Kidney Transplantation

Kidney Transplantation

Kidney transplantation has become the treatment of choice for most patients with ESRD. During the past 40 years, more than 380,000 kidney transplantations have been performed world-wide, and more than 174,000 have been performed in the United States. This number includes over 10,000 kidney-pancreas trans-plantations. In January 2003 there were almost 54,000 persons on the waiting list for kidney transplantation (http://www.unos.org., December 25, 2002). Patients choose kidney transplantation for various reasons, such as the desire to avoid dialysis or to improve their sense of well-being and the wish to lead a more normal life. Additionally, the cost of maintaining a successful transplantation is one-third the cost of treating a dialysis patient.

Kidney transplantation involves transplanting a kidney from a living donor or human cadaver to a recipient who has ESRD (Chart 45-9). Kidney transplants from well-matched living donors who are related to the patient (those with compatible ABO and HLA antigens) are slightly more successful than those from ca-daver donors. The success rate increases if kidney transplanta-tion from a living donor is performed before dialysis is initiated (Mange, Joffe & Feldman, 2001). Due to the overwhelming numbers of persons on kidney transplant waiting lists, new tech-niques for matching nonrelated living donors are being devel-oped (Gridelli & Remuzzi, 2000).

A nephrectomy of the patient’s own native kidneys may be performed before transplantation. The transplanted kidney is placed in the patient’s iliac fossa anterior to the iliac crest. The ureter of the newly transplanted kidney is transplanted into the bladder or anastomosed to the ureter of the recipient (Fig. 45-5).

PREOPERATIVE MANAGEMENT

Preoperative management goals include bringing the patient’s metabolic state to a level as close to normal as possible, making sure that the patient is free of infection, and preparing the patient for surgery and the postoperative course.

Medical Management

A complete physical examination is performed to detect and treat any conditions that could cause complications after transplanta-tion. Tissue typing, blood typing, and antibody screening are per-formed to determine compatibility of the tissues and cells of the donor and recipient. Other diagnostic tests must be completed to identify conditions requiring treatment before transplantation. The lower urinary tract is studied to assess bladder neck function and to detect ureteral reflux.

The patient must be free of infection at the time of renal trans-plantation because after surgery the patient will receive medications to prevent transplant rejection. These medications suppress the immune response, leaving the patient immunosuppressed and at risk for infection. Therefore, the patient is evaluated and treated for any infections, including gingival (gum) disease and dental caries.

A psychosocial evaluation is conducted to assess the patient’s ability to adjust to the transplant, coping styles, social history, social support available, and financial resources. A history of psy-chiatric illness is important to ascertain because psychiatric con-ditions are often aggravated by the corticosteroids needed for immunosuppression after transplantation.

Hemodialysis is often performed the day before the scheduled transplantation procedure to optimize the patient’s physical sta-tus if a dialysis routine had already been established. However, it is preferable to avoid initiation of dialysis before transplantation when a donor kidney is available (Mange et al., 2001).

Nursing Management

The nursing aspects of preoperative care are similar to those for pa-tients undergoing other elective abdominal surgery. Preoperative teaching can be conducted in a variety of settings, including the outpatient preadmission area, the hospital, or the transplantation clinic during the preliminary workup phase. Patient teaching ad-dresses postoperative pulmonary hygiene, pain management options, dietary restrictions, intravenous and arterial lines, tubes (indwelling catheter and possibly a nasogastric tube), and early am-bulation. The patient who receives a kidney from a living related donor may be concerned about the donor and how the donor will tolerate the surgical procedure.

Most patients have been on dialysis for months or years before transplantation. Many have waited months to years for a kidney transplant and are anxious about the surgery, possible rejection, and the need to return to dialysis. Helping the patient to deal with these concerns is part of the nurse’s role in preoperative manage-ment, as is teaching the patient about what to expect after surgery.

POSTOPERATIVE MANAGEMENT

The goal of care is to maintain homeostasis until the transplanted kidney is functioning well. The patient whose kidney functions immediately has a more favorable prognosis than the patient whose kidney does not.

Immunosuppressive Therapy

The survival of a transplanted kidney depends on the ability to block the body’s immune response to the transplanted kidney. To overcome or minimize the body’s defense mechanism, immuno-suppressant agents such as azathioprine (Imuran), corticosteroids (prednisone), cyclosporine, and OKT-3 (a monoclonal antibody) are administered (Shapiro, 2000b).

Cyclosporine is available in a microemulsion form (Neoral), which delivers the medication reliably, thus producing a steady-state serum concentration. Tacrolimus (Prograf, formerly called FK-506) is similar to cyclosporine and about 100 times more potent. Mycophenolate (CellCept, RS-61433) has been approved by the U.S. Food and Drug Administration (FDA) solely for the pre-vention of renal transplant rejection. It may be used in patients who have failed to respond to the standard corticosteroid pulse therapy or OKT-3. Antilymphocyte globulin is occasionally used to modify the immune response. Leukapheresis, lymph drainage, and cyclophosphamide (Cytoxan) are other methods of immuno-suppression, but they are rarely used.

Treatment with combinations of these new agents has dramat-ically improved survival rates. The newest class of agents, the first of which is sirolimus, is called target of rapamycin (TOR) in-hibitors; these agents are used with cyclosporine for maintenance therapy. Immunosuppressive drug therapy after kidney transplan-tation continues to evolve (Chan, Gaston & Hariharan, 2001).

Doses of immunosuppressant agents are gradually reduced (ta-pered) over a period of several weeks, depending on the patient’s immunologic response to the transplant. The patient will, how-ever, take some form of antirejection medication for the entire time that he or she has the transplanted kidney (Chart 45-10).

The clinical profile of neurotoxicity caused by immunosup-pression has changed. When toxic levels are reached, both cy-closporine and tacrolimus may produce a clinical spectrum that varies from tremor and acute confusional state to status epilepti-cus and major speech or language abnormalities. Coma has be-come an unusual manifestation (Baan et al., 2001; Shapiro, 2000; Wijdicks, 2001).

Postoperative Nursing Management

ASSESSING THE PATIENT FOR TRANSPLANT REJECTION

After kidney transplantation, the nurse assesses the patient for signs and symptoms of transplant rejection: oliguria, edema, fever, increasing blood pressure, weight gain, and swelling or tender-ness over the transplanted kidney or graft. Patients receiving cy-closporine may not exhibit the usual signs and symptoms of acute rejection. In these patients, the only sign may be an asymptomatic rise in the serum creatinine level (more than a 20% rise is con-sidered acute rejection).

The results of blood chemistry tests (BUN and creatinine) and leukocyte and platelet counts are monitored closely because im-munosuppression depresses the formation of leukocytes and platelets. The patient is closely monitored for infection because of susceptibility to impaired healing and infection related to immunosuppressive therapy and complications of renal failure.

Clinical manifestations of infection include shaking chills, fever, rapid heartbeat and respirations (tachycardia and tachypnea), and either an increase or a decrease in WBCs (leukocytosis or leukopenia).

PREVENTING INFECTION

Infection may be introduced through the urinary tract, the respi-ratory tract, the surgical site, or other sources. Urine cultures are performed frequently because of the high incidence of bacteriuria during early and late stages of transplantation. Any type of wound drainage should be viewed as a potential source of infection be-cause drainage is an excellent culture medium for bacteria. Cath-eter and drain tips may be cultured when removed by cutting off the tip of the catheter or drain (using aseptic technique) and placing the cut portion in a sterile container to be taken to the laboratory for culture.

The nurse ensures that the patient is protected from exposure to infection by hospital staff, visitors, and other patients with ac-tive infections. Careful hand hygiene is imperative; facemasks may be worn by hospital staff and visitors to reduce the risk for transmitting infectious agents while the patient is receiving high doses of immunosuppressants.

MONITORING URINARY FUNCTION

The vascular access for hemodialysis is monitored to ensure pa-tency and to evaluate for evidence of infection. After successful renal transplantation, the vascular access device may clot, possi-bly from improved coagulation with the return of renal func-tion. Hemodialysis may be necessary postoperatively to maintain homeostasis until the transplanted kidney is functioning well.

A kidney from a living donor related to the patient usually be-gins to function immediately after surgery and may produce large quantities of dilute urine. A kidney from a cadaver donor may un-dergo acute tubular necrosis and therefore may not function for 2 or 3 weeks, during which time anuria, oliguria, or polyuria may be present. During this stage, the patient may experience signifi-cant changes in fluid and electrolyte status. Therefore, careful monitoring is indicated. The output from the urinary catheter (connected to a closed drainage system) is measured every hour. Intravenous fluids are administered on the basis of urine volume and serum electrolyte levels and as prescribed by the physician.Hemodialysis may be required if fluid overload and hyperkalemia occur (Gridelli & Remuzzi, 2000).

ADDRESSING PSYCHOLOGICAL CONCERNS

The rejection of a transplanted kidney remains a matter of great concern to the patient, the family, and the health care team for many months. The fears of kidney rejection and the complica-tions of immunosuppressive therapy (Cushing’s syndrome, dia-betes, capillary fragility, osteoporosis, glaucoma, cataracts, acne) place tremendous psychological stresses on the patient. Anxiety and uncertainty about the future and difficult posttransplantation adjustment are often sources of stress for the patient and family.

An important nursing function is the assessment of the patient’s stress and coping. The nurse uses each visit with the patient to de-termine if the patient and family are coping effectively and the pa-tient is complying with the prescribed medication regimen. If indicated or requested, the nurse refers the patient for counseling.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

The patient undergoing kidney transplantation is at risk for the postoperative complications that are associated with any surgical procedure. In addition, the patient’s physical condition may be compromised because of the complications associated with long-standing renal failure and its treatment. Therefore, careful assess-ment for the complications related to renal failure and those associated with a major surgical procedure are important aspects of nursing care. Strategies to promote surgical recovery (breath-ing exercises, early ambulation, care of the surgical incision) are important aspects of postoperative care.

GI ulceration and corticosteroid-induced bleeding may occur. Fungal colonization of the GI tract (especially the mouth) and urinary bladder may occur secondary to corticosteroid and anti-biotic therapy. Closely monitoring the patient and notifying the physician about the occurrence of these complications are im-portant nursing interventions. In addition, the patient is moni-tored closely for signs and symptoms of adrenal insufficiency if the treatment has included use of corticosteroids.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care. The nurse works closely with thepatient and family to be sure that they understand the need for continuing the immunosuppressive therapy as prescribed. Addi-tionally, the patient and family are instructed to assess for and re-port signs and symptoms of transplant rejection, infection, or significant adverse effects of the immunosuppressant regimen. These include decreased urine output; weight gain; malaise; fever; respiratory distress; tenderness over the transplanted kidney; anx-iety; depression; changes in eating, drinking, or other habits; and changes in blood pressure readings. The patient is instructed to inform other health care providers (eg, dentist) about the kidney transplant and the use of immunosuppressive agents.

Continuing Care. The patient needs to know that follow-up careafter transplantation is a lifelong necessity. Individual verbal and written instructions are provided concerning diet, medication, fluids, daily weight, daily measurement of urine, management of intake and output, prevention of infection, resumption of activ-ity, and avoidance of contact sports in which the transplanted kidney may be injured. Because of the risk of other potential complications, the patient is followed closely. Cardiovascular dis-ease is now the major cause of morbidity and mortality after transplantation, due in part to the increasing age of transplanta-tion patients. An additional problem is possible malignancy; pa-tients receiving long-term immunosuppressive therapy have been found to develop cancers more frequently than the general pop-ulation. Because of the usual need for health promotion along with the increased risks for malignancy because of immuno-suppressive therapy, the patient is reminded of the importance of health promotion and health screening.

The American Association of Kidney Patients is a nonprofit organization that serves the needs of those with kidney disease. It has many helpful sugges-tions for patients and family members learning to cope with dial-ysis and transplantation.