Focus on Kidney Transplant (Relates to Chapter 47, “Nursing Management: Acute Kidney Injury and...

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.

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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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•Extremely successful•1-year graft survival rate

90% for cadaver transplants 95% for live donor

transplants


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•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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•Live donor Laparoscopic donor

nephrectomy•Alternative to conventional nephrectomy

•Most common approach of live kidney procurement


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•Kidney transplant recipient Usually placed

extraperitoneally in the iliac fossa

Right iliac fossa is preferred.


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Kidney Transplant


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 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 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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•Postoperative care Live donor

•Care is similar to laparoscopic nephrectomy.

•Close monitoring of renal function

•Close monitoring of hematocrit


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•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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•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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•Rejection (cont’d) Acute rejection

•Occurs days to months after transplantation


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•Rejection (cont’d) Chronic rejection

•Process that occurs over months or years and is irreversible


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• Infection Most common infections

observed in the first month•Pneumonia •Wound infections• IV line and drain infections


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• Infection (cont’d) Fungal infections

•Candida•Cryptococcus •Aspergillus•Pneumocystis jiroveci


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• Infection (cont’d) Viral infections

•CMV One of the most common

•Epstein-Barr virus•Herpes simplex virus


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•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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•Malignancies Primary cause is

immunosuppressive therapy. Regular screening is

important preventive care.


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•Recurrence of original renal disease Glomerulonephritis IgA nephropathy Diabetes mellitus Focal segmental sclerosis


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•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


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

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

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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?


Focus on Kidney Transplant (Relates to Chapter 47, “Nursing Management: Acute Kidney Injury and...

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