Renal Transplant Seminar

8/22/2019 Renal Transplant Seminar

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SEMINAR ON

KIDNEYTRANSPLANTATION


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Introduction:

Kidney transplantation is the modality of choicefor management of end-stage renal

disease(ESRD). Successful transplantation is more thana lifestyle choice for the ESRD

patient; it offerspatients a durable survival advantage over main-tenance hemodialysis. The

risk of mortality onthe waitlist is halved by successful transplantation . Health related quality

of life measuresare also substantially improved compared to waitlisted patients .

Transplantation involvesupfront risks to mortality stemming from a majorsurgical procedure

in a recipient with medicaland surgical comorbidity that is compounded bypharmacologic

immunosuppression. As such, thetransplant evaluation must be carried out by adedicated

multidisciplinary team of skilled medi-cal professionals with specific training and experience

in the field. The importance of such anapproach is underscored by the fact that transplant

centers are mandated to staff their centerswith such teams in order to maintain accreditation .

This session details the evaluation of the adultpatient with advanced kidney disease or

ESRDbeing considered for kidney transplantation.

Definition :

Kidney transplantation involves transplanting a kidney from a living donor or deceased donor

to a recipient who no longer has renal function

A living donor is a person who is alive at the time of donation and may or may not be related

to the recipient.

A deceased or cadaveric transplant comes from someone who has died and donated his or

her organs. Transplantation from well-matched living donors who are related to the patient

(those with compatible ABO and human leukocyte antigens) is slightly more successful than

from cadaver donors. The success rate further increases if kidney transplantation from a

living donor is performed before dialysis is initiated

Who Is a Kidney TransplantCandidate?

There is no strict cut off level of estimated GFR when referral for kidney transplant should be


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made. As a general guideline, the patient withadvancing chronic kidney disease (CKD), with

a glomerular filtration rate (GFR) estimate ormeasurement approaching 20 mL/min should

bereferred for transplant evaluation as an integralpart of their medical management. Ideally,

thought should be given to transplant referralwhen the prospective candidate is at NKF Stage

4 CKD, i.e., estimated GFR less than 30 mL/min or is anticipated to progress to ESRD within

the next 2 years. Diabetics have both a morerapid progression to ESRD and acceleration of

vascular disease on dialysis and should bereferred for transplantation earlier in the courseof

their renal disease to minimize the lead timeto transplantation.

Indications to kidneytransplantation :

Advancing CKD with estimated GFR approaching20 mL/min andProjected survival of 5

years irrespective of kidney

disease

Contraindications to kidney transplantation:

Reversible renal disease Active or recent malignancy (or metastatic) Active or recent untreated infection Severe irreversible extrarenal disease Severe functional disability with limited rehabilitationpotential Unmodifiable nonadherence to treatment Psychiatric illness: not remitting with treatmentand could affect consent and/or

adherence

Active current recreational drug use Prohibitively high risk of recurrence of native kidney disease


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Suggested elements of patient educationduring transplant candidate evaluation

1. Surgical Episode:Nature of the operation, surgical risks, medical and surgical complications, expected

length of stay, risks and side effects of medication, return to work dates, expected

functionalimprovement

2. Transplant Modalities:Relative benefits of living vs.deceased donor transplant and type of deceased donor

kidney (ECD vs. SCD, DCD, centers for diseasecontrol (CDC) High risk, etc.)

3. Waiting Time: Discuss relative impact of deceaseddonor kidney choice on waiting time. Provide reasonable estimates of expected waiting time. Explain pros and cons of listing at multiple centers. Explain the cadaver kidney allocation process.

4. Immunologic Risk: Explain the process of establishing histocompatibility and measuring sensitizationfor

cadaveric and living donation.

nature ofimmunosuppression. risks of immunosuppression(infection, malignancy, side effects). rates ofrejection . types of regimens used at the center

5. Expected Outcomes:Patient and graft survivalstatistics and rejection rates for the transplant center

and explain in the context of national statistics.

6. Donor Quality:Particularly applicable in thecontext of cadaveric donor transplants.

7. Compliance:Emphasize need for an enduringtherapeutic alliance compliance with dialysis when

waitlisted and with follow-up and treatmentadherence post-transplant.

8. Miscellaneous:Impact of transplant on functionalstatus, fertility, employment.

9. Financial:Explain costs associated with the transplant episode followup waitlist followup cost


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of immunosuppression; educate regarding assistance/fundraising.

10.Psychosocial:Explain possible stressors through the process and means for coping.

Pretransplant evaluation of the renal transplant candidate

1. History

(a) Cause of renal disease and pre ESRD treatment especially steroids, cytotoxics and

immunosuppression.

Review biopsy pathology

(b) Dialysis: duration, modality, access, progress

(c) Previous transplants: If yes, rejections, antibody induction, complications, compliance

(d) Blood Transfusions: establish sensitization

(e) Allergies and Medication intolerance

(f) Occupation, addiction (smoking, alcohol, otherdrugs), functional status, hobbies,

socialsupport

(g) Recent hospitalizations

(h) History of thromboembolic events

2. Review of systems

3. Past medical/surgical history including exposure to TB, travel, pets

4. Psychosocial evaluation

5. Medications: identify potential interactions with immunosuppressants and possible

substitutes

6. Physical examination

(a) BMI, vitals

(b) Visual and auditory deficits

(c) Heart murmur, evidence of heart failure

(d) Lungs: signs of COPD, fluid overload

(e) Abdomen: hepatomegaly, ascites, pain, herniae,

organomegaly, scars, dialysis access, bruits

(f) Vascular: Bruits: carotid, iliac, femoropopliteal,

peripheral pulses, ischemic ulcers

(g) Neurologic: Cognitive deficits, sequelaeof CVAs


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(h) Cutaneous: Skin cancers

7. Age and gender appropriate cancer screening(colonoscopy, mammogram, pap smear,

PSA)

8. Laboratory investigations:

(a) Complete blood count, coagulation profile,chemistries including liver function

panel,calcium phosphorus and PTH

(b) Urinalysis and Culture: (Routine but difficult tointerpret at times)

(c) Infectious Disease Panel: CMV serologies, EBVserology, VZV titers, hepatitis B and

C serologies, HIV antibody,

PPD with anergypanel, rapid plasma reagin (RPR; syphilis)

(d) Immunologic profile: Blood type (ABO), HLA

typing, and panel reactive antibody (PRA)

9. 12-lead EKG and chest X ray

10. Cardiac workup

(a) Assessment of exercise capacity

(b) Stress test: Dobutamine stress echocardiogram,

dipyridamole or adenosine stress test

(c) 2-D echocardiogram with Doppler

(d) Coronary angiography if needed

11. Urologic workup (select patients)

(a) Voiding cystourethrogram

(b) Urodynamic studies

(c) Cystoscopy

Cardiac evaluation of potential kidneytransplant recipient

No prior history of coronary artery disease: If patient is less than 40 years of age, has two or fewerrisk factors, normal ECG, and

has excellent functional

capacity (e.g., can climb two flights of steps quickly without stopping, jogging; orother equivalent to 6METS or greater), proceed directly to surgery orlisting. Repeat

assessment based on team judgment.

If patient does not qualify with all of the above, thencardiac stress testing orcatheterization is requiredwithin the year prior to evaluation.

Exercise or dobutamine-based testing must reach greaterthan 85% maximum


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predicted heart rate to beaccepted as a valid test.

If stress testing is acceptable, proceed with surgery orlisting. Repeat evaluation(s) atregularly interval atdiscretion of evaluating team.

If a positive stress test is discovered, then cardiologyreferral or catheterization isrequired to completecardiac evaluation.

The transplant team

During the evaluation process, you will be interviewed by many members of the transplant

team. The following are some of the members of the team:

Transplant surgeons. Doctors who specialize in transplants and who will beperforming the surgery.

Nephrologist. A doctor who specializes in disorders of the kidneys. Nephrologists willhelp manage your condition before and after the surgery.

Transplant nurse coordinator. A nurse who organizes all aspects of care provided toyou before and after the transplant. The nurse coordinator will provide patient

education, and coordinates the diagnostic testing and follow-up care.

Social workers. Professionals who will help your family deal with many issues thatmay arise including lodging and transportation, finances, and legal issues.

Dietitians. Professionals who will help you meet your nutritional needs before andafter the transplant.

Physical therapists. Professionals who will help you become strong and independentwith movement and endurance after the transplantation.

Pastoral care. Chaplains who provide spiritual care and support. Other team members. Several other team members will evaluate you before

transplantation and will make recommendations to the team. These include, but are not

limited to, the following:

Anesthesiologist Hematologist Infectious disease specialist Psychologist


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DONARS FOR KIDNEY TRANSPLANT

Deceased donor source and quality :

Term Definition:

Expanded criteria donors (ECD)

For kidney, any deceased donor over the age of 60 years; or from adonor over the age of 50

years with two of the following: a history of hypertension, a terminal serum creatinine >1.5

mg/dL, or death resulting from a cerebrovascular accident (stroke)

Donation after cardiac death (DCD)

Donation of any organ from a patient whose heart has irreversiblystopped beating. Includes

donors who also qualify as ECD

Standard criteria donors (SCD)

For kidney, a deceased donor who is neither ECD nor DCD.These donors have fewer risks

associated with graft failure

Kidney Transplant Recipient Surgery

Implant Location

The most common location for placing a kidneytransplant is in the retroperitoneal iliac

fossa,with vascular anastomoses to the external orinternal iliac artery and the iliac vein and

ureteralanastomosis directly to the bladder. There areseveral practical advantages for these

heterotopicchoices. Staying out of the peritoneal cavityallows more rapid return of bowel

function andany hemorrhage or urine leak is confined to asmaller nonabsorptive space,

making diagnosiseasier and more rapid. The kidney lies just underthe skin without any

intervening bowel, whichsimplifies subsequent percutaneous biopsy.


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Finally, the distance to the bladder is short,allowing for use of the better vascularized

proximal donor ureter for implantation.

Either side can be used for either kidney, andwhen both sides are equally available most

surgeons favor the right side because the rightiliac vein is usually more superficial than the

left and should the iliac vessels prove unsuitable,it is easier to move up to the aorta and

inferiorvena cava while still remaining retroperitoneal.

An alternate view is held by some surgeons whofavor keeping the renal pelvis and ureter

anterior(e.g., left kidney to right side, right kidney to leftside) to facilitate ureteral

reconstruction in theface of donor ureteral necrosis.

Rarely, if the pelvis is not useable, an orthotopic transplant can be done by removing the left

native kidney and anastomosing the donor veinto the recipient renal vein, the donor artery to

the splenic artery, and the donor ureter to therecipient ureter.

Preparation of Donor Kidney:

Typically, the donor kidney is prepared prior toimplantation on a back table, which allowsoptimal positioning, lighting, and magnification. Thekidney is kept in a basin that contains

both sterilesaline and ice. As long as both saline and ice arepresent, the temperature of the

fluid shouldremain between 1C and 4C. The degree ofgraft preparation could vary from

minimal in thecase of an open living kidney donor to significant in the case of an en bloc

kidney procurement. Preferably to start by placing a mosquitoclamp on the end of the ureter

and holding it offto the side to prevent inadvertent transection.The renal vein and artery are

then cleaned andany side branches that do not enter the kidneyare ligated.

Venous Preparation:

The left renal vein is usually of sufficient lengthonce the main side branches (adrenal,

lumbar,and gonadal) are ligated. Note that the entiregonadal vein should be dissected away,

becauseit can take small tributary branches from the kidney and ureter and therefore may

bleed eventhough both ends are ligated. Because the venousdrainage communicates within

the kidney, smallaccessory renal veins may be tied off; however,when multiple veins are of


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similar size, theyshould be preserved, either by conjoining or byusing a jump graft.

The right renal vein has two limitations: it is shorter than the left renal vein and is often

thinner, especially posteriorly. In a living donor, acuff of donor cava can give thicker tissue

toanastomose. In a cadaveric donor, when the kidneys are split, the entire remaining cava

shouldbe sent with the right kidney. This allows the useof cava to extend the right renal

vein, often to alength equal to or exceeding the right renalartery. When inspecting the donor

cava, firstensure that the suprarenal portion is intact, as it may be damaged or scalloped

during removalof the liver. The most common reconstructiontechnique is to cut the cava in

line with the rightrenal vein and to then sew the superior and inferior parts of the cava with

5-0 Prolene suture. The left renal vein orifice oftenremains as a convenient opening to

anastomoseto the recipient. If more length is required, thenthe cava can be rotated in line

with the renal veinand only the superior opening closed withProlene (Fig. 10.3). The lower

cava can then beanastomosed end to side directly to the recipient.

Note that this requires careful ligation of allremaining lumbar venous branches coming from

the cava and may result in a very wide anastomosis. After any reconstruction, testing of the

vessels by irrigating with heparinized saline shouldshow any missed branches or large gaps

in theclosures.

Arterial Preparation:

The renal artery orifice should be carefullyexamined for injury, especially flaps of intimal

plaque or aneurysms, which may not be obviouswhen the artery is undistended. The artery

shouldbe cleaned followed towards the hilum, takingcare to preserve renal branches. All

renal arteriesare end arteries, so any branches that are ligatedwill result in a region of non-

perfused renalparenchyma. This is especially important forlower pole branches, which often

provide theentire blood supply for the donor ureter. Notethat an upper pole branch may at

first appear tosimply be an adrenal artery. Trace its path proximally and you may discover

that it takes a sharpturn into the renal parenchyma. When the renalartery does not have

donor aorta attached (livingdonor or diseased cadaveric aorta) I prefer tomake a small


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spatulation inferiorly, which aidsin orientation later. When donor aorta is attachedand

healthy, a small rim of aorta can be preserved(Carrel patch), which minimizes trauma to the

renal intima during anastomosis (Fig. 10.4).

Multiple renal arteries can be handled by avariety of techniques, depending upon number,

size, relative length, presence and health ofdonor aorta, and separation. With a cadaveric

donor,the simplest approach is to use a patch of donoraorta that includes all the renal artery

orificesFig. 10.3). This necessitates a longer recipientarteriotomy, and if the resultant patch

is greaterthan 4 cm, it can be reconstructed on the backtable to still allow a single recipient

anastomosisbut not be so long. If donor aorta is not availableor too diseased, arteries can be

anastomosed

Kidney with multiple vessels placed in stockinette. Stockinette is filled with iced slush and

the vessels brought out through separate openings, which allows the kidney to remain cold

during the recipient anastomosis. Two renal arteries kept together on a common

aortic patch (A). The two renal veins were kept on the inferior cava which was rotated in line

with the vessels to provide extra length (B). A third lower pole renal artery, not identified

during the organ procurement was anastomosed separately (C)


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Left kidney after back table preparation. There is a small Carrel patch on the artery (A). The

renal vein has all side branches tied (B). Perinephric fat in the golden triangle between the

lower pole of the kidney and proximal ureter is intact to preserve ureteral blood

supply (C)

Final Preparation:

Once the vessels and ureter are prepared, perinephric fat is removed, taking care not to cut the

renal capsule, which may be adherent to the fat. Any suspicious solid lesions should be

biopsied and sent for frozen section and any large cysts should be deroofed to ensure no

internal solid components. All vessels should be flushed manually with cold heparinized

saline to ensure no leaks requiring ligation or suture. It is a preference to place the kidney in a

sterile cloth stockinette that is filled with slush. Both ends are closed with clips and the

vessels brought out through a separate opening at the midpoint

This allows the kidney to remain cold throughout the anastomosis and makes manipulation of

the kidney easier


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Renal transplantation: Repair of transplant ureteral necrosis using

the native ureter (uretero-ureterostomy). (a) Distal ureteral

necrosis. Pooling of urine is seen in the wound. (b)

After repair. The native ureter mobilized and transected.

Anastomosis to the proximal transplant ureter was end to

end over an indwelling stent using running 5-0 PDS

suture. The native ureter was tied proximally without

native nephrectomy

1, The transplanted kidney is placed in the iliac

fossa.

2, The renal artery of the donated kidney is sutured to the ileac artery, and the renal vein is

sutured to the iliac vein.


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3,The ureter of the donated kidney is sutured to the bladder or to the patients ureter.

1. Transplanted donorkidney cradled in ilium

2. Renal artery sutured

to iliac artery

Renal vein sutured to

iliac vein

3. Ureter sutured


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Kidney Transplant Recipient Surgery

Back table repairof short

renal vessels:

Twoshort renal veins were

extended with the use of

cadaveric iliac vein (A). The

short renal artery wasextended

with a segment ofgonadal vein

(B)

Back table preparation of a right kidney:

The right renal vein has been extended with the inferior

vena cava by cutting the cava in line with the vein and

oversewing the superior and inferior openings (A). The

old orifice of the left renal vein can then be used to anastomose to the recipient. Note Carrel patch on renal

artery, which still needs to be trimmed (B)


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Ureteral Preparation

Since all perfusion of the donor ureter must comefrom the donor renal arteries, preservation of

theureteral blood supply is essential.

This is bestaccomplished by leaving intact the fat and adven-titial tissue found in a triangle

formed by the ure-ter, inferior pole of the kidney, and renalartery(ies).

.

Medical Management


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After a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3

to 14 days (acute), or after many years. The long-term survival of a transplanted kidney depends

on how well it matches the recipient and how well the bodys immune response is controlled.

Since the bodys immune system views the transplanted kidneyas foreign, it continually works

to reject it. To overcome or minimize the bodys defense mechanisms, immunosuppressive

agents are administered. Optimally, medications modify the immune system enough to prevent

rejection, but not enough to allow infections or malignancies to occur.

Combinations of glucocorticoids and medications specifically developed to affect the action of

lymphocytes are used to minimize the bodys reaction to the transplanted organ.

Treatment with combinations of new agents has dramatically improved survival rates, and now

90% to 95% of transplanted kidneys still function after 1 year (American Nephrology Nurses

Association, 2007b). Doses of immunosuppressive agents are often adjusted depending on the

patients

immunologic response to the transplant. However, the patient will be required to take some form

of

immunosuppressive therapy for the entire time that he or she has the transplanted kidney.

THE RISKS ASSOCIATED WITH TAKING IMMUNOSUPPRESSIVE MEDICATIONS

INCLUDE (American Nephrology Nurses Association, 2006).

1. nephrotoxicity2. hypertension3. hyperlipidemia4. hirsutism,5. tremors,6. blood dyscrasias,7. cataracts8. gingival hyperplasia,9. several types of cancer

Nur sing M anagement

Assessing the Patient for Transplant Rejection


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After kidney transplantation, the nurse assesses the patient for signs and symptoms of transplant

rejection: oliguria, edema,fever, increasing blood pressure, weight gain, and swelling or

tenderness over the transplanted kidney or graft.

Patients receiving cyclosporine may not exhibit the usual signs and symptoms of acute rejection.

In these patients, the only sign may be an asymptomatic rise in the serum creatinine level

(more than a 20% rise is considered acute rejection).

Preventing Infection

The results of blood chemistry tests and leukocyte and platelet counts are monitored closely

because immunosuppression depresses the formation of leukocytes and platelets.

The patient is closely monitored for infection because of susceptibility to impaired healing and

infection related to immunosuppressive therapy and complications of renal failure.

Clinical manifestations of infection include shaking chills, fever, rapid heartbeat (tachycardia),

and respirations (tachypnea), as well as either an increase or a decrease in WBCs (leukocytosis

or leukopenia).

Infection may be introduced through the urinary tract,the respiratory tract, the surgical site, or

other sources.

Urine cultures are performed frequently because of the high incidence of bacteriuria during early

and late stages of transplantation.

Any type of wound drainage should be viewed as a potential source of infection because

drainage is an excellent culture medium for bacteria. Catheter and drain tips may be cultured

when removed by cutting off the tip of the catheter or drain (using aseptic technique) and placing

the

tip in a sterile container to be taken to the laboratory for culture

The nurse ensures that the patient is protected from exposure to infection by hospital staff,

visitors, and other

Renal Transplant Rejectionand In fection

Renal graft rejection and failure may occur within 24 hours (hyperacute), within 3 to 14 days

(acute), or after many years (chronic). It is not uncommon for rejection to occur

during the first year after transplantation.


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Detecting Rejection

Ultrasonography may be used to detect enlargement of the kidney; percutaneous renal biopsy

(most reliable) and x-ray techniques are used to evaluate transplant rejection. If the body rejects

the transplanted kidney, the patient needs to return to dialysis. The rejected kidney may or may

not be

removed, depending on when the rejection occurs (acute versus chronic) and the risk for

infection if the kidney is left in place.

Potential Infection

About 75% of kidney transplant recipients have at least one episode of infection in the first year

after transplantation because of immunosuppressant therapy. Immunosuppressants

of the past made the transplant recipient more vulnerable to opportunistic infections (candidiasis,

cytomegalovirus,Pneumocystis pneumonia) and infection with other relatively nonpathogenic

viruses, fungi, and protozoa, which can be a major hazard.

Cyclosporine therapy has reduced the incidence of opportunistic infections because it selectively

exerts

its effect, sparing T cells that protect the patient from life-threatening infections. In addition,

combination immunosuppressant therapy and improved clinical care have produced 1-year

patient survival rates approaching 100% and graft survival exceeding 90%. Infections,

however, remain a major cause of death at all points in time for kidney transplant recipients

(Danovitch, 2005 patients with active infections. Attention to hand hygiene by all who come in

contact with the patient is imperative.

Monitoring Urinary Function

A kidney from a living donor related to the patient usually begins to function immediately after

surgery and may produce large quantities of dilute urine. A kidney from a cadaver donor

may undergo acute tubular necrosis and therefore may not function for 2 or 3 weeks, during

which time anuria, oliguria, or polyuria may be present. During this stage, the patient may

experience significant changes in fluid and electrolyte status.


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Therefore, careful monitoring is indicated. The output from the urinary catheter (connected to a

closed drainage system) is measured every hour. IV fluids are administered on the basis of urine

volume and serum electrolyte levels and as prescribed by the physician. Hemodialysis may be

necessary postoperatively to maintain homeostasis until the transplanted kidney is functioning

well. It also may be required if fluid overload and hyperkalemia occur. After successful renal

transplantation,

the vascular access device may clot, possibly from improved coagulation with the return of renal

function. The vascular access for hemodialysis is monitored to ensure patency

and to evaluate for evidence of infection.

Addressing Psychological Concerns

The rejection of a transplanted kidney is of great concern to the patient, the family, and the

health care team for many months. The fear of kidney rejection and the complications of

immunosuppressive therapy (Cushings syndrome, diabetes, capillary fragility, osteoporosis,

glaucoma, cataracts,

acne, nephrotoxicity) place tremendous psychological stress on the patient. Anxiety and

uncertainty about the future and difficult posttransplantation adjustment are often sources of

stress for the patient and family.

An important nursing function is the assessment of thepatients stress and coping. The nurse

uses each visit with the patient to determine if the patient and family are coping effectively and

the patient is adhering to the prescribed medication regimen. If indicated or requested, the nurse

refers the patient for counseling.

Monitoring and Managing Potential Complications

The patient undergoing kidney transplantation is at risk for the postoperative complications that

are associated with any surgical procedure. In addition, the patients physical condition may be

compromised because of the effects of long-standing renal failure and its treatment. Therefore,


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careful assessment for the complications related to renal failure and those associated with a

major surgery are important aspects of nursing care. Breathing exercises, early ambulation,

and care of the surgical incision are important aspects of postoperative care.

GI ulceration and corticosteroid-induced bleeding may occur. Fungal colonization of the GI tract

(especially the mouth) and urinary bladder may occur secondary to corticosteroid

and antibiotic therapy. Closely monitoring the patient and notifying the physician about the

occurrence of these complications are important nursing interventions. In addition, the patient is

monitored closely for signs and symptoms of adrenal insufficiency if the treatment has included

use of corticosteroids.

Promoting Home and Community-Based Care

Teaching Patients Self -Care.

The nurse works closely with the patient and family to be sure that they understand the need for

continuing immunosuppressive therapy as prescribed.

Additionally, the patient and family are instructed to assess for and report signs and symptoms of

transplant rejection, infection, or significant adverse effects of the immunosuppressive

regimen. These include decreased urine output; weight gain; malaise; fever; respiratory distress;

tenderness over the transplanted kidney; anxiety; depression;changes in eating, drinking, or other

habits; and changes in blood pressure. The patient is instructed to inform other health care

providers (eg, dentist) about the kidney transplant and the use of immunosuppressive agents.

Continuing Care. The patient needs to know that follow up care after transplantation is a

lifelong necessity. Individual verbal and written instructions are provided concerning

diet, medication, fluids, daily weight, daily measurement of urine, management of I&O,

prevention of infection, resumption of activity, and avoidance of contact sports in which the

transplanted kidney may be injured. Because of the risk for other potential complications, the

patient is followed closely.

Cardiovascular disease is the major cause of morbidity and mortality after transplantation, due in

part to the increasing age of patients with transplants. An additional problem is possible

malignancy; patients receiving long-term immunosuppressive therapy are at higher risk for

cancers


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than the general population. So the patient is reminded of the importance of health promotion

and health screening.

WARNING SIGNS OF POSSIBLE TRANSPLANT REJECTION

Fever over 100F (38C) "Flu-like" symptoms: chills, aches, headache, dizziness, nausea and/or vomiting New pain or tenderness around the kidney Fluid retention (swelling) Sudden weight gain greater than 2 to 4 pounds within a 24-hour period Significant decrease in urine output

Causes of kidney transplant failure

Death with function Failure of the transplant kidney Chronic allograft nephropathy chronic transplant glomerulopathy Recurrent or de novo disease (including BK virus nephropathy: 110%) Miscellaneous and mixed picture (unknown, multifactorial, end-stage renal disease from medical illness) Technical and thrombosis Outright rejection

Potential Complications


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Hemodynamic instability

Hypervolemia/hypovolemia

Hypertension/hypotension

Renal failure (donor kidney)

Excessive immunosuppression

Electrolyte imbalances

Deep vein thrombosis

Sepsis

Nursing management of patients for greater renal transplant success

Nurses have an important role in helping tailor individual immunosuppressive regimens to

maximise patient and kidney graft survival and to aid concordance with treatment, a key issue in

managing transplant patients.

Causes of chronic graft dysfunction

. Histocompatibility and/or insufficient immunosuppression are well-known risk factors for acute

rejection. However, as more potent immunosuppression has been developed, very few renal

transplants are now lost from acute rejection.

In chronic graft failure, a variety of predisposing factors seem to contribute Chronic transplant

nephropathy accounts for 30% of graft loss and is one of the commonest causes of the need for

dialysis (Moore, 2000).

Long-term complications

One key issue in transplantation is how much immunosuppressive therapy should be given. Too

little immunosuppression increases the risk of infections, including bacterial disease, viruses


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(particularly cytomegalovirus and herpes zoster), and fungal conditions, such as candida. There

is also a risk of post-transplant lymphoproliferative disease. This disorder may respond to a

reduction in the dose of immunosuppression, but can be fatal (Amlot, 2000).

In the long term, immunosuppression is associated with further risks, including:

- Malignancy, which is common among transplant patients

- Ischaemic heart disease (related to drug-associated hypertension, nephrotoxicity and lipid

abnormalities)

- Osteoporosis, especially in relation to steroids (Paul, 1999; Ball et al, 2000).

Non-concordance

Non-concordance is known to be an important factor in graft failure (Fernando, 1997) and

represents a significant health risk for patients (Box 3). Non-concordance with

immunosuppressive medications has been reported to be the third leading cause of such loss,

after rejection and systemic infection (Greenstein and Siegal, 1998).

All immunosuppressive agents have side-effects, and this can be a key factor affecting patient

concordance. Since patients must continue taking immunosuppressive treatments for the life of

their graft, it is essential to take into account the side-effect profiles of different agents and their

potential impact on patient concordance. For example, altered body image can cause renal

transplant recipients great anxiety and stress, while cosmetic and general side-effects can affect

concordance with the immunosuppressive regimen (Hasselder, 1999).

Managing a successful transplant involves communication, education, as well as understanding

by the patient of the treatment and its side-effects. Monitoring clinical outcome requires regular

follow-up of all patients by the transplant team. The focus of patient management is on long-term

survival of the kidney graft and the long-term physical and mental health of the transplant

recipient. The transplant nurse has a particular role in this area (Lipkin, 1999). Concordancemanagement is a multidisciplinary task but the role of the nurse is critical (De Geest, 1998).


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The transplant nurse practitioner

The response of the individual patient to life with a transplant vary greatly: age, gender,

employment status, stability, security and personality will all have an impact.

Education and support are probably the most important ways in which nurses can influencepatients. Throughout the entire process of transplantation, from first entering the waiting list,

through the operative period itself, to the follow-up care stage, there is a need for extensive

nursing input (Mackenzie, 2001).

The best approach is to build a relationship with the transplant recipient throughout the process

and develop a caring, supportive environment in which patients feel able to discuss problems

(Fernando, 1997; Hasselder, 1999). High-quality education is also needed. This should start

before the transplant so that patients are aware of the potential side-effects of the drugs they willbe taking (Trevitt et al, 2000). Some patients may feel intimidated by doctors, while others leave

the clinic unable to remember all the information they have been given. To help overcome these

problems many hospitals employ nurse practitioners.

The nurse clinician

The complementary roles of nurse clinician and the nurse-led clinic provide a unique opportunity

to combine a holistic approach to the care of renal transplant patients (Holley and McGuirl,

2000). There is evidence that patients find high levels of satisfaction from nurse consultations(Murray, 1997) and are accepting of alternative care delivery systems (Fitzmaurice et al, 2000).

Key roles of nurses in renal transplantation

Non-concordance with immunosuppressive medications is common among renal transplant

patients and is a significant contributor to graft loss. Nurses can play a key role in the

multidisciplinary team in the prevention of problems, providing early detection and prompt

management. The friendliness of a particular team may be an important factor. Patients may feel

the transplant does not eliminate health-related stress, so they need to be able to approach non-physician members and discuss particular problems in regard to how they handle the demands of

their therapy.

The role of the nurse in transplant patient care has enhanced the transplant service for both the

patient and the multidisciplinary team (Valentine and Russell, 1998; Reece, 1999). One goal of


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treating transplant patients is to ensure that their quality of life is as high as possible, and

monitoring the side-effects of immunosuppression regimens is a way to help achieve this. Nurses

have more interaction with patients than any other health professionals, giving them an

advantage when monitoring for side-effects, such as cardiovascular risk factors, which may not

be immediately apparent to the patient as more superficial problems.

NURSING CARE PLAN :

PREPROCEDURE PERIOD

Nursing Diagnosis

1. knowledge deficit related to diagnosis and anticipated surgical experience2. Anxiety related to the wait for a donor kidney to become availablePOSTOPERATIVE PERIOD

Nursing Diagnosis

1. High risk for infection related to altered immune system secondary toimmunosuppressant medications

2. High risk for altered oral mucous membrane related to increased susceptibility toinfection secondary to immunosuppression

3. High risk for self-concept disturbance related to transplant experience, potential forrejection, and side effects of medications

4. High risk for noncompliance related to complexity of treatment regimen and euphoria5. High risk for ineffective management of therapeutic regimen related to insufficient

knowledge of prevention of infection, activity progression, dietary management, daily

record keeping, pharmacologic therapy, signs and symptoms of infection and rejection,

effective birth control measures/pregnancy recommendations, follow-up care, and

community resources.


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1. Knowledge Deficit Related To Diagnosis And Anticipated Surgical ExperienceOutcome/Short Term

Patient Centered

Goals

Planning/Interventions

Implementation

Rationale for

interventions

Evaluation

Patient will improve

his knowledge

Prepare the patient for

transplantation and a

prolonged recovery period

and offer him ongoing

emotional support.

Encourage the patient to

express his feelings.

Describe routine

preoperative measures,

such as thorough physical

examination and

a battery of laboratory tests

to detect any infection.

Tell the patient the hellundergo dialysis the day

before surgery to clean his

blood of unwanted fluid

and electrolytes.

Teach the patient the

proper methods for

performing coughing,

turning, deep breathing

and, if ordered incentive

spirometry.

Administer blood

transfusions as ordered.

The high level of

anxiety and tension is

reduced by orienting

patient to the need

for surgery and the

postoperative care

Patient is confident

to face the operation

with least tension

and doubtsas

evidenced by his

voluntary consent

and cooperation to

undergo surgery .


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Ensure the patient or a

responsible family member

has signed a consent form

consenting to a

transplantation.

Throughout the recovery

period, watch for signs and

symptoms of tissue

rejection.

Assess the patient for pain

and provide analgesics as

ordered.

Carefully monitor urine

output.

Connect the patients

indwelling catheter to a

closed drainage urinary

catheter to a closed

drainage system to prevent

overextension of the

bladder.

Review daily results of

renal function test.

Stress strict compliance

with all prescribed

medication regimens.


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Nursing Diagnosis: Risk for Infection related to inadequate secondary defenses

(immunosuppression)

Outcome/Short TermPatient Centered

Goals

Planning/InterventionsImplementation

Rationale forinterventions

Evaluation

Patient will remain

free of infection.

Maintain a clean

patient environment,

wear a mask in

patients room if policy

indicates.Follow strict hand

washing technique.

Limit the number and

duration of invasive

devices.

Encourage incentive

spirometry, deep

breathing and

ambulation.

Assess patients mouth

for white lesions

characteristic of oral

The high level of

immunosuppression in

the first month post

transplant predisposes

the patient to developnosocomial infections.

However, the patient

has not been

immunosuppressed

long enough to develop

opportunistic

infections.

After the first month

the patient may

develop candidiasis.

Patient will be

afebrile, WBC count

will be within normal

limits, there will be

no infiltrates on chestx-ray, IV sites will be

benign, no evidence

of UTI, fatigue,

anorexia, diarrhea, or

candidiasis.


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candidiasis.

Apply topical

antifungal as directed.

Nursing Diagnosis: Risk for Fluid Volume Excess related to renal insufficiency, steroid therapy

or decreased cardiac output

Outcome/Short Term

Patient Centered Goals


Implementation

Rationale for

interventions

Evaluation

Patient will remain

euvolemic.

Weigh patient daily

and

monitor blood

pressure: Compare

both to baseline values.

Auscultate lungs for

crackles.

Monitor RAP and

PAWP if indicated.

Notify physician of

indications of fluid

volume excess

including 3 pound

weight gain in three

days.

Collaborate with

physician and patient to

determine fluid

Following renal

transplantation from a

deceased donor, the

kidney may not

function optimally at

first resulting in fluid

volume excess. Fluid

volume excess may

also develop from use

of steroids and from

decreased cardiac

output in any

transplant recipient.

The nurse must

identify the volume

excess and collaborate

with the patient and

physician return the

Weight and blood

pressure will return to

baseline.

Lungs will remain

clear to auscultation.

RAP and PAWP will

return to baseline.

Serum Sodium will

remain within normal

limits.


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allotment and

medication or dialysis

management of volume

excess.

Monitor serum

Sodium and potassium

levels.

patient to a euvolemic

state.

Nursing Diagnosis: Disturbed Body Image related to permanent changes in body due toimmunosuppression

Outcome/Short Term

Patient Centered Goals


Implementation

Rationale for

interventions

Evaluation

Patient will develop a

realistic sense of self.

Provide an empathetic

environment so that

patient can discuss herconcerns about her

changed body.

Collaborate with

patient to develop

strategies to cope with

changes such as:

Help female patients

to find a way to

manage excessive

facial hair.

Encourage exercise

and appropriate diet to

Encouraging the

patient to describe her

concerns will assurethat the nurse is

addressing the

patients concerns.

Jointly developed

strategies are more

likely to be successful

Patient will identify

strategies to respond

to the changes in herbody.

Patient will verbalize

that her body feels

like her own.


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limit weight gain.

Encourage patient to

socialize with family

and peers.

JOURNAL :

http://www.sciencedaily.com/releases/2010/09/100902173249.htm

New Warning Signs May Predict Kidney Transplant Failure

Sep. 3, 2010Kidney transplants that show a combination of fibrosis (scarring) and

inflammation after one year are at higher risk of long-term transplant failure, according to a

study appearing in an upcoming issue of theJournal of the American Society of

Nephrology (JASN).

To identify these abnormalities, doctors would need to perform routine biopsies on apparently

normal kidney transplants -- rather than waiting for problems to occur. "Even for some

transplants that would be expected to have a very long graft survival, protocol biopsies

performed in the first year may indicate the kidney is undergoing damaging inflammation, which

is associated with increased risk for reduced function and graft survival," comments Mark D.

Stegall, MD (Mayo Clinic, Rochester, MN).

As part of a project to explore the reasons for long-term kidney transplant failure, the Mayo

Clinic transplant program has been performing routine biopsies at regular intervals after

transplantation. The Mayo Clinic program was among the first to incorporate such "protocol"

biopsies into the routine care of clinically stable transplants.

The researchers analyzed factors related to transplant survival in 151 patients who had no

apparent problems after living-donor kidney transplantation. One-year biopsies showed no

abnormalities in 57 percent of kidneys; another 30 percent had fibrosis (scarring) but no
http://www.sciencedaily.com/releases/2010/09/100902173249.htmhttp://www.sciencedaily.com/releases/2010/09/100902173249.htmhttp://www.sciencedaily.com/releases/2010/09/100902173249.htm


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inflammation. In these two groups, the transplanted kidney continued to function normally from

one to five years' follow-up.

However, in the remaining 13 percent of transplants, the biopsies showed fibrosis plus

inflammation. These transplants had declining kidney function and a reduced long-term

survival rate. Kidneys showing fibrosis plus inflammation also had increased numbers of

immune cells as well as a "rejection-like" gene expression signature.

Thus, in apparently normal kidney transplants, biopsies showing fibrosis and inflammation

signal kidney damage and an increased risk of long-term failure. "It is likely that the

intragraft environment of patients with fibrosis and inflammation is damaging to the allograft,"

says Stegall.

Without routine "protocol" biopsies, these warning signs would go undetected until clinical

abnormalities developed, according to Stegall. "The use of protocol biopsies allows for more

detailed investigations of the intragraft environment," he says. "Such routine biopsies could

provide a unique way to predict which kidney transplant recipients may be at increased risk for

loss of kidney function, or to identify potential targets for early preventative treatment."

The study was limited to patients who received kidneys from living donors and who had no

apparent complications during the first year. As a result, the findings may not apply to other

groups of transplant recipients, including those who have complications such as delayed

transplant function or acute rejection.

Conclusion

Nurses caring Renal Transplant patients must have expertise not only in nephrology but also in

immunology .Management of medication, fluid balance and other problems often surrounded by

complications such as Graft Loss, Failing Renal Transplant and Obstructive Uropathy pose


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serious challenges to renal nurses. Development of protocols and incorporation of Nursing

Theories into the care process enhances nurse care for renal transplant patients.

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Immunology and transplant (Shrigley Hall, November 24, 1998). Tunbridge Wells:

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http://www.asrn.org/journal-nursing/375-nurse-interventions-in-renal-transplantation.html
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Renal Transplant Seminar

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