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CARE OF THE KIDNEY RECIPIENT PATIENT

CARE OF THE KIDNEY RECIPIENT PATIENT. Hany Elbarbary MD,MRCP Nephrology Lecturer. Preparation for Kidney Transplantation. Application phase Funding? Eligible for transplant evaluation? Evaluation phase Medical Psycho/Social Maintenance phase From listing … until transplant.

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CARE OF THE KIDNEY RECIPIENT PATIENT

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  1. CARE OF THE KIDNEY RECIPIENT PATIENT Hany Elbarbary MD,MRCP Nephrology Lecturer

  2. Preparation for Kidney Transplantation • Application phase • Funding? • Eligible for transplant evaluation? • Evaluation phase • Medical • Psycho/Social • Maintenance phase • From listing … until transplant

  3. Preparation for Kidney Transplantation • Application phase • Funding source covering transplant evaluation at transplant center of patient’s choice? • Kidney function declined enough to warrant transplant evaluation? • Private insurance • > 20 ml/min Creatinine clearance • Medicare/Medicaid • 20 ml/min or less Creatinine clearance • Transplant information & Health History review

  4. Preparation for Kidney Transplantation • Evaluation phase • Healthy enough for the surgery? • Cardiac, vascular, BMI, urological, etc. • Healthy enough for the medication afterwards, being immunosuppressed? • Infection, cancer, liver status • Can they cope with it? • Risk for surgical complications … • Risk for DM, side-effects of all medications … • Cost of medicines, clinic visits, hospital admissions … • Support available …

  5. Preparation for Kidney Transplantation • Maintenance phase • Keeping an eye on the patient while on the waiting list • Average waiting time for donor is 4-5 years, but can happen any time! • Regular evaluation can catch problems before they are called in for a kidney offer • Communication with the dialyses unit – essential!! • Placing patients “on hold” and “off hold”

  6. PREOPERATIVE CARE An organ donor has been located and tested….Happy News in Transplant Unit The organ bank enters the tissue typing of the donor into the UNOS Waiting List ... A list of potential recipients is compiled, ranked by a point system based on urgency, time, HLA matching, antibodylevels, age, and/or previous organ donation …

  7. IMMUNOLOGY AND GENETICS Tissue Typing … ? HLA matching … ? Antibody levels … ?

  8. IMMUNOLOGY AND GENETICS The Immune System Protects the body from invasion by foreign substances; bacteria, virus, even a transplant • Antigens – substance on all living cells, cell markers, able to initiate immune response • Antibody – immunoglobulin that attach to foreign antigens, aids in the destruction • Leucocytes – White Blood Cells • Nonspecific/inflammatory response by granulocytes and monocytes • Specific response/acquired immunity by B and T lymphocytes, very important in transplantation

  9. IMMUNOLOGY AND GENETICS Acquired Immunity • B Lymphocytes – Humoral Immunity • Foreign antigen found • B cells activated, start making plasma cells • Plasma cells makes specific antibodies until the antigen is destroyed (IgM) • Macrophages and “helper” T-cells help in stimulation of antibody production • Memory B cells remains as part of the immune system for a faster secondary response to that specific antigen (IgG)

  10. IMMUNOLOGY AND GENETICS Acquired Immunity • T Lymphocytes – Cellular Immunity • Differentiate self through expression of antigen receptors • Provide immunity against viruses, fungi, TB, cancer, and TRANSPLANTS • Killer T cells (CD8) – kill directly or through lymphokines (interferon and interleukins) • Helper T cells (CD4) - assists B cells in antibody production, produce lymphokines • Memory T cells – for a faster second response • Suppressor cells – inhibit B cells and killer T cells

  11. IMMUNOLOGY AND GENETICS Histocompatibility • Two antigen system impacting transplants • ABO - A and B antigens on red blood cells • Safe transplant follows blood transfusion rules • HLA - Human Leukocyte Antigens • Group of genes on Chromosome 6 that are involved in immune response • 4 gene sites important Class I - A, B, (C) Class II – DR, (DQ, DP) • This gene grouping, haplotype, is inherited, one from the mother, one from the father • Perfect match – 2 haplotypes, “0 mismatch”, or “6 out of 6” match

  12. IMMUNOLOGY AND GENETICS HLA Matching: Mom A 2, 5 B 5, 15 DR 15, 17 3/6 Dad A 1, 30 B 75, 21 DR 1, 7 3/6 #1 A 2, 1 B 5, 75 DR 15, 1 self #2 A 5, 30 B 15, 21 DR 17, 7 0/0 #3 A 2, 30 B 5, 21 DR 15, 7 3/6 #4 A 5, 1 B 15, 75 DR 17, 1 3/6 #5 A 2, 1 B 5, 75 DR 15, 1 6/6

  13. IMMUNOLOGY AND GENETICS Tissue Typing … Finding out a person’s HLA antigens - A ?,?, B ?,?, DR ?,? HLA matching … Compare the HLA with the potential donor’s HLA antigens to get the match or mismatch – in haplotype, or 0-6/6 Antibody levels … How many antibodies towards other people’s antigens they have – measured as a % of common antigens in the Panel-Reactive Antibody test (PRA)

  14. PREOPERATIVE CARE Organ bank call out the organ offer Surgeon on call accepts or decline the offer Locate the patient within 1 hour of the call from the organ bank interview with the patient to determine current status and contraindications for transplantation Plan NPO to start 6-8 hours before estimated time of surgery

  15. PREOPERATIVE CARE After patient has arrived at the hospital – medical clearance and preparation for transplant have to be done quickly to keep the cold ischemia time as short as possible • Infections? • Cancer? • Cardiovascular problems? • Compatible donor kidney?

  16. PREOPERATIVE CARE • History & physical, chart review • Laboratory testing: • Hematology • Chemistries • Urine cultures • Final cross match • Type & Cross for 2 units PRBC

  17. PREOPERATIVE CARE • Chest X-ray • ECG • Vital signs • Pre op dialysis as needed • Weight after dialysis • Pre and post operative teaching for patient and family • Shower, skin preparation, and access care

  18. PREOPERATIVE CARE • Signed OR consent form and final cross match report on the chart • Placement of IV lines • Placement of Foley catheter • Preop immunosuppressive medication? • Preop antibiotics? • Calcium channel blocker (Verapamil)?

  19. POSTOPERATIVE CARE AFTER THE SURGERY • Circulatory and pulmonary functions • Fluid and electrolyte balance • Administer pain control as needed • Immunosuppressive regimen - provide and monitor for side effects • Psychosocial management of the recipient and the family

  20. POSTOPERATIVE CARE MAINTAIN CIRCULATORY FUNCTION • Frequent monitoring of vital signs blood pressure, pulse, respirations, central venous pressure • Monitor pulses femoral, popliteal, pedal • Monitor cardiac status • Early ambulation is strongly encouraged

  21. POSTOPERATIVE CARE MAINTAIN PULMONARY FUNCTION • Humidified oxygen if indicated • cough, and deep breath R Ex • Encourage ambulation • Monitor temperature

  22. POSTOPERATIVE CARE MAINTAIN FLUID AND ELECTROLYTE BALANCE • Monitor fluid intake and output • Daily weight • Fluid replacement per protocol • Daily laboratory testing • Monitor vital signs frequently

  23. POSTOPERATIVE CARE Physical assessment of fluid imbalance • Hypotension/Hypertension • Dry mucus membranes • Poor skin turgor • Concentrated urine • Shortness of breath • Presence of edema

  24. POSTOPERATIVE CARE MONITOR FOR COMPLICATIONS • Infection • ATN • Rejection • Renal artery stenosis • Renal artery thrombosis • Renal vein thrombosis • Urologiccomplication • Graft rupture • Wound complications

  25. POSTOPERATIVE CARE PREVENTION OF INFECTION • Careful hand washing • Adequate nutrition for wound healing • Meticulous pulmonary toilet • Encourage good oral and skin hygiene • Isolate patients with leukopenia • Assess patients for signs and symptoms of infection • Administer antiviral and antibiotics as prescribed

  26. POSTOPERATIVE CARE ACUTE TUBULAR NECROSIS ( ATN ) Etiology • Prolonged cold ischemia time • Prolonged warm ischemia time • Severe rejection episode Symptoms • Decreased urine output • Elevated BUN and Creatinine • Often high output ATN - high urine volume with low clearance

  27. POSTOPERATIVE CARE Treatment for ATN • Alteration of diet Decreased protein intake Decrease fluid intake • Manage hyperkalemia • Dialysis as indicated • Patience …

  28. POSTOPERATIVE CARE RENAL ARTERY STENOSIS • Bruit over graft site is diagnostic evidence - confirmed by arteriography • Results in hypo perfusion of the kidney which then produces more rennin to compensate causing hypertension • Symptoms - hypertension and renal dysfunction • Treatment – antihypertensive therapy, surgical repair or balloon angioplasty

  29. POSTOPERATIVE CARE RENAL ARTERY THROMBOSIS • Uncommon - usually occurs in early post transplant period • Requires early detection for treatment to be effective • Signs and symptoms – sudden anuria and graft tenderness

  30. POSTOPERATIVE CARE RENAL VEIN THROMBOSIS • Symptoms swelling of the graft, thigh, and leg decreased urine output, proteinuria, and hematuria • Treatment anticoagulation therapy • May require nephrectomy

  31. POSTOPERATIVE CARE GRAFT RUPTURE • Signs and symptoms swollen and painful graft, hematuria • Usually caused by the swelling of the graft during a severe rejection episode • Surgical repair or graft nephrectomy is always required

  32. POSTOPERATIVE CARE UROLOGIC COMPLICATIONS • Urine leak results from ureteral leakage, ureteral disruption, or leak from the bladder. • Related to poor tissue healing, ureteral stenosis, or poor vascularity with tissue necrosis

  33. POSTOPERATIVE CARE WOUND COMPLICATIONS • Perinephric hematomas, urinomas, lymphoceles, and abscesses can exert pressure on the kidney or ureters resulting in deterioration of renal function • Wound infection • Signs and symptoms: Swelling and tenderness over the graft, fever, and possible wound drainage

  34. POSTOPERATIVE CARE TEACHING AND DISCHARGE PLANNING • General post-op care • Medications • Signs of rejection • Record keeping • Prevention of infection • Whom to call • Where to go in case of an emergency

  35. POSTOPERATIVE CARE • Schedule post-op visits with the referring physician and/or clinic • Be sure patient has a month’s supply of all necessary medications

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