LITERATURE REVIEW 1

AN INTEGRATIVE LITERATURE REVIEW ON POST ORGAN TRANSPLANT MORTALITY DUE TO RENAL

FAILURE: CAUSES AND NURSING CARE

By

(Student’s Name)

Course Title

Lecturer’s Name

Institution’s Name

Institution’s Location

Date
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Table of Contents
ABSTRACT................................................................................................................................................ 3
Introduction ............................................................................................................................................ 4
Methods .................................................................................................................................................. 5
Literature Search................................................................................................................................. 5
Quality Appraisal ................................................................................................................................. 6
Data analysis ....................................................................................................................................... 6
Results ..................................................................................................................................................... 6
Prediction model to mortality rates due to kidney transplant ........................................................... 7
Post-Transplant diabetes mellitus (PTDM) and Patients survival ....................................................... 8
Reduction of the mortality rates through management and prevention of post-transplant
malignancies. .................................................................................................................................... 10
Discussion.............................................................................................................................................. 11
Limitations of the review ...................................................................................................................... 12
Recommendations ................................................................................................................................ 12
Conclusion ............................................................................................................................................. 13
Bibliography .......................................................................................................................................... 14
 LITERATURE REVIEW 3

ABSTRACT
Chronic kidney disease is currently a global public health epidemic challenge affecting all age

groups. Most countries have reported to have recorded an increase in the number of people having

the infection per year. Organ transplant is always associated with several post organ transplant

challenges that when not properly attended, may consequently lead to death. Some of the resulting

problems include cardiovascular disease, immunosuppressive failures, and other infectious diseases.

Therefore, to prevent any successive complications, pre-transplant and post-transplant nursing are

highly vital.

The main objective of this integrative literature review is to examine post organ transplant

mortality due to renal failure relating to causes and nursing care practices. Whittemore and Knafl’s

used five-staged comprehensive review approach that includes problem identification, literature

review, quality appraisal, data analysis, and presentation of results. There was the use of qualitative,

quantitative, and mixed methods of data collection. The study used a critical cohort appraisal skill for

qualitative and quantitative. From the researchers conducted, the qualitative methods provided

valuable results. However, the quantitative methods failed to work effectively with only two of them

giving the desirable outcome. Pre-transplant and post-transplant nursing cares are very crucial

toward prevention of post organ transplant.

KEY WORDS: Quality of life, Pre-transplant nursing care, Post-transplant nursing care, renal failure,

and post organ transplant mortality.

 LITERATURE REVIEW 4

Introduction
The latest results published by various research institutes showed that different healthcare

institutions annually record an increasingly growing number of patients undergoing renal

transplantation. According to the National Nephrology, Dialysis, and Transplant system in Turkey, a

report presented in the year 2016 puts Turkey as one of the countries recording an increasing

diagnosis of patients with kidney transplant problems. There was diagnosis of patients where certain

occasions lead to death, adding to the records of post-organ transplant mortality across the globe.

Nurses, doctors, and other health practitioners including nursing research agencies such as AHRQ,

PubMed, and others conducted researches with aims of finding causes to the mortality cases and

nursing care practices.

However, despite this treatment becoming too risky, it is the most preferred method of

treatment of patients with end-stage renal disease (ESRD). There are other possible resolutions

besides undergoing kidney transplantation such as renal replacement, haemodialysis, and peritoneal

dialysis. However, many diagnoses of the disease are risky thus have lowers the quality of life, cost

of health care services, and survival chances. Therefore, this makes kidney transplant as the only

available standard treatment to most of the people around the world. The most discouraging reports

departing in every country within the continent is that the number of patients diagnosed with end-

stage renal disease keeps on growing on daily basis. The first successful kidney transplant was in the

year 1975 in Turkey to an 18-year-old patient, with the donor being at the age of 48 years old.

Contrary, another kidney transplant was carried out in 1978 with the donor deceases. Both of the

treatment operations were conducted in Turkey by the Hibernal and associates. Hence, post organ

transplant mortality is not a problem, but an issue with laid backgrounds obtained from different

scenarios across the globe. This challenge comes in through certain ways and procedures which are

unperceivable. They include both individual health care practices and may as well include nursing
 LITERATURE REVIEW 5

care practices carried out before the treatment and after the treatment (pre-transplant and post-

transplant nursing care practices) respectively. The core responsibility of this integrative literature

review is to conduct a simple critical analysis of the literature available concerning the mortality

challenge. The facts based on the c1auses and nursing practices that may lead to post organ

transplant mortality.

Aim of the Review

The main objective of this integrative literature review is to examine the post-organ

transplant mortality due to renal failure due to causes and nursing care practices. Another aim of the

review was to analyse the causes of renal failure disease, and the various nursing care practices that

contribute to the disease.

Methods
The methodology involved the application of the integrated research methods of

Whittemore and Knafl’s, which guaranteed the use of both qualitative and quantitative research

methods. The combination of the two methods allow an insightful analysis and description of data

besides the easy comparison that we can make between the available phenomena of perceptions of

items. The research methodology takes a procedural five-path way towards arriving at desirable

result. These five paths include problem identification, literature search, quality appraisal, analysis of

data, and the presentation of the result.

Literature Search
In order to obtain valid literatures, various databases were visited in which the qualitative

and quantitative analysis were applied to help in acquisition of the desirable literature sources. A

time interval of between 2015 and 2019 were used in order to determine the most current

contemporary issues concerning the post organ transplant mortality within the country and across
 LITERATURE REVIEW 6

the globe. This information helps in presenting the dynamics facing the nursing care practices of

kidney transplants and various modern approaches towards treating end-stage renal disease (ESRD).

Quality Appraisal
Coming up with the best and suitable outcomes from the various resources reviewed require

proper, and intensive integrated approach in quality appraisal. In the determination of the quality

resource, five path integrated qualitative and quantitative appraisal approaches were used together

with the respective critical appraisal program skills. The mixed-method tool used had different items

of questioning in which the individual response was presented as weak, adequate, moderate, or

strong. Only the qualitative appraisal tools gave the desirable outcomes that ranged from moderate-

to-strong. The step was followed by the mixed-method appraisal tool and lastly followed by the

quantitative appraisal approach, which gives the least expected result. Its results did not show the

relationship between the researchers and the problem identified hence was not suitable for use in

the analysis.

Data analysis
During the analysis of the data, Whittemore and Knafl’s constant comparison approaches

were deployed. The procedure included reducing of the data, display of the data, comparisons

withdrawn, and verified conclusions. A series of comparison, and similarity of the data arrived on the

four reviews presented below in the results.

Results

Determining the survival rate of patients undergoing kidney transplantation

To determine the survival rate to the number of patients who undergo renal transplant. This

aimed at exploring the numbers of patients who survived after the transplantation of kidney and

other related organs. Briggs (2001) argues that there were considerable improvements in the

numbers of patient who underwent renal transplantation. Currently, one could say that there was an
 LITERATURE REVIEW 7

expected survival rate of 95% within a span of a year and 90% survival rate within a period of 2-3

years. Briggs (2001) further argued that the risk of deaths due to renal transplant had reduced

significantly in many patients. However, the survival rate differs from various categories of patients.

For instance, the survival rate for the patients aged 35 years and above was 90% while, the survival

rate for the patients below the age of 35 years was 95% as per the year 1990 research results. This

shows a deviation of 5% in the survival rate due to the age factor. In this research, qualitative data

was used. The qualitative data used was done in comparison to factors such as age, time intervals

since the transplant, the transplant centre, geographical position, the era of the transplant, and

presence of some other diseases. The data obtained was analysed and tabulated with respect to

each factor of transplant. There was justification that considering the era of transplant was

important in understanding the influence of the changing immunosuppressive regimen on mortality

rates due to renal transplant. The data collection was done inclusively to involve such factors as age,

time, era, and geographical position. There was also more information and relevant data analysis

provided on each factor. However, the researcher did not justify the sample size used during data

collection with respect to each factor1.

Prediction model to mortality rates due to kidney transplant

Nastasi et al (2018) aim at getting the prediction model to the mortality rates due to kidney

transplantation. They argued that objective measure of the potential factors that can be modified

has a positive correlation to predictions. Consequently, raising the interventions to the survival rate

during kidney transplantation. As such, objective tests avoid candidates’ bias and give room for

potential improvement of mortality rate prediction (Nastasi et al. 2018). The research made use of a

well-validated, objective tool of assessment called Short Physical Performance Battery (SPPB), which

1
Briggs, J.D., 2001. Causes of death after renal transplantation. Nephrology Dialysis Transplantation,

16(8), pp.1545-1549.
 LITERATURE REVIEW 8

have lowered extremity functions. This employed both qualitative and qualitative data with respect

to age, sex, other diseases, and body mass. The study sample size used was (N=645) from August

2009 to June 2016 from Johns Hopkins Hospital, and (N=74) from February 2013 to December 2016

from The University of Michigan. A total of (N=719) patients were studied. The SPPB involved

physical assessment of patients (speed of walking, standing balances and repeated chair stand) and

was measured at during kidney transplant admissions. The SPPB projected that the SPPB-impaired

patients regardless of age and sex showed a significant post-kidney transplant mortality rate. The

SPPB model therefore played a big role in renal transplant mortality rate. The strengths of the SPPB

model included use of the large sample size (N=719), and patients from different centres, covering

different age brackets, races, body masses, and presence of other diseases. However, the covariates

to be used in the model were limited by the large sample size. In addition, the SPPB model had

independent correlation on the mortality rate with factors like age2.

Post-Transplant diabetes mellitus (PTDM) and Patients survival

In the past decades, many people have linked post-transplant diabetes mellitus (PTDM) to

allograft losses and shorter patients’ survival. Consequently, increment in the level of awareness,

health care improvements through nurses and modifications of the immunosuppressive regimens

have modified the association between patient’s survival and post-transplant diabetes mellitus.

Therefore, in this study, Dienemann et al. (2016) aimed at examining the relationship between post-

transplant diabetes mellitus (PTDM) and patient and allograft survival. According to Dienemann et

al. (2016), pre-transplant diabetes mellitus in the kidney recipients have narrow association with

2
Nastasi, A.J., McAdams‐DeMarco, M.A., Schrack, J., Ying, H., Olorundare, I., Warsame, F.,

Mountford, A., Haugen, C.E., González Fernández, M., Norman, S.P. and Segev, D.L.,

2018. Pre‐kidney transplant lower extremity impairment and post‐kidney transplant

mortality. American Journal of Transplantation, 18(1), pp.189-196.

 LITERATURE REVIEW 9

increasing risk of cardiovascular infections and consequently, higher rates of mortality due to renal

related complications. Furthermore, this study cohort sought to explore the roles of the severities of

post- transplant diabetes mellitus (PTDM) and clinical outcomes for time post-transplant activities. In

this regard, Dienemann et al. (2016) sought to explore the causes of Post organ transplant mortality

due to renal failures. The study reviewed the results of (N=209) consecutive number of patients

during five years’ time lap, from 1974 to 1979. The mean age of the patients under study was 34.4

(ranging between 4 years and 63 years). Eleven percent of the patients under study had diabetes.

The study employed observation methods to collect the necessary data on the causes of deaths due

to renal failures. During the five years of observations and follow-ups, 34 % of the patients under

the study died from kidney related problems. The number of patients who died after receiving

transplant was 12 while the diabetic patients who died were 11. Most of the deaths occurred 9 days

to 59 months after kidney transplant.

This study therefore, showed that the causes of death due to renal complications were

effects of other infections (22 patients). Cardiovascular infections (11 patients), suicide (8 patients),

gastrointestinal tract complications (7 patients), and miscellaneous causes of death (4 patients). 18

deaths occurred within the first three months after kidney transplant, 10 deaths occurred between

four to 12 months after transplant, while 26 deaths occurred one year and above after the

transplant. This study therefore was came up with the causes of death due to renal failure. The

causes outlined in the study included infections, cardiovascular problems, suicide due to stress and

depression, gastrointestinal tract problems, malignant neoplasm issues, and miscellaneous causes.

Miscellaneous deaths were the deaths that were potentially easy to prevent but occurred due to

other causes such as aspiration and inter bronchial haemorrhage. The study design was significantly

strong due to the large sample size and the fact that the data was collected over a long period of
 LITERATURE REVIEW 10

time. However, the PTDM study design may always reduce the consequences of renal complications

and thereby reducing the quality of data desired3.

Reducing mortality rates through management and prevention of post-transplant

malignancies.

The aim of this study was to focus on the management and preventions of post-transplant

malignancies due to kidney transplantation. According to Stallone et al. (2015), developing

immunosuppressive drugs is important in the success of allograft functions. There were four areas

that required consideration as a way of nursing care. These distinct areas had potential, and serious

outcomes on recipient afters transplant. They included: (i) risks of malignancy transmission to the

recipients within donor organs. (ii) complications of the previous malignancy that were diagnosed

and treated. (iii) prevention of post-transplant complications, and (IV) management of the other

clinical complications. There was an introduction of many immunosuppressive drugs during the

1990s on the basis to reduce the incidences of acute rejection and the corresponding influences on

the graft outcomes. Many study cohorts have shown that malignancies are the major causes of

mortality during kidney transplant (Stallone et al. 2015).

There was qualitative data analysis of the nursing care activities through the introduction of

immunosuppressive drugs. However, there was no quantitative data used in this regard. The study

focused on the nursing care practises that sought to reduce the mortality rates due to renal

transplant and related problems such as failure. It is necessary for the nurses to avoid organ

transplant from donors with any malignant disease. In relation to this, there should be clinical

3
Dienemann, T., Fujii, N., Li, Y., Govani, S., Kosaraju, N., Bloom, R.D. and Feldman, H.I., 2016. Long‐

term patient survival and kidney allograft survival in post‐transplant diabetes

mellitus: a single‐center retrospective study. Transplant International, 29(9),

pp.1017-1028.
 LITERATURE REVIEW 11

analysis and medical examination of the organ donors to avoid such related malignancies in the

recipients. In addition, there should be retrospective analysis of pre-existing neoplastic diseases on

the recipients. Such patients should not undergo kidney transplant. Patients having risk of

developing malignancies should also not undergo kidney transplants. In addition, as a nursing care

practise, there should be use of anti-proliferative drugs. As such, immunosuppressive drugs like

Azathioprine have been used during clinical transplant. The study gives comparative qualitative data

that focuses on the prevention of mortality rates due to kidney transplant. However, there was no

clear quantitative data that showed the effectiveness of such nursing practises4.

Discussion
There are many cases of mortalities due to renal transplant outcomes in the world. Many

countries have put much emphasis on the incidences and prevalence of such deaths and sought to

know the causes of death due to kidney transplant and the related nursing care practises that

function as management and preventive mechanisms for the deaths. Some of the causes highlighted

here were:

I. effects of other infections

ii. Malignancies (malignancies can may from the donors)

iii. Cardiovascular infections

iv. Suicide due to stress and depression of renal complications

V. gastrointestinal tract complications

4
Stallone, G., Infante, B. and Grandaliano, G., 2015. Management and prevention of post-transplant

malignancies in kidney transplant recipients. Clinical kidney journal, 8(5), pp.637-

644.
 LITERATURE REVIEW 12

vi. Miscellaneous causes of death

Some of the nursing care strategies that would help reduce the prevalence of such mortalities

include:

I. clinical analysis of organ donors before undertaking transplant,

ii. Medical examination of the donors

iii. Retrospective analysis of pre-existing neoplastic diseases on the recipients that should

undergo kidney transplant

iv. Use of immunosuppressive drugs

Limitations of the review

As the case of any other research study, there exist some limitations for the interpretation of

the study results. The study did not include the integration of computerized data, and information

and thus, there might be some inconsistencies in the data. In addition, it is not possible to get all the

desired piece of information. The reason being that some data are not authorized for every

individual while some other study materials are published in other foreign languages. In addition,

reaching out to the public to extract raw information within desired period was difficult.

Recommendations
This study has implications in the real-life situation and as such, preventing mortality rates

due to renal transplant is necessary. The following are the possible recommendations:

i. Creating awareness about the clinical use of the immunosuppressive drugs during transplant

ii. Nursing clinicians should complement the doctors’ roles through history taking; clinical

examination, therapeutic and pharmacology communications in order to reduce delay in the delivery

of health care services.

 LITERATURE REVIEW 13

iii. Governments should create awareness through education and media on the knowledge

about neoplastic disease before transplant. Patients with neoplastic diseases should be encouraged

not to undergo transplant.

Conclusion
Chronic renal infectious may in certain conditions results into a disease known as end-stage

renal disease. This consequently leads to renal failure that is most commonly diagnosed by kidney

transplant despite of other available options like peritoneal dialysis and haemodialysis. However,

this standard method of diagnosis, kidney transplant, in some cases may lead to death of the patient

involved. This integrative literature review presented four causes of the post-organ transplant

mortality together with the nursing practices that may gears such an undesirable outcome before,

during or after the treatment. Some of these causes include the quality of life cost and accessibility,

pre-transplant nursing care practices and post-transplant nursing care practices.

 LITERATURE REVIEW 14

Bibliography
Briggs, J.D., 2001. Causes of death after renal transplantation. Nephrology Dialysis Transplantation,

16(8), pp.1545-1549.

Dienemann, T., Fujii, N., Li, Y., Govani, S., Kosaraju, N., Bloom, R.D. and Feldman, H.I., 2016. Long‐

term patient survival and kidney allograft survival in post‐transplant diabetes

mellitus: a single‐center retrospective study. Transplant International, 29(9),

pp.1017-1028.

Nastasi, A.J., McAdams‐DeMarco, M.A., Schrack, J., Ying, H., Olorundare, I., Warsame, F., Mountford,

A., Haugen, C.E., González Fernández, M., Norman, S.P. and Segev, D.L., 2018. Pre‐

kidney transplant lower extremity impairment and post‐kidney transplant mortality.

American Journal of Transplantation, 18(1), pp.189-196.

Stallone, G., Infante, B. and Grandaliano, G., 2015. Management and prevention of post-transplant

malignancies in kidney transplant recipients. Clinical kidney journal, 8(5), pp.637-

644.