely to survive the wait list than be transplanted. Patients with non-adherence, obesity, and potentially reversible disease had relatively low mortality rates, were more likely to survive, and possibly be transplanted at a time with the prospect of a better outcome.

This study gives some credence that many patients with a contraindication are not likely to benefit. A better framework of defining contraindications is needed to allow better decision-making.