Download CARE OF THE KIDNEY TRANSPLANT RECIPIENT (Cadaveric and

CARE OF THE KIDNEY
TRANSPLANT RECIPIENT
(Cadaveric and Living Donor)
Kimberly Kenney
Nurse Clinician
November 12, 2009
OBJECTIVES

Upon completion of this lesson you will be able
to:







Identify leading causes of end stage renal disease
Describe expected physical findings in a stable postop kidney recipient
Identify problems with the foley catheter and
implement appropriate interventions
Administer correct I.V. fluids to replace urine output
Manage a hypertensive recipient
Identify signs and symptoms of post-op complications
State purpose and side effects of prograf and neoral
THE KIDNEY




Each processes 1700L of blood per day
Nephron is functional unit and has
glomerulus
Glomerulus is where materials are
selectively reabsorbed or filtered
Large blood flow needed for efficient GFR
FUNCTIONS OF THE KIDNEY







Regulate sodium and potassium
Regulate pH
Eliminate urea and uric acid
Eliminate certain drugs
Secrete renin
Erythropoietin production
Activate vitamin D
CREATININE




Reflects glomerular filtration rate and renal
function
Filtered in glomeruli, but NOT reabsorbed into
blood
If the creatinine doubles this indicates that the
kidney function is reduced in half
If the GFR is less than 5% then hemodialysis or
a kidney transplant is needed for survival
LEADING CAUSES OF END
STAGE RENAL DISEASE IN US
 Polycystic
kidney disease
 Glomerulonephritis
 Diabetes
 Hypertension
Polycystic Kidney Disease






Results from autosomal dominant inherited trait
Genetic mutation on chromosomes 4 & 16
Fluid filled cysts form on functioning nephrons
Tubular dilatation occurs
Kidneys become enlarged
Slow progressive renal failure
CLINICAL MANIFESTATIONS
AND DIAGNOSIS





Pain from enlarging cysts
Gross hematuria
Infected cysts from UTI
HTN from compression on vessels
Diagnose with CT scan, ultrasound,
genetic workup
GLOMERULONEPHRITIS




Inflammation of glomerulus
Can be primary condition
Can result from diabetes, lupus, viral
infection, staph, or streptococcus
Many cases have immune origin
GLOMERULONEPHRITIS

Nephritic Syndrome
Inflammatory process damages capillary
wall and decreases permeability
 RBCs in urine, decreased GFR,
nitrogenous waste in blood, oliguria,
water retention, HTN

Glomerulonephritis

Nephrotic Syndrome
Inflammatory process increases capillary
permeability
 Massive loss of protein and lipids in
urine
 Edema due to Na and H20 retention and
decreased albumin
 Dyspnea due to water retention

GLOMERULONEPHRITIS

Nephrotic Syndrome (cont.)
Infection due to loss of globulins
 Drug toxicity since binding proteins are
lost
 Thrombotic complications
 Atherosclerosis due to liver producing
lipoproteins

DIABETES






Glomerulus is commonly affected structure
Elevated glucose alters development of
glomerular membrane
Leads to thickening and sclerosing of glomerulus
Elevated glucose may increase capillary pressure
Large proteins escape
Tubules overworked and nephrons destroyed
HYPERTENSION




Cause and effect of kidney function
Sclerotic changes in glomerular structures
Vascular structures thicken and perfusion
decreases
Nephrons less able to concentrate urine
FACTORS CONSIDERED DURING
TRANSPLANT WORKUP








Basic lab work
ABO bloodtyping
Hepatitis and HIV screening
Cardiovascular workup
Psychiatric history
Metastatic history
Current infection
Drug abuse
THE TRANSPLANT PROCEDURE
ASSESSMENT






Dressing intact
Jackson-Pratt drain
Urine output at least 100 mL/hr
Urine bloody at first, but clears with
hydration
Look for any clots, complaints of feeling
full, sudden drop in urine output
***MD or NP ONLY ONES who flush
foley
FLUID REPLACEMENT
D5 ½ normal saline at 50 mL/hr for
maintenance
 Replace urine output mL per mL with
0.45% normal saline

BLOOD PRESSURE REGULATION







Too high: urine leak and bleeding
Too low: vascular thrombosis and ATN
Systolic should be 110-160
Consider pain management
Labetolol and hydralazine
Avoid ACE inhibitors
***Ca+ channel blockers increase
cyclosporine levels
OTHER POST-OP
CONSIDERATIONS
Wean for extubation
 Pulmonary toileting
 SCDs
 Labs
 Donor information kept confidential
 POU or Transplant ICU

POST-OPERATIVE
COMPLICATIONS

Bleeding
 Sanguinous drainage on dressing or in
JP
 Bloody urine continues despite
hydration
 Increasing abdominal pain
 Firm, distended abdomen
 Ultrasound ordered to rule out bleed
 Possible return to OR
POST-OPERATIVE
COMPLICATIONS

Urine Leak
 Increased yellow serous drainage in JP
or on dressing
 Check creatinine of JP drain
 Decreased urine output in foley bag
 Increased serum creatinine
 Ultrasound to rule out leak
 Possible return to OR
POST-OPERATIVE
COMPLICATIONS

Acute Tubular Necrosis (ATN)
Due to ischemic injury or preservation
injury
 Oliguric or anuric
 Urine appears very concentrated or
bloody
 Increased serum creatinine
 Days to weeks to resolve
 Hold prograf and neoral
 Hemodialysis

POST-OPERATIVE
COMPLICATIONS

Vascular Thrombosis
 Urine output suddenly drops
 Tenderness over graft site
 Increased serum creatinine
 Ultrasound done to view vessels
 Possible return to OR
POST-OPERTIVE COMPLICATIONS

Infection
 Post-op cephalosporin
 Check CMV status of patient before
giving blood
 Hand washing and being mindful of
environment
IMMUNOSUPPRESSION
 Prograf
OR Neoral (NOT BOTH)
 Simulect 20mg in OR
 Solumedrol 1000mg in OR
 Solumedrol taper post-op
Prograf (tacrolimus)/Neoral
(cyclopsporine)





Prevent rejection
Inhibit T-lymphocytes
Doses based on trough and renal function
Troughs drawn 6am and 6pm
Cardizem CD given with Neoral to
potentiate level
SIDE EFFECTS








***Hypomagnesmia***
Hyperkalemia
Hyperglycemia
Hypertension
Tremors
Nephrotoxicity
Neurotoxicity
dyslipidemia
QUESTIONS
????????
THANK YOU!!!!