renal transplantation

1. Nursing Management of Patient Undergoing Renal
Transplantation
Presented By
Karana Ram
Msc.(n) 1st year

3. INTRODUCTION
➢Renal transplantation is the treatment of choice for
chronic irreversible renal failure.
➢The current donation rate is much higher in the four
states of Tamil Nadu, Andhra Pradesh, Gujarat and
Maharashtra with it being 0.3 per million
population

4. ➢Definition
➢ Renal transplantation is the surgical implantation of a
Human kidney from a compatible donor in a recipient”.
OR
➢A kidney transplant is a surgery to place a healthy
Kidney from a living or deceased donor into a person
Whose kidneys no longer function properly.

5. History
➢1902- The first successful experimental kidney transplants were
performed at the Vienna Medical School in Austria with animals.
➢1909 - The first kidney transplant experiments were performed
humans in France using animal kidneys.
➢1933 - The first human-to-human kidney transplant was performed.
➢1950 - Cortisone-like medications were used to suppress the
human body immune system resulting kidney transplant success.

6. INDICATION
➢ ESRD
➢Chronic glomerulonephritis
➢Chronic pyelonephritis
➢Solitary functioning kidney as a result of trauma
➢Renal cancer
➢Genetics disease- polycystic kidney diseases.
➢Chronic renal failure (CRF).

7. DONOR
Selection of donor -
➢Age : 2 -70 years
➢Free from diseases.
➢Kidneys should be capable of good
function

8. TYPES OF DONOR
➢Living donor
➢Cadaver donar
➢Non-heart-beating donors

9. Preoperative Diagnosis
Basic Investigation are- CBC, KFT, SGPT, S.ALBUMIN,
CALCIUM/PO4, LDH, BLOOD SUGAR ,HbA1c,TSH, PT/
APTT ,HbS Ag, Anti HCV, LIPID PROFILE, URINE
MICROSCOPY, URINE CULTURE, 24 hour urine Protein,
ECG,, USG whole Abdomen, Chest X-Ray, Blood Grouping,
GFR.
• DTPA Scan OF RECIPIENT ASAP (date with in 2 weeks)
• Rh incompatibility
• Abo incompatibility
• Platelet different study
• HLA testing.

10. PRE-OPERATIVE/CHECKLIST-
1. VBG- Post Haemodialysis after admission
2. CBC, KFT, PT /APTT,.
3. Blood Grouping and cross matching.
4. ECG.
S. Nil orally.
6. Part preparation .
7. P.C. enema
8. Betadine paint
10. Written Consent
,11. Injection Emeset
12. Injection Augmentin- Dose: 600 mg IV BD
13. Injection Magnex forte 1.5 gm IV
14.Cap. Tacrolimus
16. Tab. Mofetyl S 720 mg
17. Tab. Ativan- 1mg
18. Injection rabbit ATG 75 MG
19. Injection Augmentin, Injection Magnex forte to be sent with patient in OT.
20. Recipient's arterial line, central line ON LEFT IJV

11. CONTRAINDICATION
Active malignancy
Active infection
Peripheral vascular disease
Severe cardiac or pulmonary disease
Active IV drug abuse

12. MEMBER OF RENAL TRANSPLANT TEAM
Transplant Surgeons.
Transplant Nephrologists.
Transplant Coordinators.
Transplant Fellows and Residents
Transplant nursing officer
Other supportive staff.

13. SURGICAL PROCEDURE

14. DONOR
 Client placed in lateral decubitus
position
 Incision made at level of 11th rib.
 The left kidney mostly preferred for
laparoscopic removal.

15. HTK- Custodial Solution
 HTK (Histidine-
Tryptophan-Ketoglutarate)
Solution.
 HTK is perfused as a cold
solution, so that its
hypothermic effect
contributes to a
decreased metabolic rate.

16. RECIPIENT
 Incision made between iliac crest and pubis.

 Transplanted kidney placed in iliac fossa.

17. Contd,,
 Renal artery anastomosed with external iliac artery and renal
vein with external iliac vein.
 Donor ureter anastomosed with bladder mucosa

19. Preoperative Management
•A complete physical examination is performed to
detect and treat any conditions that could cause
complications after transplantation.
•The patient must be free of infection at the time of
renal transplantation because after surgery the patient
will receive medications to prevent transplant
rejection.
•Hemodialysis is often performed the day before the
scheduled transplantation
•Provide psychological support to the patient.

20. Contd,,
• Patient should be NPO for 6 hours before
surgery.
• Informed consent should be taken from
patient as well as relatives also.
• Antibiotic should be given before surgery
as prescribed by surgeon.
• Skin preparation of operating site should
be done.

21. POST OPERATIVE MANAGEMENT
❑ Immunosuppressive therapy-
 glucocorticoid
 calcineurine inhibitor
 purine antagonist

22. GLUCOCORTICOID
 Eg: prednisolone
 Maintenance dose: 10 to 15 mg per day
SIDE EFFECTS :
 Impaired wound healing
 Infection

23. CALCINEURIN INHIBITORS
 Eg: cyclosporine , tacrolimus
 Dose : 6-8 mg/ kg per day
SIDE EFFECTS :.
Nephrotoxicity
Glucose intolerance
Hypertention
Gingival hyperplasia

24. PURINE ANTAGONIST
 Azathioprine (Azoran)
 DOSE: 1.5 to 2 mg/kg per day
ACTION: Inhibits both DNA & RNA synthesis and
prevents growth of lymphocytes
Side effects
●Neutropenia (main)
●Alopecia
●Muscular pains
●Malignancy
●Altered liver function

25. POSTOPERATIVE NURSING
MANAGEMENT
 Maintaining the normal blood pressure.
 Assessing the surgical site.
 Blood sugar monitoring 4 hourly.
 Maintain strict aseptic precautions and
Preventing from infection
 Monitoring and managing potential complication.
 Strictly monitor urine output hourly.
 Assessing the patient from transplant rejection.
 Replace the urine output with IV fluid.
 Vaccinated the patient.

26. POST OPERATIVE NURSING DIAGNOSIS
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 exercises

27. RISK FOR FLUID AND ELECTROLYTE IMBALANCE
RELATED TO POTENTIAL GRAFT DYSFUNCTION
➢Assess CVP and urine output hourly.
➢Fluids given are 5% dextrose, RL, NS.
administered through central venous line.
➢Oral fluids are given once the patient
tolerates.
➢ 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

28. ACUTE PAIN RELATED TO SURGICAL
SITE INCISION
 Assess pain : patterns, any radiating pain.
 Administer analgesics as prescribed
●Epidural analgesia or PCA Opiate derivative-
morphine is commonly used
●Non pharmacological measures like
distraction, imagery, relaxation etc can be
used.

29. RISK FOR TRANSPLANT REJECTION IN THE RECIPIENT
RELATED TO NON HISTOCOMPATIBILITY
 Assess for oliguria, edema , fever, increase BP, weight gain,
and swelling or tenderness over graft.

30. POTENTIAL FOR DEVELOPING INFECTION RELATED TO
THE IMMUNO SUPPRESSED STATE
➢Assess for infection: chills and fever, tachycardia,
tachypnea & decrease or increase in WBC count
➢Strict hand hygiene & use of barrier nursing
➢Meticulous care of urinary catheter, wound, peritoneal
catheter site & CVP line using aseptic technique.
➢Visitors are minimized and monitored for infections
➢Maintain patient’s personal & oral hygiene

31. DISCHARGE TEACHING
▪ 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.
▪ Explain the patient need for life long follow up care.
▪ Avoid long time sitting,
▪ Watch for malignancy as the patient is receiving long term
immunosuppressive therapy.

32. DIETARY MODIFICATIONS
➢ 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

33. Clinic visits
➢ Upto 2 months : twice a week
➢ 3 to 6 month : once a week
➢ 6 to 1 yr : once a month
➢ More than 1 yr : Atleast once in 3 months
Lab tests
➢ Test for kidney function
➢ Test for blood count
➢ Test for liver function
➢ Blood glucose

34. PROGNOSIS
▪ 1 year graft survival rates are 85% to 90% with
transplants from living donors and 75% to 80% with
cadaver kidneys
▪ The overall mortality rate 2 year after transplantation
is about 10%

35. COMPLICATION
❑ Infection
❑ Rejection
❑ Cardiovascular disease
❑ Renal artery stenosis
❑ Blood clots and bleeding
❑ Corticosteroid related complications

36. GRAFT REJECTION
Sign and symptoms-
•Temperature higher than 100 °F (37.8 °C)
•Pain or tenderness over the grafted kidney
• 2- to 3-lb weight gain in 24 hours
•Edema
•Hypertension
•Elevated blood urea nitrogen and serum
creatinine levels Decreased creatinine clearance
Elevated white blood cell count

37. TYPES
Hyperacute rejection-
 Hyperacute rejection occurs immediately in the
operating room or within 48 hours after the transplant.
Intervention:-
 Removal of rejected kidney

38. ACUTE REJECTION
 Occurs within 1 week postoperatively, but can occur
any time post transplantation.
Intervention:
 Potentially reversible with increased
immunosuppressive therapy and corticosteroids.

39. CHRONIC REJECTION
 Occurs slowly months to years after transplant(Gradual
decline in renal function.)
 Associated with renal ischemia, hypertention, tubular
atrophy, interstitial fibrosis. Can be due to HLA
incompatibility, age, and ischemic history of a donor kidney.
Interventions:
 Immunosuppressive medications and dialysis if
necessary.

40. RESEARCH ARTICLE
A Study on the Correlations of Anxiety and
Depression With Self-Management Ability
and Endogenous Creatinine Clearance Rate
in Renal Transplant Recipients

41. ABSTRACT
Objective: To explore the e
ff
ects of anxiety and depression on the
self-management ability and endogenous creatinine clearance rate of
renal transplant patients.
Method: Eighty-eight renal transplant recipients who were followed
up in the outpatient clinic of the A
ffi
liated Hospital of Zunyi Medical
University were selected using convenient sampling. The self-made
general data sheet, Self-Rating Anxiety Scale, Self-Rating Depression
Scale, and Self-Management Scale for Kidney Transplant Recipients
were used. Correlation analysis was used to
fi
nd factors related to
endogenous creatinine clearance, while multiple linear regression was
used to identify factors in
fl
uencing endogenous creatinine clearance.
Patients with or without anxiety and depression were divided into
groups, and the indexes of the groups were compared using the
independent samples t test or chi-squared test.

42. Contd,,
Results: Anxiety was present in 12.5% of patients, depression in 25%, and
a moderate level of self-management of renal transplant recipients had
endogenous creatinine clearance within the normal range, and 34.1% had a
body mass index not in the normal range .The endogenous creatinine
clearance rate was negatively correlated with age and degree of
depression, and positively correlated with body mass index, treatment
management score, and psychosocial management score. The main
in
fl
uencing factors of endogenous creatinine clearance rate were age, sex,
depression, body mass index, and treatment management score. The
endogenous creatinine clearance rate and psychosocial management
ability were signi
fi
cantly higher in patients without anxiety and depression
than in patients with anxiety and depression.
Conclusions: Anxiety and depression showed signi
fi
cant negative e
ff
ects
on the psychosocial self-management ability and endogenous creatinine
clearance rate of renal transplant recipients and thus should be given more
attention.

43. SUMMARY
In today’s seminar we have discussed about
the nursing management of patient
undergoing renal transplantation including
definition, history, indication, pre operative
screening and checklist ,contraindication
and its management.

44. CONCLUSION
The kidneys are a vital organ critical to the human
body. From filtering waste from blood to produce
red blood cells, it serves a crucial role. Renal failure
is a serious condition that could complicate the
course of many of patients. Therefore, renal
transplant is an important aspect leading to the
saving the life of individual at end stage. Successful
renal transplantation significantly improves the
outcome of a patient with end stage renal disease.

45. REFERANCE
1)Brunner and Suddarth; Textbook of Medical Surgical
Nursing 13th Edition Volume II. New Delhi; Wolters
Kluwer Publication.
2)Lewis. Medical Surgical Nursing Assessment and
Management of clinical problems.2015. New Delhi.
Elsevier. 2nd Edition. Volume II.
3)Petrica A. Potter; Fundamentals of Nursing South Asian
Edition Volume I. New Delhi; Elsevier Publications
4)Joyce M. Black, Jane Hokanson Hawks. Medical Surgical
Nursing Clinical Management of Positive Outcomes.2015.
New Delhi. Reed Elsevier India Private Limited. Volume
II.