Kidney Trnasplantation

Introduction Treatment of choice for ESRD. Kidney taken from well matched living donors who are related to the patient those with compatible ABO and HLA antigens Kidney from a living donor or human cadaver Nephrectomy of the patient’s kidneys may be performed before kidney transplantation. The transplanted kidney is placed in the patient’s iliac fossa anterior to the iliac crest The ureter of the transplanted kidney is transplanted into the bladder or anastomosed to the ureter of the reciepient

Preoperative Management Metabolic status of the patient is made as normal as possible Free of infection Prepare for surgery and the post operative course

Medical Management Tissue typing Blood typing Antibody screening are done to determine the compatibility of the tissues and cells of the donor and recipient Lower urinary tract is studied Assess bladder neck function Look for ureteral reflux

A psychosocial evaluation – to assess The patient’s ability to adjust to the transplant, Coping styles, Social history, Social support available Financial resources Presence of any psychiatric illness Haemodialysis done on the eve of transplantation However initiation of dialysis is preferably avoided before transplantation, when a donor kidney is available

Nursing Mangement Preoperativ care nutrition fluid and electrolyte balance preoperative antibiotic prepare the parts for anaesthesia and surgery Teach about postoperative pulmonary hygiene, pain management options, dietary restrictions, intravenous and arterial lines, tubes (urinary caths, Ryle’s tube) and early ambulation Alleviate anxiety about donor

Postoperavive Management The patient whose kidney functions immediately has a more favourable prognosis. Immunosuppressive therapy Survival of the kidney depends on the ability to block the body’s immune response to the transplanted kidney Immunosuppressant agents used : - azathioprine corticosteroids cyclosporine OKT-3 (a monoclonal antibody) sirolimus Doses of immunosuppresant agents are gradually reduced over several weeks Some form of antirejection medication for the entire time that he or she has the transplanted kidney

Rejection Renal graft rejection and failure may occur within 24 hours – hyperacute within 6 to 14 days – acute or after many years – chronic within the first year – not uncommon Usgm Percutaneous biopsy The rejected kidney may or may not be removed

Postoperative Nursing Management Assessing the patient for transplant rejection Signs and symptoms of transplant rejection: oliguria edema fever ↑ BP wt gain swelling and tenderness over the transplanted kidney With cyclosporin the classical symptoms absent asymptomatic ↑ in creatinine; > 20% rise  acute rejection

Monitor TC urea creatinine platelet count monitor for infection – because of immunosuppression (shaking chills, fever, tachycardia, tachypnoea ↑ or ↓ in TC

Preventing Infection Infection through urinary tract respiratory tract surgical site drainage site drainage tips and catheter tips may be cultured Reverse isolation Careful hand hygiene Wearing mask by all

Monitoring Urinary Function Take care of the vascular – patency Haemodialysis may be needed until the new kidney starts functioning The kidney from a relative donor may start functioning immediately producing large quantities of dilute urine – fluid and electrolyte balance to be maintained Kidney from cadaver – take many weeks to funtion – ATN - dialysis needed Urine measured hourly

Addressing Psychological Concerns Fears of rejection have to be alleviated Complications of immunosuppresive therapy : Cushing’s syndrom, diabetes, capillary fragility, osteoporosis, cataract, glaucoma, acne – all have an effect on the patient The family’s stress considered If needed the nurse should refer the patient or the family members to counselling.

Monitoring and Managing Potential Complications Post operative complications to be expected and taken care of. Promote surgical recovery : breathing exercises, early ambulation, care of the surgical incision Look for and manage peptic ulceration due to steroid Fungal colonization of the gut dealt with (due to immunosuppressive therapy and antibiotics)

Promoting Home andCommunity-Based care The patient and family taught about ther signs and symptoms of rejection, infection, side effects of immunosuppressive therapy The family is instructed to monitor the urinary output and the vital signs Continuing care : the patient is made to realise that the care of the transplanted kidney is to be continued life long.