Renal Transplantation

Background
Renal Transplantation is the organ transplant of a kidney in patients with End-Stage Renal Disease. Renal Transplantation
is classified as Deceased-Donor or Living-Donor Transplantation depending on the source of the recipient kidney. A
successful kidney transplant offers enhanced quality and duration of life and is more effective (medically and
economically) than chronic dialysis therapy. (1) Mortality of patients in the first year after transplantation is now less than
5 percent. (2)
The 3 diseases most commonly leading to CRF and treated by kidney transplantation are (i) type 1 diabetes mellitus, (ii)
glomerulonephritis, and (iii) hypertensive nephrosclerosis, accounting for about 75 % of the total candidate population.
(2)
Patients with ESRD have 3 options for renal replacement therapy: (i) hemodialysis; (ii) chronic ambulatory peritoneal
dialysis; or (iii) transplantation. The choice should be based on the relative risks and benefits. The best recipients for
transplantation are young individuals whose renal failure is not due to a systemic disease that will damage the transplanted
kidney or cause death from extrarenal causes. (2)
The new kidney is placed on the lower right or left side of
the abdomen where it is surgically connected to nearby
blood vessels. Placing the kidney in this position allows it to
be easily connected to blood vessels and the bladder.
Conditions requiring diseased kidney removal during
transplantation:
Repeated infection that could spread to the
transplanted kidney
Uncontrollable hypertension caused by your
original kidneys
Backup of urine into your kidneys/Reflux (3)

Risks of Renal transplantation (4)

Surgical risks during and after kidney transplant
-

Wound infections (1% of kidney transplant surgeries)

Bleeding (most commonly occurs during or within the first week after kidney transplant surgery)
Clotting of blood vessels to the transplant kidney (up to 8% of kidney transplant pt)
Urine leakage where the new kidney is attached to the bladder (can happen within first 2-3 days of transplant)
Kidney artery stenosis (can happen 3 months to 2 years after transplant)
Narrowing of the transplant kidney ureter (can happen over time)
GI complications can include nausea, vomiting, blockage of the bowel, gall bladder infection, infection of the
stomach , bowel, or pancreas and injury to the bowel during surgery
Other surgical risks include blood blots in legs, decreased blood flow to the leg on the same side as the new
kidney, pneumonia, heart attack, stroke, death.
Medical risks after kidney transplant

Acute rejection- risk of the body seeing new kidney as a foreign object and attacking it is about 20%. The risk is
greater during first year after transplant.
Delayed graft function requiring dialysis happens in about 20% of deceased donor kidney transplant. Rare in
living donor kidney transplant (<5%).

Bacterial infections (bladder infection, pneumonia, blood infection and other)

Viral infections such as Cytomegalovirus infection (can include fever and can attack the stomach and/or bowel,
liver, pancreas, lungs, eyes, and or/brain and nerves.
BK (polyoma) virus infection of the transplanted kidney possibly resulting in failure of the kidney (approx.1-10%
chance).
Increased risk of cancer due to the medications to decrease bodys natural response to the new kidney. Nonmelanoma skin cancer is the most common type of cancer after transplant with a 91 times increased risk 3 years
after transplant.
Post-Transplant Lymphoproliferative Disease (PTLD)-white blood cell cancer caused from lowered immune
system.
Heart disease such as heart attack and stroke is twice as likely to happen in a transplant pt as in the general US
population.
Complications related to long term use of immunosuppressive (antirejection) medications include nausea,
abdominal bloating, diarrhea, leucopenia and anemia, high bllod fat level, high BP, new diabetes, headache,
shakiness and damage of the transplanted kidney.
Loss of function of transplanted kidney (most transplanted kidneys work for about 13 years for deceased donor
kidneys and 20 years for living donor kidneys)

Renal Graft Rejection (4,5)

The biggest problem facing all transplant patients is the possibility of rejection. Rejection is the body's attempt to get rid
of a foreign substance by immune system attacking it. There are several kinds of rejection, and they can be a common and
life-long issue.
Hyperacute - This severe form of rejection happens within minutes or hours after transplant surgery. The new kidney must
then be taken out. This form of rejection is very rare.
Acute - This is the most common type of rejection, and while it can happen anytime, it more frequently occurs during the
first six months after transplant.
Chronic - This type of rejection can happen at any time, including years after the transplant.
A common cause of (chronic) late rejection is not taking immunosuppressive (anti-rejection) medication, skipping days,
or taking the wrong dosage. In order for the new organ to not be rejected, transplant recipients will need to stay on
immunosuppressive medicines for the rest of their life.Signs and symptoms of 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

Identification of Rejection
The Transplant Team will be able to determine if the body is rejecting the new kidney by completing routine tests
of kidney function during patients hospital stay. The following tests may be conducted in case any problem is
suspected.

Repeated blood work including a complete blood count

Renal flow scan (which checks blood flow to the kidney)
Renal ultrasound (which checks for other physical problems)
Kidney biopsy

The rejection may be treated with one or more of the following:

- High Doses of Prednisone (may be increased for five to nine days)
- Thymoglobulin- This drug is given intravenously over four hours every day for 7 days. Patient must
be in the hospital for the first, second and third doses. More frequent lab monitoring is needed during this
treatment.
Some of side effects of these medications:

Fever, chills
Headaches
Nausea, vomiting
Weakness
Diarrhea
General flu-like symptoms

Nursing Care (6)

Nurse interventions can be classified as pre- and post-renal transplantation interventions. Pre-transplant interventions
include physical, psychological and educational support to the patient and family members. Since, Kidney Transplantation
is an elective procedure, the entire procedure requires extensive pre-transplant evaluation and the patient is normally
maintained on a schedule of pre-transplant dialysis. Transplant is delayed with the onset of chest pain, infection,
pneumonia, or gastrointestinal bleeding. If the serum potassium exceeds 5.5 mEq/l, the patient is put on dialysis preceding
the transplant procedure.
Post-transplant nursing care for the patient begins in the post-anesthesia care unit. Since the transplant is placed in a
heterotropic retroperitoneal location in the lower pelvis, nurse's awareness of the transplant positioning in the operating
room is vital for an effective postoperative care.
-The patient's hemodynamic status and fluid volume need to be monitored to avoid post-transplant complications while
maintaining central venous pressure at 10 mmHg and systolic blood pressure above 120 mmHg.
-Intravenous administration of steroids such as methyl prednisolone and diuretics such as mannitol or furosemide
enhances diuresis.
-Urine output is replaced on an hourly milliliter-for-milliliter basis and recorded hourly.
-Reduced capillary spasms and normal renal blood flow is achieved by calcium channel blocker administration into the
renal artery.
- It is important to keep the patient euvolemic or mildly hypervolemic by adequate intravenous fluid replacement which is
usually 0.45% normal saline closely resembling the sodium content of a newly transplanted diuresing Kidney.
-Nurse assessment of hourly urine output includes assessment of Anuria where there is no urine output and Oliguria where
the output is less than 50 ml per hour.

Following tables (7)

Resources used
1. Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in
clinically relevant outcomes. Am J Transplant. Oct 2011;11(10):2093-109.
2. Kidney Transplantation. http://www.aetna.com/cpb/medical/data/400_499/0493.html
3. Kidney Transplant Procedure.
http://my.clevelandclinic.org/services/kidney_transplantation/hic_kidney_transplant_procedure.aspx.
4. Penn State Patient Information Handbook- Kidney Transplant.
http://pennstatehershey.org/c/document_library/get_file?uuid=285a31e8-88c2-4cd1-ada0548fd0e04a92&groupId=78413
5. OHSU Patient Information Hanfbook- You and your new transplant. www.ohsu.edu/transplant/kid&pncohsu_pt-handbk110410.pdf
6. Nurse Intervention in Renal Transplant. http://www.asrn.org/journal-nursing/375-nurse-interventions-inrenal-transplantation.html
7. Caring for Transplant Recipients in a Nontransplant Setting.
http://ccn.aacnjournals.org/content/26/2/53.full