CARE OF THE KIDNEY TRANSPLANT RECIPIENT (Cadaveric and Living Donor )

1. CARE OF THE KIDNEY TRANSPLANT RECIPIENT(Cadaveric and Living Donor) Kimberly Kenney Nurse Clinician November 12, 2009

2. 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 post-op 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

3. 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

4. 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

5. 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

6. LEADING CAUSES OF END STAGE RENAL DISEASE IN US • Polycystic kidney disease • Glomerulonephritis • Diabetes • Hypertension

7. 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

8. 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

9. GLOMERULONEPHRITIS • Inflammation of glomerulus • Can be primary condition • Can result from diabetes, lupus, viral infection, staph, or streptococcus • Many cases have immune origin

10. GLOMERULONEPHRITIS • Nephritic Syndrome • Inflammatory process damages capillary wall and decreases permeability • RBCs in urine, decreased GFR, nitrogenous waste in blood, oliguria, water retention, HTN

11. 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

12. 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

13. 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

14. HYPERTENSION • Cause and effect of kidney function • Sclerotic changes in glomerular structures • Vascular structures thicken and perfusion decreases • Nephrons less able to concentrate urine

15. FACTORS CONSIDERED DURING TRANSPLANT WORKUP • Basic lab work • ABO bloodtyping • Hepatitis and HIV screening • Cardiovascular workup • Psychiatric history • Metastatic history • Current infection • Drug abuse

16. THE TRANSPLANT PROCEDURE

17. 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

18. FLUID REPLACEMENT • D5 ½ normal saline at 50 mL/hr for maintenance • Replace urine output mL per mL with 0.45% normal saline

19. 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

20. OTHER POST-OP CONSIDERATIONS • Wean for extubation • Pulmonary toileting • SCDs • Labs • Donor information kept confidential • POU or Transplant ICU

21. 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

22. 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

23. 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

24. 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

25. POST-OPERTIVE COMPLICATIONS • Infection • Post-op cephalosporin • Check CMV status of patient before giving blood • Hand washing and being mindful of environment

26. IMMUNOSUPPRESSION • Prograf OR Neoral (NOT BOTH) • Simulect 20mg in OR • Solumedrol 1000mg in OR • Solumedrol taper post-op

27. 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

28. SIDE EFFECTS • ***Hypomagnesmia*** • Hyperkalemia • Hyperglycemia • Hypertension • Tremors • Nephrotoxicity • Neurotoxicity • dyslipidemia

29. QUESTIONS???????? THANK YOU!!!!