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)