1. Kidney Transplantation
Chapter 47
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2. Kidney Transplantation
More than 93,000 patients are currently awaiting kidney transplants
Fewer than 25% ever receive a kidney
Transplantation from a deceased donor usually requires a prolonged waiting period; differences in waiting time depend on age, gender, and race.
Average wait times in the United States for a cadaveric kidney to become available are approximately 2 to 5 years.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3. Kidney Transplantation
Very successful
One-year graft survival rate
Cadaver transplants: 90%
Live donor transplants: 95%
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4. Kidney Transplantation
Advantages of kidney transplantation over 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
Preemptive transplantation (before dialysis is required) is possible if the recipient has a living donor
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 ESKD, preemptive transplantation (before dialysis is required) is possible if a living donor is available.
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6. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
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C.L., a 49 year-old woman, has a history of type 1 diabetes.
She recently received a diagnosis of chronic kidney disease.
She is interested in pursuing preemptive kidney transplantation to avoid long-term effects of dialysis.
We will now walk through a case study of a patient undergoing kidney transplantation.
Have students discuss the benefits of early transplantation for C.L.
What questions would you ask in relation to other medical and psychosocial history that might prevent C.L. from being a candidate for transplantation?
{See next slide.}
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7. 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 with a diagnosis of HIV were denied the opportunity for kidney transplantation.
However, centers that have included HIV-infected patients demonstrate graft and patient survival rates similar to those in the HIV-negative population.
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8. Kidney Transplantation Recipient Selection
On basis of evaluation, procedures may be required before transplantation
Coronary artery bypass or coronary angioplasty
Cholecystectomy
Bilateral nephrectomy
Coronary artery bypass or coronary angioplasty may be indicated for advanced coronary artery disease.
Cholecystectomy may be necessary for patients with a history of gallstones, biliary obstruction, or cholecystitis.
On rare occasions, bilateral nephrectomies may be necessary for patients with refractory hypertension, recurrent urinary tract infections, or kidneys that are grossly enlarged as a result of polycystic kidney disease.
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9. 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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10. Kidney Transplantation Donor Sources
Deceased donors with compatible blood type
Blood relatives
Emotionally related living donors
Altruistic living donors
Paired organ donation
Paired organ donation occurs when one donor/recipient pair who are biologically incompatible or poorly matched with each other find one or more donor/recipient pairs with whom they can exchange kidneys.
Paired organ donation is the practice of matching biologically incompatible donor/recipient pairs to enable transplantation in both candidates with a well-matched organ.
Expanding the living donor pool is one of the best possibilities for decreasing the size of the waiting list and reducing wait times for people needing a deceased donor.
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11. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
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C.L. is married with two school-age children.
She has a very supportive extended family
Her husband and two sisters are tested to see if they are a compatible match to donate.
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Case Study
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It is determined that C.L.’s 39-year-old sister is a compatible donor.
What information does C.L.’s sister need about the preoperative diagnostic studies and surgery?
{See next slides.}
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13. Kidney Transplantation Donor Sources
Live donor
Extensive multidisciplinary evaluation
Psychosocial and financial evaluations
Crossmatches
Advantages
Better patient and graft survival rates
Immediate organ availability
Minimal cold time
Crossmatches are done at the time of the evaluation and about a week before the transplantation to ensure that no antibodies to the donor are present or that the antibody titer is below the allowed level.
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14. Kidney Transplantation Donor Sources
Live donor
Laboratory studies
24-Hour urine
Creatinine clearance
Total protein
Complete blood cell count
Chemistry and electrolyte profiles
Hepatitis B and C, HIV, CMV testing
An ECG and chest x-ray are also done.
Renal ultrasonography and renal arteriography or three-dimensional CT scanning are performed to ensure that the blood vessels supplying each kidney are adequate, to ensure that there are no anomalies, and to determine which kidney will be removed.
A transplant psychologist or social worker will determine if the donor is emotionally stable and able to deal with the issues related to organ donation.
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Kidney Transplantation Donod Sources
Deceased donor
Deceased (cadaver) kidney donors are relatively healthy individuals
Have suffered an irreversible brain injury and are declared brain dead
The brain-dead donor must have effective cardiovascular function and be supported on a ventilator to preserve the organs.
Even if the donor carried a signed donor card, permission from the donor’s legal next of kin is still requested after brain death is determined.
The kidneys are removed and can be preserved for up to 72 hours, but most transplant surgeons prefer to transplant kidneys before the cold time (time outside of the body when being transported from the deceased donor to the recipient) reaches 24 hours.
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16. Kidney Transplantation Surgical Procedure
Live donor
Nephrectomy performed by a urologist or transplant surgeon
Begins 1 or 2 hours before the recipient’s surgery is started
Rib may need to be removed for adequate view
Takes about 3 hours
The recipient is surgically prepared for the kidney transplantation in a nearby operating room.
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17. Kidney Transplantation Surgical Procedure
Live donor
Laparoscopic donor nephrectomy
Alternative to conventional nephrectomy
Most common approach for 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.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

18. Kidney Transplantation Surgical Procedure
Kidney transplant recipient
Organ usually placed extraperitoneally in the iliac fossa
Right iliac fossa is preferred
{See next slide for figure.}
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19. Kidney Transplantation
A, Surgical incision for renal transplantation.
B, Surgical placement of transplanted kidney.
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20. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
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C.L. and her sister arrive together the morning of surgery.
Her sister is taken to the OR first and has a laparoscopic nephrectomy.
C.L. is taken into the OR to begin preparing to receive the kidney.
What can C.L. expect for her procedure?
How will her surgery differ from that of her sister’s?
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21. 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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22. 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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23. 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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24. 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 problems 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 the patient undergoes surgery.
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Case Study
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C.L. and her sister are transferred to a progressive care unit.
C.L. is resting comfortably after IV analgesics were administered.
Her sister continues to complain of discomfort after two doses of analgesia.
Have students divide into two groups; each group should develop a concept map for postoperative period for one of the sisters.
Have the groups compare and contrast the different concept maps.
{See next slides.}
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26. Kidney Transplantation Nursing Management
Postoperative care
Live donor
Care is similar to that for open or laparoscopic nephrectomy
Close monitoring of renal function
Close monitoring of hematocrit
The donor who has had a open nephrectomy experiences greater pain than the donor who has had a laparoscopic procedure. In general, all donors have more pain than their recipients do.
Donors who have undergone an open surgical approach are ready to be discharged from the hospital in 4 or 5 days and can usually return to work in 6 to 8 weeks.
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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27. Kidney Transplantation Nursing Management
Postoperative care
Recipient
Maintenance of fluid and electrolyte balance is first priority
Large volumes of urine soon after transplanted kidney placed, as a result of
New kidney’s ability to filter BUN
Abundance of fluids during operation
Initial renal tubular dysfunction
Urine output during this phase may be as high as 1 L/hr and gradually decreases as the BUN and serum creatinine levels return toward normal.
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28. Kidney Transplantation Nursing Management
Postoperative care
Recipient
Urine output replaced with fluids milliliter by milliliter hourly
Urine output closely measured
Acute tubular necrosis can occur
May necessitate 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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POST OP CARE
-First day in ICU
-Early diuresis is common (1 L/hr)
-Monitor & maintain I&O balance
-Monitor& maintain electrolyte balance
-ATN may develop- *Start dialysis
-*Major concern- sudden decrease in u/o post-op may signify dehydration, obstruction, rejection
-Education on importance of taking immunosuppressants
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30. 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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31. 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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32. Kidney Transplantation Complications
Rejection
Acute rejection
Occurs days to months after transplantation
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33. Kidney Transplantation Complications
Rejection
Chronic rejection
Process that occurs over months or years and is irreversible
Patients with chronic rejection should be put on the transplant list in the hope that they can undergo repeat transplantation before dialysis is required.
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Case Study
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C.L.’s sister is discharged on postoperative day 3.
C.L. is scheduled to be discharged 3 days later.
What are the priority teaching needs for C.L.?
Have students develop a discharge teaching plan.
What are the priority teaching interventions?
Early signs of rejection
Medications
Incision care
Activity
Because C.L. has diabetes, what are her special needs?
Her glucose metabolism will change after kidney function is restored.
In addition, if she will be taking corticosteroids following the transplantation, these drugs increase blood glucose. She will need to monitor her blood glucose carefully and discuss treatment with her nephrologist and endocrinologist.
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35. Kidney Transplantation Complications
Infection
Most common infections observed in the first month
Pneumonia
Wound infections
IV line and drain infections
Urinary tract 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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36. Kidney Transplantation Complications
Infection
Fungal infections
Candida
Cryptococcus
Aspergillus
Pneumocystis jiroveci
Fungal and viral infections are not uncommon because of the patient’s immunosuppressed state.
Fungal infections are difficult to treat, necessitate 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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37. Kidney Transplantation Complications
Infection
Viral infections
CMV
One of the most common
Epstein-Barr virus
Herpes simplex virus (HSV)
Varicella-zoster virus
Polyomavirus (e.g., BK 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 dormant virus exists in a patient and emerges from dormancy 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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38. Kidney Transplantation Complications
Cardiovascular disease
Transplant recipients have increased incidence of atherosclerotic vascular disease
Immunosuppressants can worsen hypertension and hyperlipidemia
Patients need to adhere to antihypertensive regimen
Cardiovascular disease is the leading cause of death after renal transplantation.
Hypertension, dyslipidemia, diabetes mellitus, smoking, rejection, infections, and increased homocysteine levels can all contribute to CV disease.
Immunosuppressants can worsen hypertension and dyslipidemia. Teach the patient to control risk factors such as elevated cholesterol, triglyceride, and blood glucose levels and weight gain.
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39. Kidney Transplantation Complications
Malignancies
Primary cause is immunosuppressive therapy
Regular screening is important
Preventive care
Protective clothing
Sunscreen
The overall incidence of malignancy is greater in kidney transplant recipients than in the general population.
The most common types of cancer after transplantation are basal and squamous cell carcinoma of the skin, Hodgkin’s and non-Hodgkin’s lymphoma, and Kaposi sarcoma.
Other cancers for which patients are at risk include cancers of the liver, stomach, oropharynx, anus, vulva, and penis.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

40. Kidney Transplantation Complications
Recurrence of original renal disease
Glomerulonephritis
IgA nephropathy
Diabetes mellitus
Focal segmental sclerosis
Patients must be informed before transplantation if they have a disease that is known to recur.
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41. Kidney Transplantation Complications
Corticosteroid-related complications
Aseptic necrosis of the hips, knees, and other joints
Peptic ulcer disease
Glucose intolerance and diabetes
In the first year after transplantation, corticosteroid doses are usually decreased to 5 to 10 mg/day.
The use of tacrolimus and cyclosporine has allowed the corticosteroid doses to be much lower than they were in the past.
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42. Kidney Transplantation Complications
Corticosteroid-related complications
Dyslipidemia
Cataracts
Increased incidence of infection and malignancy
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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43. 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 kidney transplantation from a deceased donor, a patient develops a temperature of 101.2º F (38.5º C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate
Acute rejection, which is not uncommon and is usually reversible.
Hyperacute rejection, which will necessitate removal of the transplanted kidney.
An infection of the kidney, which can be treated with IV antibiotics.
The onset of chronic rejection of the kidney with eventual failure of the kidney.
Answer: a
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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