Focus on Kidney Transplant
(Relates to Chapter 47, “Nursing Management:
Acute Kidney Injury and Chronic Kidney Disease,”
in the textbook)
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Kidney Transplantation
•More than 75,000 patients are currently awaiting kidney transplants.
•Less than ¼ ever receive a kidney.
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Kidney Transplantation
•Extremely successful•1-year graft survival rate
90% for cadaver transplants 95% for live donor
transplants
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Kidney Transplantation
•Advantages of kidney transplant compared with dialysis Reverses many of the
pathophysiologic changes associated with renal failure
Eliminates dependence on dialysis Less expensive than dialysis after
the first year
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Kidney TransplantationRecipient Selection
•Candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers.
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Kidney TransplantationRecipient Selection
•Contraindications to transplantation Disseminated malignancies Untreated cardiac disease Chronic respiratory failure Extensive vascular disease Chronic infection Unresolved psychosocial
disorders
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Kidney TransplantationHistocompatibility Studies
•Purpose of testing is to identify the HLA antigens for both donors and potential recipients.
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Kidney TransplantationDonor Sources
•Compatible blood type deceased donors
•Blood relatives•Emotionally related living
donors•Altruistic living donors•Paired organ donation
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Kidney TransplantationSurgical Procedure
•Live donor Nephrectomy performed by a
urologist or transplant surgeon Begins an hour or two before
the recipient’s surgery is started
Rib may need to be removed for adequate view
Takes about 3 hours
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Kidney TransplantationSurgical Procedure
•Live donor Laparoscopic donor
nephrectomy•Alternative to conventional nephrectomy
•Most common approach of live kidney procurement
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Kidney TransplantationSurgical Procedure
•Kidney transplant recipient Usually placed
extraperitoneally in the iliac fossa
Right iliac fossa is preferred.
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Kidney Transplant
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Fig. 47-15. A, Surgical incision for a renal transplant. B, Surgical placement of transplanted kidney.
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Kidney Transplantation Surgical Procedure
Kidney transplant recipient•Before incision
Urinary catheter placed into bladder
Antibiotic solution instilled•Distends the bladder•Decreases risk of infection
Crescent-shaped incision
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Kidney Transplantation Surgical Procedure
Kidney transplant recipient•Rapid revascularization
critical•Donor artery anastomosed to
recipient internal/external iliac artery
•Donor vein anastomosed to recipient external iliac vein
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Kidney Transplantation Surgical Procedure
Kidney transplant recipient•When anastomoses
complete, clamps released and blood flow reestablished
•Urine may begin to flow, or diuretic may be given.
•Surgery takes 3 to 4 hours.
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Kidney TransplantationNursing Management
•Preoperative care Emotional and physical
preparation Immunosuppressive drugs ECG Chest x-ray Laboratory studies
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Kidney TransplantationNursing Management
•Postoperative care Live donor
•Care is similar to laparoscopic nephrectomy.
•Close monitoring of renal function
•Close monitoring of hematocrit
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Kidney TransplantationNursing Management
•Postoperative care (cont’d) Recipient
•Maintenance of fluid and electrolyte balance is first priority.
•Large volumes of urine soon after transplanted kidney placed due to
New kidney’s ability to filter BUN Abundance of fluids during operation Initial renal tubular dysfunction
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Kidney TransplantationNursing Management
•Postoperative care (cont’d) Recipient
•Urine output replaced with fluids milliliter by milliliter hourly
Urine output closely measured•Acute tubular necrosis can occur.
May need dialysis•Maintain catheter patency.
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Kidney TransplantationImmunosuppressive Therapy
•Goals Adequately suppress the
immune response. Maintain sufficient immunity
to prevent overwhelming infection.
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Kidney TransplantationComplications
•Rejection Hyperacute (antibody-
mediated, humoral) rejection•Occurs minutes to hours after transplantation
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Kidney TransplantationComplications
•Rejection (cont’d) Acute rejection
•Occurs days to months after transplantation
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Kidney TransplantationComplications
•Rejection (cont’d) Chronic rejection
•Process that occurs over months or years and is irreversible
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Kidney TransplantationComplications
• Infection Most common infections
observed in the first month•Pneumonia •Wound infections• IV line and drain infections
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Kidney TransplantationComplications
• Infection (cont’d) Fungal infections
•Candida•Cryptococcus •Aspergillus•Pneumocystis jiroveci
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Kidney TransplantationComplications
• Infection (cont’d) Viral infections
•CMV One of the most common
•Epstein-Barr virus•Herpes simplex virus
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Kidney TransplantationComplications
•Cardiovascular disease Transplant recipients have
increased incidence of atherosclerotic vascular disease.
Immunosuppressant can worsen hypertension and hyperlipidemia.
Adhere to antihypertensive regimen.
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Kidney TransplantationComplications
•Malignancies Primary cause is
immunosuppressive therapy. Regular screening is
important preventive care.
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Kidney TransplantationComplications
•Recurrence of original renal disease Glomerulonephritis IgA nephropathy Diabetes mellitus Focal segmental sclerosis
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Kidney TransplantationComplications
•Corticosteroid-related complications Aseptic necrosis of the hips,
knees, and other joints Peptic ulcer disease Glucose intolerance and
diabetes
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Kidney Transplantation Complications
•Corticosteroid-related complications (cont’d) Dyslipidemia Cataracts Increased incidence of
infection and malignancy Close monitoring of side
effects
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Nursing ManagementEvaluation
•Maintenance of ideal body weight
•Acceptance of chronic disease•No infection•No edema•Hematocrit, hemoglobin, and
serum albumin levels in acceptable range
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Six days after a kidney transplant from a deceased donor , the patient develops a temperature of 101.2° F (38.5°C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate:
1. Acute rejection, which is not uncommon and is usually reversible.2. Hyperacute rejection, which will necessitate removal of the transplanted kidney.3. An infection of the kidney, which can be treated with intravenous antibiotics.4. The onset of chronic rejection of the kidney with eventual failure of the kidney.
Audience Response Question
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Case Study
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Case Study (same patient as in dialysis presentation)
•65-year-old woman with history of progressive renal failure for 5 years
•Diagnosed with type 1 diabetes mellitus when 15 years old
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Case Study (same patient as in dialysis presentation)
•After waiting for 9 months, she is notified that a diseased (cadaver) kidney has become available.
•The kidney transplant is done.
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Discussion Questions
1. She does very well postoperatively and is ready for discharge. What are the priority teaching interventions?
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Discussion Questions
2. Because she is a diabetic individual, what are her special needs?
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