INTRODUCTION

Chronic Kidney disease is a major health concern. When kidney function declines to a certain
level, patients have end stage renal disease and require either dialysis or renal transplant to
sustain their life. Renal transplant offers the closest thing to a normal life because the
transplanted kidney can replace the failed kidneys. In terms of survival, health care costs and
quality of life, the standard treatment for ESRD is kidney transplant.

A successful kidney transplant offers enhanced quality and duration of life and is more
effective (medically and economically) than long-term dialysis therapy for patients with
chronic or end-stage renal disease. However, it also involves a life-long dependence on drugs
to keep the new kidney healthy.

Renal Transplantation is the renal replacement modality of choice for patients with End
Stage Renal Disease.

DEFINITION: Renal transplantation is the surgical implantation of a human kidney from a

compatible donor in a recipient.

Position: The transplanted kidney is placed extraperitoneal in the iliac fossa. The renal
artery is anastomosed to the recipient hypogastric internal or external iliac artery
(occasionally the aorta) and the renal vein is anastomosed to the recipient’s iliac vein.
INDICATION

End Stage Renal Disease

 Irreversible GFR of less than 15 ml/min

 Serum creatinine level of greater than 8 mg/dl

COMMON CAUSES OF END STAGE RENAL DISEASE

 Diabetes mellitus
 High blood pressure
 Glomerulonephritis
 Polycystic Kidney Disease
 Severe anatomical problems of the urinary tract

DONOR SOURCES

Kidneys for transplant may be obtained from :

 Compatible blood type deceased (Cadaver) donors

 Blood relatives
 Living donors (spouses, distant cousins) and
 Altruistic living donors who are known friends and unknown to the recipient.

Live Donor

Extensive multidisciplinary evaluation: Donor is in good health and have no history of

disease that would place them at risk for developing kidney failure or operative
complications.

Psychosocial and financial evaluations are done as well .

Cross match are done.

Advantages of live donor

  Better patient and graft survival rate because histocompatibility matches.
 Immediate organ availability
 Immediate function because of minimal cold time (kidney out of body and getting
blood supply)
 The opportunity to have the recipient in best possible medical condition because the
surgery is elective.

Deceased Donor

Deceased ( cadaver) kidney donors are relatively healthy individuals who have suffered an
irreversible brain injury. The most common cause of injury is cerebral trauma from motor
vehicle accidents or gunshot wounds, intracerebral or subarachnoid haemorrhage, and anoxic
brain damage caused by cardiac arrest.

The brain dead donor must have effective cardiovascular function and be supported on a
ventilator to preserve the organs.

The age of most suitable kidney donors is from 2 to 70 years. The age of donor is less
important than quality.

Exclusion criteria for deceased donor: The donor must be free of active IV drug abuse,
severe hypertension, long standing diabetes mellitus, malignancies, sepsis and communicable
diseases.

Legal consent from the donor’s relatives must be required after brain’s death.

RECEPIENT SELECTION

Willing family members are evaluated for physical and mental health and screened for ABO
blood group compatibility, tissue specific antigen, and human leukocyte antigen
histocompatibility.

Exclusion criteria for living donor

Absolute contraindications

 Age less than 18 years and more than 70 years.

  Uncontrolled hypertension.
 Diabetes mellitus.
 High risk of thromboembolism
 History of bilateral kidney stone
 Medically significant illness ( chronic lung disease, recent malignant tumours,
heart disease)
 Current substance abuse

Relative contraindications

 Psychiatric disorders
 Obesity
 Active chronic infections (T B, Hepatitis B and C, Parasites)

PRETRANSPLANT PHASE / PREOPERATIVE TRANSPLANT MANAGEMENT

Initial Clinical assessment pre-transplant

Patients on kidney transplant waiting list have usually undergone a thorough medical and
surgical assessment prior to listing to identify significant comorbidities that would preclude
transplantation. Optimisation of cardiovascular comorbidities, including diabetes mellitus
(DM ) and hypertension, is important not only for prevention of cardiovascular disease but
also for avoidance of hypertension and diabetic damage to the transplanted graft.

When the intended recipient is admitted to the hospital for transplantation, a thorough
reassessment is important to identify any new medical issues, as well as to ensure that the
recipient is sufficiently medically stable for a general anaesthetic and surgery.

Basic pre-transplant studies

 Blood tests 
 Serological tests: Serological tests for certain viruses ( Hepatitis B and C, and HIV
infection) will be done. Serology for Cytomegalo virus (CMV), Epstein Bar Virus,
(EBV) , VZV.
 Renal and liver chemistry: including phosphate, calcium, and LDH ( Lactate
dehydrogenase)
  Coagulation profile
 Chest radiography
 Pulmonary studies
 Echocardiogram. 
 Cardiac stress test : This measures the heart’s ability to respond to stress in a controlled
environment.  It checks whether the heart is fit enough for a transplant surgery.
 Exercise and dipyridamole thallium scintigraphy

 Coronary arteriography (if indicated)

Studies in transplant recipients

 Transplant ultrasonography to identify urinary obstruction, as well as fluid
collections suggesting urine extravasation, abscess, pyelonephritis, or wound infection
 Color flow Doppler ultrasonography to evaluate vascular occlusion or stenosis
 Renal biopsy usually required for definitive diagnosis of most renal graft dysfunction
 Lumbar puncture in cases of suspected meningitis, particularly that believed to be
caused by Listeria species

 Non invasive vascular studies

 Cancer screening : The recipient must be cancer-free before undergoing a kidney
transplant. You will have some cancer screening tests, which may include:

 Colonoscopy: A flexible camera is used to check the colon for polyps, tumors,
and any unusual growths that might indicate cancer or other medical problems.
If you are over age 50 or have a personal or family history of colon cancer,
this test will be included.

o Papanicolaou (PAP) smear

o Skin cancer screening
o Prostate exam (men)
o Mammography (women).
 Pregnancy screening
 Dental evaluation : This is done to make sure that donor do not have infections,
cavities, or gum disease.  If any of these dental problems is present, it is best to have
them corrected before transplant because they can cause problems after transplant.
 Immunologic evaluation
Recipients of kidney transplants undergo an extensive immunologic evaluation that primarily
serves to avoid transplants that are at risk for antibody-mediated hyper acute rejection. The
immunologic evaluation consists of the following 4 components:
 ABO blood group determination
 Human leukocyte antigen (HLA) typing
 Serum screening for antibody to HLA phenotypes /Anti HLA antibodies / PRA
antibody
 Crossmatching

Blood typing:
The first test establishes the blood type. There are four blood types: A, B, AB, and O.
Everyone fits into one of these inherited groups. The recipient and donor should have either
the same blood type or compatible ones, unless they are participating in a special program
that allow donation across blood types. The list below shows compatible types:

 If the recipient blood type is A Donor blood type must be A or O

 If the recipient blood type is B Donor blood type must be B or O
 If the recipient blood type is O Donor blood type must be O
 If the recipient blood type is AB Donor blood type can be A, B, AB, or O
The AB blood type is the easiest to match because that individual accepts all other blood
types.

Blood type O is the hardest to match. Although people with blood type O can donate to all
types, they can only receive kidneys from blood type O donors. For example, if a patient with
blood type O received a kidney from a donor with blood type A, the body would recognize
the donor kidney as foreign and destroy it.

Tissue typing / HLA Typing: HLA typing is also called tissue typing. HLA stands for
human leukocyte antigen. Antigen are protein on the cells in the body. Out of over 100
different antigens that are been identified, there are six that have been shown to be the most
important in organ transplantation. Of these six antigens we inherit three from each parent.
 The HLA types of recipient and donor is to be determined. This test allows for
determination of the amount of mismatch between a donor and a recipient. Except in the
cases of identical twins and some siblings, it is rare to get a six antigen match between two
people, especially if they are unrelated. The chance of a perfect or six antigen match between
two unrelated people is about 1 in 100,000.

Anti HLA antibodies / PRA testing : This test determines the presence and identity of any
anti HLA antibodies by testing against a reference cell panel, otherwise known as Panel
Reactive Antibody.

Cross Match Testing: Lastly donor specific antibody response is measured in cross match
assay. Cross-match is done to ensure the recipient does not have pre-formed antibodies to the
donor .

The cross-match is done by mixing the recipient's blood with cells from the donor. If the
cross-match is positive, it means that there are antibodies against the donor. The recipient
should not receive this particular kidney unless a special treatment is done before
transplantation to reduce the antibody levels. If the cross-match is negative, it means the
recipient does not have antibodies to the donor and that they are eligible to receive this
kidney.

Cross-matches are performed several times during preparation for a living donor transplant,
and a final cross-match is performed within 48 hours before this type of transplant.

Management of pre-existing medication

Patients with advanced kidney disease are often on multiple medications, many of which can
be safely discontinued at the time of transplantation, including most anti hypertensive
medication, phosphate binders, cinacalcet and erythropoiesis stimulating agents.

However some medications should usually be continued as follows:

Active vitamin D compounds in patients post parathyroidectomy are usually continued.

Beta blockers are usually not stopped abruptly in the perioperative period due to concerns
that this may lead to rebound tachycardia and increase the risk of mortality. However it may
be reasonable to reduce the dose and / or convert patients to a beta blocker with a shorter
duration of action (e.g., metoprolol ) to reduce the risk of hypotension in the post operative
period.

Statins, although generally safe, can predispose to rhabdomyolosis if used in conjunction

with CYP450-3A4 inhibitors. Therefore ceasing statins until outside the perioperative period.

Antiplatelet therapy with aspirin is usually continued perioperatively and many transplant
centres routinely prescribe aspirin to recipients who are not already receiving this agent to
reduce the risk of transplant vessel thrombosis, although this has a poor evidence base.

Dual antiplatelet therapy with aspirin plus platelet P2Y12 receptor inhibitors (eg, clopidegrol
and ticagrelor) would usually be considered a contraindication to transplantation, both
because of the increased risk of bleeding and frequent association of significant vascular
disease in patients requiring this combination.

Erythropoiesis stimulating agents (ESA) may be continued on basis of some studies

identifying anaemia as an independent predictor of mortality in the intermediate post
transplant period.

Reversal of anticoagulation: Potential transplant recipients who are anti-coagulated with

warfarin require urgent reversal of anticoagulation prior to surgery. There are often local
protocols of warfarin reversal but a typical approach would be 1 -2 mg of oral vitamin K
administered as soon as the patients presents to the hospital, followed by infusion of either
fresh frozen plasma or a prothrombin complex concentrate, such as prothrombinex – VF,
depending on the INR.

Preoperative management of diabetes and hyperglycaemia

Diabetes is a common cause of ESRD which necessitates a renal transplantation. Therefore

hyperglycemia must be managed preoperatively. The presence of autonomic neuropathy
should be noted, as this may help predict haemodynamic instability and risk for graft
hypoperfusion post operatively. Similarly gastroparesis may have important implications for
immunosuppressive drug absorption if severe and retinopathy may complicate post operative
medication management if visual acuity is substantially reduced.

After admission for kidney transplantation, patients with type 2 diabetes should omit
hypoglycaemic medication during the period of preoperative fasting, with regular capillary
glucose monitoring every 1- 2 hour. Hypoglycemia is managed with intravenous dextrose. If
significant hyperglycemia develops then an intravenous insulin infusion is safest method to
control glucose levels until the recipient is able to eat post operatively.

Immunosupression

 After the decision has been made to proceed with transplant, an immunosupression
regimen is selected. This regimen is usually initiated before the recipient goes to the
theatre so that immune function is attenuated prior to donor antigen exposure after
reperfusion of the allograft. The choice of immunosuppressive regimen is
individualised depending on the circumstances of the recipient and, in particular the
perception of immunological risk.
 Most patients undergoing kidney transplantation will receive induction
immunosuppression typically consisting of intravenous methylprednisolone
combined with either a monoclonal anti – C 25 antibody, such as basiliximab or
lymphocyte depleting antibody such as alemtuzumab.;

RISK STATUS DONOR TYPE

Very Low risk Identical twin donor
Low risk HLA identical sibling donor, no DSA ( Donor specific
antibody )
Average risk HLA mismatched donor, no DSA
High risk HLA mismatched donor, detectable DSA, negative cross
match or ABO incompatible donor following
desensitization
Very high risk HLA mismatched donor, detectable DSA, positive cross
match
ABO incompatible transplants as well transplants where there is a pre transplant DSA
requires plasma exchange prior to transplantation.

Prophylactic medication

The administration of immunosuppression needs to be balanced against increased risk of

infection. With ESKD patients being routinely subjected to hospital environments, additional
consideration should be given for prophylaxis in patients colonised with multi resistant
organisms.

Patients with prior known serious or recurrent infections should be evaluated carefully and
assessed for recurrence and presence of occult infection prior to proceeding with
transplantation. In addition, gastro protection, infection and (VTE) Venous Thrombo
Embolism prophylaxis is charted.

Gastro protection Ranitidine (or PPI) therapy while on high dose steroids
Bacterial protection Perioperative antibiotic therapy prescribed based on local
guidelines and adapted recipient multi resistant organism
colonization or potential donor infection
PJP (Pneumocystis jiroveci 6 -12 months co-trimoxazole. Consider life long therapy.
pneumonia) prophylaxis
UTI prophylaxis 6 months co-trimoxazole
Oropharyngeal candiasis Oral nystatin or amphotericin for duration of admission.
Systemic fungal infection Not generally prescribed due to low incidence of invasive
fungal infection.
CMV prophylaxis Oral Valganciclovir. Duration depending on donor and
recipient serostatus.
VTE prophylaxis Unfractionated heparin and mechanical calf compression
unless contraindicated patient mobile.

Despite some controversy for the use of surgical antibiotic prophylaxis, routine prescribing is
common , generally following local practice sand guidelines. No consensus currently exists
for optimal antibiotic prophylaxis, but the general approach is to minimize dose and duration
of administration to prevent emergence of antibiotic resistance.
TRANSPLANT PHASE ( Intra operative and immediate post operative
considerations )

Transplant Surgery
The transplant surgery is performed under general anaesthesia. The operation usually takes 2-
4 hours. This type of operation is a heterotopic transplant meaning the kidney is placed in a
different location than the existing kidneys. (Liver and heart transplants are orthotopic
transplants, in which the diseased organ is removed and the transplanted organ is placed in
the same location.) The kidney transplant is placed in the front (anterior) part of the lower
abdomen, in the pelvis.

The original kidneys are not usually removed unless they are causing severe problems such as
uncontrollable high blood pressure, frequent kidney infections, or are greatly enlarged. The
artery that carries blood to the kidney and the vein that carries blood away is surgically
connected to the artery and vein already existing in the pelvis of the recipient. The ureter is
connected to the bladder. Recovery in the hospital is usually 3-7 days.

Perioperative fluid management

Optimal fluid management strategy is contentious, although there is a good evidence that
fluid loading to maintain cardiac output and optimise renal perfusion, improves outcomes.
Currently no guidelines exist on fluid management in the perioperative phase of renal
transplant.

A common strategy for managing post operative fluid replacement in the hours after kidney
transplantation is to replace the urine output from previous hour plus 30 ml to account for
insensible losses.

A loop diuretic and / or mannitol is sometimes administered during the transplant surgery to
precipitate a diuresis, decreasing requirement for dialysis, but has not been shown to improve
graft outcomes.

CVP monitoring: Central venous line is placed at the time of surgery and CVP is monitored
intra operatively and in the immediate post operative period. It is important to acknowledge
controversies in absolute CVP targets, with studies advocating improved outcomes with
increased CVP ( 10 – 15 mm Hg ) targets at reperfusion and other studies observing increased
kidney dysfunction with CVP > 11 mm Hg.

Post operative documentation

Intraoperative events have significant impacts on patient and graft outcomes. Review and
documentation of intraoperative and immediate post operative factors can help predict and
guide subsequent clinical course.

Any surgical complications or anatomical challenges (notably presence of multiple renal

arteries, difficult bench surgery and renal capsule tear ) should be communicated by the
transplant surgeons as these can help predict perioperative complications. If available
intraoperative Doppler assessments should be documented to confirm adequate post perfusion
flow parameters in the transplanted kidney.

Significant blood loss, requirement of inotropic support and intraoperative haemodynamic

instability indicate suboptimal organ perfusion and are risk factors for delayed graft function.

Post Transplant Period

The post transplant period requires close monitoring of the following:-

Monitoring fluid and electrolyte status:

Frequent clinical assessment of the recipient’s fluid status, including the jugular venous
pressure, heart rate, blood pressure and urine output is important to ensure adequate fluid
replacement and to avoid volume overload. Traditional parameters and clinical assessment of
fluid status, however may be unreliable due to compromised homeostatic mechanisms in
ESKD and post ischemic transplanted kidney. Some recipients may develop a significant
diuresis, passing over a litre of urine per hour, and in this situation, frequent monitoring of
blood tests 4- 6 hours is recommended to avoid over or under replacement of electrolytes.

Blood tests to monitor serum creatinine and electrolytes are collected immediately post
transplant and then 6 – 12 hours to monitor renal function and exclude hyperkalaemia.

Hyperkalemia: Despite preoperative optimization, hyperkalemia is common post operatively

due to tissue trauma and resorption of intra abdominal blood. The presence of hyperkalemia >
6 m mol/ L in the immediate post operative period shoule prompt consideration of dialysis
depemding on the urine output. If the graft urine output is > 100 ml/h, it may be reasonable
to manage the patient medically with insulin dextrose infusion and loop diuretics. It should be
noted that intraoperative use of glucose dextrose often results in rebound hyperkalemia post
operatively.

Hypokalemia: Perioperative hyperkalaemia is often followed by hypokalaemia due to

diuretics and polyuria combined with large volume IV fluid replacement.

Hypomagnesemia is exacerbated by the tubular effects of CNI therapy (Calcineurin

inhibitors) and is associated with an increased risk of post transplant diabetes. To reduce
chances of arrhythmia IV electrolyte replacement should target potassium levels in the
normal range (3.5 – 5 m mol / L) and a serum magnesium > 0.4 m mol / L.

Monitoring graft function : A good urine output in the early transplant period is a helpful
indicator of early graft function, although it may not be possible to differentiate allograft
urine output from native urine output in recipients who have a significant residual renal
function. Oligoanuria may be an indicator of delayed graft function. An urgent ultrasound is a
useful investigation to assess perfusion of the allograft at the bedside and to check for
evidence of ureteric or vascular complications.

Identifying early signs of rejection: Rejection is an expected side effect of transplantation

and up to 30% of people who receive a kidney transplant will experience some degree of
rejection. Most rejections occur within six months after transplantation, but can occur at any
time, even years later. Prompt treatment can reverse the rejection in most cases.

Rejection is suspected if serum creatinine rises. Symptoms such as pyrexia, graft tenderness
and decreased urine output develop at a relatively late stage. If no obvious cause for
creatinine rising can be seen, then to confirm the diagnosis of rejection a biopsy of transplant
tissue is taken under local anesthesia and is examined in the laboratory. Borderline mild
rejection may be treated with an increase in oral immunosupression or with intravenous high
dose prednisolone. More severe rejection can be treated with additional administration of
ATG.
OTHER POST OPERATIVE CONSIDERATIONS

Myelosuppression is commonly observed in post transplant patients receiving

immunosuppressive therapy. Investigations focus on identification of the underlying cause
for the haematological abnormality.

Post operative anaemia is observed in around 40% of kidney transplant recipients due to
erythropoietin deficiency, pre transplant anaemia and intra operative blood loss.
Administration of erythropoietin stimulating agent may be appropriate in recipients with poor
initial graft function.

Lymphopenia and neutropenia are also common after transplantation, typically as a

consequence of the medication related bone marrow suppression associated with anti
proliferative agents (mycophenolate and azathioprine), m TOR inhibitors (sirolimus and
everolimus) and antiviral agents such as valganciclovir for CMV prophylaxis. G-CSF
(Granulocyte Colony Stimulating Factor) is typically administered if the absolute neutrophil
count falls below 1000 /μL. Neutrophil count below 500/ μL is associated with a significant
risk of severe infections and require barrier nursing. Aletrnative causes of neutropenia should
be considered including parvovirus B 12and CMV infection.

Thrombocytopenia is comparatively less common, often occurring in conjunction with

leukopenia due to bone marrow suppression. More severe thrombocytopenia is a risk factor
for bleeding and platelet transfusion may be necessary if invasive procedures, such as renal
biopsy, are required.

COMPLICATIONS OF RENAL TRANSPLANT

Complications such as bleeding, infection or wound healing can occur with any surgery.

Numerous complications are associated with kidney transplantation. These include the
following:

 Rejection: Transplantation of allograft (organ transplanted between genetically

different individuals of same species) elicit and immune response in which the antigens
in tissue of organs are recognized as foreign, hence a series of events occur, resulting in
rejection of the organ.
 o Hyper acute rejection of the renal allograft occurs within hours of the
transplant; nephrectomy is indicated
o Acute rejection appears within the first 6 months after transplantation (15% of
cases)
o Chronic rejection occurs more than 1 year after transplantation and is a major
cause of allograft loss

 Nephrotoxicity of calcineurin inhibitors (ie, cyclosporine, tacrolimus)

 Recurrence of native kidney disease

 Delayed graft function: Delayed graft function is defined by the need for dialysis in
the first week after transplantation. Delayed graft function is rare with living donor
grafts, probably because of the short cold ischemia time and recovery of the kidney
from a healthy live donor. For deceased donor kidneys, cold ischemia time remains the
best predictor of delayed graft function.

 Vascular complications are divided into early and late.

Early complications comprise Renal artery thrombosis (rare 1%) and Renal Vein
Thrombosis (6%). They must be recognized promptly using a Doppler ultrasound and will
require taking back to theatre urgently if identified. Aspirin and heparin are often started post
operatively to reduce this risk.

Late complications include Renal artery stenosis, which usually presents several months
post transplantation with uncontrollable hypertension and worsening graft function.
Angiography confirms the diagnosis and the treatment of choice is typically angioplasty.
Figure showing angiogram following angioplasty, in a patient with renal artery stenosis.

Ureteral Complications: Ureteric leaks occur from a breakdown of the ureteric bladder
anastomosis, presenting with a decreased urine output and increasing abdominal pain. They
often require repeat surgical intervention.

Urinary tract obstruction can also occur, through ischaemic strictures in the distal ureter
(treated with dilation) or extrinsic compression from a lymphocele or haematoma (treated via
drainage).

Infection: Many factors contribute to the potential risk of infection, including the patient’s
age, nutritional status, medical condition before transplantation, infection history and
exposure and the immunosuppressive regimen.

During the first month after the transplantation, nosocomial infections are common. Then
between one and six months after transplantation, opportunistic infections such as
pneumocystitis carinii pneumonia, candia

Long term complications

The most common cause of mortality post operatively within the first year is cardiovascular
disease.

Most other longer term complications are often related to the use of immunosuppressive
agents are as follows:-

- Recurrent infections

- Diabetes mellitus
- Malignancy, which is common among transplant patients

- Ischaemic heart disease (related to drug-associated hypertension, nephrotoxicity and lipid

abnormalities)

- Osteoporosis, especially in relation to steroids

NURSING MANAGEMENT IN RENAL TRANSPLANTATION

For patients undergoing renal transplantation it is a time of great uncertainty. While it is

acknowledged that there is large number of health care professionals caring for the patients
who are waiting for a transplant, it is the renal nurse who is the centre of their care delivery.
The renal nurse needs to assist the patient and their relatives to deal effectively with this
situation and also to manage the patient’s pre and post operative care to maximise the success
of the graft.

PREOPERATIVE NURSING CARE

The successful recovery and rehabilitation of the recipient are made possible with nursing
assessment, diagnosis, intervention, and evaluation of all body system. Preoperative nursing
assessment includes history taking, general physical examination and review of all the
necessary investigations.

History taking

A detailed history of the patient which includes the following:-

History of origin of kidney disease

History of medical and surgical illness

Family history (Renal failure)

Dialysis (Type, duration, adequacy)

Drug history

Diet history
General physical examination: To ensure the patient is in optimal physical condition for
surgery

Review of all the necessary investigations should be done including ECG, Chest X ray, and
laboratory studies .

Providing Psychological And Social Support: Emotional and physical preparation for
surgery is essential because the patient and family may have been waiting years for the
kidney transplant. Psychological and emotional support process should be continued
throughout the pre-transplantation phase right through to discharge and beyond so that they
can effectively manage this life changing event.

Also a review of the operative procedure and what can be expected in the immediate post
operative recovery period is necessary.

Preoperative Teaching

It is important to stress that there is a chance the kidney may not function immediately, and
dialysis may be required for days to week.

The need for immunosuppressive drugs and measures to prevent infection must be reviewed.

Preoperative Dialysis: Dialysis may be required before surgery for any significant
abnormality such as fluid overload or hyperkalemia. The role of nurse is to assess the patient
for any signs of fluid overload and hyperkalemia.

A patient on peritoneal dialysis must empty the peritoneal cavity of all dialysate solution
before going to surgery

Because dialysis may be required after transplantation, the patency of the vascular access
must be maintained.

Immediate preoperative preparation:

Patient should be nil per oral (NPO) 6 hours before surgery.

Informed consent should be taken from the patient as well as the relatives also.

Skin preparation of the operating site should be done.

Antibiotic should be given before surgery as prescribed by the surgeon.

Relieve the anxiety of the patient by psychological support or group therapy.

POST OPERATIVE NURSING CARE

Recovery from renal transplantation depends on many factors including patients’ age, overall
health, severity of renal disease, infections, secondary organ dysfunction or complications
before or after the operation. Good understanding of the process, moral support and
encouragement from family, a positive attitude and strong will-power are important in
patients’ recovery.

The postoperative nursing care of the renal transplant recipient is similar in many ways to the
care of any patient who has undergone a major surgical procedure; the emphasis is on the
following:-

 Maintenance of patent airway

 Maintenance of fluid and electrolyte balance
 Pain management
 Wound care
 Monitoring of renal function
 Good pulmonary toilet with incentive spirometry,
 Early ambulation
 Nutritional management
 Restoration of normal bowel elimination

Post operative nursing interventions

On return to the ward the patient must have their vital signs monitored as for any patient post
major surgical procedures and general anaesthesia.

a) Assessment of signs of shock and haemorrhage: Heart rate, respiration rate, blood
pressure, temperature and SpO2.
 o Monitoring for return of consciousness: The nurse monitors the level
of consciousness. Orientation to person is the first cognitive response
to return after anaesthesia.

o Maintaining normal blood pressure: A drop in blood pressure slightly

below a patient’s preoperative baseline reading is common after
surgery; however a significant drop in blood pressure; accompanied by
an increase heart rate, may indicate haemorrhage, circulatory failure, or
fluid shifts.

o Assessing the return of sensation and motion: Check return of

motion to the extremities by asking patient to move their toes,
however, the ability to move the toes will be delayed if patient had
spinal anaesthesia.

o Assessing for normothermia: The patient is monitored for temperature

every fifteen minutes until vital signs are stable.

b) Oxygen Administration: Anaesthetist’s instruction for oxygen administration must be

observed.
c) Airway Patency : The primary nursing intervention to protect airway is to position the
head of a minimally responsive patient to the side with the chin extended forward to
prevent respiratory obstruction. Patients who are unable to clear the mucous or
vomitus from the throat require suctioning immediately.
d) Monitoring of Respiratory Function: It is important to monitor respiratory function
as the patient may be immune-suppressed, may be fluid overloaded to some degree
and susceptible to chest infection. In addition contributes to respiratory depression.

e) Maintenance of fluid and electrolyte balance :

The first priority during this period is to maintain fluid and electrolyte balance.
 Kidney transplant recipient spend the first 12- 24 hours in the ICU because close
monitoring is required. A very large volume of urine may be produced soon after the
blood supply to the transplanted kidney is reestablished.

 Urine output during this phase may be high as 1L/hr and gradually decreases as the
BUN and creatinine level return toward normal. A drop in urine output could signify
problems with fluid balance, cardiac output, graft function.
 Urine output is replaced with fluids millilitre hourly for the first 12 to 24 hours.
Replacement regime may consist of adding an extra specified volume (e.g. 30 ml) to
the total urine output of the previous hour.

 Intravenous fluid replacement may be titrated to CVP readings (via a central line). It
is important to acknowledge controversies in absolute CVP targets, with studies
advocating improved outcomes with increased CVP ( 10 – 15 mm Hg ) targets at
reperfusion and other studies observing increased kidney dysfunction with CVP > 11
mm Hg.

 Dehydration must be avoided to prevent subsequent renal hypoperfusion and renal

tubular damage.

 Electrolyte monitoring to assess for the hyponatraemia and hyperkalemia often

associated with rapid diuresis is critical.

 Treatment with potassium supplements or 0.9% normal saline solution infusion may
be indicated.

 The urinary catheter is usually removed after several days, this allows adequate time
for the anastomosis of the transplant ureter to the bladder to heal but urine output
should be still monitored.

f) Pain management: The postoperative pain treatment is one of important factors of a

successful outcome after kidney transplantation. Improperly controlled pain leads to
agitation, tachycardia, hypertension and increases risk of respiratory complications.
Postoperative analgesic regimens are PCA (Patient controlled Analgesia) , Epidural
analgesia (selected cases), intermittent subcutaneous injection, intravenous opiate
infusion, intermittent intramuscular injection.
 Many studies have demonstrated good analgesic effect of morphine delivered by the
method of patient controlled analgesia (PCA). 

 A survey demonstrated that intravenous opioid administration provided the mainstay

of analgesia following renal transplantation in the UK. The majority of centres
favoured the use of PCA morphine but a minority used PCA fentanyl. There is
 widespread acceptance of PCA as an effective postoperative analgesic technique.
Although patient satisfaction is improved by PCA following major surgery, there is
little effect on cardiovascular or pulmonary postoperative morbidity or hospital stay.

g) Wound care: The surgical site must be assessed for any evidence of bleeding, redness
and infection. The dressing over the surgical incision must be checked frequently. If it is
soiled, note the colour, type and amount of drainage. Reinforce the dressing but do not
change it or open it without surgeon’s order.

It is the surgeon’s choice to use clips or stitches which is to generally removed at 10 –

14 days post operatively. In patients who are in high doses of corticosteroids Sutures are
left in place for long up to 3 weeks to accommodate the process of slower healing. In
some centres patient will have an abdominal drain for first few days; the surgical team
will decide when the draining output over 24 hours is sufficiently low to remove the
drain.

h) Monitoring of renal function: Recipients may require blood tests and ultrasound to
monitor renal function and recovery as per standard protocol. Patients’ families are
generally updated about their progress by the transplant team once a day or more often,
if appropriate. While it is natural for patients and families to be anxious, questions for
the transplant team should be asked during the counselling sessions or during ward
rounds. Visiting hours and the number of visitors is restricted to prevent infections. 

g) Maintenance of bladder function: Catheter patency must be maintained as the catheter

remains in the bladder for 3 to 5 days in order to protect the fresh suture line between the
ureter and bladder and to allow the bladder anastomosis to heal.

 If blood clots are suspected, gentle catheter irrigation with an order from the health
care provider can re-establish patency.

 Most patients will be discharged from hospital on dialysis.

 Dialysis will be discontinued when urine output increases and BUN and creatinine
being to normalize.
i) Maintenance of GI function: Recovery of upper GI function is usually
uncomplicated, but constipation is a common problem because of ileus after a
retroperitoneal dissection and the constipating side effect of phosphate binders and
corticosteroids. Therefore, stool softeners, bulk-forming laxatives, and enemas are
administered as necessary.

j) Nutritional management:

An adequate nutritional status may improve outcomes after transplantation. Post-

transplant nutritional goals include providing adequate nutrients to treat catabolism
and promote healing, monitoring and treating electrolyte abnormalities, and achieving
optimal blood glucose control. Kidney recipients are given liquid diet followed by
normal diet in 2 - 5 days.

Dietary management is to be done keeping in view to avoid the increased risk of

infection due to immunosuppressive drugs and the side effects of corticosteroid
therapy such as:
 Increased appetite resulting in unwanted weight.
 Increased blood cholesterol and triglycerides.
 Increased blood sugar levels.
 Break down of muscle and bone tissue.

It is therefore important to make healthy food choices. Required energy after renal
transplant are 30 – 35 Kcal/kg, Protein 1.4 g/kg. Fatty foods and foods high in simple
sugar must be avoided. Low salt and high fibre diet is to be encouraged.

Low in sugar
Limit juice, soda and other high sugar drinks to less than 8 ounces a day.
Choosing of low sugar version of healthy foods, such as regular milk instead of
chocolate milk.
 Low in Fat
Limit butter, margarine, red meat, fried foods, poultry, skin, full fat dairy products,
eggs, junk food.
Limit foods like chips, crackers and cookies.

High in fibre
Serve fibre rich foods such as fruits, vegetables, whole grains, legumes.

Moderate in sodium
Although the recommended limit varies with age, most patients should get no more
than 1.5 to 2 grams (1,500 to 2,000 milligrams) of sodium a day.

Avoid grapes, pomegranate and green tea products especially if the recipient is taking
cyclosporine or prograf (specific immunosuppressive medicines) as these can increase
the amount of anti rejection medicines in the body causing harm.

In case of donors they are generally allowed liquid diet followed by normal diet in 2 -
3 days.

k) Early ambulation:

Donors  wake up immediately after surgery, although they might feel drowsy for a few hours.
They are able to get out of bed in 1 - 2 days and made to walk in 2 - 3 days. Various
intravenous lines and catheters are removed as they recover. Generally, they are shifted to the
ward in 1 - 2 days and discharged in 5 - 7 days.

Pain medicines are given depending on their pain threshold. Some patients prefer to take pain
medicines before walking or any exercise that may trigger pain or just before going to bed for
a comfortable night sleep.

Recipients are kept on a ventilator overnight and this is removed when they are fully awake.
First 24 - 48 hours are critical and their condition and renal function are monitored by doing
frequent blood tests. Patients are helped out of bed in 1 - 2 days. Various intra venous lines,
catheters and drains are removed as they make progress/ recover over 3 - 4 days. They
participate in the physiotherapy program, walk in 4 - 5 days and gradually become more
active.

l) Incentive spirometry: Kidney recipients and donors should actively do incentive

spirometry to prevent collapse of lungs, prevent lung infections and recover faster.

Discharge Planning and advice

While the patient recovers from the operation, the family should take the opportunity to-
learn about precautions to be taken after discharge

Understand the schedule for testing and follow-up appointments

Become familiar with medicines

Learn about the warning signs of potential problems

Understand the mechanism to contact the renal transplant team round the clock in case of
urgent problems.

Counselling sessions for both the patients and the donors and the relatives are conducted on a
regular basis. Attending these sessions will help in discharge planning. 

At the time of discharge, patients will get a discharge summary with detailed instructions
about testing and medication schedule, which should be discussed with the transplant
coordinator. 

After discharge, patients are required to undergo tests and visit the transplant clinic every 5 -
7 days. They should therefore stay in the vicinity of the hospital for 4 - 6 weeks after
discharge. The house where the patient would be staying after discharge should be prepared.
Prevention of infections

 The house should be thoroughly cleaned with disinfectants

 The accommodation should be close to the hospital with available transportation 24
hrs a day, there should not be too many stairs and the locality should be neat and
clean. 
 Patients are encouraged to walk and avoid using a wheel chair
 The number of visitors should be restricted for a few weeks
 Patients should avoid meeting people who are ill and report any illnesses / fever / flu /
cold / persistent cough  pain in abdomen/ loose motions or transmissible infections or
infectious diseases such as influenza, pneumonia, chicken pox, hepatitis etc.
 Patients should avoid contact with animals and birds to prevent infection
 For the first 2 to 3 months, patients are advised to wear a mask and avoid crowded
public places like malls, cinemas, restaurants, department stores, etc. After this
patients can attend social events and live a normal life.

Personal hygiene and wound care

 Frequent hand washing with soap, especially before eating, should be practiced by all
family members and hand-washing with antiseptic solution after using the bathroom
 Oral hygiene should be maintained by brushing teeth daily rinsing mouth after eating
 Finger nails should be trimmed
 On the 5th day after surgery, both patients and donors are encouraged to take a daily
shower

Food - how to prepare/ consume

 Food should be cooked hygienically

 Wash utensils well before cooking
 Wash and cook in clean water
 Use boiled / filtered water
 Eat small frequent meals
  Drink plenty of liquids; intake is not restricted
 Salt restriction is not necessary unless one has high blood pressure
 Eat plenty of fresh fruits and green leafy vegetables after washing well and peeling off
the skin
 Consume a balanced, low-fat, high-protein diet
 Take food rich in calcium, such as skimmed milk, cheese, soya, eggs, chicken, fish
 In a few weeks, patients can resume eating as they did before the transplant

Foods to avoid

 Avoid eating out and roadside food

 Avoid deep fried or greasy food
 Do not eat food left overnight
 Avoid raw eggs or mayonnaise
 Avoid partially cooked food
 Avoid red meat
 Avoid cold meat
 Avoid overripe fruits
 Do not consume expired packaged food
 If potassium is high, avoid food such as banana, coconut water, fruit juices/ pulp
 If blood sugar is high, avoid sweets and fruits such as mangoes

Activity and Exercise

 At the time of discharge, patients are generally allowed active walking and routine
activities like bending or climbing stairs. Regular exercise increases energy level,
strengthens muscles and makes one feel more active.
 It is common to experience weakness and mild abdominal discomfort at the site of the
operation, especially with movements for the first few weeks after transplant. Do not
postpone exercising because of this reason. In case one has severe discomfort with
movements, talk to the transplant team.
 Perform deep breathing exercise to expand lungs and help cough out sputum.
  The physiotherapist will teach limb exercises, so that limb muscles are strengthened,
blood circulation is increased and the risk of complications such as venous thrombosis
is reduced.
 Speak to the physiotherapists to progressively increase the level of exercise and
optimize the exercise schedule.
 Ensure adequate rest and sleep
 Avoid lifting heavy weights (> 5 kgs), including babies, or performing abdominal
exercises for first 3 months to allow the scar to strengthen and prevent hernia in the
long term.
 After 3 months, one can resume normal physical activities; perform any exercises,
including abdominal exercises, weight training and swimming. These will help
strengthen abdominal muscles and flatten the tummy.

Warning Signs of Kidney Transplant Rejection

 Fever (greater than 100°F or 38°C), chills

 Tenderness/pain over the transplanted area
 Significant swelling of hands, eyelids or legs
 Significantly decreased or no urine output
 Weight gain (1-2kgs or 2-4lbs) in 24 hours
 Significant: flu-like symptoms such as chills, nausea, vomiting, diarrhoea, loss of
appetite, headaches, dizziness, body aches, tiredness

PRE OPERATIVE NURSING DIAGNOSIS

Fear related to perceived threat of death secondary to treatment regimen.

Goals: To reduce fear level

Interventions:

 Assess the level of stress due to surgical procedure and its outcome.
 Patient must be provided proper information about surgical procedure by surgeon.
  Proper explanation of every procedure like IV cannulation, catheterization and part
preparation should be done before doing.
 The patient should be involved in planning and self care.
 The patient should be introduced to another patient who has undergone a successful
kidney transplantation.
 Emotional support to the patient and family should be provided.
 Scheduling activities should be recommended with adequate rest periods.

Deficient knowledge related to post transplant self care.

Goal: Patient will have increased knowledge about treatment regimen

Interventions

Assess patient knowledge related to disease condition and its treatment option.

Provide proper information about disease condition and its management.

Provide education about post operative exercises like deep breathing, limb flexion and
extension.

Patient must be educated regarding diet after transplant, which includes the low sugar, low
fat, low sodium and high fibre diet.

Patients must be taught about the importance of taking immunosuppressive medications and
the need to maintain general hygiene and hand hygiene, drug compliance and follow up care.

Warning signs of possible graft rejection must be explained to the patient.

POST OPERATIVE NURSING DIAGNOSIS

“ Risk for infection related to inadequate secondary defences (immunosuppression) ’’

Goals: Patient will remain free of infection

Interventions:
 Maintain a clean patient environment, wear a mask in patient’s room if policy
indicates.
 Follow strict hand washing techniques.
 Limit the number and duration of invasive devices.
 Encourage incentive spirometry, deep breathing and ambulation.
 Assess patient’s mouth for white lesions characteristics of oral candidiasis.
 Apply topical antifungal as needed.
 Teeth should be brushed after all meals and before sleeping.
 Provide adequate nutrition.
 Patients should be monitored for symptoms of pneumonia (fever, fatigue, chills,
sore throat, cough, secretion removal), with the aim of protecting against this.

 Nursing care should include monitoring body temperature; evaluating the incision
site in terms of bleeding, fluxion, redness, edema, pain, local fever,and appearance;
evaluating laboratory results

 Patients and relatives should be informed about the importance of handwashing,

symptoms of infections, ventilation of the room at certain times, and body hygiene.

“ Risk for fluid volume excess related to renal insufficiency, steroid therapy or
decreased cardiac output ”

Goal: Patient will maintain normal fluid balance

Interventions:

 Monitor hourly intake and output.

 Weigh patient daily and record findings.
 Monitor blood pressure. Compare both to baseline values.
 Auscultate lungs for crackles.
 Notify physicians of indications of fluid volume excess including 3 kg weight gain in
three days.
 Collaborate with physician and patient to determine fluid allotment and medication or
dialysis management of volume excess.

“Risk for fluid volume deficit related to diuresis, blood loss”

Goal: Patient will maintain normal fluid balance

Interventions:

 Monitor hourly intake and output.

 Weigh patient daily
 Monitor intake and output level
 Provide IV fluids and blood transfusion as per the need.
 Monitor serum sodium and potassium levels.

“Acute pain related to the abdominal incision ”

Goal: Patient will have good pain relief in the post operative period.

Interventions:

 Assess pain through use of pain scale.

 Assess for bladder distension and abdominal distension which may be due to blockage
in foley’s catheter.

 Vital signs should be monitored, and analgesic medicine should be administered

according to the physician’s request
  Nonpharmacologic methods for pain care should be included (talking,
listening to music, respiration practices). Patients should be positioned in a pain-
reducing position.

 Teach the technique of splinting the surgical incision site with pillow during
Coughing for pain management and effective coughing.

‘’ Disturbed body image related to permanent changes in body due to

immunosuppression”

Goal: Patient will develop a realistic sense of self

Interventions:

 Provide an empathetic environment so that patient can discuss her concerns about her
changed body.
 Collaborate with the patient to develop strategies to cope with changes such as:
 Help female patients to find a way to manage excessive facial hair.
 Encourage exercise and appropriate diet to limit weight gain.
 Encourage patient to socialize with family and peers.

CONCLUSION

The renal nurse needs to support and assist the patient and their relatives to cope with
transplantation in the best way possible and to manage the pre and post operative care to
maximise the success of the graft. Nurses caring for these patients require specialist
knowledge to reduce problems in early post transplant period by prevention or anticipation
and early intervention to maximise short and long term graft outcome. Patients and relatives
who engaged with the process are better equipped to care for themselves and this also
contributes to the success of the graft.
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