Chapter 60: Kidney Transplant

Chapter 60: Kidney Transplant

Improves quality of life for clients with end-stage kidney disease (ESKD) who can no longer sustain life without dialysis.

Donor sources

• Living related donors

• Living non-related donors

• Cadaveric donors

Pre-transplant screening

• ABO blood compatibility

• Histocompatibility testing

• Screening for leukocyte antigens and other minor antigens

Donor considerations

• Living donors are at risk for future kidney disease.

• Cadaveric or non-heart-beating donors require adequate perfusion to maintain organ viability.

Transplant procedure

• Donated kidney is surgically implanted into the recipient.

Kidney Transplant Indications

Indications for kidney transplant

• End-stage kidney disease

Potential Diagnoses Related to ESKD

• Anuria

• Proteinuria

• Marked azotemia

  • Elevated blood urea nitrogen (BUN)

  • Elevated blood creatinine

• Severe electrolyte imbalances

  • Hyperkalemia

  • Hypernatremia

• Fluid volume excess conditions

  • Heart failure

  • Pulmonary edema

• Uremic lung

Kidney Transplant Findings

Anorexia, nausea, vomiting

Fatigue

Numbness and tingling of extremities (uremia, electrolyte imbalance)

Shortness of breath

Dry, itchy skin

Metallic taste in the mouth

Muscle cramping

Decreased attention span

Seizures

Tremor

Heart failure

Edema of hands and feet

Dyspnea

Distended jugular veins

Anemia

Pulmonary edema

Hypertension

Cardiac dysrhythmias

Pallor

Bruising

Halitosis (ammonia-odor breath)

Diminished or dark-colored urine

Kidney Transplant Exams

Laboratory Data

• Urinalysis

  • Proteinuria

  • Hematuria

• Renal function

  • Elevated BUN

  • Elevated blood creatinine

  • Decreased glomerular filtration rate

    • Estimated from blood or urine creatinine (24-hour values)

• Hematologic findings

  • Decreased hemoglobin and hematocrit (decreased erythropoietin)

• Electrolyte abnormalities

  • Elevated magnesium and phosphorus levels

  • Decreased calcium level

  • Sodium outside expected reference range

    • Increased or decreased

• Acid–base status

  • Metabolic acidosis

Kidney Transplant Risk Factors

Extremes of age

• Younger than 2 years

• Older than 70 years (higher risk of cardiac disease and malignancy)

Advanced, untreatable cardiac disease

Active or recent cancer

Chemical dependency

Chronic infections or systemic diseases

• HIV

• Hepatitis B or C

Coagulopathies and certain immune disorders

Obesity (BMI greater than 35 kg/m²)

Diabetes mellitus

Chronic pulmonary disease

Untreated gastrointestinal disease

• Peptic ulcer disease

Kidney Transplant Considerations

Preprocedure

• Live donor considerations

  • Blood from the donor kidney may be transfused into the recipient to improve graft survival.

• Dialysis

  • Usually performed within 24 hours before surgery.

Preprocedure Nursing Actions

• Schedule preoperative labs

  • Blood chemistry

  • CBC with differential

  • Bleeding times

  • Urine culture

  • Blood type and crossmatch

• Administer prescribed preoperative medications

  • Prophylactic antibiotics (infection prevention)

  • Immunosuppressive therapy

    • Corticosteroids (decrease inflammatory and rejection response)

    • Calcineurin and antiproliferative agents

      • Cyclosporine

      • Azathioprine

      • Tacrolimus

      • Sirolimus

      • Everolimus

      • Mycophenolate mofetil

      • Belatacept

    • mTOR inhibitors (block T-cell activation)

    • Monoclonal antibodies

      • Basiliximab

      • Daclizumab

      • Bind T cells to reduce activation and growth

Client Education Preprocedure

• Prepare mentally and emotionally for transplant surgery.

• Explain the interprofessional transplant team

  • Nurses

  • Providers

  • Transplant surgeon

  • Anesthesiologist

  • Nephrologist

  • Clinical nurse specialist

• Emphasize adherence

  • Lifelong immunosuppression

  • Risk factor reduction

    • Smoking cessation

    • Blood pressure control

    • Blood glucose control

Postprocedure Nursing Actions

• Vital signs

  • Every 15 minutes initially

  • Then hourly per protocol

  • Maintain blood pressure within prescribed limits

• Intake and output

  • Monitor at least hourly

  • Urine output goal greater than 30 mL/hr

  • Report oliguria immediately

• Renal monitoring

  • Sudden decrease in urine output may indicate rejection, thrombosis, obstruction, or injury.

  • Assess urine appearance and odor

    • Initially pink or bloody

    • Gradually clears over days to weeks

• Laboratory monitoring

  • Daily blood studies

  • Urinalysis for protein, WBCs, RBCs, ketones, glucose, specific gravity, pH

• Fluid and electrolyte monitoring

  • Hypovolemia

  • Hypervolemia

  • Hyperkalemia

  • Hyponatremia

• Infection surveillance

  • Fever

  • Incisional drainage

  • Redness

• Rejection surveillance

  • Fever

  • Hypertension

  • Pain at transplant site

• Surgical site care

  • Assess dressing for bleeding

  • Monitor for hematoma

• Fluid management

  • Administer IV fluids to replace hourly urine output as prescribed.

  • Transition to oral fluids once bowel function returns.

• Urinary catheter care

  • Maintain patency

  • Continuous bladder irrigation if prescribed (prevents obstruction from clots)

  • Remove catheter as soon as possible to reduce infection risk

• Dialysis

  • Administer if oliguria or anuria persists.

• Medications

  • Osmotic diuretics

    • Mannitol preserves urine flow and reduces acute kidney injury risk.

  • Immunosuppressants

    • Corticosteroids

    • Cyclosporine or other prescribed agents

    • Monoclonal antibodies

• Complication monitoring

  • Infection

  • Hypovolemia

  • Fluid retention

• Provider notification

  • Immediately report signs of rejection.

• Gastrointestinal care

  • Administer stool softeners to prevent straining and constipation.

• Psychosocial support

  • Arrange counseling for client and family if needed.

• Follow-up

  • Schedule post-transplant appointments and interventions.

Postprocedure Client Education

• Report signs of infection

  • Fever

  • Redness

  • Drainage

  • Tenderness over transplanted kidney

• Medication adherence

  • Corticosteroids

  • Antilymphocyte agents

  • Cyclosporine

  • Monoclonal antibodies

• Activity guidelines

  • Follow prescribed activity level

  • Early ambulation

  • Turn, cough, and deep breathe

• When to notify provider

  • Decreased urine output

  • Weight gain

  • Respiratory distress

  • Changes in fluid or food intake

  • Depression

Diet Recommendations

• Low-fat diet (reduce cholesterol)

• High-fiber diet (prevent constipation)

• Increased protein intake (healing and muscle mass)

• Adequate potassium, calcium, and phosphorus intake

• Sodium restriction

  • Prevent fluid retention and hypertension

• Avoid concentrated sugars

  • Prevent hyperglycemia, especially with prednisone

• Avoid magnesium supplements

  • Cyclosporine increases magnesium levels

• Avoid grapefruit and grapefruit juice

  • Increases cyclosporine blood levels

Activity Recommendations

• Avoid contact sports (protect transplanted kidney).

• Gradually increase activity as tolerated.

Kidney Transplant Complications

Organ Rejection

• Nursing priority

  • Monitor for and report manifestations of rejection immediately.

Hyperacute Rejection

• Onset

  • Within 48 hours after surgery

• Etiology

  • Antibody mediated response

  • Small blood clots form in transplanted kidney

  • Vessel occlusion leads to massive cellular destruction

  • Not reversible

• Findings

  • Fever

  • Hypertension

  • Pain at transplant site

• Treatment

  • Immediate removal of donor kidney

Acute Rejection

• Onset

  • 1 week to 2 years after surgery

• Etiology

  • Antibody mediated response

  • Vasculitis and inflammation in donor kidney

  • Progressive cellular destruction

• Findings

  • Oliguria or anuria

  • Low grade fever

  • Hypertension

  • Tenderness over transplanted kidney

  • Lethargy

  • Azotemia

  • Fluid retention

• Treatment

  • Increased doses of immunosuppressive medications

Chronic Rejection

• Onset

  • Gradual over months to years

• Etiology

  • Blood vessel injury

  • Smooth muscle overgrowth

  • Fibrotic tissue replaces normal kidney tissue

  • Leads to nonfunctioning donor kidney

• Findings

  • Gradual return of azotemia

  • Fluid retention

  • Electrolyte imbalance

  • Fatigue

• Treatment

  • Conservative management

  • Monitor kidney function

  • Continue immunosuppressive therapy

  • Dialysis when indicated

Client Education for Rejection

• Monitor for signs of rejection and notify provider immediately.

• Rejection is diagnosed with kidney scan and biopsy.

• Adhere strictly to prescribed pharmacologic regimen.

Ischemia

• Cause

  • Delay in transplanting donor kidney after harvesting

  • Results in hypoxic injury to donor kidney

Nursing Actions

• Monitor urine output, BUN, and creatinine (detect graft failure).

• Report urine output less than 30 mL per hour.

• Assist with dialysis as prescribed.

• Prepare client for kidney biopsy to distinguish ischemia from rejection.

Client Education

• Dialysis may be required until donor kidney function improves.

Renal Artery Stenosis

• Cause

  • Scarring at surgical anastomosis

Nursing Actions

• Monitor and report

  • Hypertension

  • Bruit over artery anastomosis site

  • Decreased kidney function

    • Oliguria

    • Elevated BUN and creatinine

• Prepare client for kidney scan to assess renal blood flow.

• Angioplasty or surgery may be required.

Client Education

• Monitor for peripheral edema.

• Have blood pressure checked frequently.

Thrombosis

• Description

  • Blood clot formation in a major vessel of the transplanted kidney

Nursing Actions

• Monitor for sudden decrease in urine output.

• Prepare client for emergency transplant nephrectomy if indicated.

Client Education

• Understand the risk of blood clots.

• Report sudden decrease in urine output immediately.

Infection

• Significance

  • Common cause of morbidity and mortality in the first year post transplant

• Presentation

  • Often subtle due to immunosuppression

  • Low grade fever

  • Mild discomfort

  • Mental status changes

Nursing Actions

• Prioritize infection control

  • Frequent hand hygiene

• Monitor for localized infection

  • Wound drainage

  • Redness

• Monitor for systemic infection

  • Pneumonia

  • Sepsis

Client Education for Infection

• Monitor and report

  • Fever

  • Incisional drainage

  • Redness

  • Fatigue

  • Discomfort

• Perform infection control measures

  • Frequent hand hygiene

  • Avoid crowds and sick contacts

  • Consider wearing a mask in public

• Adhere strictly to prescribed pharmacologic regimen

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect?

Select all that apply.

a

Anuria

b

Marked azotemia

c

Crackles in the lungs

d

Increased calcium level

e

Proteinuria

a

Anuria

b

Marked azotemia

c

Crackles in the lungs

e

Proteinuria

A nurse is caring for a client with end stage kidney disease who is awaiting transplant. Upon review of the laboratory results the nurse anticipates which of the following changes?

Creatinine

Calcium

Potassium

Phosphorus

Increased

Decreased

Increased

Potassium

Phosphorus

Creatinine

Decreased

Calcium

---

End stage kidney disease to have an increase in a serum creatinine level. As the decrease in filtration through the glomeruli continues through the kidneys the phosphorus level will increase with a reciprocal decrease in the calcium level. In addition, with the decline in glomerular filtration there is also risk for hyperkalemia.

A nurse is assessing a client who is scheduled for kidney transplantation surgery. Which of the following findings are risk factors for surgery?

Select all that apply.

a

Age older than 70 years

b

BMI of 41 kg/m²

c

Administering NPH insulin each morning

d

History of treatment for lymphoma within the last year

e

Blood pressure averaging 120/70 mm Hg

a

Age older than 70 years

b

BMI of 41 kg/m²

c

Administering NPH insulin each morning

d

History of treatment for lymphoma within the last year

A nurse is planning postoperative care for a client following a kidney transplant. Which of the following actions should the nurse include?

Select all that apply.

a

Obtain daily weights.

b

Assess dressings for bloody drainage.

c

Replace hourly urine output with IV fluids.

d

Expect oliguria in the first 4 hr.

e

Monitor blood electrolytes.

a

Obtain daily weights.

b

Assess dressings for bloody drainage.

c

Replace hourly urine output with IV fluids.

e

Monitor blood electrolytes.

A nurse is teaching a client who is postoperative following a kidney transplant and is prescribed cyclosporine. Which of the following instructions should the nurse include?

a

“Decrease your intake of protein-rich foods.”

b

“Take this medication with grapefruit juice.”

c

“Monitor for and report a sore throat to your provider.”

d

“Expect your skin to turn yellow.”

c

“Monitor for and report a sore throat to your provider.”

A nurse is teaching a client who is scheduled for a kidney transplant about organ rejection. Which of the following statements should the nurse include?

Select all that apply.

a

“Expect an immediate removal of the donor kidney for a hyperacute rejection.”

b

“You might need to begin dialysis to monitor your kidney function for a hyperacute rejection.”

c

“A fever is a manifestation of an acute rejection.”

d

“Fluid retention is a manifestation of an acute rejection.”

e

“Your provider will increase your immunosuppressive medications for a chronic rejection.”

a

“Expect an immediate removal of the donor kidney for a hyperacute rejection.”

c

“A fever is a manifestation of an acute rejection.”

d

“Fluid retention is a manifestation of an acute rejection.”