CKD/ESRD
&
Transplant
Note-when viewing lab values in PPT-note that
values are given as both as “common values” as
also the specific values given in textbook
(remember, sources vary slightly-think
ranges.)2010
Bones can break, muscles can atrophy,
glands can loaf, even the brain can go to
sleep without immediate danger to
survival. But -- should kidneys fail....
neither bone, muscle, nor brain could
carry on.
Homer Smith, Ph.D.
2
REVIEW

Recall functions of the kidneys?

Recall normal creatinine & BUN; other lab
tests?

Review Diagnostic Tools
CKD- Elderly Risk (Review)
•Older Adult-normal aging (plus co-morbidities) > risk kidney dysfunction/renal failure
•Must:
•Identify/prevent damage
•Monitor/risk multiple RX/OTC meds (altered renal blood flow/dec. renal
clearance etc)
•Monitor/risk associated with dehydration (ie diuretics)
•Monitor/risk with dec ability to respond to changes to fluid/electrolyte
status (manifestation may be atypical
Functions of the Kidneys



Regulates volume and
composition of
extracellular fluid
Excretion of nitrogenous
waste products
BP control via reninangiotensin-aldosterone
system- Recall RAAS




Vitamin D activation
Acid-base balance
(HCO3 & H) regulation
through process of
_____, ____ and
______. filtration, secretion,
reabsorpton
Prostaglandin synthesis
Erythropoietin
production
Functions of the Kidneys
(cont)

Erythropoietin Release
If a patient has chronic renal failure, what
condition will occur?
 WHY???

EPO- glycoprotein hormone that controls
erythropoiesis, or red blood cell production
3/23/2016
6
Diagnostic Tools for
Assessing Renal Failure


Blood Tests
 BUN elevated (norm 10-20 mg/dl) (text 10-30mg/dl)
 Creatinine elevated (norm 0.6 - 1.2 mg/dl) (text 0.51.5mg/dl)
 K elevated (text norm 3.5-5.0 mEq/L)
 PO4 elevated (text norm 2.8-4.5mg/dl)
 Ca decreased (text norm 9-11mg/dl)
Urinalysis
 Specific gravity (text norm 1.003-1.030
 Protein (text norm 0-trace)
 Creatinine clearance (text norm 85-135ml/min)
7
BUN



Normal 8 - 20 mg/dl (text 10-30mg/dl)
Nitrogenous waste product of protein
metabolism
Unreliable in measurement of renal function

Relevance assessed in conjunction with serum
creatinine
8
Creatinine






A waste product of muscle metabolism
Normal value 0.6 - 1.2 mg/dl (text 0.51.5mg/dl)
2 times normal = 50% damage
8 times normal = 75% damage
10 times normal = 90% damage
Exception - severe muscular disease can greatly 
serum creatinine levels
9
Diagnostic Tools



Ultrasound
X-Rays
Biopsy *most definitive
10
Chronic Renal Failure/
Chronic Kidney Disease (CKD)

Slow progressive renal disorder related to
nephron loss, occurring over months to years

Culminates in End Stage Renal Disease (ESRD)
11
Characteristics of CKD > ESRD





Cause & onset often unknown
Loss of function precedes lab abnormalities
Lab abnormalities precede symptoms
Symptoms (usually) evolve in orderly sequence
Renal size is usually decreased
12
Causes of CKD






*Diabetes
*Hypertension
Glomerulonephritis
Cystic disorders
Developmental Congenital
Infectious Disease
•Neoplasms
•Obstructive disorders
•Autoimmune diseases
(lupus)
•Hepatorenal failure
•Scleroderma
•Amyloidosis
•Drug toxicity-(overuse some
common drugs, as aspirin, NSAID as
ibuprofen, cocaine and
acetaminophen)
NSAIDs-…cause prerenal ARF by blocking prostaglandin production > also alters
local glomerular arteriolar perfusion… (reduces renal blood flow)
13
Glomerular Filtration Rate (GFR)-determine stage
CKD (most accurate evaluation)





24 hour urine for creatinine clearance
Formula- urine creatinine X urine volume
serum creatinine
Can estimate creatinine clearance by:
140 – {age x weight (kg)}
72 x serum creatinine
What is normal GFR?
90 - 120 mL/min
14
Stages of CKD
NKF Classification System
Stage 1:
Stage 2:
GFR > 90 ml/min despite kidney
damage
Mild reduction (GFR 60 – 89
ml/min)
1. GFR of 60 may represent 50%
loss in function.
2. Parathyroid hormones starts to
increase. (why?)
*kidneys unable to reabsorb calcium, blood calcium levels fall, stimulating
continual secretion of parathyroid hormone to maintain normal calcium
levels in blood.
15
During Stage 1 - 2

No symptoms

Serum creatinine doubles*
(Up to 50% nephron loss

FYI-older adult- may
impaired renal function even in
presence of normal serum
creatinine
16
Stages of CKD
NKF Classification System
Stage 3: Moderate reduction (GFR 30 – 59
ml/min)
1. Calcium absorption decreases
(from the GI tract)
2. Malnutrition onset
3. Anemia
4. Left ventricular hypertrophy
17
Stages of CKD
NKF Classification System
Stage 4:
Oopstrouble!
Severe reduction (GFR 15 – 29
ml/min)
1. Serum triglycerides
2. Hyperphosphatemia
3. Metabolic acidosis
4. Hyperkalemia
K Effect & EKG
18
During Stage 3 - 4





Signs and symptoms worsen if kidneys stressed
ability to maintain homeostasis
75% nephron loss
glomerular filtration rate, solute clearance,
ability to concentrate urine and secrete hormone
Symptoms: BUN & Creatinine, mild
azotemia, anemia
19
Stages of CKD-NKF Classification System
Stage 5: Kidney failure (GFR < 15 ml/min) ESRD!!!
 Azotemia
 Residual function < 15% of normal
 Excretory, regulatory, hormonal functions
severely impaired
 Metabolic acidosis (Kussmaul breathing)
 Marked
: BUN, Creatinine, Phosphorous
 Marked : Hemoglobin, Hematocrit, Calcium
 Fluid overload
20
During Stage 5

Uremic syndrome develops- affecting all body
systems



can be diminished with early diagnosis & treatment
Last stage of progressive CKD
Fatal if no treatment
21
Manifestations of Chronic Uremia
Syndromecombination
of common
symptoms
*greater
build-up
waste
products =
greater
symptoms
Fig. 47-5
22
What happens when kidneys
don’t function correctly?
23
Manifestations of CKD Nervous System





Mood swings
Impaired judgment
Inability to concentrate and perform simple math
functions
Tremors, twitching, convulsions
Peripheral Neuropathy
 restless legs
 foot drop
Manifestations due to inc nitrogenous waste products, electrolyte imbalances, metabolic
acidosis and axonal atrophy and demyelination of nerve fibers & dec erythropoietin*
24
Manifestations of CRF
Skin





Pale, grayish-bronze color
Dry scaly
Severe itching
Bruise easily, petechiae, ecchymosis
*Uremic frost
*Manifestations due to…calcium-phosphate deposition in skin, sensory
neuropathy, platelet abnormalities; urea crystallizes (uremic frost) >if
BUN extremely high
25
Medical Mystery?
What do lab studies, etc indicate ? What causes uremic frost?
*57-year-old with HTN and CKD (Stage 5), refused dialysis found in respiratory distress after week of
upper respiratory symptoms due to viral infection
Before admission to hospital >developed asystolic cardiac arrest, was resuscitated by EMT, admitted to ICU,
required vasopressor support.
PE- diffuse deposits tiny white crystalline material on skin > lab studies- BUN 208 mg/dl; creatinine 15 mg/dl;
bicarbonate level 5 mmol per liter; anion gap-26; arterial pH of 6.74, and arterial partial pressure of carbon
dioxide of 50 mm Hg. Blood cultures- revealed-Staphylococcus aureus pneumonia, likely due to prior
Walsh S and Parada N. N Engl J Med 2005;352:e13
influenza infection. *Aggressive care measures withdrawn after consultation with patient's family >patient
died.
*Uremic frost- uncommon skin manifestation due to profound azotemia;
occurs when urea and other nitrogenous waste products accumulate in sweat
and crystallize after evaporation.
Manifestations of CKD
Eyes



Visual blurring
Occasional blindness
“Red eye”
Due to calcium-phosphate
deposits in eyes
27
Manifestations of CKD
Fluid - Electrolyte - pH



Volume expansion and fluid overload
Due to impaired kidneys unable to excrete acid load (mostly
Metabolic Acidosis from NH3); defective reabsorption/regeneration of HCO3.
Electrolyte Imbalances
Potassium
 Magnesium


Sodium
Due to dec excretion by kidneys, breakdown of cellular
protein, bleeding, metabolic acidosis, food, drugs, etc
Kidneys unable to excrete (too much magnesium
causes hyporeflexia and can lead to cardiac arrest)
Kidneys retain > water retention> fluid overload
28
Manifestations of CKD
GI Tract/Bleeding Risk





Uremic fetor
Anorexia, nausea, vomiting
GI bleeding Due to GI irritation, platelet defect; diarrhea from hyperkalemia
Anemia
Platelet dysfunction
Anemia-due to insufficient production of erythropoietin, protein
naturally produced in functioning kidneys…circulates through
bloodstream to bone marrow, stimulating production of RBCs.
Platelet dysfunction-subnormal platelet aggregation -due to fibrinogen fragments,
usually absent in normal human blood but present in uremic plasma may lead to
platelet dysfunction in uremia.
29
Manifestations of CKD-Musculoskeletal





Muscle cramps
Soft tissue calcifications
Weakness
Related to calcium phosphorous imbalances
RENAL OSTEODYSTROPHY

Fracture risk!
30
Manifestations of CKD- Heart & Lungs







Hypertension
Heart failure > pulmonary edema
Pericarditis due to uremia
Pulmonary edema
Pleural effusions- “Uremic Lung”
Atherosclerotic vascular disease*
Cardiac dysrhythmias (from HF, electrolyte imblaances)
*Major Problem!
31
Manifestations of CKD- Endocrine Metabolic







Erythropoietin
Hypothyroidism
Insulin resistance
Growth hormone
Gonadal dysfunction
Parathyroid hormone
Hyperlipidemia
and Vitamin D3
32
Treatment Options

Conservative Therapy * (Severe restrictions, dietary, fluids
maintain renal function as long as possible- if GFR > 10ml/min)

Hemodialysis
Peritoneal Dialysis
Transplant

Nothing > Death


33
Conservative Treatment
Goals





Detect/treat potentially reversible causes of
renal failure
Preserve existing renal function
Treat manifestations
Prevent complications
Provide for comfort
34
Conservative Treatment

Control
Hyperkalemia
 Hypertension
 Hyperphosphatemia
 Hyperparthryoidism
 Anemia
 Hyperglycemia
 Dyslipidemia
 Hypothyroidism
 Nutrition : Describe a renal diet?

Depends on lab values-usually low
NA, K, restricted protein,
phosphorous, & fluids (See text)
35
Hemodialysis

Removal of soluble substances and water from the blood by
diffusion through a semi-permeable membrane.

Early animal experiments began 1913
1st human dialysis 1940’s by Dutch physician Willem Kolff (2 of
17 patients survived)
Considered experimental through 1950’s, No intermittent blood
access; for acute renal failure only.
1960 Dr. Scribner developed Scribner Shunt-1960’s machines
expensive, scarce, no funding.
“Death Panels” panels within community decided who got to
dialyze.




36
Hemodialysis Process



Blood removed from patient into extracorporeal
circuit.
Diffusion and ultrafiltration take place in
dialyzer.
Cleaned blood returned to patient.
37
Extracorporeal Circuit
38
How Hemodialysis Works
39
.
How Dialysis Works-Interactive!
An Introduction to Dialysis-How
Stuff Works! (Step by Step)
YouTube- Hemodialysis! Great!
Vascular Access (click)


Arterio-venous shunt (External Shunt) *used
now for Continuous Renal Replacement
Therapy (CRRT)-temporary access
Arterio-venous (AV) Fistula (AKA-native or primary
fistula)



PTFE Graft
Temporary catheters
“Permanent” catheters
41
External Shunt (Schribner Shunt)


External- one end into
artery, one into vein.
Advantages



place at bedside
use immediately
Disadvantages





infection
skin erosion
accidental separation
limits use of extremity
*Used now only for
CRRT-temporary
42
Arterio-venous (AV) Fistula
Primary (native) Fistula



Patients own artery and vein surgically anastomosed.
Advantages
 patient’s own vein/artery
 longevity
 low infection and thrombosis rates
Disadvantages
 long time to mature, 1- 6 months
 “steal” syndrome
 requires needle sticks
davita.com
43
PTFE (Polytetraflourethylene) Graft



Synthetic “vessel” anastomosed into an artery and vein.
Advantages
 for people with inadequate vessels
 can be used in 1-4 weeks
 prominent vessels
Disadvantages
 clots easily
 “steal” syndrome more frequent
 requires needle sticks
 infection may necessitate removal of graft
44
Temporary Catheters



Dual lumen catheter placed into a central veinsubclavian, jugular or femoral.
Advantages
 immediate use
 no needle sticks
Disadvantages
 high incidence of infection
 subclavian vein stenosis
 poor flow-inadequate dialysis
 clotting
 Restricts movement
45
Cuffed Tunneled Catheters (Dacron cuff)



Dual lumen catheter with Dacron cuff
surgically tunneled into subclavian,
jugular or femoral vein.
Advantages
 immediate use; *permanent/long
term use
 can be used for patients that can have
No other permanent access
 no needle sticks
Disadvantages
 high incidence of infection
 poor flows result in inadequate
dialysis
 clotting
46
Above Native fistula (in place for over 20 years)
*Remember- assess circulation-listen for bruit,
feel for thrill!
Buttonhole technique-individual cannulates
own fistula for home dialysis YouTube video
“Temporary” vascular access catheters- if tunnelled,
with Dacron cuff, can be used long-term as Permacath,
below.
Care of Vascular Access




NO BP’s, needle sticks to arm with vascular access.
This includes finger sticks.
Place ID bands on other arm whenever possible.
Palpate thrill and listen for bruit.
Teach patient nothing constrictive, feel for
thrill.
48
Potential
Complications of Hemodialysis

During dialysis
 Fluid and electrolyte related



Cardiovascular
 arrhythmias
Associated with the extracorporeal circuit


Disequilibrium Syndrome & seizures
Musculoskeletal


exsanguination
Neurologic


hypotension
cramping
Other
 fever & sepsis

blood born diseases
49
Potential Complications of Hemodialysis

Between treatments
Long term (due to disease process &
management)
•Metabolic
Hypertension/Hypotension
•Hyperparathyroidism
 Edema
•Diabetic complications
 Pulmonary edema
•Cardiovascular
 Hyperkalemia
CHF
 Bleeding
AV access failure
 Clotting of access
Cardiovascular disease
•Respiratory
Pulmonary edema
•Neuromuscular
Neuropathy

50
Complications Hemodialysis- con’t-long term, ESRD

Long term cont’d

Hematologic


GI


bleeding
dermatologic


anemia
calcium
phosphorous
deposits
Long term cont’d
•Genitourinary
•infection
•Sexual dysfunction
•Psychiatric
•depression
•Infection
•blood borne
pathogens
Rheumatologic

amyloid deposits
51
Dietary Restrictions-Hemodialysis





Fluid restrictions Urine output + 600 ml
Phosphorous restrictions Approx 800-1200 mg/day
Potassium restrictions Approx 1-2 g/day; 40 mg/kg/IBW
Approx 1-2 g/day
Sodium restrictions
Protein to maintain nitrogen balance (complete)
too high - waste products
 too low - decreased albumin, increased mortality


Calories to maintain or reach ideal weight
52
Peritoneal Dialysis

1.
2.
3.
Removal of soluble substances and water from blood by diffusion through a
semi-permeable membrane (peritoneum) that is intracorporeal (inside
body).
 Solution warm to body temperature prior to instillation into
peritoneal cavity via peritoneal catheter
 Metabolic waste products and excessive electrolytes diffuse into
dialysate while it remains in abdomen
 Fluid removal controlled by glucose (dextrose) concentration in
dialysate (acts as “osmotic” agent)
 Excess fluid/solutes removed- gradual/constant Fluid drained by gravity into sterile bag at set intervals“Clear” solution ‘fills” abdomen
“Yellow” urine-like fluid drains out (like urine, clear)
Types of Peritoneal Dialysis
1.
*CAPD: Continuous ambulatory peritoneal dialysis
2.
*APD – Automated Peritoneal Dialysis
53
Phases of Peritoneal
Dialysis Exchange
1. Fill (inflow): fluid infused into
peritoneal cavity (usually 10-15
min).
2. Dwell time (equilibrium):
time solution (dialysate) fluid
remains in peritoneal cavity
(duration depends on method- as
CAPD 4-5 exchanges/day).
3. Drain (equilibrium): time
fluid drains from peritoneal cavity
by gravity flow (usually 20-30
min); facilitate by gently
massaging abdomen, changing
position.
CAPD
54
CAPD





APD

Catheter into peritoneal cavity
Exchanges 4 - 5 times per day
Treatment 24 hrs; 7 days a week
Solution remains in peritoneal cavity
except during drain time
Independent treatment

Click to play animation
Videos-Dialysis, all types!
Click to locate desired video
Automated Peritoneal Dialysisfluid exchanges automatically
by machine-(also known as
continuous cycling peritoneal
dialysis (CCPD), requires
“cycler machine”programmable- to automate
filling and draining process.
Treatment at home, typically at
night (while sleeping-thus no
fluid in “the belly” at daytime
Complications of Peritoneal Dialysis





Infection
 peritonitis
 tunnel infections
 catheter exit site
Hypervolemia
 hypertension
 pulmonary edema
Hypovolemia
 hypotension
Hyperglycemia
Malnutrition






Obesity
Hypokalemia
Hernia
Cuff erosion
Low back pain
Hyperlipidemia
Peritoneal Catheter Exit Site
57
Advantages of PD





Independence for patient
No needle sticks
Better blood pressure control
Some diabetics add insulin to solution
Fewer dietary restrictions
protein loses in dialysate
 generally need increased potassium
 less fluid restrictions

58
Multi-prong system
occasionally used
with PD patients in
hospital settings
Which dialysis
“bags” have already
been infused?
The “yellow”
ones!- dialysis
nurse sets up
bags, staff nurse
infuses, drains
according to
schedule.
59
Medications - Dialysis Patients & CKD (Stages 4-5)








Vitamins - water soluble
Phosphate binder - (Phoslo, Renagel, Calcium,
*Aluminum hydroxide-risks) Give with meals
Iron - don’t give with phosphate binder or calcium
Antihypertensives – typically hold prior to dialysis
Erythropoietin
Calcium Supplements - Between meals, not with iron
Activated Vitamin D3 - aids in calcium absorption
Antibiotics - hold dose prior to dialysis if it dialyzes out
61
Medications



Many drugs or their metabolites are
excreted by the kidney
Dosages - many change when used in
renal failure patients
Dialyzability - many removed by dialysis
varies between HD and PD
62
Patient
Education






Alleviate fear
Dialysis process
Fistula/catheter care
Diet and fluid restrictions
Medication
Diabetic teaching
63
Case Study
A 48 year old female with a history of uncontrolled
diabetes presents to the ER. Her chief complaints are
nausea, vomiting and fatigue.
Lab: BUN 100; Creatinine 10; H&H 7.0/21.4;
K+ 6.0, PO4 5.5; Ca++ 7.5
What do you suspect? How would she possibly be
treated?
*Access Evolve Apply Case Study- Chronic Renal Failure
*Access Renal Case Study
64
Case Study


35-year-old man began to notice
weakness with activities such as walking
distances or running.
Also began experiencing tingling all over
his body, particularly in his hands and feet
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
65
Case Study: History

At age 11, he was admitted to the same
hospital with gross hematuria.
Albuminuria 4+
 BUN 10.5 mg/dL
 Hb 15.7 g/dL
 Diagnosed with recurring acute
glomerulonephritis

Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
66
Case Study

He had no follow-up medical care after
that hospitalization until his current
admission to the hospital.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
67
Case Study

Current lab values
Potassium 6.0 mEq/L
 BUN 110 mg/dL
 Creatinine 12 mg/dL
 Hct 20%
 Hb 6 g/dL

Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
68
Discussion Questions
1.
Why would his symptoms seem similar to
diabetes?
2.
Why is he developing chronic renal failure
so many years after his primary
diagnosis?
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
69
Kidney Transplant

Treatment not cure
View also Organ Donation video
70
Kidney Transplant
•More than 75,000
patients currently awaiting
kidney transplants.
•Less than ¼ ever receive
a kidney
•Extremely successful
1-year graft survival rate
•90% cadaver transplants
•95% live donor transplants
Kidney awaiting
“owner!”
71
Advantages





Restoration of “normal”
renal function
Freedom from dialysis
Return to “normal” life
Reverses pathophysiological
changes related to RF
Less expensive than dialysis
after 1st year
Disadvantages





Life long medications
Multiple side effects
from medication
Increased risk of tumor
Increased risk infection
Major surgery
Kidney Transplantation
Recipient Selection

Candidacy determined by a variety of medical and
psychosocial factors that vary among transplant centers.
•Contraindications to transplantation
Disseminated malignancies
Untreated cardiac disease
Chronic respiratory failure
Extensive vascular disease
Chronic infection
Unresolved psychosocial disorders
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
73
Kidney Transplantation
Histocompatibility Studies Donor Sources

Purpose of testing is to identify the HLA antigens
for both donors and potential recipients.
Donor Sources
•Compatible blood type deceased donors
•Blood relatives
•Emotionally related living donors
•Altruistic living donors
•Paired organ donation
74
Kidney Transplantation
Nursing Management

Preoperative care
Emotional and physical preparation
 Immunosuppressive drugs
 ECG
 Chest x-ray
 Laboratory studies

Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
75
Kidney Transplantation
Surgical Procedure

Live donor
 Nephrectomy performed by urologist or transplant
surgeon
 Begins an hour or two before recipient’s surgery started
 Rib may need to be removed for adequate view
 Takes about 3 hours
 Laparoscopic donor nephrectomy
 Alternative to conventional nephrectomy
 Most common approach of live kidney procurement
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
76
Kidney Transplantation
Surgical Procedure

Kidney transplant recipient
 Usually placed extraperitoneally in the iliac fossa
 Right iliac fossa is preferred.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
77
Care of Recipient





Major surgery with general anesthesia
Assessment of renal function
Assessment of fluid and electrolyte
balance
Prevention of infection
Prevention and management of rejection
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Kidney Transplantation
Surgical Procedure
Kidney transplant recipient
 Before incision
 Urinary catheter placed into bladder
 Antibiotic solution instilled
 Distends bladder
 Decreases risk of infection
 Crescent-shaped incision
•Rapid revascularization critical
•Donor artery anastomosed to recipient internal/external
iliac artery
•Donor vein anastomosed to recipient external iliac vein
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
79
Kidney Transplantation
Surgical Procedure
Kidney transplant recipient
 When anastomoses complete,
clamps released -blood flow reestablished
 Urine may begin to flow, or diuretic may be given.
 Surgery takes 3 to 4 hours.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
80
Kidney Transplantation
Nursing Management

Postoperative care
 Live donor
 Care is similar to laparoscopic nephrectomy.
 Close monitoring of renal function
 Close monitoring of hematocrit

Recipient
 Maintenance of fluid and electrolyte balance-first priority.
 Large volumes of urine soon after transplanted kidney placed
due to
 New kidney’s ability to filter BUN
 Abundance of fluids during operation
 Initial renal tubular dysfunction
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Kidney Transplantation
Nursing Management

Postoperative care (cont’d)
 Recipient
 Urine output replaced with fluids milliliter by milliliter
hourly
 Urine output closely measured
 Acute tubular necrosis can occur.
 May need dialysis
 Maintain catheter patency.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
82
Post-op Care- cont

ATN? (acute tubular necrosis)







50% experience
Urine output >100 <500 cc/hr
BUN, creatinine, creatinine clearance
Fluid Balance-careful monitor
Ultrasound
Renal scans
Renal biopsy
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Kidney Transplantation
Immunosuppressive Therapy

Goals
 Adequately suppress immune response.
 Maintain sufficient immunity to prevent overwhelming
infection.
•Major complication of transplantation due to immunosuppression
HANDWASHING key
•Avoid Crowds, Kids
•Patient Education
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Complications-Rejection



Hyperacute - preformed antibodies to donor antigen
 function ceases within 24 hours
 Rx = removal
Acute - generally after 1st 10 days to end of 2nd month
 50% experience
 differentiate between rejection and cyclosporine
toxicity
 Rx = steroids, monoclonal (OKT3), or polyclonal
(HTG) antibodies
Chronic - gradual process of graft dysfunction
 Repeat rejection episodes- not completely resolved
with treatment
 4 months to years after transplant
 Rx = return to dialysis or re-transplantation
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Immunosuppressant Drugs


CorticosteroidsPrednisone
 Prevents infiltration of
T lymphocytes
Side effects
 cushingnoid changes
 Avascular Necrosis
 GI disturbances
 Diabetes
 infection
 risk of tumor


Cytoxic Agents-Azathioprine
(Imuran); Mycophenolate
(*Cellcept), *Cytoxin (less toxic
than Imuran)
 Prevents rapid growing
lymphocytes
Side Effects
 bone marrow toxicity
 hepatotoxicity
 hair loss
 infection
 risk of tumor
Immunosuppressant Drugs

Calcineuin InhibitorsCyclosporin, Neoral,
*Prograft, *FK506 (more
potent than cyclosporin)


Interferes with production of
interleukin 2 which is necessary
for growth and activation of T
lymphocytes.
Side Effects
– Nephrotoxicity
– HTN
– Hepatotoxicity
– Gingival hyperplasia
– Infection

Monoclonal antibodyOKT3 - used to treat
rejection/induce
immunosuppression



decreases CD3 cells within 1
hour
Side effects
 anaphylaxis
 fever/chills
 pulmonary edema
 risk of infection
 tumors
1st dose reaction expected
& wanted, pre-treat with
Benadryl, Tylenol, Solumedrol
Immunosuppressant Drugs cont’d


Polyclonal antibody-Atgam-treat rejection or induce
immunosuppression
 decreased number of T lymphocytes
Side effects
 anaphylaxis
 fever chills
 leukopenia
 thrombocytopenia
 risk of infection
 tumor
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Kidney Transplantation
Complications

Infection



Most common infections observed in the first month
 Pneumonia
 Wound infections
 IV line and drain infections
Fungal infections
 Candida
 Cryptococcus
 Aspergillus
 Pneumocystis jiroveci
Viral infections
 CMV
 One of the most common
 Epstein-Barr virus
 Herpes simplex virus
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
89
Kidney Transplantation
Complications


Cardiovascular disease
 Transplant recipients-inc incidence of atherosclerotic
vascular disease.
 Immunosuppressant >worsen HTN and hyperlipidemia.
 Adhere to antihypertensive regimen.
Malignancies
 Primary cause -immunosuppressive therapy.
 Regular screening-important preventive care.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
90
Kidney Transplantation
Complications


Recurrence of original renal disease
 Glomerulonephritis; IgA nephropathy
 Diabetes mellitus; Focal segmental sclerosis
Corticosteroid-related complications
 Aseptic necrosis of the hips, knees, and other joints
 Peptic ulcer disease
 Glucose intolerance and diabetes
 Dyslipidemia; Cataracts
 Inc incidence of infection and malignancy
 Close monitoring of side effects
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
91
Patient Education





Signs of infection
Prevention of infection
Signs of rejection
 decreased urine output
 increased weight gain
 tenderness over kidney
 fever > 100 degrees F
Medications
time, dose, side effects
92
Transplants
Notes from Organ Donation slides

Exclusion for Transplant not limited too
Active vasculitis; or
 Life threatening extrarenal congenital
abnormalities; or
 Untreated coagulation disorder; or
 Ongoing alcohol or drug abuse; or
 Age over 70 years with severe co-morbidities; or
 Severe neurological or mental impairment, in
persons without adequate social support, such that
the person is unable to adhere to the regimen
necessary to preserve the transplant.

93







Official Criteria for Deceased
Donors
Usually irreversible brain injury
 MVA, gunshot wounds, hemorrhage, anoxic brain injury
from MI
Must have effective cardiac function
Must be supported by ventilator to preserve organs
Age 2-70
No IV drug use, HTN, DM, Malignancies, Sepsis, disease
Permission from legal next of kin & pronoucement of death
made by MD
*Brain Death is the complete cessation of all brain
& brainstem function. It is death.
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Official Criteria for Living Donors



Psychiatric evaluation
Anesthesia evaluation
Medical Evaluation
Free from diseases listed under deceased donor
criteria
 Kidney function evaluated
 Crossmatches done at time of evaluation and 1 week
prior to procedure
 Radiological evaluation

Nurses Role in Event of
Potential Donation

Notify TOSA of possible organ donation
Identify possible donors
 Make referral in timely manner



Do not discuss organ donation with family
Offer support to families after referral is
made & donation coordinator has met with
family
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Question
Six days after a kidney transplant from a deceased donor ,
the patient develops a temperature of 101.2° F (38.5°C),
tenderness at the transplant site, and oliguria. The nurse
recognizes that these findings indicate:
1. Acute rejection, which is not uncommon and is usually
reversible.
2. Hyperacute rejection, which will necessitate removal of the
transplanted kidney.
3. An infection of the kidney, which can be treated with
intravenous antibiotics.
4. The onset of chronic rejection of the kidney with eventual
failure of the kidney.
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Case Study




65-year-old woman with history of
progressive renal failure for 5 years
Diagnosed with type 1 diabetes mellitus
when 15 years old
After waiting for 9 months, she is notified
that a diseased (cadaver) kidney has
become available.
The kidney transplant is done.
Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc.
98
Discussion Questions
1.
She does very well postoperatively and is
ready for discharge. What are the priority
teaching interventions?
99