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KIDNEY TRANSPLANTATION

PRESENTER:
DAINY THOMAS

MODERATOR:
MADAM RACHEL ANDREWS

MSc NURSING IST YEAR STUDENT, LECTURER, AIIMS. AIIMS.

INTRODUCTION
Organ transplant

of a kidney into a

patient with end- stage renal disease.


Typically classified

as deceased-

donor (formerly known as cadaveric) or living-donor transplantation

INTRODUCTION
It

is the most cost effective treatment method for ESRD.

KIDNEY TRANSPLANTATION
Living-donor Genetically Non-related

renal transplants:

related (living-related) (living-unrelated)

transplants, depending on whether a biological relationship exists between the donor and recipient.

Donor kidney-placed inferior of the normal kidneyanatomical location.

HISTORY
y

First human to human transplant done in 1936, from a B+ cadaver to O+ recipient.

First cadaveric kidney transplantation in the United States 1950- polycystic kidney disease, at Illinois.

The first kidney transplants between living patients -1954 (Boston and Paris).

HISTORY (CONTD)
y

The procedure was done between identical twins to eliminate any problems of an immune reaction.

Dr. Murray received - Nobel Prize for Medicine(1990).

ADVANTAGES
The kidney - easiest organ to transplant: Tissue typing - simple. Organ - relatively easy to remove and implant. Live donors could be used without difficulty. In the event of failure, dialysis was available from the 1940s.

INDICATIONS FOR KTP


End-Stage Renal Disease (ESRD), regardless of the primary cause. y ESRD is defined as a drop in the glomerular filtratration rate (GFR) <15% of normal. y Individuals with chronic renal failure who have a living donor available may undergo pre-emptive transplantation before dialysis is needed.
y

CONTRAINDICATIONS
y y y y

MALIGNANCY RECURRENT DISEASES INFECTION HIGH PROBABILITY OF POST OPERATIVE MORBIDITY& MORTALITY

NONCOMPLIANCE

Contraindications for KTP


Cardiac Hepatic

and pulmonary insufficiency, disease terminal infectious diseases

Incurable Morbid

obesity and/or significant on-

Psychiatric illness

going substance abuse issues.

SOURCES OF KIDNEY
Depending on the source of the recipient organ.
y

Living-donor transplantation
Genetically related (living-related) Non-related (living-unrelated)

SOURCES(Contd)
y

Deceased-donor (formerly known as cadaveric). Brain-dead (BD) donors or ("heartbeating): Donor's heart continues to pump and maintain the circulation. Donation after Cardiac Death (DCD): Have elected via a living will or through family to withdraw support.

PAIRED KIDNEY DONATION


y

It is an option for patients in need of a kidney transplant who have a living donor whose blood or tissue type is not compatible. Known as KIDNEY SWAPING

Recipient evaluation process


y y y y y y y y y y

Early referral : as soon as CKD is diagnosed. Patient education Age Polycystic kidneys Urinary tract Cardiac disease evaluation GIT evaluation Respiratory disease evaluation Obesity Oral hygiene

Benefits of a renal transplantation


y y y y y y y

Improved quality of life Freedom from dialysis Normal healthy diet Freedom from liquid restriction Travel freely Employment Improved fertility

PRE TRANSPLANTATION PREPARATION


STAGE 1: Information and discussion
  

Desire to receive a transplant Benefits of a renal transplant Risks/ disadvantages of a renal transplant

STAGE 2 : Clinical assessment


 Clinical  Renal

history

disease & disease progression; dialysis

status

Pre transplantation prep.


STAGE 2:
 Previous medical history: BT, pregnancy,

surgery
 Current clinical status  Social history& family 

status

Personal history: smoking , alcohol, drug abuse

 Current medication, allergies, blood group  System wise

assessment

Pre transplantation prep


y Information: discussion
x x x x x

Risks Further investigation Living donor or cadaveric list Immuno suppression regimen Decision

y Stage 3      

: Routine Investigations

Blood group Tissue typing Biochemistry Haematology Liver function tests Lipid level

Pre transplantation prep


   

Virology: Hep B &C, HIV, CMV Chest X- ray, ECG Mid stream urine Specific investigation required 4:

y STAGE

Orientation, Final cross match

DONOR AND RECIPIENT MATCHING


y y

ABO Blood group Major histocompatibility complex (human leukocyte antigen): Two major types: class 1& class 2 Class 1: HLA A, HLA B,HLA C Class 2: HLA DP, HLA DQ, HLA DR A,B,C & DR - 4 Main series important for transplantation

Pre transplant cross matching

Pre transplant cross- match


y

Blood sample of recipient + lymphocytes from the donor.

y y

If donors cell die, its a +ve cross match i.e. recipient is adversely reacting to donors antigens, so the transplantation would be rejected.

Sensitization
y

It is defined as being immunized, or able to mount an immune response, against an antigen by previous exposure to that antigen.

Desensitization
y y

IVIG (2g/kg) IVIG + Plasmapheresis

Research input
y

A comparison of the results of renal transplantation from non-heart-beating, conventional cadaveric, and living donors.

y y y

Nicholson ML et al Kidney Int. 2000 Dec;58(6):2585-91 The initial function rates for NHBD, HBD, and LD transplants were 6.5, 76.3, 93% respectively .Despite being associated with poor initial graft function, the long-term allograft survival of NHBD kidneys does not differ significantly from the results of HBD and LD transplants.

KIDNEY HARVESTING
From a living donor: Steps

1.Assessment & preparation for donation:


  

Donor & recipient matching. Informed consent Physical and clinical examination

2.Investigations 3. Assessment of surgical risk: Is donation safe for the recipient & donor ? 4.Preoperative assessment

ASSESSMENT AND PREPARATION OF DONORS


THREE STAGES y STAGE 1: Assessment 1. Age 2. Informed consent 3. Preliminary medical history 4. Renal disease 5. Smoking, Drug or alcohol abuse 6. Obesity

Stage 2: Donor blood clinical tests


Blood group y Tissue typing: T cell &B cell cross match y Urea ,electrolytes & creatinine y LFT, fasting glucose y Hemoglobin & clotting screen y Viral screen y Urine tests y B. P, pulse, weight ,height
y

Investigations : 2nd stage


y y y y   

Done prior to medical assessment Blood tests: repeat tissue typing, LFT, hematology Clinical tests: chest X-ray, ECG, USG of renal system Urine tests: Midstream urine, Urinalysis: proteinuria, hematuria Assess GFR: 24hr urine for creatinine clearance, clearance scan.

Stage 3: Medical Assessment


y Is donation y Is donor y Can

safe for recipient?

fit for a nephrectomy?

donor afford the gift?

Preoperative Assessment Of both donor and recipient


y y

Final cross matching & tissue typing Methicillin-resistant swabs for Staph. aureus( throat, nose, axilla, groin)

y y

Mid stream urine, urinalysis Biochemistry,LFT, Hematology,clotting system

CONTD
y ECG, BP,

Pulse, Temperature,Chest

X ray
y Orientation to y Final crossy Pre

the unit.

match.

post op. care.

CADAVERIC DONATION
Cadaveric donors are patients who suffered irreversible brain stem damage. Criteria for multiple organ donation Patient: y Is aged between 18months-80 years 18monthsy Has suffered irreversible brain damage y Is maintained on a ventilator y Has no major untreated sepsis y Is HIV, Hep B&C negative

LIVING DONORS
EXCLUSION CRITERIA y Cognitive deficit y Active drug or alcohol abuse y Evidence of renal disease ( low GFR, proteinuria, abnormal renal anatomy) y Diabetes , hypertension, CAD y Active infection, chronic viral infection(Hep B, Hep C) y Current/history of neoplasm, family history of any renal cell cancer y Current pregnancy

Surgical technique for living donor nephrectomy


Two approaches: flank incision with y Rib resecting y Supra costal approach

Surgical techniques for nephrectomy


y Trans abdominal y Laparoscopic y Single port

access surgery

y Natural orifice

Transluminal endoscopic surgery

Kidney harvesting

Transplantation Operation
y

In most cases the barely functioning existing kidneys are not removed.

The new kidney is placed in the iliac fossa. Right side regardless of the side origin from donor. Contralateral side to the side of donor. Ipsilateral side to the donor kidney.

Cont
y

Its blood vessels connected to arteries and veins in the recipient's body i.e., Renal artery of the kidney, is often connected to the external iliac artery in the recipient. Renal vein of the new kidney, is often connected to the external iliac vein in the recipient.

Cont

Kidney preservation
1.Cold storage method:
y Suitable upto

30hrs of preservation.

2.Machine perfusion
y Suitable upto

48 hrs.

Solutions used for preservation


y y

Collins solution. University of Wisconsin solution HTK- Custodial solution

HTK Solution
y

HTK (HistidineTryptophanKetoglutarate) Solution. HTK is perfused as a cold solution, so that its hypothermic effect contributes to a decreased metabolic rate.

Contd Contd
Surgery lasts five hours on average. y Living donor kidneys normally require 35 days to reach normal functioning levels. y Cadaveric donations stretch that interval to 715 days. y Hospital stay is typically for 47 days.
y

Indications for pretransplantation native nephrectomy


      

Chronic renal parenchymal infections. Infected stones Heavy Proteinuria Intractable hypertension Polycystic kidney disease Acquired renal cystic disease Infected reflux

Postoperative management: living donor


Hydration: fluid & electrolyte balance  IV hydration for first 24- 48 hrs  monitoring of fluid & electrolyte balance  intake output monitoring y Wound management- Regular inspection bleeding and infection y Emotional support y Discharge
y

PostPost-op Mx of donors
y y y

Check vital signs. Input/ output charting Get a Chest -X-ray to exclude any pneumothorax

y y

Early ambulation Administer analgesics as prescribed

PostPost-op Mx of donors
y y y y

Can eat 24-48 hrs post-op. Wound management Complete recovery takes about 6-8 wks. Educate the donor for some lifestyle changes for risk modification.

PostPost- Op Nursing Care

Vital signs every 1hr for 24 hrs, then every 4hrs.

I/O every hr for 24 hrs. Intravenous fluids as prescribed Daily weight Turn, cough, deep breathing, intensive spirometry.

PostPost- Op Nursing Care


Dressing changes, palpate fistula every 4 hr. No BP or venipuncture in extremity with fistula.

Catheter care and irrigation Notify if urine output <30ml/hr Blood chemistry to be done. Notify hyperthermia

COMMONLY GIVEN FLUIDS


y y

Types of fluids 5% dextrose Ringer Lactate NS

Amount of fluid to be given


Output less than 50ml/hr : inform Output 50- 200ml/hr: output+150ml Output 200-400ml/hr: output amount Output 400-500ml/hr:400ml of fluid

Post operative management..


y y

For a delayed functioning graft Intravenous fluids- maintain CVP 10-15 cm water & frusemide to induce diuresis

Serum electrolytes: any disturbances warrant immediate attention

Post op management of recipient


Immunosuppressant drugs are must for good outcome. y Most common medication are
y

Calcineurin inhibitors: Tacrolimus or cyclosporine Mycophenolate mofetil and Azathioprine Corticosteroids: prednisolone IVIG

Uses of immunoglobulins
To reduce high levels of preformed antiHLA antibodies in sensitized patients. y To facilitate living donor transplants in case of +ve cross-match or ABO incompatibility. y To treat acute rejection. y To treat certain post transplant viral infection.
y

Post operative management..


Tubes and drains

catheter removal: in the first week


Closed suction drain removal: when output decreases to<50ml/day Urinary stent removal: in OPD within 6-12 weeks

1.Renal transplant rejection


Three types:
y Hyper y Acute

acute rejection rejection

y Chronic rejection

HYPER ACUTE REJECTION


Occurs

immediately in the operating room, when the graft becomes mottled and cyanotic. Causes: previous exposure to the donor antigens. As in: Previous rejected kidney transplant. Multiparous women. Previous blood transfusion. Prognosis: kidney removal

HYPER ACUTE REJECTION

ACUTE REJECTION
Appears

within the first 3 post transplant

months.
Affects

30% of cadaveric transplants and 27%

of transplants from living donors.


20%

of patients with transplants experience

recurrent rejection episodes.

SIGNS AND SYMPTOMS


Decreasing urine output Hypertension, rising creatinine Mild leukocytosis Fever Graft swelling Pain Tenderness may be observed Final diagnosis depends upon a graft biopsy

ACUTE REJECTION
y Investigations

Radio isotope renography Ultra sound Urine culture and sensitivity Needle biopsy yTreatment: high dose pulses of glucocorticoids

Management
1.High dose corticosteroids.
Not enough

2.Repeated.
Not enough

3.Triple therapy.
a) b) c)

Corticosteroids Calcineurin inhibitor. Antiproliferative agents 4. Plasmapheresis

CHRONIC REJECTION
y Gradual decline

in renal function

associated with interstitial fibrosis & vascular changes


y Factors associated with

chronic

rejection are both immunological + non-immunological

Management
y y

Irreversible & cannot be prevented. Only treatment is a new transplant after 10 years

2.Acute occlusion of transplant renal artery or vein.


y y y y

Occurs in first transplant week (0.5-8%). Causes oligo/anuria and ARF. With renal vein thrombosis, graft tenderness, dark Hematuria and decreased urine volume. Diagnosis is via doppler ultrasound or radioisotope scanning to demonstrate lack of blood flow. Treatment is surgery.

3.Peritransplant haematoma
Early post- op complication y Severe pain over allograft, decreased Hb or Hct, increased serum creatinine. y Recurrent increased K+ due to lysis of RBC in haematoma. y Diagnosis via USG or CT. y Treatment is surgical and usually leads to allograft nephrectomy.
y

4.Urinary Leak
y y

First transplant month. (2-5%) Patient presents with urine extravasation and ARF, fever, pain and distended abdomen.

Diagnosis is via ultrasound which demonstrates a peri-transplant fluid collection or via radioisotope scanning.

Treatment is foleys catheter insertion and surgery.

5.Lymphocoele
Occurs within the first 3 post transplant months and is due to lymph leaking from injured lymphatics (5-15%). y It causes:
y

Pain ARF Ipsi-lateral lower extremity oedema, Occasionally iliac vein thrombosis. Most of the signs and symptoms are due to pressure effects.
y y

Diagnosis - ultrasound. Treatment- percutaneous drainage.

6.Obstructive Uropathy y Occurs in early post transplant period (36%). y Causes are: extrinsic compression of the ureter by a lymphocoele a technical problem with the ureteric anastomosis to the bladder. y Diagnosis - ultrasound demonstrating hydronephrosis. y Treatment is surgical.

7.Renal artery stenosis


y y

Late presentation. Patients present with uncontrolled HT, allograft dysfunction and peripheral oedema.

Diagnosis is via ultrasound or MRA.

8.Post-transplant lymphoproliferative disorder. 9.Imbalances in electrolytes. 10. Infections and sepsis due to the immunosuppressant drugs that are required to decrease risk of rejection.

11. Malignancy
y

Transplant recipients are at significantly higher risk for cancers than the general population because of (1) Chronic Immunosuppression, (2) Chronic antigenic stimulation, (3) Increased susceptibility to oncogenic viral infections, and (4) Direct neoplastic action of immunosuppressants.

Immuno suppression
y

Combination of drugs are given:

Triple drug regimen


y y y

a glucocorticoid ; eg; prednisolone a calcineurine inhibitor ,e.g; cyclosporine, tacrolimus a purine antagonist, eg; azathioprine

or mycophenolate mofetil + antilymphocyte antibody, eg ;OKT3

Most common immunosuppressive protocols


1.Cyclosporin/MMF/steroids 2.Tacrolimus/MMF/steroids 3. Cyclosporin/sirolimus/steroids 4. Tacrolimus/sirolimus/steroids

Immunosuppressive medications
y

The calcineurin inhibitors tacrolimus a complex with their

Eg: cyclosporine ,

MOA: formation of

respective cytoplasmic receptor proteins. This complex binds with calcineurin. Inhibition of calcineurin impairs the expression of several critical cytokine genes; eg:IL-2,IL-4, interferon and tumor necrosis factor

Immuno suppressive medication calcineurin cont


y y y x x x x

Drug is primarily excreted through bile. Drug level monitoring Drug interactions Drug concentration decreases with Rifampin, Barbiturates, phenytoin Drug concentration increases with Calcium channel blockers Antifungal agents

Immuno suppressive medication calcineurin cont


y

Side effects of cyclosporin Nephrotoxicity: decreased GFR Hypertension Hepatic dysfunction Hirsutism, hypertrichosis Hyperlipidaemia Hyperkalemia, hypomagnesemia Hyperuricemia Gum hypertrophy

Immuno suppressive medication Calcineurin cont


y

Side effect of Tacrolimus and neurological disturbances headache, insomnia

Visual

Hypertension Tremor, Raised

blood sugar level

Leukopenia

Immuno suppressive .
y

Mycophenolate mofetil action: inosine Reverse inhibitor of enzyme monophosphate dehydrogenase. Diarrhoea Vomiting leukopenia

Mechanism of x

Side effects x x x

Immuno suppressive
y

Azathioprine Inhibits both DNA & RNA synthesis and prevents growth of lymphocytes effects Neutropenia (main) Alopecia Muscular pains Malignancy Altered liver function Pancreatitis , cholestatic jaundice (rare)

Mechanism of action x

Side x x x x x x

Immuno suppressive
y

Prednisolone
Mechanism of action:
x Antiinflammatory responses with blocking of T cell and interleukin-1

Side effects:
x x x x x x Cushingoid appearance (facial swelling) Fluid retention Glaucoma Increased appetite, peptic ulcer Hypertension, increased blood sugar level Psychosis , mood swings

Immuno suppressive
y y x

Orthoclone(OKT3) monoclonal antibody Mechanism of action: React with CD-3 molecules on the lymphocytes and depletes them. Side effects: Chest pain Pulmonary edema Gastrointestinal disturbances Fever with Chills Dyspnoea Infections

y x x x x x x

Immuno suppressive..
Antilymphocyte globulin- polyclonal antibody
Mechanism of action:
Inhibits and destroy circulatory lymphocytes through antibody action

Side effects:
Rash Fever with chills Anaphylaxis Thrombocytopenia, leukopenia Myalgia

Nursing Management.
1. 2. 3. 4.

Assessing the patient for transplant rejection. Preventing infections Monitoring urinary functions Providing psychological support to the patient & family.

5. 6.

Monitoring & managing potential complications. Patient & family education.

Post operative nursing management


 Ineffective airway clearance related to

depressed

respiratory function, pain, and bed rest


 

Close monitoring of respiratory status Assess respiratory pattern, auscultate for any crackles or abnormal respiratory sounds

 

Early chest physiotherapy Encourage to do deep breathing& breathing exercises

Nursing management
 Acute   

pain related to surgical incision

Assess pain : patterns, any radiating pain Administer analgesics as prescribed Non pharmacological measures distraction , imagery, relaxation etc can be used to supplement medication.

Nursing management
 Risk    

for fluid and electrolyte imbalance related to the post operative condition Assess CVP and urinary output frequently Hourly intake equal to previous hours output plus 50ml Monitoring of serum biochemistry and hemoglobin frequently Oral fluids usually introduced in early post operative period as paralytic ileus is rare

Nursing management
y 

Risk for rejection of graft Assessing the patient for transplantation rejection : oliguria, edema , fever, increase BP, weight gain, and swelling or tenderness over graft.

Those who receive cyclosporine the only sign may be asymptomatic rise of serum creatinine >20% is considered as acute rejection.

Differentiate between infection and rejection.

Nursing management
 Potential for developing infection related to

the

immuno suppressed state


 

Assess for Signs and symptoms of infection Protect patient from exposure to infection: careful hand hygiene& use of personal protective equipment Meticulous catheter care. Urine cultures, wound drainage culture, catheter tip culture etc.

 

Research input
Cytomegalovirus infection renal transplant recipients: risk factors and outcome. Kanter J, Pallard L, et al Transplant Proc. 2009 Jul-Aug;41(6):2156-8 Recipient age older than 55 years, induction therapy with Thymoglobulin, and maintenance immuno suppression with cyclosporine were the major risk factors to develop CMV disease. Data showed that CMV is a common complication after kidney transplantation associated with older age, induction treatment with antilymphocyte globulin, worse renal function, and increased patient morbidity.

Nursing management
Monitoring and managing potential complications
 

Assess for complications related to renal failure . Assess for GI ulceration& bleeding related to corticosteroid therapy

Monitor closely for signs and symptoms of adrenal insufficiency

NURSING MANAGEMENT
Pre operative teaching include: Post operative pulmonary hygiene Pain management options Dietary restrictions Presence of indwelling catheters & IV &arterial lines Psychological concerns

Promoting home based care


Teach patient self care  Educate them about the need for continuing immunosuppressive therapy.  Instruct family members to assess for signs and symptoms of transplant rejection,

infection, & potential adverse effect of immunosuppressant medication.

Promoting home care.


Continuing care


Explain the patient need for life long follow up care. Individual verbal & written instructions to be provided to the patient concerning various aspects. Watch for malignancy as the patient is receiving long term immunosuppressive therapy.

Post transplant diet restrictions


Variety of foods Limit sodium, saturated fat and cholesterol intake Monitor weight on a daily basis Avoid sugary snacks between meals Eat 1000- 1500mg calcium daily Regular exercise 30 mins at least 3 times a week Drink plenty of fluids 3 to 4 litres per day

Behaviour modification
Eating slowly Have regular meal patterns with frequent interval Dont skip breakfast. Last meal should be taken around 8.30pm Dont sleep immediately after taking meal Eat always in pleasant atmosphere. Eat always in sitting down position

Food hygiene
Raw vegetables should be washed properly
Dont cut vegetables until just before cooking Dont overcook vegetables Oil or ghee should not be reused Cook food hygienically and freshly prepared Dont eat uncooked foods and avoid eating out Take only boiled water.

In post-transplant patient

y y y y y

y y

Proteins: 1.3 to 2.0 g/kg body wt. Calories: 30- 35 kcal/kg Carbohydrates: 50% -70% of all calories. Fat: 35% of calories. Sodium: for normotensive= no restrictions otherwise, restricted to 2g/day. K+ : restricted in hyperkalemia Fluid: normo-volumic = 2000ml/day oliguric: urine output + ~500ml/day

Resuming normal activities


Pregnancy Work Traveling Dental care Skin care Exercise Vaccinations

Avoiding infection
Wash hands often Stay away from people with cold or other infections Screen visitors for infection Wash hands after coughing and sneezing. Avoid live vaccines such as polio, mumps.. Do proper dental care. Avoid contact with animals that roam outside

Signs to watch out for


Fever Shortness of breath Cough Skin changes Pain or discomfort during micturation Decrease in urine output, hematuria

Clinic visits Upto 2 months : twice a week 3rd month : once a week

4months to 1 yr : twice a month More than 1 yr Lab tests Test for kidney function Test for blood count Test for liver function Blood glucose : atleast once in3months

Prognosis
y

The donor kidney's average life time is 10 to 15 years so it needs second transplantation or for some times dialysis again.

yReferences
Nicola Thomas ; Renal nursing ; Second edition, Page no:337-400 Walch, Retik vaughan and Wein; Campbells Urology; 8thedition; Page no: 345-373 Dr. Meenakshi Kamboj, Ms Shwetha Mattur, Dr. Sandeep Gularia; Living with a transplant. www.wikipedia.com