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PRESENTER:
DAINY THOMAS
MODERATOR:
MADAM RACHEL ANDREWS
INTRODUCTION
Organ transplant
of a kidney into a
as deceased-
INTRODUCTION
It
KIDNEY TRANSPLANTATION
Living-donor Genetically Non-related
renal transplants:
transplants, depending on whether a biological relationship exists between the donor and recipient.
HISTORY
y
First cadaveric kidney transplantation in the United States 1950- polycystic kidney disease, at Illinois.
The first kidney transplants between living patients -1954 (Boston and Paris).
HISTORY (CONTD)
y
The procedure was done between identical twins to eliminate any problems of an immune reaction.
ADVANTAGES
The kidney - easiest organ to transplant: Tissue typing - simple. Organ - relatively easy to remove and implant. Live donors could be used without difficulty. In the event of failure, dialysis was available from the 1940s.
CONTRAINDICATIONS
y y y y
MALIGNANCY RECURRENT DISEASES INFECTION HIGH PROBABILITY OF POST OPERATIVE MORBIDITY& MORTALITY
NONCOMPLIANCE
Incurable Morbid
Psychiatric illness
SOURCES OF KIDNEY
Depending on the source of the recipient organ.
y
Living-donor transplantation
Genetically related (living-related) Non-related (living-unrelated)
SOURCES(Contd)
y
Deceased-donor (formerly known as cadaveric). Brain-dead (BD) donors or ("heartbeating): Donor's heart continues to pump and maintain the circulation. Donation after Cardiac Death (DCD): Have elected via a living will or through family to withdraw support.
It is an option for patients in need of a kidney transplant who have a living donor whose blood or tissue type is not compatible. Known as KIDNEY SWAPING
Early referral : as soon as CKD is diagnosed. Patient education Age Polycystic kidneys Urinary tract Cardiac disease evaluation GIT evaluation Respiratory disease evaluation Obesity Oral hygiene
Improved quality of life Freedom from dialysis Normal healthy diet Freedom from liquid restriction Travel freely Employment Improved fertility
Desire to receive a transplant Benefits of a renal transplant Risks/ disadvantages of a renal transplant
history
status
surgery
Current clinical status Social history& family
status
assessment
Risks Further investigation Living donor or cadaveric list Immuno suppression regimen Decision
y Stage 3
: Routine Investigations
Blood group Tissue typing Biochemistry Haematology Liver function tests Lipid level
Virology: Hep B &C, HIV, CMV Chest X- ray, ECG Mid stream urine Specific investigation required 4:
y STAGE
ABO Blood group Major histocompatibility complex (human leukocyte antigen): Two major types: class 1& class 2 Class 1: HLA A, HLA B,HLA C Class 2: HLA DP, HLA DQ, HLA DR A,B,C & DR - 4 Main series important for transplantation
y y
If donors cell die, its a +ve cross match i.e. recipient is adversely reacting to donors antigens, so the transplantation would be rejected.
Sensitization
y
It is defined as being immunized, or able to mount an immune response, against an antigen by previous exposure to that antigen.
Desensitization
y y
Research input
y
A comparison of the results of renal transplantation from non-heart-beating, conventional cadaveric, and living donors.
y y y
Nicholson ML et al Kidney Int. 2000 Dec;58(6):2585-91 The initial function rates for NHBD, HBD, and LD transplants were 6.5, 76.3, 93% respectively .Despite being associated with poor initial graft function, the long-term allograft survival of NHBD kidneys does not differ significantly from the results of HBD and LD transplants.
KIDNEY HARVESTING
From a living donor: Steps
Donor & recipient matching. Informed consent Physical and clinical examination
2.Investigations 3. Assessment of surgical risk: Is donation safe for the recipient & donor ? 4.Preoperative assessment
Done prior to medical assessment Blood tests: repeat tissue typing, LFT, hematology Clinical tests: chest X-ray, ECG, USG of renal system Urine tests: Midstream urine, Urinalysis: proteinuria, hematuria Assess GFR: 24hr urine for creatinine clearance, clearance scan.
Final cross matching & tissue typing Methicillin-resistant swabs for Staph. aureus( throat, nose, axilla, groin)
y y
CONTD
y ECG, BP,
Pulse, Temperature,Chest
X ray
y Orientation to y Final crossy Pre
the unit.
match.
CADAVERIC DONATION
Cadaveric donors are patients who suffered irreversible brain stem damage. Criteria for multiple organ donation Patient: y Is aged between 18months-80 years 18monthsy Has suffered irreversible brain damage y Is maintained on a ventilator y Has no major untreated sepsis y Is HIV, Hep B&C negative
LIVING DONORS
EXCLUSION CRITERIA y Cognitive deficit y Active drug or alcohol abuse y Evidence of renal disease ( low GFR, proteinuria, abnormal renal anatomy) y Diabetes , hypertension, CAD y Active infection, chronic viral infection(Hep B, Hep C) y Current/history of neoplasm, family history of any renal cell cancer y Current pregnancy
access surgery
y Natural orifice
Kidney harvesting
Transplantation Operation
y
In most cases the barely functioning existing kidneys are not removed.
The new kidney is placed in the iliac fossa. Right side regardless of the side origin from donor. Contralateral side to the side of donor. Ipsilateral side to the donor kidney.
Cont
y
Its blood vessels connected to arteries and veins in the recipient's body i.e., Renal artery of the kidney, is often connected to the external iliac artery in the recipient. Renal vein of the new kidney, is often connected to the external iliac vein in the recipient.
Cont
Kidney preservation
1.Cold storage method:
y Suitable upto
30hrs of preservation.
2.Machine perfusion
y Suitable upto
48 hrs.
HTK Solution
y
HTK (HistidineTryptophanKetoglutarate) Solution. HTK is perfused as a cold solution, so that its hypothermic effect contributes to a decreased metabolic rate.
Contd Contd
Surgery lasts five hours on average. y Living donor kidneys normally require 35 days to reach normal functioning levels. y Cadaveric donations stretch that interval to 715 days. y Hospital stay is typically for 47 days.
y
Chronic renal parenchymal infections. Infected stones Heavy Proteinuria Intractable hypertension Polycystic kidney disease Acquired renal cystic disease Infected reflux
PostPost-op Mx of donors
y y y
Check vital signs. Input/ output charting Get a Chest -X-ray to exclude any pneumothorax
y y
PostPost-op Mx of donors
y y y y
Can eat 24-48 hrs post-op. Wound management Complete recovery takes about 6-8 wks. Educate the donor for some lifestyle changes for risk modification.
I/O every hr for 24 hrs. Intravenous fluids as prescribed Daily weight Turn, cough, deep breathing, intensive spirometry.
Dressing changes, palpate fistula every 4 hr. No BP or venipuncture in extremity with fistula.
Catheter care and irrigation Notify if urine output <30ml/hr Blood chemistry to be done. Notify hyperthermia
For a delayed functioning graft Intravenous fluids- maintain CVP 10-15 cm water & frusemide to induce diuresis
Calcineurin inhibitors: Tacrolimus or cyclosporine Mycophenolate mofetil and Azathioprine Corticosteroids: prednisolone IVIG
Uses of immunoglobulins
To reduce high levels of preformed antiHLA antibodies in sensitized patients. y To facilitate living donor transplants in case of +ve cross-match or ABO incompatibility. y To treat acute rejection. y To treat certain post transplant viral infection.
y
y Chronic rejection
immediately in the operating room, when the graft becomes mottled and cyanotic. Causes: previous exposure to the donor antigens. As in: Previous rejected kidney transplant. Multiparous women. Previous blood transfusion. Prognosis: kidney removal
ACUTE REJECTION
Appears
months.
Affects
Decreasing urine output Hypertension, rising creatinine Mild leukocytosis Fever Graft swelling Pain Tenderness may be observed Final diagnosis depends upon a graft biopsy
ACUTE REJECTION
y Investigations
Radio isotope renography Ultra sound Urine culture and sensitivity Needle biopsy yTreatment: high dose pulses of glucocorticoids
Management
1.High dose corticosteroids.
Not enough
2.Repeated.
Not enough
3.Triple therapy.
a) b) c)
CHRONIC REJECTION
y Gradual decline
in renal function
chronic
Management
y y
Irreversible & cannot be prevented. Only treatment is a new transplant after 10 years
Occurs in first transplant week (0.5-8%). Causes oligo/anuria and ARF. With renal vein thrombosis, graft tenderness, dark Hematuria and decreased urine volume. Diagnosis is via doppler ultrasound or radioisotope scanning to demonstrate lack of blood flow. Treatment is surgery.
3.Peritransplant haematoma
Early post- op complication y Severe pain over allograft, decreased Hb or Hct, increased serum creatinine. y Recurrent increased K+ due to lysis of RBC in haematoma. y Diagnosis via USG or CT. y Treatment is surgical and usually leads to allograft nephrectomy.
y
4.Urinary Leak
y y
First transplant month. (2-5%) Patient presents with urine extravasation and ARF, fever, pain and distended abdomen.
Diagnosis is via ultrasound which demonstrates a peri-transplant fluid collection or via radioisotope scanning.
5.Lymphocoele
Occurs within the first 3 post transplant months and is due to lymph leaking from injured lymphatics (5-15%). y It causes:
y
Pain ARF Ipsi-lateral lower extremity oedema, Occasionally iliac vein thrombosis. Most of the signs and symptoms are due to pressure effects.
y y
6.Obstructive Uropathy y Occurs in early post transplant period (36%). y Causes are: extrinsic compression of the ureter by a lymphocoele a technical problem with the ureteric anastomosis to the bladder. y Diagnosis - ultrasound demonstrating hydronephrosis. y Treatment is surgical.
Late presentation. Patients present with uncontrolled HT, allograft dysfunction and peripheral oedema.
8.Post-transplant lymphoproliferative disorder. 9.Imbalances in electrolytes. 10. Infections and sepsis due to the immunosuppressant drugs that are required to decrease risk of rejection.
11. Malignancy
y
Transplant recipients are at significantly higher risk for cancers than the general population because of (1) Chronic Immunosuppression, (2) Chronic antigenic stimulation, (3) Increased susceptibility to oncogenic viral infections, and (4) Direct neoplastic action of immunosuppressants.
Immuno suppression
y
a glucocorticoid ; eg; prednisolone a calcineurine inhibitor ,e.g; cyclosporine, tacrolimus a purine antagonist, eg; azathioprine
Immunosuppressive medications
y
Eg: cyclosporine ,
MOA: formation of
respective cytoplasmic receptor proteins. This complex binds with calcineurin. Inhibition of calcineurin impairs the expression of several critical cytokine genes; eg:IL-2,IL-4, interferon and tumor necrosis factor
Drug is primarily excreted through bile. Drug level monitoring Drug interactions Drug concentration decreases with Rifampin, Barbiturates, phenytoin Drug concentration increases with Calcium channel blockers Antifungal agents
Side effects of cyclosporin Nephrotoxicity: decreased GFR Hypertension Hepatic dysfunction Hirsutism, hypertrichosis Hyperlipidaemia Hyperkalemia, hypomagnesemia Hyperuricemia Gum hypertrophy
Visual
Leukopenia
Immuno suppressive .
y
Mycophenolate mofetil action: inosine Reverse inhibitor of enzyme monophosphate dehydrogenase. Diarrhoea Vomiting leukopenia
Mechanism of x
Side effects x x x
Immuno suppressive
y
Azathioprine Inhibits both DNA & RNA synthesis and prevents growth of lymphocytes effects Neutropenia (main) Alopecia Muscular pains Malignancy Altered liver function Pancreatitis , cholestatic jaundice (rare)
Mechanism of action x
Side x x x x x x
Immuno suppressive
y
Prednisolone
Mechanism of action:
x Antiinflammatory responses with blocking of T cell and interleukin-1
Side effects:
x x x x x x Cushingoid appearance (facial swelling) Fluid retention Glaucoma Increased appetite, peptic ulcer Hypertension, increased blood sugar level Psychosis , mood swings
Immuno suppressive
y y x
Orthoclone(OKT3) monoclonal antibody Mechanism of action: React with CD-3 molecules on the lymphocytes and depletes them. Side effects: Chest pain Pulmonary edema Gastrointestinal disturbances Fever with Chills Dyspnoea Infections
y x x x x x x
Immuno suppressive..
Antilymphocyte globulin- polyclonal antibody
Mechanism of action:
Inhibits and destroy circulatory lymphocytes through antibody action
Side effects:
Rash Fever with chills Anaphylaxis Thrombocytopenia, leukopenia Myalgia
Nursing Management.
1. 2. 3. 4.
Assessing the patient for transplant rejection. Preventing infections Monitoring urinary functions Providing psychological support to the patient & family.
5. 6.
depressed
Close monitoring of respiratory status Assess respiratory pattern, auscultate for any crackles or abnormal respiratory sounds
Nursing management
Acute
Assess pain : patterns, any radiating pain Administer analgesics as prescribed Non pharmacological measures distraction , imagery, relaxation etc can be used to supplement medication.
Nursing management
Risk
for fluid and electrolyte imbalance related to the post operative condition Assess CVP and urinary output frequently Hourly intake equal to previous hours output plus 50ml Monitoring of serum biochemistry and hemoglobin frequently Oral fluids usually introduced in early post operative period as paralytic ileus is rare
Nursing management
y
Risk for rejection of graft Assessing the patient for transplantation rejection : oliguria, edema , fever, increase BP, weight gain, and swelling or tenderness over graft.
Those who receive cyclosporine the only sign may be asymptomatic rise of serum creatinine >20% is considered as acute rejection.
Nursing management
Potential for developing infection related to
the
Assess for Signs and symptoms of infection Protect patient from exposure to infection: careful hand hygiene& use of personal protective equipment Meticulous catheter care. Urine cultures, wound drainage culture, catheter tip culture etc.
Research input
Cytomegalovirus infection renal transplant recipients: risk factors and outcome. Kanter J, Pallard L, et al Transplant Proc. 2009 Jul-Aug;41(6):2156-8 Recipient age older than 55 years, induction therapy with Thymoglobulin, and maintenance immuno suppression with cyclosporine were the major risk factors to develop CMV disease. Data showed that CMV is a common complication after kidney transplantation associated with older age, induction treatment with antilymphocyte globulin, worse renal function, and increased patient morbidity.
Nursing management
Monitoring and managing potential complications
Assess for complications related to renal failure . Assess for GI ulceration& bleeding related to corticosteroid therapy
NURSING MANAGEMENT
Pre operative teaching include: Post operative pulmonary hygiene Pain management options Dietary restrictions Presence of indwelling catheters & IV &arterial lines Psychological concerns
Explain the patient need for life long follow up care. Individual verbal & written instructions to be provided to the patient concerning various aspects. Watch for malignancy as the patient is receiving long term immunosuppressive therapy.
Behaviour modification
Eating slowly Have regular meal patterns with frequent interval Dont skip breakfast. Last meal should be taken around 8.30pm Dont sleep immediately after taking meal Eat always in pleasant atmosphere. Eat always in sitting down position
Food hygiene
Raw vegetables should be washed properly
Dont cut vegetables until just before cooking Dont overcook vegetables Oil or ghee should not be reused Cook food hygienically and freshly prepared Dont eat uncooked foods and avoid eating out Take only boiled water.
In post-transplant patient
y y y y y
y y
Proteins: 1.3 to 2.0 g/kg body wt. Calories: 30- 35 kcal/kg Carbohydrates: 50% -70% of all calories. Fat: 35% of calories. Sodium: for normotensive= no restrictions otherwise, restricted to 2g/day. K+ : restricted in hyperkalemia Fluid: normo-volumic = 2000ml/day oliguric: urine output + ~500ml/day
Avoiding infection
Wash hands often Stay away from people with cold or other infections Screen visitors for infection Wash hands after coughing and sneezing. Avoid live vaccines such as polio, mumps.. Do proper dental care. Avoid contact with animals that roam outside
Clinic visits Upto 2 months : twice a week 3rd month : once a week
4months to 1 yr : twice a month More than 1 yr Lab tests Test for kidney function Test for blood count Test for liver function Blood glucose : atleast once in3months
Prognosis
y
The donor kidney's average life time is 10 to 15 years so it needs second transplantation or for some times dialysis again.
yReferences
Nicola Thomas ; Renal nursing ; Second edition, Page no:337-400 Walch, Retik vaughan and Wein; Campbells Urology; 8thedition; Page no: 345-373 Dr. Meenakshi Kamboj, Ms Shwetha Mattur, Dr. Sandeep Gularia; Living with a transplant. www.wikipedia.com