AN EXAMINATION OF THE RENAL-TRANSPLANT EVALUATION PROCESS FOCUSING ONCOST AND THE REASONS FOR PATIENT EXCLUSION

A medical evaluation of prospective renal transplant recipients is per formed to identify conditions that may exclude patients from transplan tation because of unacceptable risks. Protocols for evaluating potenti al transplant candidates are available, but there is little informatio n about reasons for excluding patients from transplantation. To assess the effectiveness and cost of our renal transplant-recipient evaluati on process, we retrospectively reviewed patients excluded from renal t ransplantation between January 1993 and December 1995 to categorize th e reasons for exclusion. We also examined the costs of the evaluation. The study group included all adults referred for kidney-only transpla ntation during the study period who were excluded from transplantation (n = 125). Demographics of the 160 patients with end-stage renal dise ase (ESRD) who underwent renal transplantation during the study period were also examined. Compared with the patients who underwent transpla ntation, the excluded patients were older (48 +/- 14 v 43 +/- 12 years ; P = 0.006) and more likely to be women (66 of 125 patients; 53% v 57 of 160 patients; 36%; P = 0.005) and diabetic (59 of 125 patients; 47 % v 30 of 160 patients; 19%; P = 0.005), The most common reason for ex cluding patients was medical contraindication (46%), followed by patie nt declined (25%), obesity (10%, defined as a body mass index [BMI] gr eater than or equal to 35), patient death (6%), and insurance/financia l (5%), The medical reasons for exclusion were heart disease (38%), no ncompliance (28%), miscellaneous (22%), and cancer (12%), Tests perfor med after the initial evaluation included cardiac testing (stress thal lium or echocardiography and coronary angiography) in 50 patients, Dop pler studies of the lower extremities in 28 patients, and hepatitis C polymerase chain reaction (PCR) or recombinant immunoblot assay (RIBA) assays in 8 patients. The cost of standard pretransplantation blood w ork for selected tests (ABO blood group typing, HLA, hepatitis B and C , and cytomegalovirus)was $709, Deferring such routine pretransplantat ion blood work until after the patient education session and history a nd physical examinations by nephrology and surgery in the 31 patients( 25%) who declined transplantation at the initial visit would have resu lted in considerable savings. Our evaluation process now includes prer eferral information on a prospective recipient's medical problems, hei ght and weight, and basic screening laboratory tests. This protocol ha s resulted in a more efficient and cost-effective evaluation process. Further examination of the cost-effectiveness of the transplant evalua tion process is warranted. (C) 1998 by the National Kidney Foundation, Inc.