Policy: Kidney/Pancreas Pre-Transplant: Recipient Evaluation Testing Protocol
Statement: 1. Activation date: 8/9/06
2. Affected Department: Kidney/Pancreas Transplant Program and The Radiology and Cardiology Departments of
Emory Healthcare
3. Vision Strategy: Patient Care
4. Policy Statement: The Emory Transplant Center will comply with all applicable federal, state and local laws,
regulations and policies regarding patient
care.
5. Basis: This policy is necessary for the protection of patients, physicians and staff
6. Administrative Responsibility: Section heads, physicians, practitioners, and staff are responsible for compliance
with this policy.
Scope/Procedure:
PROTOCOL:
The mid-level practitioners will determine and order appropriate testing after the patient’s History and Physical
Examination performed on Day One of the evaluation. This is not a complete list and individualized testing may be
necessary as determined by mid-level provider or attending physician.
I. GENERAL TESTING
A. All patients who are evaluated for a kidney and/or pancreas transplant will have the following basic testing as a
part of their transplant
evaluation:
1. EKG
2. Chest x-ray, PA and Lateral views
II. BASIC RADIOLOGY IMAGING
All patients who are evaluated for a kidney and/or pancreas transplant will have a basic package of abdominal
imaging studies performed in the Department of Radiology (8-9729) as indicated as a part of their transplant
evaluation
The purpose of these studies is to screen for findings that could potentially impact the patient’s outcome after
transplant and to define the vascular anatomy in the abdomen and pelvis that is critical for optimal planning of
the surgical procedure and will consist of one of the outlined packages below.
A. Package 1: MRI of the abdomen and pelvis
1. Patients who are able to physically tolerate an MRI study and do not have an absolute contraindication to MRI
imaging (as
determined by the MRI screening tool) who meet the following criteria:
a) Non dialysis patients
b) Peritoneal Dialysis Patients
c) Hemodialysis patients with reasonable urine output or who do not require fluid restriction
B. Package 2: MRI of the abdomen and pelvis and MRA of the aorta and iliac vessels
1. Patients who are able to physically tolerate an MRI study and do not have an absolute contraindication to MRI
imaging (as
determined by the MRI screening tool) and require pelvic imaging to define vasculature due to:
2. Known vascular disease, bruit on exam, poor peripheral pulses on exam, aneurysm
3. Previous transplant
C. Package 3: Non-Contrast CT of the abdomen and pelvis “Stone Protocol”
1. Ordered in addition to MRI of abdomen/pelvis to “rule out mass”
2. Patients with history of nephrolithiasis
D. Package 4: CT with and without contrast of the abdomen and pelvis
1. Patients who are on hemodialysis and are oliguric or anuric and have NO CONTRAST ALLERGY
E. Package 5: CT with and without contrast and CTA of abdomen and pelvis
1. Patients who are on hemodialysis and are oliguric or anuric and have NO CONTRAST ALLERGY who also need
imaging of
pelvis to define vasculature due to:
2. Known vascular disease, bruit on exam, poor peripheral pulses aneurysm
3. Previous transplant
***For patients who cannot tolerate an MRI and are unable to tolerate contrast CT due to an allergy to contrast dye
or relative contraindication to contrast, a non-contrast CT, abdominal ultrasound or other imaging will be considered
depending on medical history***
III. ADDITIONAL RADIOLOGICAL IMAGING
The following studies may be added to any of these packages by midlevel provider as follows:
A. Carotid Doppler Ultrasound
1. Known peripheral vascular disease
2. Known coronary artery disease
3. Type 1 Diabetes
4. Type 2 Diabetes
5. History of CVA or TIA
6. Significant history of tobacco abuse
7. Significant history of hyperlipidemia
8. Bruit on physical exam
B. MRA carotids
1. Known history of carotid stenosis
2. Previous carotid endarterectomy with or without bruit on exam
C. CT of Chest, without contrast, high resolution
1. History of abnormal chest x-ray
2. History of significant lung disease (ex: sarcoidosis, TB, histoplasmosis, malignancy, recurrent pleural effusion,
etc)
3. History of other malignancy to rule out metastasis
D. MRV of abdomen and pelvis to assess IVC and iliac veins
1. History of DVT
2. History of IVC filter placement
3. Chronic lower extremity edema
4. History of clotting disorder
IV. CARDIAC TESTING
All patients who are evaluated for a kidney and/or pancreas transplant will have a basic package of cardiac
imaging studies performed in the Cardiac Imaging Center (8-7226) as indicated as a part of their transplant
evaluation.
The purpose of these studies is to screen for findings that could potentially impact the patient’s outcome after
transplant, evaluate cardiac function and discover underlying coronary artery disease.
A. Package One: Transthoracic Echocardiogram (2D echo)
1. Patients < age 45 in otherwise generally good health with a normal EKG
2. Normal Cardiac catheterization within the past year
3. Normal, maximal stress test within past 6 months
4. CABG within the past 6 months
B. Package Two (A or B): Stress Test
1. Patients > 45 years old
2. Patients with an abnormal EKG
3. Patients with diabetes
4. Patients with a history of MI or known coronary artery disease
5. Patients with Systemic Lupus
6. Patients with greater than three major cardiac risk factors
7. Patients with significant family history of premature coronary artery disease
C. Package 2A: Adenosine Thallium Scan with Transthoracic Echocardiogram. All patients who need stress testing
and meet one of the
following criteria:
a. Patients taking significant doses of Beta Blocker Medication
b. Pacemaker/AICD
c. Aortic stenosis on exam, or known history of aortic stenosis
d. Concerning arrhythmia on EKG, or known history of concerning arrhythmia (i.e. atrial fibrillation, ventricular
fibrillation, heart
block,)
e. Known restrictive cardiomyopathy (sarcoidosis, amyloidosis)
f. HCT <25
g. Uncontrolled hypokalemia
h. Uncontrolled hypertension
D. Package 2B: Dobutamine Stress Echocardiogram
All patients who need stress testing who do not meet criteria above for Package 2A.
V. The medical secretary senior will schedule testing and fax requisitions to the appropriate departments, complete
with reason for testing, statement of basic history provided by midlevel provider.
Example: Non-Contrast CT Abdomen and Pelvis: Reason: Renal Transplant Evaluation, history of
kidney stone
Example: DSE: Reason: Renal Transplant Evaluation, Abnormal EKG
VI. Patients will be made aware of all testing to be completed. The medical secretary will provide patient with basic
written information about the tests to be performed, preparation instructions and directions to scheduled testing.
VII. Medical secretary senior will cancel testing if the patient no-shows for Day Two of their kidney transplant
evaluation. They will then contact the patient’s transplant coordinator who will contact the patient to determine if
testing should be rescheduled.
VIII. Critical results identified by these tests will be communicated by the respective department physicians to the
renal transplant department (404-727-0717). The medical secretary will notify the appropriate pre-transplant
coordinator and the ordering physician via OTTR email. Findings that require emergent attention or any significant
finding identified outside of normal business hours will be communicated by paging the ordering physician or the
renal transplant surgeon on call.
Approved by: Renal Transplant Leadership Group
_____________________________________
Thomas C. Pearson, M.D., DPhil
Chair, Renal Transplant Leadership Group
Director, Renal Transplant Program