diagnosis and management of waiting patients

The waiting list process follows a common procedure for all transplant centers.

The diagnosis and treatment of patients awaiting an organ transplant are defined according to the severity of the pathology from which they suffer.

Kidney transplant

A kidney transplant never takes on the characteristics of life-saving therapy, as is the case with liver, heart and lung transplants, but is a choice aimed at improving the quality of life.

Particular attention must therefore be paid to the assessment of risk factors.

The absolute contraindications to transplantation are now limited to borderline situations where other very serious pathologies are present.

Even age is not an immediate exclusion factor, although additional investigations are necessary as one ages.

More frequently, the contraindications are not so much related to kidney transplantation, understood as a surgical procedure, as to immunosuppressive treatment.

Liver transplant

Cirrhosis in all its forms is the leading cause of liver failure in Europe and the United States.

The conditions for inclusion on a waiting list are based on in-depth medical evaluations which mainly concern

  • irreversibility of liver failure;
  • the stage of the disease;
  • the presence of intercurrent illnesses;
  • the possibility of behavior in the patient that can lead to a recurrence of liver disease (alcoholism, drug addiction).

When the potential patient is not yet an adult, liver disease can cause growth retardation.

Pediatric liver transplantation is therefore indicated at an earlier stage of the disease than in adults.

The contraindications are important for the selection of candidates for transplantation and are mainly the unacceptable operative and postoperative risk.

Many are general contraindications for any major surgery, such as severe lung and heart disease.

Others, such as uncontrolled infections or intercurrent tumours, may be aggravated by immunosuppressive therapy.

Heart transplant

It is indicated in any heart failure which reaches the terminal stage of its evolution and for which there is no other therapeutic alternative.

The cardiomyopathies that most frequently lead to a transplant are:

  • Dilated cardiomyopathies: almost always primary;
  • Ischemic cardiomyopathies: in elderly patients,
  • Cardiomyopathies of other origin: these are rarer (valvular cardiomyopathy and congenital tumoral cardiomyopathy).

To be placed on the waiting list, the candidate for heart transplantation must present no absolute contraindications.

Some conditions that were universally recognized as absolute contraindications in the early 1980s are now only relative contraindications or have even been dropped as selection criteria.

Relative contraindications

  • Advanced age
  • Severe pulmonary hypertension
  • Severe renal or hepatic dysfunction
  • Systemic infection in active phase
  • History of behavioral problems
  • Insulin-dependent diabetes mellitus

Lung transplant

In order to assess the risk and benefit of lung transplantation, it is necessary to define the natural history, stage, quality of life and life expectancy associated with the pathology leading to end-stage chronic respiratory failure. .

This pathology must not be too advanced, so as not to exclude the success or the possibility of transplantation, and at the same time its severity must be such that it justifies the risks of transplantation.

It is important that the patient understands the importance of this evaluation process and is informed that with lung transplantation they will have a better quality of life and longer life expectancy, but may experience side effects and will still have to undergo treatment and post-operative clinical examinations.

The graft can be single or bilateral; it is usually bilateral if an infectious component is present, to prevent spread to the transplanted organ.

In the case of pathologies likely to recur in the transplanted organ (eg neoplasms, post-embolic pulmonary hypertension, pulmonary fibrosis secondary to connective tissue disease), the indication for transplantation must be carefully assessed.

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