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.

Transcript 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.

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.

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 composition of extracellular fluid and Excretion of nitrogenous waste products BP control via angiotensin-aldosterone system renin-

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 4/30/2020 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 0.5 1.5mg/dl)    K elevated (text norm 3.5-5.0 mEq/L) PO 4 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 0.5 1.5mg/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-

acetaminophen)

(

overuse some common drugs, as aspirin, NSAID as ibuprofen, cocaine and NSAIDs-…cause prerenal ARF by blocking prostaglandin production > also alters local glomerular arteriolar perfusion… ( reduces renal blood flow )

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 90 - 120 mL/min  What is normal GFR?

Stage 1: Stage 2:

Stages of CKD

NKF Classification System

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.

During Stage 1 - 2



No symptoms

  Serum creatinine doubles* ( Up to

50%

nephron loss

FYI-older adult creatinine may impaired renal function even in presence of normal serum

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

Stage 4:

Oops trouble!

Stages of CKD

NKF Classification System

Severe reduction (GFR 15 – 29 ml/min) 1. Serum triglycerides 2.

Hyper

phosphatemia 3. Metabolic

acidosis

Hyper

kalemia 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)  Azotemia  Residual function <

15% of normal

ESRD!!!

   Excretory, regulatory, hormonal functions severely impaired Metabolic

acidosis

(

Kussmaul breathing ) Marked : BUN, Creatinine, Phosphorous   Marked : Hemoglobin, Hematocrit, Calcium Fluid

overload

During Stage 5

  

Uremic

systems  syndrome develops- affecting all body

can be diminished with early diagnosis & treatment

Last stage of progressive

CKD Fatal

if no treatment 21

Manifestations of Chronic Uremia

Syndrome combination of common symptoms *greater build-up waste products = greater symptoms Fig. 47-5

What happens when kidneys don’t function correctly?

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*

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

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 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 influenza infection. *Aggressive care measures withdrawn after consultation with patient's family >patient died. tiny white crystalline material on skin > lab studies- BUN 208 mg/dl; creatinine 15 mg/dl; Staphylococcus aureus Walsh S and Parada N. N Engl J Med 2005;352:e13 pneumonia, likely due to prior * 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

Manifestations of CKD Fluid - Electrolyte - pH

 Volume expansion and fluid overload   Metabolic Acidosis

Due to impaired kidneys unable to excrete acid load (mostly

from NH3); defective reabsorption/regeneration of HCO3.

Electrolyte Imbalances  Potassium  Magnesium

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)

 Sodium

Kidneys retain > water retention> fluid overload

Manifestations of CKD GI Tract/Bleeding Risk

 Uremic fetor  Anorexia, nausea, vomiting  GI bleeding  Anemia

Due to GI irritation, platelet defect; diarrhea from hyperkalemia

 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 usually absent in normal human blood but present in uremic plasma may lead to

platelet dysfunction in uremia.

due to fibrinogen fragments,

Manifestations of CKD-Musculoskeletal

     Muscle cramps Soft tissue calcifications Weakness Related to calcium phosphorous imbalances

RENAL OSTEODYSTROPHY



Fracture risk!

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!

Manifestations of CKD- Endocrine Metabolic

 Erythropoietin  Hypothyroidism  Insulin resistance  Growth hormone  Gonadal dysfunction   Parathyroid hormone and Vitamin D 3 Hyperlipidemia 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

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)

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.

Hemodialysis Process

 Blood removed from patient into extracorporeal circuit.  Diffusion dialyzer. and ultrafiltration take place in  Cleaned blood returned to patient. 37

Extracorporeal Circuit

How Hemodialysis Works

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 vein subclavian, 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

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.

Potential

Complications of Hemodialysis

 During dialysis       Fluid and electrolyte related 

hypotension

Cardiovascular  arrhythmias Associated with the extracorporeal circuit 

exsanguination

Neurologic  Musculoskeletal  cramping Other  fever & sepsis 

Disequilibrium Syndrome & seizures blood born diseases

Potential Complications of Hemodialysis



Between treatments

      Edema Pulmonary edema Hyperkalemia Bleeding

Clotting of access Long term

(due to disease process & management

)

•Metabolic •Hyperparathyroidism •Diabetic complications •Cardiovascular CHF AV access failure Cardiovascular disease •Respiratory Pulmonary edema •Neuromuscular Neuropathy 50

Complications Hemodialysis- con’t-long term, ESRD  Long term cont’d  Hematologic  anemia  GI  bleeding  dermatologic  calcium phosphorous deposits  Rheumatologic  amyloid deposits Long term cont’d •Genitourinary •infection •Sexual dysfunction •Psychiatric •depression •Infection •blood borne pathogens 51

Dietary Restrictions-Hemodialysis

 Fluid restrictions

Urine output + 600 ml

 Phosphorous restrictions

Approx 800-1200 mg/day

 Potassium restrictions  Sodium restrictions

Approx 1-2 g/day; 40 mg/kg/IBW Approx 1-2 g/day

 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

Removal of soluble substances and water from blood by semi-permeable membrane (peritoneum) that is intracorporeal (inside body).

diffusion through a

 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

dialysate (acts as “osmotic” agent) ) concentration in Excess fluid/solutes removed- gradual/constant  Fluid drained by gravity into sterile bag at set intervals-

“Clear” “Yellow”

solution ‘fills” abdomen urine-like fluid drains out (like urine, clear)

Types of Peritoneal Dialysis *CAPD

: Continuous ambulatory peritoneal dialysis

*APD – Automated Peritoneal Dialysis

Phases of Peritoneal Dialysis Exchange

1. Fill (inflow min).

): fluid infused into peritoneal cavity (usually 10-15 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 position.

): time fluid drains from peritoneal cavity by gravity flow (usually 20-30 min); facilitate by gently massaging abdomen, changing CAPD

    

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 

utomated dialysis (

eritoneal fluid exchanges automatically by machine-(also known as continuous cycling peritoneal

CCPD

“cycler machine”-

ialysis ), requires programmable- to automate filling and draining process.  Treatment at home, typically at night (while sleeping-thus no fluid in “the belly” at daytime

Click to play animation

Videos-Dialysis, all types!

Click to locate desired video

    

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

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.

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 D 3 - 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

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, PO 4 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.

Case Study: History

 At age 11, he was admitted to the same hospital with gross hematuria.

Case Study

Discussion Questions

Why would his symptoms seem similar to diabetes?

Why is he developing chronic renal failure so many years after his primary diagnosis?

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 Disadvantages

     Restoration of “normal” renal function Freedom from dialysis Return to “normal” life Reverses pathophysiological changes related to RF Less expensive than dialysis after 1 st year      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 disorder s Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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

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.

Kidney Transplantation Surgical Procedure

 Kidney transplant recipient  Usually placed extraperitoneally in the iliac fossa  Right iliac fossa is preferred.

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 78

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.

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.

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 81



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.

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 83

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 84

  

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 (OKT 3 ), 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 85

Immunosuppressant Drugs

 

Corticosteroids-

Prednisone  Prevents infiltration of T lymphocytes Side effects  cushingnoid changes  Avascular Necrosis  GI disturbances  Diabetes  infection  risk of tumor  

Cytoxic Agents

(* Cellcept than Imuran)

Azathioprine (Imuran); Mycophenolate ), *Cytoxin (less toxic  Prevents rapid growing lymphocytes

Side Effects

 bone marrow toxicity     hepatotoxicity hair loss infection risk of tumor

Immunosuppressant Drugs



Calcineuin Inhibitors-

Cyclosporin, 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 antibody-

OKT 3 - used to treat rejection/induce immunosuppression  decreases CD 3 hour cells within 1 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 88

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

 

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.

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.

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;

 Life threatening extrarenal congenital abnormalities;

 Untreated coagulation disorder;

 Ongoing alcohol or drug abuse;

 Age over 70 years with severe co-morbidities;

 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.

      

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.

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 96

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.

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.

Discussion Questions

She does very well postoperatively and is ready for discharge. What are the priority teaching interventions?