Focus on Kidney Transplant (Relates to Chapter 47, “Nursing Management: Acute Kidney Injury and Chronic Kidney Disease,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Kidney Transplantation Extremely successful 1-year graft survival rate 90% for cadaver transplants 95% for live donor transplants Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Kidney Transplantation Surgical Procedure Kidney transplant recipient Usually placed extraperitoneally in the iliac fossa Right iliac fossa is preferred. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Kidney Transplant A, Surgical incision for a renal transplant. B, Surgical placement of transplanted kidney. Fig. 47-15. A, Surgical incision for a renal transplant. B, Surgical placement of transplanted kidney. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 14-19. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Kidney Transplantation Complications Rejection Hyperacute (antibody-mediated, humoral) rejection Occurs minutes to hours after transplantation These types of rejection are discussed in Chapter 14. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Kidney Transplantation Complications Rejection (cont’d) Acute rejection Occurs days to months after transplantation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Kidney Transplantation Complications Rejection (cont’d) Chronic rejection Process that occurs over months or years and is irreversible Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Kidney Transplantation Complications Corticosteroid-related complications Aseptic necrosis of the hips, knees, and other joints Peptic ulcer disease Glucose intolerance and diabetes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.