1. Focus on Kidney Transplant
(Relates to Chapter 47, “Nursing Management: Acute Kidney Injury and Chronic Kidney Disease,” in the textbook)
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2. Kidney Transplantation
More than 75,000 patients are currently awaiting kidney transplants.
Less than ¼ ever receive a kidney.
Transplantation from a deceased donor usually requires a prolonged waiting period with differences in waiting time dependent on age, gender, and race, as well as the availability of a matching blood type. Blood types B and O have the longest waiting times.
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3. Kidney Transplantation
Extremely successful
1-year graft survival rate
90% for cadaver transplants
95% for live donor transplants
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4. 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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5. Kidney Transplantation Recipient Selection
Candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers.
Some transplant programs exclude patients who are morbidly obese or who continue to smoke (despite smoking cessation interventions).
Certain patients, particularly those with cardiovascular disease and diabetes mellitus, are considered at high risk and must be carefully evaluated and then monitored closely after the transplantation.
For a small number of patients who are approaching ESRD, a preemptive transplant (before dialysis is required) is possible if they have a living donor.
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6. Kidney Transplantation Recipient Selection
Contraindications to transplantation
Disseminated malignancies
Untreated cardiac disease
Chronic respiratory failure
Extensive vascular disease
Chronic infection
Unresolved psychosocial disorders
At one time, patients diagnosed with HIV were denied the opportunity for kidney transplantation. However, centers that have included HIV patients demonstrate similar graft and patient survival rates for patients with HIV when compared with those in the HIV-negative population.
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7. Kidney Transplantation Histocompatibility Studies
Purpose of testing is to identify the HLA antigens for both donors and potential recipients.
Histocompatibility studies, including HLA testing and crossmatching, are discussed in Chapter 14.
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8. Kidney Transplantation Donor Sources
Compatible blood type deceased donors
Blood relatives
Emotionally related living donors
Altruistic living donors
Paired organ donation
Paired organ donation occurs when one donor/recipient pair who are incompatible or poorly matched with each other find another donor/recipient pair(s) with whom they can exchange kidneys.
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9. Kidney Transplantation Surgical 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
Live donors are required to undergo an extensive multidisciplinary evaluation to be certain that they are in good health and have no history of disease that would place them at risk for developing kidney failure or operative complications.
Advantages of a live donor kidney include better patient and graft survival rates regardless of histocompatibility match, immediate organ availability, immediate function because of minimal cold time (kidney out of body and not getting blood supply), and the opportunity to have the recipient in the best possible medical condition because the surgery is elective.
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10. Kidney Transplantation Surgical Procedure
Live donor
Laparoscopic donor nephrectomy
Alternative to conventional nephrectomy
Most common approach of live kidney procurement
The laparoscopic approach significantly decreases the hospital stay, pain, operative blood loss, debilitation, and length of time off work. For these reasons, the number of people willing to donate a kidney has increased significantly.
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11. Kidney Transplantation Surgical Procedure
Kidney transplant recipient
Usually placed extraperitoneally in the iliac fossa
Right iliac fossa is preferred.
{See next slide for figure.}
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Kidney Transplant
A, Surgical incision for a renal transplant.
B, Surgical placement of transplanted kidney.
Fig A, Surgical incision for a renal transplant. B, Surgical placement of transplanted kidney.
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13. 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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14. 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
Kidney transplants with living donors can be technically more difficult because the blood vessel lengths can be shorter than in deceased donor transplants.
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15. 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.
The donor ureter in most cases is tunneled through the bladder submucosa before entering the bladder cavity and being sutured in place. This approach is called ureteroneocystostomy. This allows the bladder wall to compress the ureter as it contracts for micturition, thereby preventing reflux of urine up the ureter into the transplanted kidney.
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16. Kidney Transplantation Nursing Management
Preoperative care
Emotional and physical preparation
Immunosuppressive drugs
ECG
Chest x-ray
Laboratory studies
Dialysis may be required before surgery for any significant abnormality such as fluid overload or hyperkalemia.
A patient on PD must empty the peritoneal cavity of all dialysate solution.
The vascular access extremity should be labeled “dialysis access, no procedures” to prevent use of the affected extremity for BP measurement, blood drawing, or IV infusions before going to surgery.
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17. Kidney Transplantation Nursing Management
Postoperative care
Live donor
Care is similar to laparoscopic nephrectomy.
Close monitoring of renal function
Close monitoring of hematocrit
The creatinine should be <1.4 mg/dL, and the hematocrit should not fall more than 3 to 6 points.
Generally, all donors have more pain than their recipients do.
Laparoscopic donors are able to be discharged from the hospital in 2 to 4 days and can return to work in 4 to 6 weeks.
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18. Kidney Transplantation Nursing 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
Laparoscopic donors are able to be discharged from the hospital in 2 to 4 days and can return to work in 4 to 6 weeks.
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19. Kidney Transplantation Nursing 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.
Central venous pressure readings are essential for monitoring postoperative fluid status.
ATN can occur because of prolonged cold ischemic times and the use of marginal cadaveric donors (those who are medically suboptimal).
A sudden decrease in urine output in the early postoperative period is a cause for concern. It may be due to dehydration, rejection, a urine leak, or obstruction.
Postoperative teaching should include the prevention and treatment of rejection, infection, and complications of surgery, and the purpose and side effects of immunosuppression.
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20. Kidney Transplantation Immunosuppressive Therapy
Goals
Adequately suppress the immune response.
Maintain sufficient immunity to prevent overwhelming infection.
Immunosuppressive therapy is discussed in Chapter 14 and in Table
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21. Kidney Transplantation Complications
Rejection
Hyperacute (antibody-mediated, humoral) rejection
Occurs minutes to hours after transplantation
These types of rejection are discussed in Chapter 14.
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22. Kidney Transplantation Complications
Rejection (cont’d)
Acute rejection
Occurs days to months after transplantation
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23. Kidney Transplantation Complications
Rejection (cont’d)
Chronic rejection
Process that occurs over months or years and is irreversible
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24. Kidney Transplantation Complications
Infection
Most common infections observed in the first month
Pneumonia
Wound infections
IV line and drain infections
Underlying systemic illness such as diabetes mellitus or systemic lupus erythematosus, malnutrition, and older age can further compound the negative effects on the immune response.
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25. Kidney Transplantation Complications
Infection (cont’d)
Fungal infections
Candida
Cryptococcus
Aspergillus
Pneumocystis jiroveci
Fungal infections are difficult to treat, require prolonged treatment periods, and often involve the administration of nephrotoxic drugs.
Transplant recipients usually receive prophylactic antifungal drugs, such as clotrimazole (Mycelex), fluconazole (Diflucan), and trimethoprim/sulfamethoxazole (Bactrim), to prevent these infections.
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26. Kidney Transplantation Complications
Infection (cont’d)
Viral infections
CMV
One of the most common
Epstein-Barr virus
Herpes simplex virus
Primary infections occur as new infections after transplantation from an exogenous source such as the donated organ or a blood transfusion.
Reactivation occurs when a virus exists in a patient and becomes reactivated after transplantation because of immunosuppression.
If a recipient has never had CMV and receives an organ from a donor with a history of CMV, antiviral prophylaxis (e.g., ganciclovir [Cytovene], valganciclovir [Valcyte]) will be administered.
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27. Kidney Transplantation Complications
Cardiovascular disease
Transplant recipients have increased incidence of atherosclerotic vascular disease.
Immunosuppressant can worsen hypertension and hyperlipidemia.
Adhere to antihypertensive regimen.
Cardiovascular disease is the leading cause of death after renal transplantation.
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28. Kidney Transplantation Complications
Malignancies
Primary cause is immunosuppressive therapy.
Regular screening is important preventive care.
The overall incidence of malignancy in kidney transplant recipients is about 6%, which is 100 times greater than in the general population.
Malignancies include cancer of the skin, lips, kidney, hepatobiliary system, vulva, and perineum; lymphomas; and Kaposi sarcoma and other sarcomas.
The two most common types of cancer post transplant are basal cell carcinoma of the skin and lymphoma (posttransplant lymphoproliferative disease).
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29. Kidney Transplantation Complications
Recurrence of original renal disease
Glomerulonephritis
IgA nephropathy
Diabetes mellitus
Focal segmental sclerosis
Patients must be advised before transplantation if they have a disease that is known to recur.
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30. Kidney Transplantation Complications
Corticosteroid-related complications
Aseptic necrosis of the hips, knees, and other joints
Peptic ulcer disease
Glucose intolerance and diabetes
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31. Kidney Transplantation Complications
Corticosteroid-related complications (cont’d)
Dyslipidemia
Cataracts
Increased incidence of infection and malignancy
Close monitoring of side effects
Many transplant programs have initiated corticosteroid-free drug regimens because of the problems associated with long-term corticosteroid use. Other centers withdraw patients from corticosteroids over a short time period following transplantation.
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32. Nursing Management Evaluation
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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Audience Response Question
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.
Answer: 1
Rationale: Signs of acute kidney rejection include pain at the site of the transplant, flulike symptoms, fever, weight changes, swelling, changes in heart rate, and reduction in urine output.
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Case Study
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35. 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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36. 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
She does very well postoperatively and is ready for discharge. What are the priority teaching interventions?
1. She needs to know the early signs of rejection and to report them immediately to her nephrologist so she can be treated. Because she has vision impairment, she may need help with preparing and taking her medications.
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Discussion Questions
Because she is a diabetic individual, what are her special needs?
2. Her glucose metabolism will change after kidney function is restored. In addition, she will be taking corticosteroids following the transplant. These drugs increase blood glucose, so she will need to monitor her blood glucose carefully and discuss treatment with her nephrologist and endocrinologist.
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