A kidney transplant involves surgically removing a healthy kidney from a living or deceased donor and implanting it into a recipient with kidney failure. The recipient must take lifelong immunosuppressive drugs to prevent rejection of the new organ. Complications can include infection, cardiovascular issues, and cancer due to immunosuppression. Care after transplant focuses on monitoring for signs of rejection like changes in urine output or kidney function tests and treating rejection promptly if it occurs. Long term management also involves managing side effects of immunosuppressants and screening for related health issues.

1. KIDNEY TRANSPLANT
BY: S.BHAGAT

2. • A human kidney from a compatible donor is implanted into a recipient. 2. Kidney
transplantation is performed for irreversible kidney failure; specific criteria are
established for eligibility for a transplant. 3. The recipient must take
immunosuppressive medications for life.

3. KIDNEY SURGERY:
• Kidney surgery may include partial or total nephrectomy (removal of the kidney),
kidney transplantation for end-stage renal disease (ESRD), procedures to remove
stones or tumors, and procedures to insert drainage tubes (nephrostomy). Incisional
approaches vary but may involve the flank, thoracic, and abdominal regions.
Nephrectomy is most commonly performed for malignant tumors of the kidney but
may also be indicated for trauma and kidneys that no longer function due to
obstructive disorders and other renal disease.
• Nephrectomy is also the procedure of choice to remove a healthy kidney for donation
to a transplant recipient. The absence of one kidney does not result in impaired renal
function when the remaining kidney is normal and healthy.

4. • First kidney transplant was performed in 1954 in Boston between identical twins.
• The prevalence of people needing some form of renal transplant therapy in India
is around 0.8% to 1.4 % of population.. Every year nearly 1.5 million need dialysis
or renal transplant, yet less than 0.2% ever receive a kidney. Approximately, 3000
kidney transplants are done annually in India.
• Kidney transplant is very successful with 1 year graft survival rates over 90% for
deceased donor transplant and 95% for live donor transplant.

5. ADVANTAGES OVER DIALYSIS:
• Kidney transplant reverses many of the pathophysiologic changes associated with
renal failure.
• It also eliminates the dependence on dialysis and the accompanying dietary and
lifestyle restrictions.
• Less expensive than dialysis after the first year.

6. RECIPIENT SELECTION
• Appropriate recipient selection is important for a successful outcome.
• Exclude patient who are obese or who smoke continuously despite smoking
cessation intervention.
• Certain patients, particularly those with CV and diabetes are high risk and must be
carefully evaluated and monitored closely after transplantation.
• For a small number of patients who are approaching ESKD, a preemptive
transplant (before dialysis is required) is possible if they have a living donor. This
is most advantageous for patient with diabetes.

7. • Contraindication to transplantion:
• Disseminated malignancies
• Refractory or untreated cardiac disease
• Chronic respiratory failure
• Extensive vascular disease
• Chronic infection
• Unresolved psychosocial disorders (e.g non adherence to medical regimens,
alcoholism, drug addiction).

8. • Previous HIV denied but now acceptable and good survival rate.
• Client with Hep B or C is not a contraindicated to transplantation.

9. HISTOCOMPATIBILITY STUDIES
• Human leukocyte antigen (HLA) testing.
• Crossmatching

10. DONOR SOURCE:
• Donors
• 1. Donors may be living donors (related or unrelated to the client), non-heart-
beating donors (NHBDs), or cadaver donors.
• 2. The most desirable source of kidneys for transplantation is living related donors
who closely match the client.
• 3. Non-heart-beating donors are those who have been declared dead by
cardiopulmonary criteria and have organs harvested immediately after death;
these persons have consented previously to organ donation.

11. • 4. Cadaver donors arethose who havesuffered irreversible brain injury; these
persons are maintained with mechanical ventilation and must have adequate
perfusion to the kidneys. 5. Physical criteria for donors include absence of
systemic disease and infection, no history of cancer, no kidney disease or
hypertension, and adequate kidney function.
• 6. Donors are screened for ABO blood group, tissue-specific antigen, human
leukocyte antigen suitability, and mixed lymphocyte culture index
(histocompatibility); donors are also screened for the presence of any
communicable diseases and undergo a complete medical evaluation as well as a
nephrology consultation.

12. • 7. The donor must be in excellent health, with 2 properly functioning kidneys.
• 8. The emotional well-being of the donor is determined.
• 9. Complete understanding of the donation process and outcome by the donor is
necessary; usually kidney removal from the donor is done using a laparoscopic
procedure.

13. SURGICAL PROCEDURE:
• LIVE DONOR-
• Many surgical procedures were previously performed as “open” procedures, but
are now being done with laparoscopic “keyhole” surgeries.
• Laparoscopic donor nephrectomy- most common technique for removing a
kidney in a living donor.
• An endoscope is introduced, and the abdomen is inflated with carbon dioxide.
Instruments are passed through other sites, or a sleeve may be used, which allows
a hand to be introduced at the operative site.

14. • After the kidney has been removed, it is flushed with chilled, sterile electrolyte
solution and prepared for immediate transplant into the recipient.
• Advantages are decreased postoperative pain, decreased blood loss, and, in
some cases, decreased length of hospital stay.
• Laparoscopic is minimally invasive with fewer risk and short recovery time than
open procedure.

15. • Open nephrectomy- the donor is placed in lateral decubitus position on the
operating table. Incision is made at the level of 11th rib. The rib may be removed
to provide adequate visualization of the kidney.
• KIDNEY TRANSPLANT RECIPIENT-
• The transplanted kidney is usually placed extra peritoneally in the iliac fossa.
right iliac fossa is preferred to facilitate anastomoses of the blood vessels and
ureter and minimize the occurrence of paralytic ileus.

16. • Before any incision is made, urinary catheter is placed into bladder. An antibiotic
solution is instilled to distend the bladder and decrease the risk of infection. A
cresent shaped incision is made extending from iliac crest to the symphysis pubis.
• The donor artery is anastomosed to the recipient’s internal iliac (hypogastric) or
external iliac artery. The donor vein is anastomosed to the recipient’s external iliac
vein.
• When anastomoses are complete, the clamps are released, and blood flow to the
kidney is reestablished. The kidney should become firm and pink. Urine may
begin to flow from the ureter immediately.

19. PREOPERATIVE INTERVENTIONS
• 1. Verify histocompatibility tests of donor, which will be done by organ bank
personnel.
• 2. Administer immunosuppressive medications to the recipient as prescribed.
• 3. Maintain strict aseptic technique.
• 4. Verify that hemodialysis of the recipient was completed 24 hours before
transplantation.
• 5. Ensure that the recipient is free of any infections.
• 6. Assess renal function studies.
• 7. Encourage discussion of feelings of the live donor and the recipient. 8. Provide
psychological support to the live donor, NHBD, or cadaver donor family and to the
recipient.

20. POSTOPERATIVE INTERVENTIONS FOR THE
RECIPIENT
• .1. The transplanted kidney is placed in the anterior iliac fossa; usually the
recipient’s diseased kidneys are left in place except for those with polycystic
kidney disease in which the kidneys are often very enlarged and painful.
• 2. Urine output usually begins immediately if the donor was a living donor; it may
be delayed for a few days or more with other donor types.
• 3. Hemodialysis may be performed until adequate kidney function is established.
• 4. Monitor vital signs and for signs of complications such as rejection, thrombosis,
renal artery stenosis, or wound problems.

21. • 5. Monitor urine output hourly; immediately report an abrupt decrease in output.
• 6. Monitor IV fluids closely; for the first 12 to 24 hours, IV fluid replacement is
based on hourly urine output.
• 7. Administer prescribed diuretics and osmotic agents.
• 8. Monitor daily weight to evaluate fluid status.
• 9. Monitor daily laboratory results to evaluate renal function, including
hematocrit, BUN, and serum creatinine levels, and monitor urine for blood and
specific gravity.

22. • 10. Position the client in a semi-Fowler’s position to promote gas
exchange,turning from the back to the nonoperative side.
• 11. Monitor urinary catheter patency; the urinary catheter usually remains in the
bladder for 3 to 5 days to allow for anastomosis healing; it is removed as soon as
possible to prevent infection.
• 12. Note that urine is pink and may be bloody initially but gradually returns to
normal within several days to weeks.
• 13. Notify the HCP if gross hematuria and clots are noted in the urine.

23. • 14. Monitorthe3-waybladderirrigation,if present, for clots; irrigate only if an HCP’s
prescription is present.
• 15. Maintain aseptic technique and monitor for infection.
• 16. Maintain strict aseptic technique with wound care.
• 17. Monitor for bowel sounds and for the passage of flatus; initiate a specific diet
and oral fluids as prescribed when flatus and bowel sounds return (usually, fluids,
sodium, and potassium are restricted if the client is oliguric).

24. • 18. Maintain good oral hygiene, monitoring for stomatitis and bacterial and
fungal infections.
• 19. Encourage coughing and deep-breathing exercises.
• 20. Administer immunosuppressive medicationsas prescribed.
• 21. Assess for signs of organ rejection.
• 22. Promote relationship between the live donor and recipient.
• 23. Monitor both the donor and the recipient for depression.

25. • 24. Provide the recipient with instructions following the kidney transplantation.
• 25. Assist the recipient to cope with the body image disturbances that occur from
long-term use of immunosuppressants.
• 26. Advise the recipient of available support groups

26. COMPLICATION OF TRANSPLANTATION-
• Rejection of transplant- hyperacute, acute, chronic
• Susceptibility to infection
• Cardiovascular disease
• Malignancies
• Recurrence of kidney disease
• Corticosteroid related complication- aspectic necrosis of hip, knees, and other
joints from chronic corticosteroid therapy.

27. GRAFT REJECTION:
• Assessment

28. CLINICAL SIGNS OF RENAL TRANSPLANT (GRAFT)
REJECTION:
• ▪ Temperature higher than 100 °F (37.8 °C)
• ▪ Pain or tenderness over the grafted kidney
• ▪ 2- to 3-lb (0.9 to 1.4 kg) weight gain in 24 hours
• ▪ Edema
• ▪ Hypertension
• ▪ Malaise
• ▪ Elevated blood urea nitrogen and serum creatinine levels
• ▪ Decreased creatinine clearance
• ▪ Elevated white blood cell count
• ▪ Rejection indicated by ultrasound or biopsy

29. GRAFT REJECTION
• 1. 2. Hyperacute rejection
• a. Hyperacute rejection occurs within 48 hours after the transplant.
• b. Intervention: Removal of rejected kidney
• 3. Acute rejection
• a. Occurs within 1 week postoperatively, but can occur any time post
transplantation.
• b. Intervention: Potentially reversible with increased immunosuppressive therapy.

30. • 3. Chronic rejection
• a. Occurs slowly months to years after transplant.
• b. Interventions: Immunosuppressive medications and dialysis if necessary.
• NOTE: Except in identical twin donors and recipients, the major postoperative
complication following renal transplant is graft rejection.

31. REFERENCE
• Lewis..pgno- 1176
• Saunder …pg no 833..7th edition
• Lippincott..pgno -793