CE: Continuing Education Article PRE- AND POST-TRANSPLANT CARE: NURSING MANAGEMENT OF THE RENAL TRANSPLANT RECIPIENT: PART 2

Ray Trevitt1, RGN, MSc, Victoria Dunsmore1, RGN, Fiona Murphy2, RGN, RNT, BSc (Hons) Renal Nurs, BSc (Hons) Health Stud, PGDip Adv Nurs Scie, PGDip CHScieEdu, MA, MSc, Lilibeth Piso1, BSc RN, Charlotte Perriss1, RGN, Belinda Englebright1, BSc RN, Melissa Chamney3, RGN, MN (Nephrology), Grad.Dip.Ac.Practice, Renal Cert 1 Barts and The London NHS Trust. 2 School of Nursing & Midwifery, Trinity College, Dublin. 3 Renal Programme, City University, London.

This continuing education article, which is based on the best available evidence, includes various learning activities aimed at developing your knowledge and understanding of pre and post transplant care of the patient. After reading this article and on completion of the learning activities you will have achieved 3 hours of learning in accordance with the EDTNA/ERCA criteria for continuing professional development.

Trevitt R., Dunsmore V., Murphy F., Piso L., Perriss C., Englebright B., Chamney M. (2012). Pre- and post-transplant care: nursing management of the renal transplant recipient: part 2. Journal of Renal Care 38(2), 107-114.

SUMMARY
This is the second article in a three part continuing education series on renal transplantation which addresses the specialised knowledge and skills required in order to prepare a patient admitted to hospital for renal transplantation and then how to care for that patient afterwards. The first article in this series addressed patient health and well-being while waiting for a renal transplant. The third article will look at the long-term care of kidney recipients.

K E Y W O R D S Education Nursing Renal transplantation

AIM
The aim of this continuing education article is to enable the nephrology nurse to assess, plan, implement and evaluate the care given to patients admitted to hospital for renal transplantation.

LEARNING OUTCOMES
After reading this CE article the reader should be able to:

Discuss the assessment, planning, implementation and evaluation of the care given to patients admitted for renal transplantation. Discuss the importance of post-transplant observations and the significance of any changes. Discuss the management of the common complications post-transplantation.

B I O D ATA
R a y T r e v i t t is a Living Kidney Donor Coordinator at Barts and The London NHS Trust. His previous EDTNA/ ERCA roles include Consultant on Transplantation issues and Chair of the Transplant Interest Group. V i c t o r i a D u n s m o r e is a Clinical Nurse Specialist, and has worked in transplantation for over 20 years. She is currently studying for an MSc in Nursing. F i o n a M u r p h y is a Lecturer and Renal Educational Facilitator. Fiona is the former Education Officer of the Irish Nephrology Nurses Association and was a member of the former Education Research Board of the EDTNA/ERCA. CORRESPONDENCE L i l i b e t h P i s o is a Clinical Nurse Specialist in Renal Transplantation working with pre and post transplant patients. C h a r l o t t e P e r r i s s is a Clinical Nurse Specialist in Renal Transplantation with special responsibility for paediatric transition patients. B e l i n d a E n g l e b r i g h t is a Living Kidney Donor Coordinator and is studying for a Business Diploma. M e l i s s a C h a m n e y is a Senior Lecturer of Renal Care & Programme Manager at City University, London. She was a member of the former Education Research Board of the EDTNA/ERCA.

Ray Trevitt, Department of Nephrology and Transplantation, Royal London Hospital, London E1 1BB, United Kingdom Tel.: 020 7377 7000 Fax: 020 7377 7093 ray.trevitt@bartsandthelondon.nhs.uk

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INTRODUCTION
For patients undergoing renal transplantation it is a time of great uncertainty. While it is acknowledged that there is a large number of healthcare professionals caring for patients who are waiting for a transplant, it is the renal nurse who is at the centre of their care delivery (Murphy 2007a). The renal nurse needs to assist the patient and their relatives to deal effectively with this situation and also to manage the patients pre- and postoperative care to maximise the success of the graft. A good start for the transplant is a predictor of a good long-term outcome (Hariharan et al. 2002). The importance of patient wellbeing while waiting for transplantation was highlighted in the first of this series of articles (Murphy et al. 2011). Psychological and social support is vital for patients, their spouses/partners and family members especially as patients endure their dialysis treatment and wait for that call for renal transplantation. This support process must be continued throughout the pre-transplantation phase right through to discharge and beyond so that they can effectively manage this life-changing event.

Donor A A B AB O Yes Yes Yes Yes B

Recipient AB Yes Yes Yes Yes Yes O

Table 1: Compatible blood groups.

information and help him/her to prepare emotionally. The patient and their family members should be encouraged to ask questions during this time. At this point, the patient will be asked to provide written consent for transplantation.

TESTS
Pre-operative preparation follows a similar process in all centres. The patient will have routine pre-operative blood tests and also a tissue type crossmatch to check if he/she has any antibodies against the donor. Deceased donor kidneys are almost always from a blood group compatible donor (see Table 1) so blood group antibodies will not be an issue. With tissue type antibodies, if the patient has been negative for a period beforehand and has not received a recent blood transfusion then some centres do not require a prospective crossmatch. Crossmatching takes up to six hours to perform. In the past, a positive result meant that the transplant could not proceed as the body would reject the kidney straight away. However, a positive crossmatch is no longer a roadblock to kidney transplantation. Some degree of positivity may be acceptable depending on local policy. The surgery can still go ahead but the patient must receive additional immunosuppression such as antithymocyte globulin (ATG) to decrease antibody activity which is destructive to the graft (Danovitch 2009). A negative crossmatch means that there are no reactions between the donor and the recipients blood, meaning that the transplant can go ahead as the recipient should not rapidly reject the kidney when immunosuppression therapy is given (Chamney 2009). The patient may require renal replacement therapy (RRT) (haemodialysis or peritoneal dialysis) and other routine preoperative tests such as ECG and chest x-ray. Once all the results are back and are satisfactory, the transplant can proceed. If not, the reasons for this negative outcome must be discussed with the patient and they should be seen again in clinic for review. They may be suspended from the transplant list pending further assessment.

ADMISSION TO HOSPITAL
When a patient is active on the transplant list it is important that they remain fit and well, and that they inform the centre of any changes in contact details. This is because it is usual for the patient to receive a telephone call from the transplant centre to inform them that there is a kidney available. They will be advised to come to the hospital straight away, within a few hours. Although they are warned that there is no guarantee that they will receive the kidney, they should be advised to prepare to be admitted to hospital and bring personal things with them. They will be instructed not to eat or drink from this point onwards in order to be ready for surgery. Upon arrival in the transplant ward, the admission procedures and orientation are carried out by the nurse. Observations or vital signs are taken to help ensure that the patient will be fit for surgery and fit for the immunosuppression therapy they will receive. The nephrologists will also examine the patient and review his/her medical history. It is important at this stage to establish that the patient is free from infection and that any comorbidities present, such as vascular disease, would not cause undue risk. The patient will be informed about the forthcoming procedures for the immediate future and the surgeon and anaesthetist will assess whether the patient is fit enough to undergo transplantation. The surgeon will explain in detail the risks and benefits of the surgery itself. The aim is to reduce patient anxiety, provide appropriate

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Time out activity Review your hospital protocols for pre-operative preparation. Are these the same as above?

United Kingdom the median CIT in 20082010 was 16 hours (NHS BT 2011a)

THE TRANSPLANT RECIPIENT

When anaesthetised and intubated the patient may have a venous line inserted into a peripheral vein and a double lumen neck line. The kidney is place in the iliac fossa. The graft vein and artery are sewn to the recipients vein and artery and the ureter to the bladder. Ureteric anastamosis is usually to the recipients bladder or into the native ureter. A urinary catheter is inserted to ensure continuous bladder drainage and many centres use a ureteric stent, which is left in place for several weeks, to protect and keep open the ureteric anastamosis. Drains may also be placed in the peritoneal space during surgery to drain any excess blood or lymph fluid. During this period the patient needs to be well perfused to establish diuresis and graft function and maintain blood pressure. Time out activity Find a detailed account of renal transplant surgery (e.g. Trevitt 2008, Chamney 2009). Try to find an aspect of care that interests you. It may be something you do not understand the purpose of, or do not agree with, or differs from practice at your own centre. See if you can find evidence to support continuing with this aspect of care using a search engine such as google scholar or Pub Med.

In special circumstances, most commonly with living donors (LD), it is possible to transplant from a blood group incompatible donor (Wilpert et al. 2010).

THE DONATED KIDNEY

Donors can fall into several categories which may have a bearing on expectations for the kidney due to the condition of the donor at the time of retrieval (Gutirrez 2009): Donors after Brain Death (DBD) donors circulation continues up to point of retrieval; Donors after Cardiac Death (DCD) donors heart stops before retrieval commences; Extended Criteria Donors (ECD), for example, donor may be older with comorbidities; LD give the best quality of kidney. Time out activity Find out about different types of kidney donor and any implications for the transplant outcome. Why do living donor kidneys provide the best quality transplant?

When a deceased donor organ becomes available, the national organ procurement agency allocates it according to their regulations and matching criteria. For the United Kingdom, these details can be found on the Organ and Donation website (NHS BT 2011a). Criteria for acceptance of kidneys may vary slightly from hospital to hospital, as can local criteria for accepting patients for transplantation. Local criteria for acceptance of a kidney include donor age, any transmittable disease, anatomical abnormalities or damage and ischaemic time (NHS BT 2011a).

REMOVAL OF DECEASED DONOR KIDNEYS

The surgeon dissects each kidney with the vessels and ureters intact. They are cooled and flushed whilst in situ to minimise warm ischaemic time. Multiple organ retrieval usually begins with retrieval of heart, lungs then liver or pancreas followed by kidneys. Cold ischaemic time (CIT), when the kidney is in cold storage, is far less damaging then warm ischaemia. A CIT of greater than 20 hours may adversely affect outcome due to chronic damage to the kidney. In the

Commonly used measures of success are patient and graft survival and comparisons with patient outcome on RRT. In the United Kingdom, for the period 20052008, for first adult DBD donor kidney transplants, one-year graft survival was 93%. For the period 20022004 the five-year graft survival rate is 85% (NHS BT 2011b). For the same groups the patient survival is 96% and 87%, respectively.

POST-OPERATIVE COMPLICATIONS
The complications cited below are specific to renal transplant surgery and are in addition to general complications postabdominal surgery, for example, deep vein thrombosis (DVT), post-surgical ileus (temporary paralysis of a section of the intestines).

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BLEEDING Significant post-operative bleeding occurs in up to 15% of patients post-transplant (Hernndez et al. 2006). This complication can be life threatening and requires immediate intervention. Bleeding can result from loosening of the suture at the arterial or venous anastomosis, from a mycotic aneurysm (an aneurysm resulting from infection in the vessel wall) at the arterial anastomosis or from rupture of the kidney due to aggressive early rejection. Monitoring of the patients wound, abdomen and vital signs including urine output are key in detecting this complication. ACUTE VASCULAR THROMBOSIS This is the formation of a clot which blocks the flow of blood in the kidney. Typically this occurs within 24 hours of surgery in as many as 8% of patients and can involve either the transplant renal artery or vein (Veale et al. 2009). The patient may complain of pain and swelling over the transplant site and have decreased urine output. Ultrasound Doppler is used to determine whether there is blood flow in the renal artery and vein. If detected straight away the graft may be saved by surgical intervention, however in many cases this is not possible and the graft is lost. The cause of acute vascular thrombosis is often unknown but there are pre-disposing factors: technical problems at the time of surgery due to small vessels in the recipient or donor; pre-existing atherosclerotic vascular disease in the recipient or donor; undiagnosed clotting disorder in the recipient. URINE LEAK This can occur in around 4% of patients (Hernndez et al. 2006). Urine leaks into the abdominal cavity due to ureteric obstruction or necrosis. The patient may complain of abdominal discomfort and have reduced urine output. Ultrasound investigation of the abdomen can confirm a urinary leak. Treatment is usually insertion of an indwelling urinary catheter which remains in situ until the leak is healed. Occasionally surgical intervention will be necessary. LYMPHOCOELE A collection of lymph fluid can accumulate following transplant surgery, occurring in approximately 18% of patients (Veale et al. 2009). A lymphocele can be present without adverse effects but can become problematic if large as it

may compress the iliac vein leading to swelling of the leg, or compress the transplant ureter leading to graft dysfunction. Presence of a lymphocele can be identified by ultrasound. INFECTION Due to the effects of immunosuppression transplant recipients are at higher risk of infection from bacterial, viral and fungal sources. Prevention of chest infection can be ensured postoperatively by encouraging deep breathing, promoting early mobility and physiotherapy. Close attention should be paid to the surgical wound to prevent and/or detect infection. Monitoring of vital signs, particularly temperature is important in order to detect signs of infection. REJECTION Rejection rates of between 15% and 30% have been reported in renal transplant recipients depending on immunosuppressive regime (Vincenti et al. 2008) and can be either cellular or vascular in nature. Rejection is suspected if the serum creatinine rises (or fails to fall). Symptoms such as pyrexia, graft tenderness and decreased urine output develop at a relatively late stage. If no obvious cause for the creatinine rising can be seen, then to confirm the diagnosis of rejection a biopsy of transplant tissue is taken under local anaesthetic and is examined in the laboratory. Treatment depends on the type and severity of rejection. Borderline or mild rejection (cellular) may be treated with an increase in oral immunosuppression or with intravenous high dose Prednisolone. More severe rejection (cellular or vascular) can be treated as mentioned above or by additional administration of ATG. Time out activity What types of rejection are there? See Malhotra et al. (2011).

IMMUNOSUPPRESSION
Without medication to suppress the patients immune system the transplanted kidney would be rejected. This type of medication is referred to as immunosuppression. Immunosuppressive medication used at the time of transplant surgery is referred to as induction. Once transplanted the patient must continue to take immunosuppression for as long as the organ functions, this is known as maintenance immunosuppression.

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Time out activity Think about what information you would give to a patient following transplantation regarding their medication, for example, how to take their medication, when to stop and what side effects to expect?

POST-OPERATIVE OBSERVATIONS
On return to the ward the patient must have their vital signs monitored as for any patient post major surgical procedure and general anaesthetic, observing for signs of shock and haemorrhage. The anaesthetists instructions for oxygen administration must be observed. It is important to monitor respiratory function at this time as the patient will be immunosuppressed, may be fluid overloaded to some degree and susceptible to chest infection. Analgesia will be required which also contributes to respiratory depression. Patients are encouraged to mobilise the day after transplant surgery to minimise the development of DVT and chest infection. FLUID BALANCE Each patient will have a urinary catheter in situ on return from theatre; this enables accurate measurements of urine output to help ensure adequate hydration of the patient and to determine the presence of bleeding and/or blood clots. A drop in output could signify problems with fluid balance, cardiac output, with the kidney itself or within the urinary tract. Intravenous fluid replacement may be titrated to central venous pressure (CVP) readings (via a central line) and urine/drain output. Alternatively a fluid replacement regime may consist of adding an extra specified volume (e.g. 30 ml) to the total urine output for the previous hour. The urinary catheter is usually removed after several days, this allows adequate time for the anastomosis of the transplant ureter to the bladder to heal but urine output should still be monitored. The patient will have peripheral access to enable administration of intravenous fluids. Central and peripheral access should be removed as soon as possible, when no longer required, in order to minimise the risk of infection. Time out activity Why do we need to maintain an accurate fluid balance chart post renal transplant surgery?

WOUND CARE The surgical wound should be observed regularly for signs of bleeding, redness and infection. It is the surgeons preference as to whether clips or stitches are used to close the wound; these are generally removed at 1014 days post-operatively. In some centres patients will have an abdominal drain for the first few days; the surgical team will decide when the draining output over 24 hours is sufficiently low to remove the drain.

RRT
The patient may require RRT initially after transplant surgery until the kidney is working sufficiently. If the patient was on dialysis prior to the transplant their access may still be in place, if this is a haemodialysis or peritoneal dialysis line this may be removed prior to discharge or will need to be reviewed in out-patient clinic.

NUTRITION
As with any abdominal surgery, the patient should remain nil by mouth (NBM) until bowel sounds are present then started on fluids, proceeding to a light diet.

MEDICATIONS AND DISCHARGE

Patients will have blood tests every day. Important results include serum creatinine for renal function, CRP and white cell count for infection, and drug levels. These help determine how effectively the kidney is working, indicate quickly the first signs of possible rejection or infection and show whether drug levels are within the therapeutic range. Each patient will be required to take a regimen of tablets called immunosuppressive medications (see Table 2). Doses are decided by local policy and blood test results. Patients and donors will have been screened for cytomegalovirus (CMV) antibody before surgery. This virus remains a common cause of post-transplant morbidity. CMV recipients receiving a CMV kidney should receive prophylaxis with valganciclovir for three months to reduce the risk of CMV disease. In addition, CMV patients receiving strong antirejection treatment such as ATG also receive prophylaxis. CMV disease typically presents as a flu-like illness but can also cause localised damage in the graft, gastrointestinal tract and lungs. Valganciclovir can be used at a higher dose for treatment (British Transplantation Society 2004).

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Drug class/group Calcineurin inhibitor (CNI) Cyclosporin Tacrolimus (Tac) Corticosteroid Prednisolone Methylprednisolone Antimetabolite Azathioprine Mycophenolate Mofetil (MMF) Mammalian target of rapamycin (mTOR) inhibitor Sirolimus Everolimus Monoclonal antibody Muronomab CD3 (OKT3) Polyclonal antibody Rabbit antithymocyte globulin (rATG) Interleukin (IL)-2 receptor antagonist Daclizumab Basiliximab

Use Maintenance immunosuppression

Side effects Raised creatinine (nephrotoxicty), hyperkalaemia, hyperlipidaemia, neurotoxicity, infection, glucose intolerance (Tac), hypertension Impaired healing, glucose intolerance, cosmetic changes, mood and behaviour changes, adrenal suppression, infection, osteoporosis Diarrhoea & upper gastrointestinal disturbance (MMF), anaemia, leucopaenia, thrombocytopaenia, infection, increased incidence non-melanoma skin cancers Impaired healing, hyperlipidaemia, pneumonia, infection, rash, proteinuria Infusion reactions common (fever, shivering, rash), leucopaenia, neutropaenia, pulmonary oedema Infusion reactions common (fever, shivering, rash), leucopaenia, neutropenia Hypersensitivity reactions can occur

Induction, maintenance and treatment of rejection Maintenance immunosuppression

Maintenance immunosuppression Induction & treatment of rejection Induction & treatment of rejection

Induction

Table 2: Immunosuppressive drugs in current use including short-term side effects. Note: Adapted from Meier-Kriesche and Lodhi (2010) and Danovitch (2009).

Patients need to be familiar with taking all of their medications before being discharged home. Patients can expect to be in hospital for 610 days on average and will receive close follow-up in a nephrology out-patient setting thereafter.

Time out activity What do patients need to be educated about prior to being discharged post renal transplantation? What tools are available to help educate patients could you improve on this?

DISCHARGE ADVICE
Patients can face many challenges when discharged into the primary care setting following the renal transplant. They will need intensive support from the transplant clinic and the primary care setting when discharged (Murphy 2011). Education remains the cornerstone in the care of these patients. They must be taught how to manage the care of their transplant and be competent in self-care skills (Murphy 2007b). It is important that patients are assessed in terms of their ability to learn and comprehend this new knowledge and skills. These teaching sessions must be conducted on an individualised basis using an informal, non-threatening manner. There may be physical difficulties such as visual or hearing impairments or language and literacy challenges when assessing these patients. These can be managed through various means such as electronic blood pressure screening equipment, use of diagrams, daily dosette boxes, translation services and involving family members in teaching sessions as applicable (Trevitt 2008).

The issues regarding concordance to treatment, especially with medication, must be addressed, as poor concordance increases the risk of acute rejection and graft loss. There must be provision of education, prevention and treatment methods to address non-concordance in patients, and family members/carers must be involved (Murphy 2011). Kidney Disease Improving Global Outcomes (KDIGO 2010) asserts that there should be more levels of screening for those patients that are at greater risk for non-concordance towards their medication. After discharge from the ward the patients must attend the transplant clinic on a continuous outpatient basis. This can all be a very overwhelming timeframe for patients and their family members/carers who are adapting to this new life changing circumstances (Wilkinson 2009). It is important that patient care is managed holistically. They should be empowered to manage their rehabilitation from a psychosocial perspective and not just regarded in terms of their renal function and the progress of the actual transplant (Trevitt 2008). Psychosocial concerns must be

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Be able to recognise, comprehend and report the significance of any changes in the following Blood pressure Pulse Temperature Respirations Weight Urinary output Identify the signs & symptoms of the following: Rejection Infection Comprehend the action, dose and side effects of medication regime and the necessity for concordance Have the contact details for the transplant unit and the key personnel to contact should there be any issues as listed above Table 3: Discharge advice post-transplant. Note: Adapted from Trevitt (2008).

includes the importance of a healthy balanced diet, avoiding weight gain and exercise. Skin care advice is necessary due to the higher risk of malignancies from the immunosuppression regime. Fertility and lifestyle issues must also be discussed and reiterated with patients and their family members. Long-term aspects of renal transplantation will be addressed in the third article of this three part continuing education series on transplantation.

CONCLUSION
The renal nurse needs to support and assist the patient and their relatives to cope with transplantation in the best way possible and to manage the pre- and post-operative care to maximise the success of the graft. Nurses caring for these patients require specialist knowledge to reduce problems in the early post-transplant period by prevention or anticipation and early intervention to maximise short- and long-term graft outcome. Patients (and relatives) who are engaged with the process are better equipped to care for themselves and this also contributes to the success of the graft. Time out activity Standards are an important tool to improve the care of patients. Examples from the United Kingdom are the National Service Framework for Renal Services (Department of Health 2004); a strategy to improve the outcomes and experiences of people with kidney disease, and there is also the National Institute for Health and Clinical Effectiveness guidance on both clinical and cost effectiveness of transplantation (NICE 2004). Have a look at these national documents and see if you agree or disagree with how they should apply to local transplant centres.

addressed with patients and their family members/carers as they begin to adapt to life post-transplantation. These may include the freedom from their dialysis regime and the associated lifestyle restrictions and the learning of a new regime for their transplant. Relevant issues such as financial (potential changes to their current welfare payments and the impact that this can have on the family) and vocational concerns must be addressed with the applicable social care worker with a view that patients may get the opportunity to re-enter the workforce for the first time in a number of years. The revised role of patients within their families, and their relationships with spouses/partners and children should be addressed as patients may have adapted to the sick role in the past whilst living with their chronic illness. They may, therefore, find it challenging to move away from this concept and see themselves as a valued member of the family. Patients can worry about potential graft loss. All of these overwhelming emotions may result in patients becoming distressed and anxious which could lead to depression (Murphy 2011). This change in circumstances may cause additional difficulties in the family home as their spouses/partners and family members try to assist them to adapt. The family members also need time to adapt to these events. It is vital that patients and family members are provided with the opportunity to discuss their concerns and are actively listened to. The majority of transplant units should have counselling support services to assist patients in this new dynamic life changing event. They should be encouraged to attend these services but also to engage with the nurses and voice their concerns (Murphy 2011). See Table 3 for some of the discharge advice that patients require post-transplant. Other relevant discharge advice

Key Learning Points Nurses caring for pre and post-renal transplant patients require specialist knowledge and skills. Minimising problems in the early post-transplant period by prevention or anticipation and early intervention maximises transplant outcome. It is important that nurses empower patients to be involved in their care delivery.

Author contributions:
RT: concept and design of paper and drafting of sections on admission, surgery, post-operative and final approval paper.

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VD: concept and design of paper and drafting of section on post-operative complications and immunosuppression and final approval of paper. FM: concept and design of paper and drafting of sections on discharge advice and final approval of paper. LP: concept and design of paper and drafting of sections on pre-transplant period and final approval of paper. CP: concept and design of paper and drafting of sections on post-

operative observations and final approval of paper. BE: concept and design of paper and drafting of sections on the donor kidney and final approval of paper. MC: contribution to design of paper, revising article for important intellectual content and final approval of paper. All authors confirm no conflict of interest.

REFERENCES
British Transplantation Society. (2004). guidelines for the prevention and management of CMV disease after solid organ transplantation. http://www.bts.org.uk/transplantation/standards-andguidelines/ (accessed 4 December 2011). Chamney M. (2009). The Kidney Transplant: nursing management of the patient. In Renal Transplantation: A Guide to Clinical Practice (ed Trevitt R.). Luzern: EDTNA/ERCA. Danovitch G.M. (2009). Immunosuppressive medications and protocols for kidney transplantation. In Handbook of Kidney Transplantation (ed Danovitch G.M.), 5th edn, pp. 77126. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins. Gutirrez E. (2009). Donation issues. In Renal Transplantation: A Guide to Clinical Practice (ed Trevitt R.). Luzern: EDTNA/ERCA. Hariharan S., Mcbride M.A., Cherikh W.S., Tolleris C.B., Bresnahan B.A. & Johnson C.P. (2002). Post-transplant renal function in the first year predicts long-term kidney transplant survival. Kidney International 6 2, 311-318. Hernndez D., Rufino M., Armas S., Gonzlez A., Gutirrez P., Barbero P., Vivancos S., Rodrguez C., Rodrguez de Vera J. & Torres A. (2006). Retrospective analysis of surgical complications following cadaveric kidney transplantation in the modern transplant era. Nephrology Dialysis Transplantation 2 1 , 2908-2915. http://ndt.oxfordjournals.org/content/21/10/2908.full.pdf1html (accessed 20 September 2011). Kidney Disease Improving Global Outcomes. (KDIGO) (2010). Managing your adult patients who have a kidney transplant. http://www.kdigo.org/pdf/KDIGO_TX_PCP_Tool.pdf (accessed 21 May 2011). National Institute for Health and Clinical Effectiveness. (2004). Renal transplantation. http://nice.org.uk (accessed 04 April 2011). National Service Framework for Renal Services. (2004). Part one: dialysis and transplantation (2004) Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4137331.pdf (accessed 04 December 2011). Malhotra P., Malu S. & Kapur S. (2011). Immunology of transplant rejection. [Medscape reference, online] http://emedicine.medscape. com/article/432209-overview#aw2aab6b6 (accessed 20 October 2011). Meier-Kriesche H. & Lodhi S.A. (2010). 30-Year retrospective on organ transplant immunosuppression in the Era of Calcineurin Inhibitors. [Medscape Education Transplantation, online] http://www. medscape.org/viewarticle/726494 (accessed 16 August 2011). Murphy F. (2007a). The role of the nurse in pre-renal transplantation. British Journal of Nursing, 1 6(10), 582-587. Murphy F. (2007b). The role of the nurse in post renal transplantation. British Journal of Nursing, 1 6(11), 667-675. Murphy F., Trevitt R., Chamney M. & McCann M. (2011). Patient health and well-being while waiting for renal transplantation: Part 1. Journal of Renal Care 3 7(4):224-231. Murphy F. (2011). Managing post-transplant patients in primary care. Practice Nursing, 2 2(6), 292-297. NHS BT (2011a). Cold ischaemia time for kidney transplants. http://www.organdonation.nhs.uk/ukt/statistics/centre-specific_ reports/pdf/cold_ischaemia_time.pdf (accessed 05 October 2011). NHS BT (2011b). kidney graft and patient survival. http://www. organdonation.nhs.uk/ukt/statistics/transplant_activity_report/arc hive_activity_reports/pdf/ukt/activity_report_2009_10.pdf (accessed 05 October 2011). Trevitt R. (2008). Renal transplantation. In Renal Nursing (ed Thomas N.), 3rd edn, pp. 363-436. London: Balliere Tindall. Veale J.L., Singer J.S. & Albin Gritsch H. (2009). The transplant operation and its surgical complications. In Handbook of Kidney Transplantation (ed Danovitch G.), 5th edn, pp. 181-197. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins. Vincenti F., Schena F.P., Paraskevas S., Hauser I.A., Walker R.G. & Grinyo J. on behalf of the FREEDOM Study Group. (2008). A randomized, multicenter study of steroid avoidance, early steroid withdrawal or standard steroid therapy in kidney transplant recipients. American Journal of Transplantation, 8 , 307-316. http://onlinelibrary.wiley.com/doi/10.1111/j.16006143.2007.02057.x/full (accessed 20 September 2011). Wilkinson A. (2009). The first quarter. The first three months after transplantation. In Handbook of Kidney Transplantation (ed Danovitch G.), 5th edn, pp. 198-216. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins. Wilpert J., Fischer K.G., Pisarski P., Wiech T., Daskalakis M., Ziegler A., Neumann-Haefelin E., Drognitz O., Emmerich F., Walz G. & Geyer M. (2010). Long-term outcome of ABO-incompatible living donor kidney transplantation based on antigen-specific desensitization. An observational comparative analysis Nephrology Dialysis Transplantation, 1 1(25), 3778-3786.

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