SEMINAR ON

KIDNEY TRANSPLANTATION

Introduction:

Kidney transplantation is the modality of choice for management of end-stage renal disease(ESRD). Successful transplantation is more than a lifestyle choice for the ESRD patient; it offers patients a durable survival advantage over main-tenance hemodialysis. The risk of mortality on the waitlist is halved by successful transplantation . Health related quality of life measures are also substantially improved compared to waitlisted patients . Transplantation involves upfront risks to mortality stemming from a major surgical procedure in a recipient with medical and surgical comorbidity that is compounded by pharmacologic immunosuppression. As such, the transplant evaluation must be carried out by a dedicated multidisciplinary team of skilled medi-cal professionals with specific training and experience in the field. The importance of such an approach is underscored by the fact that transplant centers are mandated to staff their centers with such teams in order to maintain accreditation . This session details the evaluation of the adult patient with advanced kidney disease or ESRD being considered for kidney transplantation.

Definition : Kidney transplantation involves transplanting a kidney from a living donor or deceased donor to a recipient who no longer has renal function A living donor is a person who is alive at the time of donation and may or may not be related to the recipient. A deceased or cadaveric transplant comes from someone who has died and donated his or her organs. Transplantation from well-matched living donors who are related to the patient (those with compatible ABO and human leukocyte antigens) is slightly more successful than from cadaver donors. The success rate further increases if kidney transplantation from a living donor is performed before dialysis is initiated

Who Is a Kidney Transplant Candidate?

There is no strict cut off level of estimated GFR when referral for kidney transplant should be
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made. As a general guideline, the patient with advancing chronic kidney disease (CKD), with a glomerular filtration rate (GFR) estimate or measurement approaching 20 mL/min should be referred for transplant evaluation as an integral part of their medical management. Ideally, thought should be given to transplant referral when the prospective candidate is at NKF Stage 4 CKD, i.e., estimated GFR less than 30 mL/min or is anticipated to progress to ESRD within the next 2 years. Diabetics have both a more rapid progression to ESRD and acceleration of vascular disease on dialysis and should be referred for transplantation earlier in the course of their renal disease to minimize the lead time to transplantation.

Indications to kidney transplantation :

Advancing CKD with estimated GFR approaching 20 mL/min and Projected survival of 5 years irrespective of kidney disease

Contraindications to kidney transplantation:

Reversible renal disease Active or recent malignancy (or metastatic) Active or recent untreated infection Severe irreversible extrarenal disease Severe functional disability with limited rehabilitation potential Unmodifiable nonadherence to treatment Psychiatric illness: not remitting with treatment and could affect consent and/or adherence Active current recreational drug use Prohibitively high risk of recurrence of native kidney disease

Suggested elements of patient education during transplant candidate evaluation

1. Surgical Episode: Nature of the operation, surgical risks, medical and surgical complications, expected length of stay, risks and side effects of medication, return to work dates, expected functional improvement 2. Transplant Modalities: Relative benefits of living vs.deceased donor transplant and type of deceased donor kidney (ECD vs. SCD, DCD, centers for disease control (CDC) High risk, etc.) 3. Waiting Time: Discuss relative impact of deceased donor kidney choice on waiting time. Provide reasonable estimates of expected waiting time. Explain pros and cons of listing at multiple centers. Explain the cadaver kidney allocation process.

4. Immunologic Risk: Explain the process of establishing histocompatibility and measuring sensitization for cadaveric and living donation. nature of immunosuppression. risks of immunosuppression (infection, malignancy, side effects). rates of rejection . types of regimens used at the center

5. Expected Outcomes: Patient and graft survival statistics and rejection rates for the transplant center and explain in the context of national statistics. 6. Donor Quality: Particularly applicable in the context of cadaveric donor transplants. 7. Compliance: Emphasize need for an enduring therapeutic alliance compliance with dialysis when waitlisted and with follow-up and treatment adherence post-transplant. 8. Miscellaneous: Impact of transplant on functional status, fertility, employment. 9. Financial: Explain costs associated with the transplant episode followup, waitlist followup, cost
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of immunosuppression; educate regarding assistance/fundraising. 10. Psychosocial: Explain possible stressors through the process and means for coping.

Pretransplant evaluation of the renal transplant candidate

1. History (a) Cause of renal disease and pre ESRD treatment especially steroids, cytotoxics and immunosuppression. Review biopsy pathology (b) Dialysis: duration, modality, access, progress (c) Previous transplants: If yes, rejections, antibody induction, complications, compliance (d) Blood Transfusions: establish sensitization (e) Allergies and Medication intolerance (f) Occupation, addiction (smoking, alcohol, other drugs), functional status, hobbies, social support (g) Recent hospitalizations (h) History of thromboembolic events 2. Review of systems 3. Past medical/surgical history including exposure to TB, travel, pets 4. Psychosocial evaluation 5. Medications: identify potential interactions with immunosuppressants and possible substitutes 6. Physical examination (a) BMI, vitals (b) Visual and auditory deficits (c) Heart murmur, evidence of heart failure (d) Lungs: signs of COPD, fluid overload (e) Abdomen: hepatomegaly, ascites, pain, herniae, organomegaly, scars, dialysis access, bruits (f) Vascular: Bruits: carotid, iliac, femoropopliteal, peripheral pulses, ischemic ulcers (g) Neurologic: Cognitive deficits, sequelae of CVAs
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(h) Cutaneous: Skin cancers 7. Age and gender appropriate cancer screening (colonoscopy, mammogram, pap smear, PSA) 8. Laboratory investigations: (a) Complete blood count, coagulation profile,chemistries including liver function panel,calcium phosphorus and PTH (b) Urinalysis and Culture: (Routine but difficult to interpret at times) (c) Infectious Disease Panel: CMV serologies, EBV serology, VZV titers, hepatitis B and C serologies, HIV antibody, PPD with anergy panel, rapid plasma reagin (RPR; syphilis) (d) Immunologic profile: Blood type (ABO), HLA typing, and panel reactive antibody (PRA) 9. 12-lead EKG and chest X ray 10. Cardiac workup (a) Assessment of exercise capacity (b) Stress test: Dobutamine stress echocardiogram, dipyridamole or adenosine stress test (c) 2-D echocardiogram with Doppler (d) Coronary angiography if needed 11. Urologic workup (select patients) (a) Voiding cystourethrogram (b) Urodynamic studies (c) Cystoscopy

Cardiac evaluation of potential kidney transplant recipient No prior history of coronary artery disease: If patient is less than 40 years of age, has two or fewer risk factors, normal ECG, and has excellent functional capacity (e.g., can climb two flights of steps quickly without stopping, jogging; or other equivalent to 6METS or greater), proceed directly to surgery or listing. Repeat assessment based on team judgment. If patient does not qualify with all of the above, then cardiac stress testing or catheterization is required within the year prior to evaluation. Exercise or dobutamine-based testing must reach greater than 85% maximum
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predicted heart rate to be accepted as a valid test. If stress testing is acceptable, proceed with surgery or listing. Repeat evaluation(s) at regularly interval at discretion of evaluating team. If a positive stress test is discovered, then cardiology referral or catheterization is required to complete cardiac evaluation.

The transplant team During the evaluation process, you will be interviewed by many members of the transplant team. The following are some of the members of the team:

Transplant surgeons. Doctors who specialize in transplants and who will be performing the surgery.

Nephrologist. A doctor who specializes in disorders of the kidneys. Nephrologists will help manage your condition before and after the surgery.

Transplant nurse coordinator. A nurse who organizes all aspects of care provided to you before and after the transplant. The nurse coordinator will provide patient education, and coordinates the diagnostic testing and follow-up care.

Social workers. Professionals who will help your family deal with many issues that may arise including lodging and transportation, finances, and legal issues.

Dietitians. Professionals who will help you meet your nutritional needs before and after the transplant.

Physical therapists. Professionals who will help you become strong and independent with movement and endurance after the transplantation.

Pastoral care. Chaplains who provide spiritual care and support. Other team members. Several other team members will evaluate you before transplantation and will make recommendations to the team. These include, but are not limited to, the following:

Anesthesiologist Hematologist Infectious disease specialist Psychologist

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DONARS FOR KIDNEY TRANSPLANT Deceased donor source and quality :

Term Definition:

Expanded criteria donors (ECD)

For kidney, any deceased donor over the age of 60 years; or from a donor over the age of 50 years with two of the following: a history of hypertension, a terminal serum creatinine >1.5 mg/dL, or death resulting from a cerebrovascular accident (stroke)

Donation after cardiac death (DCD)

Donation of any organ from a patient whose heart has irreversibly stopped beating. Includes donors who also qualify as ECD

Standard criteria donors (SCD)

For kidney, a deceased donor who is neither ECD nor DCD.These donors have fewer risks associated with graft failure

Kidney Transplant Recipient Surgery

Implant Location The most common location for placing a kidney transplant is in the retroperitoneal iliac fossa,with vascular anastomoses to the external or internal iliac artery and the iliac vein and ureteral anastomosis directly to the bladder. There are several practical advantages for these heterotopic choices. Staying out of the peritoneal cavity allows more rapid return of bowel function and any hemorrhage or urine leak is confined to a smaller nonabsorptive space, making diagnosis easier and more rapid. The kidney lies just under the skin without any intervening bowel, which simplifies subsequent percutaneous biopsy.

Finally, the distance to the bladder is short,allowing for use of the better vascularized proximal donor ureter for implantation. Either side can be used for either kidney, and when both sides are equally available most surgeons favor the right side because the right iliac vein is usually more superficial than the left and should the iliac vessels prove unsuitable,it is easier to move up to the aorta and inferior vena cava while still remaining retroperitoneal. An alternate view is held by some surgeons who favor keeping the renal pelvis and ureter anterior (e.g., left kidney to right side, right kidney to left side) to facilitate ureteral reconstruction in the face of donor ureteral necrosis. Rarely, if the pelvis is not useable, an orthotopic transplant can be done by removing the left native kidney and anastomosing the donor vein to the recipient renal vein, the donor artery to the splenic artery, and the donor ureter to the recipient ureter.

Preparation of Donor Kidney:

Typically, the donor kidney is prepared prior to implantation on a back table, which allows optimal positioning, lighting, and magnification. The kidney is kept in a basin that contains both sterile saline and ice. As long as both saline and ice are present, the temperature of the fluid should remain between 1C and 4C. The degree of graft preparation could vary from minimal in the case of an open living kidney donor to significant in the case of an en bloc kidney procurement. Preferably to start by placing a mosquito clamp on the end of the ureter and holding it off to the side to prevent inadvertent transection. The renal vein and artery are then cleaned and any side branches that do not enter the kidney are ligated.

Venous Preparation:

The left renal vein is usually of sufficient length once the main side branches (adrenal, lumbar,and gonadal) are ligated. Note that the entire gonadal vein should be dissected away, because it can take small tributary branches from the kidney and ureter and therefore may bleed even though both ends are ligated. Because the venous drainage communicates within the kidney, small accessory renal veins may be tied off; however,when multiple veins are of
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similar size, they should be preserved, either by conjoining or by using a jump graft.

The right renal vein has two limitations: it is shorter than the left renal vein and is often thinner, especially posteriorly. In a living donor, a cuff of donor cava can give thicker tissue to anastomose. In a cadaveric donor, when the kidneys are split, the entire remaining cava should be sent with the right kidney. This allows the use of cava to extend the right renal vein, often to a length equal to or exceeding the right renal artery. When inspecting the donor cava, first ensure that the suprarenal portion is intact, as it may be damaged or scalloped during removal of the liver. The most common reconstruction technique is to cut the cava in line with the right renal vein and to then sew the superior and inferior parts of the cava with 5-0 Prolene suture. The left renal vein orifice often remains as a convenient opening to anastomose to the recipient. If more length is required, then the cava can be rotated in line with the renal vein and only the superior opening closed with Prolene (Fig. 10.3). The lower cava can then be anastomosed end to side directly to the recipient.

Note that this requires careful ligation of all remaining lumbar venous branches coming from the cava and may result in a very wide anastomosis. After any reconstruction, testing of the vessels by irrigating with heparinized saline should show any missed branches or large gaps in the closures.

Arterial Preparation:

The renal artery orifice should be carefully examined for injury, especially flaps of intimal plaque or aneurysms, which may not be obvious when the artery is undistended. The artery should be cleaned followed towards the hilum, taking care to preserve renal branches. All renal arteries are end arteries, so any branches that are ligated will result in a region of nonperfused renal parenchyma. This is especially important for lower pole branches, which often provide the entire blood supply for the donor ureter. Note that an upper pole branch may at first appear to simply be an adrenal artery. Trace its path proximally and you may discover that it takes a sharp turn into the renal parenchyma. When the renal artery does not have donor aorta attached (living donor or diseased cadaveric aorta) I prefer to make a small
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spatulation inferiorly, which aids in orientation later. When donor aorta is attached and healthy, a small rim of aorta can be preserved (Carrel patch), which minimizes trauma to the renal intima during anastomosis (Fig. 10.4).

Multiple renal arteries can be handled by a variety of techniques, depending upon number, size, relative length, presence and health of donor aorta, and separation. With a cadaveric donor, the simplest approach is to use a patch of donor aorta that includes all the renal artery orifices Fig. 10.3). This necessitates a longer recipient arteriotomy, and if the resultant patch is greater than 4 cm, it can be reconstructed on the back table to still allow a single recipient anastomosis but not be so long. If donor aorta is not available or too diseased, arteries can be anastomosed

Kidney with multiple vessels placed in stockinette. Stockinette is filled with iced slush and the vessels brought out through separate openings, which allows the kidney to remain cold during the recipient anastomosis. Two renal arteries kept together on a common aortic patch (A). The two renal veins were kept on the inferior cava which was rotated in line with the vessels to provide extra length (B). A third lower pole renal artery, not identified during the organ procurement was anastomosed separately (C)

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Left kidney after back table preparation. There is a small Carrel patch on the artery (A). The renal vein has all side branches tied (B). Perinephric fat in the golden triangle between the lower pole of the kidney and proximal ureter is intact to preserve ureteral blood supply (C)

Final Preparation:

Once the vessels and ureter are prepared, perinephric fat is removed, taking care not to cut the renal capsule, which may be adherent to the fat. Any suspicious solid lesions should be biopsied and sent for frozen section and any large cysts should be deroofed to ensure no internal solid components. All vessels should be flushed manually with cold heparinized saline to ensure no leaks requiring ligation or suture. It is a preference to place the kidney in a sterile cloth stockinette that is filled with slush. Both ends are closed with clips and the vessels brought out through a separate opening at the midpoint This allows the kidney to remain cold throughout the anastomosis and makes manipulation of the kidney easier

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Renal transplantation: Repair of transplant ureteral necrosis using the native ureter (uretero-ureterostomy). (a) Distal ureteral necrosis. Pooling of urine is seen in the wound. (b) After repair. The native ureter mobilized and transected. Anastomosis to the proximal transplant ureter was end to end over an indwelling stent using running 5-0 PDS suture. The native ureter was tied proximally without native nephrectomy 1, The transplanted kidney is placed in the iliac fossa. 2, The renal artery of the donated kidney is sutured to the ileac artery, and the renal vein is sutured to the iliac vein.

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3,The ureter of the donated kidney is sutured to the bladder or to the patients ureter.

1. Transplanted donor kidney cradled in ilium 2. Renal artery sutured to iliac artery Renal vein sutured to iliac vein 3. Ureter sutured

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Kidney Transplant Recipient Surgery Back table repair of short renal vessels:

Two short renal veins were extended with the use of cadaveric iliac vein (A). The short renal artery was extended with a segment of gonadal vein (B)

Back table preparation of a right kidney: The right renal vein has been extended with the inferior vena cava by cutting the cava in line with the vein and oversewing the superior and inferior openings (A). The old orifice of the left renal vein can then be used to anastomose to the recipient. Note Carrel patch on renal artery, which still needs to be trimmed (B)

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Ureteral Preparation

Since all perfusion of the donor ureter must come from the donor renal arteries, preservation of the ureteral blood supply is essential. This is best accomplished by leaving intact the fat and adven- titial tissue found in a triangle formed by the ure-ter, inferior pole of the kidney, and renal artery(ies). . Medical Management

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After a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3 to 14 days (acute), or after many years. The long-term survival of a transplanted kidney depends on how well it matches the recipient and how well the bodys immune response is controlled. Since the bodys immune system views the transplanted kidney as foreign, it continually works to reject it. To overcome or minimize the bodys defense mechanisms, immunosuppressive agents are administered. Optimally, medications modify the immune system enough to prevent rejection, but not enough to allow infections or malignancies to occur. Combinations of glucocorticoids and medications specifically developed to affect the action of lymphocytes are used to minimize the bodys reaction to the transplanted organ. Treatment with combinations of new agents has dramatically improved survival rates, and now 90% to 95% of transplanted kidneys still function after 1 year (American Nephrology Nurses Association, 2007b). Doses of immunosuppressive agents are often adjusted depending on the patients immunologic response to the transplant. However, the patient will be required to take some form of immunosuppressive therapy for the entire time that he or she has the transplanted kidney.

THE RISKS ASSOCIATED WITH TAKING IMMUNOSUPPRESSIVE MEDICATIONS INCLUDE (American Nephrology Nurses Association, 2006).

1. nephrotoxicity 2. hypertension 3. hyperlipidemia 4. hirsutism, 5. tremors, 6. blood dyscrasias, 7. cataracts 8. gingival hyperplasia, 9. several types of cancer Nursing Management Assessing the Patient for Transplant Rejection
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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 tenderness over the transplanted kidney or graft. Patients receiving cyclosporine 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 considered acute rejection).

Preventing Infection The results of blood chemistry tests and leukocyte and platelet counts are monitored closely because immunosuppression 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 (tachycardia), and respirations (tachypnea), as well as either an increase or a decrease in WBCs (leukocytosis or leukopenia). Infection may be introduced through the urinary tract,the respiratory 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 because drainage is an excellent culture medium for bacteria. Catheter and drain tips may be cultured when removed by cutting off the tip of the catheter or drain (using aseptic technique) and placing the tip 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 Renal Transplant Rejection and Infection Renal graft rejection and failure may occur within 24 hours (hyperacute), within 3 to 14 days (acute), or after many years (chronic). It is not uncommon for rejection to occur during the first year after transplantation.
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Detecting Rejection Ultrasonography may be used to detect enlargement of the kidney; percutaneous renal biopsy (most reliable) and x-ray techniques are used to evaluate transplant rejection. If the body rejects the transplanted kidney, the patient needs to return to dialysis. The rejected kidney may or may not be removed, depending on when the rejection occurs (acute versus chronic) and the risk for infection if the kidney is left in place. Potential Infection About 75% of kidney transplant recipients have at least one episode of infection in the first year after transplantation because of immunosuppressant therapy. Immunosuppressants of the past made the transplant recipient more vulnerable to opportunistic infections (candidiasis, cytomegalovirus, Pneumocystis pneumonia) and infection with other relatively nonpathogenic viruses, fungi, and protozoa, which can be a major hazard.

Cyclosporine therapy has reduced the incidence of opportunistic infections because it selectively exerts its effect, sparing T cells that protect the patient from life-threatening infections. In addition, combination immunosuppressant therapy and improved clinical care have produced 1-year patient survival rates approaching 100% and graft survival exceeding 90%. Infections, however, remain a major cause of death at all points in time for kidney transplant recipients (Danovitch, 2005 patients with active infections. Attention to hand hygiene by all who come in contact with the patient is imperative. Monitoring Urinary Function A kidney from a living donor related to the patient usually begins to function immediately after surgery and may produce large quantities of dilute urine. A kidney from a cadaver donor may undergo 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 significant changes in fluid and electrolyte status.
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Therefore, careful monitoring is indicated. The output from the urinary catheter (connected to a closed drainage system) is measured every hour. IV fluids are administered on the basis of urine volume and serum electrolyte levels and as prescribed by the physician. Hemodialysis may be necessary postoperatively to maintain homeostasis until the transplanted kidney is functioning well. It also may be required if fluid overload and hyperkalemia occur. After successful renal transplantation, the vascular access device may clot, possibly from improved coagulation with the return of renal function. The vascular access for hemodialysis is monitored to ensure patency and to evaluate for evidence of infection. Addressing Psychological Concerns The rejection of a transplanted kidney is of great concern to the patient, the family, and the health care team for many months. The fear of kidney rejection and the complications of immunosuppressive therapy (Cushings syndrome, diabetes, capillary fragility, osteoporosis, glaucoma, cataracts, acne, nephrotoxicity) place tremendous psychological stress 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 patients stress and coping. The nurse uses each visit with the patient to determine if the patient and family are coping effectively and the patient is adhering to 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 patients physical condition may be compromised because of the effects of long-standing renal failure and its treatment. Therefore,
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careful assessment for the complications related to renal failure and those associated with a major surgery are important aspects of nursing care. Breathing exercises, early ambulation, and 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 antibiotic therapy. Closely monitoring the patient and notifying the physician about the occurrence of these complications are important nursing interventions. In addition, the patient is monitored 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 the patient and family to be sure that they understand the need for continuing immunosuppressive therapy as prescribed. Additionally, the patient and family are instructed to assess for and report signs and symptoms of transplant rejection, infection, or significant adverse effects of the immunosuppressive regimen. These include decreased urine output; weight gain; malaise; fever; respiratory distress; tenderness over the transplanted kidney; anxiety; depression;changes in eating, drinking, or other habits; and changes in blood pressure. 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 care after transplantation is a lifelong necessity. Individual verbal and written instructions are provided concerning diet, medication, fluids, daily weight, daily measurement of urine, management of I&O, prevention of infection, resumption of activity, and avoidance of contact sports in which the transplanted kidney may be injured. Because of the risk for other potential complications, the patient is followed closely. Cardiovascular disease is the major cause of morbidity and mortality after transplantation, due in part to the increasing age of patients with transplants. An additional problem is possible malignancy; patients receiving long-term immunosuppressive therapy are at higher risk for cancers

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than the general population. So the patient is reminded of the importance of health promotion and health screening.

WARNING SIGNS OF POSSIBLE TRANSPLANT REJECTION

Fever over 100F (38C) "Flu-like" symptoms: chills, aches, headache, dizziness, nausea and/or vomiting New pain or tenderness around the kidney Fluid retention (swelling) Sudden weight gain greater than 2 to 4 pounds within a 24-hour period Significant decrease in urine output

Causes of kidney transplant failure Death with function Failure of the transplant kidney Chronic allograft nephropathy chronic transplant glomerulopathy Recurrent or de novo disease (including BK virus nephropathy: 110%) Miscellaneous and mixed picture (unknown, multifactorial, end-stage renal disease from medical illness) Technical and thrombosis Outright rejection

Potential Complications
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Hemodynamic instability Hypervolemia/hypovolemia Hypertension/hypotension Renal failure (donor kidney) Excessive immunosuppression Electrolyte imbalances Deep vein thrombosis Sepsis

Nursing management of patients for greater renal transplant success Nurses have an important role in helping tailor individual immunosuppressive regimens to maximise patient and kidney graft survival and to aid concordance with treatment, a key issue in managing transplant patients. Causes of chronic graft dysfunction . Histocompatibility and/or insufficient immunosuppression are well-known risk factors for acute rejection. However, as more potent immunosuppression has been developed, very few renal transplants are now lost from acute rejection. In chronic graft failure, a variety of predisposing factors seem to contribute Chronic transplant nephropathy accounts for 30% of graft loss and is one of the commonest causes of the need for dialysis (Moore, 2000).

Long-term complications One key issue in transplantation is how much immunosuppressive therapy should be given. Too little immunosuppression increases the risk of infections, including bacterial disease, viruses
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(particularly cytomegalovirus and herpes zoster), and fungal conditions, such as candida. There is also a risk of post-transplant lymphoproliferative disease. This disorder may respond to a reduction in the dose of immunosuppression, but can be fatal (Amlot, 2000). In the long term, immunosuppression is associated with further risks, including: - Malignancy, which is common among transplant patients - Ischaemic heart disease (related to drug-associated hypertension, nephrotoxicity and lipid abnormalities) - Osteoporosis, especially in relation to steroids (Paul, 1999; Ball et al, 2000). Non-concordance Non-concordance is known to be an important factor in graft failure (Fernando, 1997) and represents a significant health risk for patients (Box 3). Non-concordance with immunosuppressive medications has been reported to be the third leading cause of such loss, after rejection and systemic infection (Greenstein and Siegal, 1998). All immunosuppressive agents have side-effects, and this can be a key factor affecting patient concordance. Since patients must continue taking immunosuppressive treatments for the life of their graft, it is essential to take into account the side-effect profiles of different agents and their potential impact on patient concordance. For example, altered body image can cause renal transplant recipients great anxiety and stress, while cosmetic and general side-effects can affect concordance with the immunosuppressive regimen (Hasselder, 1999). Managing a successful transplant involves communication, education, as well as understanding by the patient of the treatment and its side-effects. Monitoring clinical outcome requires regular follow-up of all patients by the transplant team. The focus of patient management is on long-term survival of the kidney graft and the long-term physical and mental health of the transplant recipient. The transplant nurse has a particular role in this area (Lipkin, 1999). Concordance management is a multidisciplinary task but the role of the nurse is critical (De Geest, 1998).

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The transplant nurse practitioner The response of the individual patient to life with a transplant vary greatly: age, gender, employment status, stability, security and personality will all have an impact. Education and support are probably the most important ways in which nurses can influence patients. Throughout the entire process of transplantation, from first entering the waiting list, through the operative period itself, to the follow-up care stage, there is a need for extensive nursing input (Mackenzie, 2001). The best approach is to build a relationship with the transplant recipient throughout the process and develop a caring, supportive environment in which patients feel able to discuss problems (Fernando, 1997; Hasselder, 1999). High-quality education is also needed. This should start before the transplant so that patients are aware of the potential side-effects of the drugs they will be taking (Trevitt et al, 2000). Some patients may feel intimidated by doctors, while others leave the clinic unable to remember all the information they have been given. To help overcome these problems many hospitals employ nurse practitioners. The nurse clinician The complementary roles of nurse clinician and the nurse-led clinic provide a unique opportunity to combine a holistic approach to the care of renal transplant patients (Holley and McGuirl, 2000). There is evidence that patients find high levels of satisfaction from nurse consultations (Murray, 1997) and are accepting of alternative care delivery systems (Fitzmaurice et al, 2000). Key roles of nurses in renal transplantation Non-concordance with immunosuppressive medications is common among renal transplant patients and is a significant contributor to graft loss. Nurses can play a key role in the multidisciplinary team in the prevention of problems, providing early detection and prompt management. The friendliness of a particular team may be an important factor. Patients may feel the transplant does not eliminate health-related stress, so they need to be able to approach nonphysician members and discuss particular problems in regard to how they handle the demands of their therapy. The role of the nurse in transplant patient care has enhanced the transplant service for both the patient and the multidisciplinary team (Valentine and Russell, 1998; Reece, 1999). One goal of
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treating transplant patients is to ensure that their quality of life is as high as possible, and monitoring the side-effects of immunosuppression regimens is a way to help achieve this. Nurses have more interaction with patients than any other health professionals, giving them an advantage when monitoring for side-effects, such as cardiovascular risk factors, which may not be immediately apparent to the patient as more superficial problems. NURSING CARE PLAN : PREPROCEDURE PERIOD Nursing Diagnosis 1. knowledge deficit related to diagnosis and anticipated surgical experience 2. Anxiety related to the wait for a donor kidney to become available POSTOPERATIVE PERIOD Nursing Diagnosis 1. High risk for infection related to altered immune system secondary to immunosuppressant medications 2. High risk for altered oral mucous membrane related to increased susceptibility to infection secondary to immunosuppression 3. High risk for self-concept disturbance related to transplant experience, potential for rejection, and side effects of medications 4. High risk for noncompliance related to complexity of treatment regimen and euphoria 5. High risk for ineffective management of therapeutic regimen related to insufficient knowledge of prevention of infection, activity progression, dietary management, daily record keeping, pharmacologic therapy, signs and symptoms of infection and rejection, effective birth control measures/pregnancy recommendations, follow-up care, and community resources.

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1. Knowledge Deficit Related To Diagnosis And Anticipated Surgical Experience Outcome/Short Term Planning/Interventions Patient Centered Goals Patient will improve1. his knowledge Prepare the patient for transplantation and a prolonged recovery period and offer him ongoing emotional support. 2. Encourage the patient to express his feelings. 3. Describe routine preoperative measures, such as thorough physical examination and a battery of laboratory tests to detect any infection. 4. Tell the patient the hell undergo dialysis the day before surgery to clean his blood of unwanted fluid and electrolytes. 5. Teach the patient the proper methods for performing coughing, turning, deep breathing and, if ordered incentive spirometry. 6. Administer blood transfusions as ordered.
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Rationale for interventions

Evaluation

Implementation

The high level of

Patient is confident

anxiety and tension is to face the operation reduced by orienting patient to the need for surgery and the postoperative care with least tension and doubtsas evidenced by his voluntary consent and cooperation to undergo surgery .

7.

8. Ensure the patient or a responsible family member has signed a consent form consenting to a transplantation. 9. Throughout the recovery period, watch for signs and symptoms of tissue rejection. 10. Assess the patient for pain and provide analgesics as ordered. 11. Carefully monitor urine output. 12. Connect the patients indwelling catheter to a closed drainage urinary catheter to a closed drainage system to prevent overextension of the bladder. 13. Review daily results of renal function test. 14. Stress strict compliance with all prescribed medication regimens.

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Nursing Diagnosis: Risk for Infection related to inadequate secondary defenses (immunosuppression) Outcome/Short Term Patient Centered Goals Patient will remain free of infection. Maintain a clean patient environment, wear a mask in The high level of Patient will be Planning/Interventions Implementation Rationale for interventions Evaluation

immunosuppression in afebrile, WBC count the first month post will be within normal limits, there will be no infiltrates on chest x-ray, IV sites will be benign, no evidence of UTI, fatigue, anorexia, diarrhea, or

patients room if policy transplant predisposes indicates. Follow strict hand washing technique. Limit the number and duration of invasive devices. Encourage incentive spirometry, deep breathing and ambulation. Assess patients mouth for white lesions characteristic of oral After the first month the patient may develop candidiasis. the patient to develop nosocomial infections. However, the patient has not been immunosuppressed

long enough to develop candidiasis. opportunistic infections.

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candidiasis. Apply topical antifungal as directed.

Nursing Diagnosis: Risk for Fluid Volume Excess related to renal insufficiency, steroid therapy or decreased cardiac output Outcome/Short Term Planning/Interventions Rationale for interventions Following renal transplantation from a deceased donor, the kidney may not Weight and blood pressure will return to baseline. Lungs will remain clear to auscultation. RAP and PAWP will return to baseline. Serum Sodium will remain within normal limits. Evaluation

Patient Centered Goals Implementation Patient will remain euvolemic. Weigh patient daily and monitor blood pressure: Compare

both to baseline values. function optimally at Auscultate lungs for crackles. Monitor RAP and PAWP if indicated. Notify physician of indications of fluid volume excess including 3 pound weight gain in three days. Collaborate with first resulting in fluid volume excess. Fluid volume excess may also develop from use of steroids and from decreased cardiac output in any transplant recipient. The nurse must identify the volume excess and collaborate

physician and patient to with the patient and determine fluid physician return the

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allotment and medication or dialysis management of volume excess. Monitor serum Sodium and potassium levels.

patient to a euvolemic state.

Nursing Diagnosis: Disturbed Body Image related to permanent changes in body due to immunosuppression Outcome/Short Term Planning/Interventions Rationale for interventions Encouraging the Patient will identify Evaluation

Patient Centered Goals Implementation Patient will develop a realistic sense of self. Provide an empathetic environment so that patient can discuss her concerns about her changed body. Collaborate with patient to develop strategies to cope with changes such as: Help female patients to find a way to manage excessive facial hair. Encourage exercise and appropriate diet to

patient to describe her strategies to respond concerns will assure that the nurse is addressing the patients concerns. Jointly developed strategies are more likely to be successful Patient will verbalize that her body feels like her own. to the changes in her body.

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limit weight gain. Encourage patient to socialize with family and peers.

JOURNAL : http://www.sciencedaily.com/releases/2010/09/100902173249.htm New Warning Signs May Predict Kidney Transplant Failure Sep. 3, 2010 Kidney transplants that show a combination of fibrosis (scarring) and inflammation after one year are at higher risk of long-term transplant failure, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN).

To identify these abnormalities, doctors would need to perform routine biopsies on apparently normal kidney transplants -- rather than waiting for problems to occur. "Even for some transplants that would be expected to have a very long graft survival, protocol biopsies performed in the first year may indicate the kidney is undergoing damaging inflammation, which is associated with increased risk for reduced function and graft survival," comments Mark D. Stegall, MD (Mayo Clinic, Rochester, MN). As part of a project to explore the reasons for long-term kidney transplant failure, the Mayo Clinic transplant program has been performing routine biopsies at regular intervals after transplantation. The Mayo Clinic program was among the first to incorporate such "protocol" biopsies into the routine care of clinically stable transplants. The researchers analyzed factors related to transplant survival in 151 patients who had no apparent problems after living-donor kidney transplantation. One-year biopsies showed no abnormalities in 57 percent of kidneys; another 30 percent had fibrosis (scarring) but no
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inflammation. In these two groups, the transplanted kidney continued to function normally from one to five years' follow-up. However, in the remaining 13 percent of transplants, the biopsies showed fibrosis plus inflammation. These transplants had declining kidney function and a reduced long-term survival rate. Kidneys showing fibrosis plus inflammation also had increased numbers of immune cells as well as a "rejection-like" gene expression signature.

Thus, in apparently normal kidney transplants, biopsies showing fibrosis and inflammation signal kidney damage and an increased risk of long-term failure. "It is likely that the intragraft environment of patients with fibrosis and inflammation is damaging to the allograft," says Stegall. Without routine "protocol" biopsies, these warning signs would go undetected until clinical abnormalities developed, according to Stegall. "The use of protocol biopsies allows for more detailed investigations of the intragraft environment," he says. "Such routine biopsies could provide a unique way to predict which kidney transplant recipients may be at increased risk for loss of kidney function, or to identify potential targets for early preventative treatment." The study was limited to patients who received kidneys from living donors and who had no apparent complications during the first year. As a result, the findings may not apply to other groups of transplant recipients, including those who have complications such as delayed transplant function or acute rejection.

Conclusion Nurses caring Renal Transplant patients must have expertise not only in nephrology but also in immunology .Management of medication, fluid balance and other problems often surrounded by complications such as Graft Loss, Failing Renal Transplant and Obstructive Uropathy pose

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