Kidney Transplant
donors are discharged _____ and can return to work in _____
2-4 days (5 if open surgery) 4-6 weeks (6-8 if open)
Labs/procedures done on the donor prior to transplant
24-hour urine for creatinine clearance and total protein CBC chemistry and electrolyte profiles Hep B/C, HIV, and cytomegalovirus testing ECG and Chest Xray renal ultrasound and renal arteriogram or 3D CT scan
postop urinary catheter stays in for
3-5 days
What accurately describes rejection following transplantation? A. hyperacute rejection can be treated with OKT3 B. acute rejection can be treated with sirolimus or tacrolimus C. chronic rejection can be treated with tacrolimus or cyclosporine D. hyperacute reaction can usually be avoided if crossmatching is done before the transplant
D. hyperacute reaction can usually be avoided if crossmatching is done before the transplant
leading cause of death after renal transplant
CV disease
high risk transplant patients are those with
CV disease beetus
essentialfor monitoring postoperative fluid status
CVP
Calcineurin Inhibitors cyclosporine (sandimmune, neoral, gengraf) tacrolimus (prograf) Mechanism of Action
acts on t helper cells to prevent production and release of IL-2 inhibits proliferation of T and B cells tacrolimus is more effective than cyclosporine
rejection that occurs within the first 6 months usually a cell-mediated imune response or when antibodies develop to the transplanted organ
acute rejection
transplant recipients usually receive prophylactic
antifungal drugs
an organ donor with a signed donor card still requires
authorization from next of kin
hyperacute rejection requires the donor organ
be removed
patients with __________ have a much higher mortality rate on dialysis than those without
beetus
Advantages to live kidney donors: better patient and graft survival rates regardless of __________ immediate organ __________ immediate __________ because of minimal cold time opportunity to have the recipient in the best possible medical condition because the surgery is __________
better patient and graft survival rates regardless of histocomatibility match immediate organ availability immediate function because of minimal cold time opportunity to have the recipient in the best possible medical condition because the surgery is elective
calineurin inhibitors do not cause __________ or alter the __________
bone marrow supression inflammatory response
for the first 12-24 hours urine output is replaced
by matching the output (1200mls out 1200mls in)
rejection that occurs over months to years and is non reversible
chronic rejection
common cause of sudden decrease in urine output in the early postop phase
clots in urinary catheter
time an organ spends outside the body is known as
cold time
done to determine the existence of antibodies against the potential donor
crossmatch
most widely used calcineurin inhibitor
cyclosporine
acute tubular necrosis after transplant must be treated with
dialysis
most patients on the transplant list
die while waiting
contraindications to transplantation
disseminated malignancies refractory/untreated cardiac disease chronic respiratory failure extensive vascular disease chronic infections unresolved psychosocial disorders
the recipient's own kidneys __________ before receiving a donor kidney
do not have to be removed
in a live donor operation the _________ surgery begins 1-2 hours before the _________
donor's recipient's
Complications of Peritoneal dialysis
exit site infection peritonitis abdominal pain catheter outflow hernias lower back pain CV disease atelectasis/pneumonia/bronchitis PROTEIN LOSS carbohydrate abnormalities lipid abnormalities encapsulating sclerosing peritonitis
time period of greatest risk for infection in transplant patients
first few months after the transplant
a patient on monoclonal antibodies (muromonab-CD3) may experience __________ during the first few days of treatment
flu-like syndrome
action if blood clots are suspected to be in urinary catheter
gentle irrigation
graft tissue rejects the host tissue
graft-versus-host disease
consuming __________ while taking cyclosporine or tacrolimus increases their toxicity
grapefruit juice
rejection that occurs within 24 hours with no treatment
hyperacute rejection
immunosupressants can worsen
hypertension and dyslipidemia
electrolyte imbalance associated with rapid diuresis
hyponatremia hypokalemia
Complications of hemodialysis
hypotension muscle cramps exsanguination hepatitis infection/sepsis disequilibrium syndrome CV disease
mycophenolate mofetil given IV must be reconstituted with __________ and must not be give as __________
in D5W and no other solution IV bolus (infuse over 2+ hours)
HIV or hepatitis B or C infection is/is not a contraindication to transplantation
is not
symptoms of graft versus host disease
itchy/painful rash initially on palms/soles of feet, shedding skin, jaundice, hepatic coma, diarrhea, abdominal pain, GI bleeds, malabsorption
best treatment option available to end stage renal disease patients
kidney transplant
immunosupressive therapy is a __________ balance between __________ and __________
lifelong rejection and infection
plasmapheresis allows transplant candidates to receive kidneys from
live donors with blood types that would normally be incompatible
preemptive transplant is possible if there is a
living donor
first priority during potoperative period is
maintenance of fluid and electrolyte balance
antigens responsible for rejection of genetically unlike tissue
major histocompatibility anitgens (human leukocyte antigen HLA)
postop care includes
monitor renal function monitor hematocrit to assess for bleeding treat pain
used to treat and prevent acute rejection episodes
monoclonal antibodies
the patient is less likely to reject the kidney if they match more/less antigens
more
major side effects of this immunospressant include GI toxicities (N/V, diarrhea)
mycophenolate mofetil
indicates that no preformed antibodies are present and it is safe to proceed with the transplant
negative crossmatch
Calcineurin Inhibitors Side Effects
nephrotoxicity increased risk for infection neruotoxicity (tremor/seizure) hepatotoxicity lymphoma hypertension tremors hirsutism leukopenia gingival hyperplasia
large volumes of urine produced after kidney transplantation is due to
new kidney's ability to filter BUN abundance of fluids administered during surgery initial renal tubular dysfunction (cannot concentrate urine normally)
an ABO abnormality exists between a potential donor and recipient, a viable alternative would be __________ or __________
paired donor exchange plasmapheresis
A and B are not donor compatible. Neither is C and D. BUT A and C and B and D are compatible. this is
paired organ donation
Corticosteroids prednisone, methylprednisone (solu-medrol) Side Effects
peptic ulcers hypertension osteoporosis sodium/water retention muscle weakness easy bruising delayed healing hyperglycemia increased risk for infection
if no other living donor is available a donor with postivie crossmatch can donate if
plasmapheresis or IV immunoglobulin is done to remove antibodies
in high PRA patient's __________ and __________ can be used to lower the number of antibodies
plasmapheresis; IV immunoglobulin
most common infections observed in the first month after transplantation
pneumonia wound infection IV lines and drain infections UTIs fungal/viral
a high PRA indicates
poor chance of finding a compatible donor
transplanting before dialysis is required
preemptive transplant
immunosupressant doses are __________ over time
reduced
teaching to prevent cancers after transplants
regular screening avoid sun exposure
Complications of transplantation
rejection of transplant (hyperacute, acute, chronic) susceptibility to infection CV disease malignancies recurrence of kidney disease corticosteroid related complications
an advantage of transplant over dialysis is that transplant __________ many of the pathologic changes associated with renal disease
reverses
acute rejection is usually __________ with additional __________
reversible; immunosupressive therapy
a panel of reactive antibodies (PRA) indicates the recipient's
sensitivity to various HLA's
immunosupressive agent that suipresses t cell activation and proliferation used in combination with corticosteroids, cyclosporine, and/or tacrolimus
sirolimus
in HLA typing there is a total of _______ antigens identified
six
commonly affected organs of graft versus host disease
skin, liver, GI tract
Corticosteroids prednisone, methylprednisone (solu-medrol) Mechanism of Action
suppresses inflammatory response inhibits cytokine production and T cell activation and proliferation
preop teaching includes explaining there is a chance __________ and that _________ may be required for days to weeks. Also they must be on __________ for life
the kidney may not function dialysis immunosuppressive drugs
a positive crossmatch indicates __________ and is a __________ to transplantation
the recipient has cytotoxic antibodies to the donor it is an absolute contraindication
Cytotoxic (antiproliferative) drugs mycophenolate mofetil (cellcept, myfortic), azathioprine (imuran), cyclophosphamide (cytoxan, neosar), sirolimus (rapamune), everolimus (zortress) Side effects
varies by individual medication but they all seem to have these in common diarrhea, N/V, increased risk of infection, neutropenia, anemia
Cytotoxic (antiproliferative) drugs mycophenolate mofetil (cellcept, myfortic), azathioprine (imuran), cyclophosphamide (cytoxan, neosar), sirolimus (rapamune), everolimus (zortress) Mechanism of Action
varies by individual medication but they all supress T and B cells
graft versus host disease usually occurs
7-30 days after transplantation
cadaver donor kidneys can be preserved ________ but ideally want them transplanted within
72 hours 24 hours
A client who is scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the client's risk of surgery? (Select all that apply.) A. Age older than 70 years B. BMI of 41 C. Administering NPH insulin each morning D. Past history of lymphoma E. Blood pressure averaging 120/70 mm Hg
A. CORRECT: A client older than 70 years has an increased risk for complications from surgery, lifelong immunosuppression, and organ rejection. B. CORRECT: A client who has a BMI of 41 is morbidly obese and is at an increased risk for complications of surgery, lifelong immunosuppression, and organ rejection. C. CORRECT: A client who requires NPH insulin for type 1 diabetes mellitus is at an increased risk from complication of surgery, lifelong immunosuppression, and organ rejection. D. CORRECT: A client who has a history of cancer, such as lymphoma, is at an increased risk for complications of surgery, lifelong immunosuppression, and organ rejection. E. Blood pressure averaging 120/70 mm Hg is within the expected reference range does not place the client at a greater risk for complication of surgery, lifelong immunosuppression, and organ rejection.
A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply.) A. Anuria B. Marked azotemia C. Crackles in the lungs D. Increased calcium level E. Proteinuria
A. CORRECT: Anuria is a manifestation of end-stage kidney disease. B. CORRECT: Marked azotemia is elevated BUN and serum creatinine, is a manifestation of end-stage kidney disease. C. CORRECT: Crackles in the lungs can indicate the client has pulmonary edema, caused from hypervolemia due to end-stage kidney disease. D. Calcium levels are decreased due to increase in serum phosphate levels when the client has end-stage kidney disease. E. CORRECT: Proteinuria is a manifestation of end-stage kidney disease.
A nurse is planning postoperative care for a client following a kidney transplant surgery. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Obtain daily weights. B. Assess dressings for bloody drainage. C. Replace hourly urine output with IV fluids. D. Expect oliguria in the first 4 hr. E. Monitor serum electrolytes.
A. CORRECT: Daily weights are obtained to assess fluid status. B. CORRECT: Drainage on the dressing is assessed to monitor for hemorrhage or hematoma. C. CORRECT: Hourly urine output with IV fluid replacement is monitored to detect abrupt decrease in urine output, which can indicate rejection or other serious conditions of the transplant kidney. D. Oliguria can indicate ischemia, acute kidney injury, rejection, or hypovolemia. Report oliguria immediately to the provider. E. CORRECT: Serum electrolytes is monitored because electrolytes loss can occur with postoperative diuresis.
A nurse is preoperative teaching with a client who is scheduled for a kidney transplant about rejection of a transplanted kidney. Which of the following statements should the nurse include in the teaching? (Select all that apply.) A. "Expect an immediate removal of the donor kidney for a hyperacute rejection." B. "You may need to begin dialysis to monitor your kidney function for a hyperacute rejection." C. "A fever is a manifestation of an acute rejection." D. "Fluid retention is a manifestation of an acute rejection." E. "Your provider will increase your immunosuppressive medications for a chronic rejection."
A. CORRECT: Immediate removal of the donor kidney is treatment for hyperacute rejection. B. Dialysis can be required as a conservative treatment to monitor the client's kidney function for the progression of chronic kidney failure following kidney transplant. C. CORRECT: Fever is a manifestation of an acute rejection. D. CORRECT: Fluid retention is a manifestation of an acute rejection. E. Immunosuppressants are increased to treat an acute rejection.
A nurse is teaching a client who is postoperative following a kidney transplant and is taking cyclosporine. Which of the following instructions should the nurse include? A. "Decrease your intake of protein-rich foods." B. "Take this medication with grapefruit juice." C. "Monitor for and report a sore throat to your provider." D. "Expect your skin to turn yellow."
A. The client should not decrease protein-rich foods in the diet, which promote healing and rebuilds muscle. There are no restrictions of protein intake for a client taking cyclosporine following a kidney transplant. B. The client should not drink grapefruit juice, which can reduce cyclosporine metabolism and cause increased cyclosporine levels. C. CORRECT: The client should report any manifestations of an infection because this medication causes immunosuppression. D. The client should report manifestations of hepatotoxicity, such as jaundice, and abdominal pain.
A kidney transplant recipient complains of having fever, chills, and dysuria over the past 2 days. What is the first action the nurse should take? A. assess temperature and initiate workup to rule out infection B. reassure the patient that this is common after transplantation C. provide warm cover for the patient and give 1g acetaminophen orally D. notify the nephrologist that the patient has developed symptoms of acute rejection
A. assess temperature and initiate workup to rule out infection
In a person havign an acute rejection of a transplanted kidney what would help the nurse understand the course of events (select all) A. a new transplant should be considered B. acute rejection can be treated with OKT3 C. acute rejection usually leads to chronic rejection D. corticosteroids are the most successful drugs used to treat acute rejection E. acute rejection is common after a transplant and can be treated with drug therapy
B. acute rejection can be treated with OKT3 E. acute rejection is common after a transplant and can be treated with drug therapy
labs/procedures done before transplant surgery on recipient
ECG chest xray dialysis to pull off fluid/treat hyperkalemia
metabolic acidosis may be treated with
IV sodium bicarbonate
Calcineurin Inhibitors cyclosporine (sandimmune, neoral, gengraf) tacrolimus (prograf) Route
PO IV
Corticosteroids prednisone, methylprednisone (solu-medrol) Route
PO IV
Cytotoxic (antiproliferative) drugs mycophenolate mofetil (cellcept, myfortic), azathioprine (imuran), cyclophosphamide (cytoxan, neosar), sirolimus (rapamune), everolimus (zortress) Route
PO (all) IV (some)
the foundation of most immunosupressant regimens. this group includes _________ and __________
calcineurin inhibitors cyclosporine and tacrolimus
major immunosupressive agents
calcineurin inhibitors (cyclosporine [sandimmune, neoral, gengraf] and tacrolimus [prograf] corticosteroids (prednisone, methylprednisone [solu-medrol]) mycophenolate mofetil (cellcept, myfortic) sirolimus (rapamune) azathioprine (imuran) cyclophophamide (cytoxan)