Running head: KIDNEY TRANSPLANT

Kidney Transplant
Beza Fissaha
Old Dominion University

KIDNEY TRANSPLANT

Kidney Transplant

Organ transplant is an operation that is conducted to replace absent or damaged organs.

Transplants can be performed using an organ from another donor or transplanting an organ
within the same body, often referred to as auto grafts (Knoll, 2013). Organs can be retrieved
from both deceased and living individuals but often require a list of criterias that the person has
to meet. Organ transplantation is a complex process as transplant rejection can often occur; this
however, can be significantly reduced by immunosuppressant drugs and by adequately matching
the donors organ to the recipient (Knoll, 2013).The allocation of organs consists of a formal
system process with ethical considerations that are used to determine the recipients of any
available organs. The organs of deceased individuals in the United States, are received through
the Organ Procurement and Transplantation Network (OPTN). The OPTN is responsible for
identifying and collecting suitable organs (Knoll, 2013). Kidney transplant is the most common
form of transplant surgery. When individuals reach end stage kidney disease (ESKD),
hemodialysis, peritoneal dialysis or kidney transplantation is considered; kidney transplantation
is preferred because it provides a better quality of life (Knoll, 2013).
End stage renal disease can be caused by many disease processes including diabetes.
Diabetes mellitus is a metabolic disease that is caused by inadequate production of insulin,
leading to elevated glucose levels in the blood (Ozougwu, Obimba, & Unakalamba, 2013).
Patients can either have type I or type II diabetes. In type I diabetes, the bodys immune system
destroys the pancreatic b-cells that are responsible for secreting insulin; insulin production is
completely destroyed. Furthermore, pancreatic a-cells are also altered. This results in excessive
production of glucagon, a hormone that assists in the breakdown of glycogen to glucose

KIDNEY TRANSPLANT

(Ozougwu, Obimba, & Unakalamba, 2013). Normally, glucagon secretions are reduced when
hyperglycemia occurs; in diabetes (type I), glucagon secretions are not reduced in the presence
of hyperglycemia. The increased glucagon levels can lead to metabolic defects because of
inadequate insulin. In type II diabetes, the production of insulin is impaired in the pancreas.
Although there is some detectable level of insulin circulating in the body, it is not used properly
(Ozougwu, Obimba, & Unakalamba, 2013). Increased glucose production leads to
hyperglycemia which can cause receptor defects. This eventually causes insulin resistance in the
tissues (Ozougwu, Obimba, & Unakalamba, 2013). Elevated glucose levels can cause the
kidneys to filter out excessive amounts of blood, causing the the blood vessels and kidneys to
over work. This damage can cause inappropriate clearance of wastes, inevitably leading to
kidney failure (Ozougwu, Obimba, & Unakalamba, 2013
The purpose of this paper is to integrate knowledge necessary to care for the patient with
an organ transplant.
Recipient Criteria
Physical Criteria
There are many criterias that are considered before determining eligibility for a kidney
transplant. The individual must have advanced kidney disease and be on dialysis or have near
loss of function reflected by a creatinine clearance of less than twenty cc per minute (Molnar et
al., 2012). The individual also has to have an adequate urinary tract. It is essential that the
bladder is functioning because the transplanted kidney will filter wastes thus the bladder is then
the reservoir for urine drainage (Molnar et al., 2012). The individual must also have a

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cardiovascular function that is acceptable. It is important to note that heart problems are the most
common complication after a transplantation. A heart evaluation is conducted before the
transplant to assist in minimizing any complications or risks (Molnar et al., 2012).
Contraindication includes severe coronary artery disease that is unmanageable. Furthermore, a
poor cardiac pump function is also considered a contraindication. The individual also must have
an acceptable vascular system (Molnar et al., 2012).The kidneys are attached to blood vessels
that help profuse blood to the lower extremities so an adequate circulation of the peripheral
system is essential. Contraindications include history or risk of a stroke (Molnar et al., 2012).It is
also important that the individual has adequate lung function. Pulmonary function tests are used
to check the function of the lungs. Cigarette smokers may be rejected for a transplant until they
stop smoking. Smokers are required to complete a six week cessation program and demonstrate
documentation of completion (Molnar et al., 2012). In addition, the individual also has to have
an acceptable liver function. Evidence of any liver disease such as hepatitis is further evaluated.
In cases of severe liver disease, kidney transplant alone is not adequate; these patients are
referred to kidney-liver transplant (Molnar et al., 2012).
The candidate also has to undergo cancer screening. For male patients over fifty years
old, a colonoscopy screening and prostatic specific antigen tests are conducted in addition with
other standardized screenings (Sellares et al., 2012).For women patients over forty years old, a
PAP smear and mammogram screening is done. In addition, any candidate who has had prior
malignancies will be further evaluated to determine the risk for reoccurrence (Rosa, Muscogiuri,
& Sarno, 2013).Obesity is also another consideration in determining if the individual is an
appropriate candidate for a transplant. Candidates have to have a body mass index (BMI) of less

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than forty; however, the suitability for a transplant is assessed and evaluated individually (Rosa,
Muscogiuri, & Sarno, 2013).The patients functional status is also considered. Candidates have
to be able to perform most if not all activities of daily living without any assistance. Any active
fungal or bacterial infection that is significant to the transplant is also a contraindication (Rosa,
Muscogiuri, & Sarno, 2013).
There are also absolute and relative contraindications that are considered with kidney
transplants. Absolute contraindications include a positive CDC-AHG cross match (Sellares et al.,
2012). This is considered because a mismatch indicates a higher risk for hyper-acute rejection.
Noncompliance is also an absolute contraindication. If there is enough evidence that suggests
that the recipient will be non-compliant with the recommendations post-transplant, the procedure
will not be done because kidney failure can occur from rejection (Sellares et al., 2012)
Inadequate financial resources is also a contraindication because the candidate might not be able
to afford the expensive treatments that are needed to prevent rejection (Sellares et al., 2012).
Pregnancy is another contraindication; sufficient time is needed after delivery for transplant
consideration (Sellares et al., 2012).Relative contraindications are also considered. These include
blood-type incompatibility, old age, history of heart disease, HIV infection, HTLV infection, and
TB (Sellares et al., 2012).
Psychosocial Criteria
The candidates psychosocial status is also considered. The candidate must be driven and
motivated while having demonstrated complete compliance to both dialysis and medical
regimens (Kiberd, Tennankore, & West, 2014). The candidate also must live in a stable
environment and have resources related to the transplant regimen. This includes having a reliable

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transportation and not being an active substance abuser (including cigarettes and marijuana)
(Kiberd, Tennankore, & West, 2014). Any candidate that was a previous drug or alcohol abuser
is required to sign a contract and agree to random screening tests in addition to attending a
treatment program. Contraindications to transplant also include untreatable psychiatric illnesses
(Kiberd, Tennankore, & West, 2014). The recipient must comprehend that awaiting for a kidney
transplant can be a long and tiring process. A study done by Chong, Kim, and Lee (2015) was
conducted to explore the experiences of waiting for a transplant in patients with end stage renal
disease. Data was collected using in depth interviews. Results demonstrated that the experience
of waiting for a kidney transplant consisted of five categories; this included experiencing the
light at the end of the tunnel, being on the on call list without any guarantee of transplant,
battling excitement and frustration, having doubts about the complexity, and getting ready for
dooms day. This study is significant because it shows that kidney transplant candidates
experience many psychosocial issues during the waiting period and has implications for the
transplant committee. Health care providers can also improve this by educating patients about
what it means to be a candidate as well as providing psychosocial support.
Donor Criteria
Physical Criteria
There are many criterias that are considered when selecting kidney donor candidates;
although brain dead donors are also acceptable, this section will specifically focus on live donors
The donor must be at least eighteen years of age and in a good mental and physical
health. To be considered an acceptable candidate, the donor must display adequate kidney

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function and have insurance coverage (Rodrigue, Rudow, & Hayes, 2015). It is essential that the
donor does not have any family history of kidney disease, hypertension, or diabetes; if the donor
has a family history of those diseases, further evaluation is taken to ensure that the risks of those
conditions occurring in that individual is minimal. In addition the donor is also tested for urinary
tract infections, nephrolithiasis, chronic infection diseases such as AIDS, heart disease, kidney
stones and lung disease (Rodrigue, Rudow, & Hayes, 2015).These are generally
contraindications to kidney donations. It is critical that the kidney donor does not display any
evidence of possible kidney disease or have any medical conditions that would increase the
chances of kidney injury occurring in the future; these include diseases such as diabetes and
congestive heart failure. Anatomic evaluation is conducted to determine which kidney has the
best function and is the safest to remove (Rodrigue, Rudow, & Hayes, 2015).This test also helps
identify any abnormality in the liver, adrenal glands, and spleen. The test may consist of a CT
angiogram or an MR angiogram. Furthermore a renal focused evaluation is also conducted to
determine the condition of the kidneys. This includes urinalysis, serum creatinine, and
Glomerular filtration rate. Non-therapeutic findings may lead to further evaluation. (Rodrigue,
Rudow, & Hayes, 2015).
General laboratory tests are retrieved to ensure that the donor has therapeutic levels.
Labs that are taken include but are not limited to CBC with platelet count, comprehensive panel,
HCG quantitative pregnancy test for women less than fifty five years of age, urine toxicology
screen, and prothrombin/partial thromboelastin time; donors are evaluated in detail if they had a
history of coagulation disorders (Rodrigue, Rudow, & Hayes, 2015).Donors also have to undergo
cancer screening. In cases that the donor does have cancer, this is done to ensure that the donor

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does not need both of the kidneys to assist with tolerating chemo or anti-cancer treatments. It is
also done to prevent potential transfer of a tumor to the recipient (Rodrigue, Rudow, & Hayes,
2015).It is critical that the donor is evaluated for multiple disease processes before approval for
kidney donation. If the donor has hypertension, heart disease/valve disease, protein in the urine
greater than three hundred milligrams, active hepatitis, or religiously used medications that can
cause kidney damage, then the donor might be declined (Rodrigue, Rudow, & Hayes, 2015).
Psychosocial Criteria

In addition to medical criterias, psychosocial aspects also have to be considered. This is done for

multiple reasons; to ensure that the donor does not have any risks for poor psychosocial outcomes such as
risks correlated to social instability, to assess the donors ability to make decisions, to evaluate support
systems available that would assist with recovery and identify that the donor fully understands all aspects
of the procedure (Duerinckx et al., 2014). Donors can potentially be denied if they do not have a
support system, a history of any psychiatric illness, poor coping mechanisms, or any other relative
concerns. During the psychosocial evaluation the evaluator collects multiple information in detail. These
include history and current status of donor, cognitive status, psychological status, relationship with the
transplant candidate, motivation, and the donors knowledge about the procedure. Contraindications
include active substance abuse and psychiatric illnesses (Duerinckx et al., 2014).

It is also pivotal that the donor committee assess if the donor is capable of undergoing the
donation processes. The donor has to be intellectually ready; this can be done by speaking to the
primary physician and doing research regarding information on living donations. It is also
important that the donor is emotionally ready (Duerinckx et al., 2014). The donor has to
comprehend that the procedure can potentially be harmful and in some cases unsuccessful. In

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addition the donor must also understand that the testing and evaluation process can reveal health
conditions that they were not aware of before (Duerinckx et al., 2014).
Therapeutic Management
Organ Rejection
Transplant rejection can occur when the immune system recognizes that the transplanted
organ is a non-self-foreign tissue. There are different types of organ rejection that can occur post
kidney transplant. One type of rejection is hyperacute rejection which is a humoral-mediated
response (Urden, Stacy, & Lough, 2014) . This type of rejection usually occurs shortly after
transplantation and often results in graft failure. B-cells are responsible for mediating humoral
immunity as well as the production of immunoglobulin and antibodies (Urden, Stacy, & Lough,
2014). In cases that the B-cell encounters an antigen, the B-cell responds by enlarging and
dividing; It then differentiates into the plasma cell. When there is a significant amount of
exposure that stimulates the B-cell memory, the antibody secreting cells mobilize rapidly (Urden,
Stacy, & Lough, 2014). The presence of reactive antibodies causes a rapid immune response.
This can be caused by transplantation that involves an incompatibility of blood type from the
donor (Puttarajappa, Shapiro, & Tan, 2012). Hyperacute rejection can be characterized by a
hemorrhage or thrombotic occlusions that often occurs in the graft vasculature (Puttarajappa,
Shapiro, & Tan, 2012).In addition, platelets and endothelial cells leak certain particles from their
membrane. This leakage induces coagulation and results in inflammation. The inflammatory
process prevents adequate graft vascularization and inevitably leads to ischemia of the graft
(Puttarajappa, Shapiro, & Tan, 2012).In addition, endothelial and arterial injuries causes
interstitial edema and cortical necrosis. Further more signs of hyperacute rejection can manifest

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by an increase in temperature, elevation in blood pressure, decreased urine output, swelling, pain,
tenderness, and an elevated creatinine (Puttarajappa, Shapiro, & Tan, 2012)
Another type of organ rejection is acute rejection. Unlike hyperacute rejection, acute
rejection often occurs weeks to months post-transplant but can still occur at any time. This is
characterized by class one or two antigens that are present on the transplanted graft. Cellularmediated response is activated by the antigens which starts an inflammatory response. Cellmediated response involves T-cells as they play a significant role in providing cell-mediated
immunity; the types of T-cells include cytotoxic T-cells, helper T-cells, and suppressor T-cells
(Urden, Stacy, & Lough, 2014). When the T-cells reject the non-self-tissue, they cause the graft
to lyse. This can also produce cytokines that assist in mediating the response of other
inflammatory cells. This eventually leads to the necrosis of the allograft tissue and can be
associated with both macrophage and lymphocyte infiltrates (Urden, Stacy, & Lough, 2014).
However, it is the cell lysis that is caused by the cytotoxic lymphocytes that is primarily
responsible for the allograft rejection (Puttarajappa, Shapiro, & Tan, 2012). Furthermore, an
early predictor of acute graft failure includes damage to the endothelial lining (Puttarajappa,
Shapiro, & Tan, 2012). Symptoms of an acute rejection include but is not limited to general
discomfort, fever, edema, pain, flu like symptoms, nausea, chills, decreased urinary output, clots,
and shortness of breath (Puttarajappa, Shapiro, & Tan, 2012).
The third type of rejection is chronic rejection. This type of rejection can occur at
different times following the transplantation and can continue to progress for years until it
eventually leads to failure of the organ. Chronic rejection is caused by the combination of
humoral mediated immune response and cellular mediated immune response (Urden, Stacy, &

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Lough, 2014). Chronic Inflammation can result in tissue scarring as well as stenosis of the
kidneys vasculature; this results in ischemia of the transplanted tissue. The production of
collagen that is produced by the fibroblast and the perforation of smooth muscle cells causes
arterial occlusion of the graft, a key component of chronic rejection (Puttarajappa, Shapiro, &
Tan, 2012).This process, referred to as graft arteriosclerosis, leads to fibrosis which is
responsible for ischemia. Symptoms of chronic rejection also include fever, pain, tenderness,
fluid retention, and weight gain (Puttarajappa, Shapiro, & Tan, 2012).
The detection of rejection can be identified by assessing urine output and examining renal
specific test. In addition, other tests are used to detect and confirm kidney transplant rejection.
These include, abdominal CT scan, chest x-ray, heart echocardiography, kidney arteriography,
kidney biopsy, kidney ultrasound, and lab test of kidney or liver function (Bissonnette et al.,
2013). It is pivotal that nurses apply in depth evidenced based practice to assess, plan and
implement interventions when caring for the transplant patient. It is essential that nurses identify
any signs of rejection as early as possible. Nurses should closely monitor the hemodynamic
status of the patient (Bissonnette et al., 2013). It is also important that the patient is kept mildly
hypervolemic. This can be achieved by fluid replacement, usually normal saline because it stays
in the vascular space (Bissonnette et al., 2013). Nurses should also monitor urine output hourly
and identify any signs of anuria or oliguria. In addition, the nurse should also provide adequate
post-operative care after the kidney transplant (Bissonnette et al., 2013). These include
maintenance of fluids, electrolyte balance, and pain management (Bissonnette et al., 2013). It is
also important that nurses teach patients about possible complications that can occur. In a study
conducted by Ferreira, Echer and Lucena (2013), researchers identified nursing diagnosis that

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were most prevalent to the kidney transplant patient. The study was done using a cross sectional
study that consisted of one hundred and sixty five patients that had kidney transplant. After
observing the patients through the post op period, the researched identified six nursing diagnosis
that best related to the patients. These included risk for infection, bathing self-care deficit,
impaired illumination, acute pain, ineffective protection, and impaired skin integrity. This study
is significant for nursing practice because it provides data about the health needs of the transplant
patient. The results also allows the nurse to prioritize information while assisting in guiding the
nursing care plan.
Immunosuppression
Immunosuppressant drugs are critical in the management of the transplant patient.
Immunosuppressant drugs are essential in the transplant patient because these category of drugs
decreases potential rejection of the transplanted organ (Scandling et al.,2015). These drugs are
used because when a foreign organ, in this case kidney, is present in the body, the body naturally
reacts by attacking the new kidney (Scandling et al.,2015).The immunosuppressant drugs
prevents this phenomenon by suppressing the bodys ability to destroy or fight the transplanted
organ (Scandling et al.,2015). The following agents are used as immunosuppressants agents;
corticosteroids are commonly used to treat acute rejections and often used as a maintenance
therapy. They act to impair the T-cells sensitivity to antigens and impair interleukins. In addition,
they prevent cytokine production and inhibit the circulation of lymphocytes (Urden, Stacy, &
Lough, 2014). Furthermore, they act to stop the mobility of macrophages. Prednisone and
Methlyprednisolone are the two most common forms that are given. Nursing implications for the
management of corticosteroid therapy includes preventing the risk of infection since it can

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predispose the patient to infection (Urden, Stacy, & Lough, 2014). In addition, it is essential that
the nurse titrates the medication to a low but effective dose. The nurse must also monitor for side
effects; these include hyperglycemia, hypertension, and as stated opportunistic infections in
addition to providing information on the importance of medication adherence. In a study
conducted by Prihodova and colleagues (2014) the researchers assessed medication adherence of
patients who had kidney transplants. The researchers found that patients who did not adequately
adhere to the immunosuppression therapy had a higher incidence of graft loss and mortality. This
is a significant study because it demonstrates that poor mediation adherence is the leading and
most preventable cause of graft loss in patients. This is important because the results show why
medical personals need to emphasize the importance of adhering to immunosuppression therapy.
Another immunosuppressant that is commonly used is cyclosporine (Urden, Stacy, & Lough,
2014).This drug works by inhibiting the action of T lymphocytes thus suppressing the
interleukin-2 production. The side effects can significantly affect the patient so it is essential that
the nurse monitors for headache, nausea, vomiting, diarrhea, cramps, hypertension,
hyperlipidemia, nephrotoxicity, and seizures (Urden, Stacy, & Lough, 2014). Tacrolimus, a drug
class that has the same mechanism of action as cyclosporine is sometimes preferred because it is
less likely to cause side effects (Urden, Stacy, & Lough, 2014).
Another drug used to prevent organ rejection is Azathioprine. This drug works by
inhibiting the RNA and DNA synthesis in proliferating cells (Urden, Stacy, & Lough, 2014).
Nursing Implications include adjusting the medication to ensure that white blood counts levels
are kept between 3000 and 5000 cells/mm. This drug also impacts other proliferative cells which
can result in thrombocytopenia, anemia, and leukopenia. It is important that the nurse monitors

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for these side effects. In addition, the nurse should also monitor kidney function and I & O
(Urden, Stacy, & Lough, 2014). Mycophenolate mofetil is also a common immunosuppressant
used. This drug is a potent inhibitor of both B and T lymphocyte proliferation. The inhibition of
the lymphocytes also disrupts cytotoxic T-cells from generating which suppresses both cellular
and humoral-mediated immunity (Urden, Stacy, & Lough, 2014). This drug commonly causes
gastrointestinal effects which are sometimes difficult to tolerate and causes some patients to omit
doses. If the patient cannot tolerate these side effects, a better tolerated alternative drug that is an
enteric-coated form of mycophenolate, mycophenolate sodium, can be given (Urden, Stacy, &
Lough, 2014). Nursing implications for this drug includes monitoring CBC weekly, usually the
first of every month. In addition, signs and symptoms of sepsis or infection should also be
monitored (Urden, Stacy, & Lough, 2014).
Nutrition
It is essential that the diet of the transplant patient is considered as it plays a significant
role in the success of the transplant. After a kidney transplant, the patient should have foods that
are low in salts (Bishop, 2012). Since blood pressure is significantly influenced by salts it is
essential that parents should be thought to restrict foods such as cured meats, chips, soda, and
foods high in salty seasonings (Bishop, 2012). In contrast, protein intake is essential posttransplant because it builds and repairs muscles and tissues and helps with healing after surgery.
It is important that the patient has adequate amounts of protein intake (Bishop,2012). Foods rich
in protein include meat, fish, eggs, and cooked beans (Bishop,2012). Potassium in a kidney
transplant patient is considered depending on the effects of the medication that the patient is on.
While some medication increases the levels of potassium, others such as corticosteroids

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decreases it (Bishop,2012). Foods high in potassium include bananas, oranges, avocados, and
tomato sauce. Calcium and phosphorus are also essential electrolytes that are needed in the
kidney transplant patient (Bishop, 2012). Calcium and phosphorus are essential for healthy bones
and prevents bone loss (Bishop, 2012). It is also essential that patients limit fat
(cholesterol/tryglyceride) because many of the immunosuppressant medications increase these
levels. This can be controlled by losing weight, limiting any alcoholic beverages, limiting oils
and fats, and avoiding fry foods (Bishop,2012).
Discharge Teaching
Discharge teaching is an essential component after transplant surgery. It is important that
the patient is informed about the importance of adhering to immunosuppressant therapy. In
addition, the patient should increase activity slowly and gradually and not put any strain in the
kidney regions (Sexton, 2011). Strenuous exercise should be avoided but walking can assist in
maintaining optimal health. It is recommended that the patient gradually starts doing short
exercises that last for a duration of ten minutes (Sexton, 2011). It is also essential that the patient
gets adequate rest while gradually returning to daily activities as tolerated. The patient should
also drink plenty of fluids and maintain a healthy weight. In addition, it is important that the
patient does not drink or smoke as it is harmful to the kidneys (Sexton, 2011). The patient may
also need to weigh themselves daily and measure their urine to assess kidney function; it is
important that nurses teach patients about recording information using a daily log (Sexton,
2011). The patient has to also take their temperature daily and obtain daily blood pressure
readings. It is also important that the patient understands the signs and symptoms of rejection so
that they are able to contact their health care provider (Sexton, 2011). These include an elevated

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temperature, flu like symptoms, weight gain, tenderness, problems urinating, or have pain that
originates from the abdomen or genital area. Follow up care should also be reviewed; the patient
should be informed about follow up appointments that they need to make in order to evaluate
function and success of the kidney (Sexton, 2011).
The patient should also be informed about the diet recommended after discharge. The
nurse should inform the patient about the importance of eating fruits and vegetables and
identifying which foods to avoid (Bishop,2012). Furthermore, it is also critical that psychosocial
considerations are evaluated. These include cultural factors, coping abilities and obtaining a
mental history. Psychosocial factors such as inadequate family support, psychiatric disorders,
history of non-compliance, personality disorders and financial issues have to be acknowledged
and addressed (Urstad & Hjorthaug, 2013). Furthermore it is also essential that information on
how to live a productive and healthy life is discussed. This includes emphasizing the importance
of staying healthy post-transplant (Urstad & Hjorthaug, 2013) . This can be done by reducing the
risk of heart disease, managing high blood pressure, reducing cholesterol, exercising, adhering to
medication regimen, maintaining a healthy weight, reducing risks for infections, maintaining a
good nutrition, and adhering to any other treatment plans (Urstad & Hjorthaug, 2013).
Conclusion
Kidney transplant is a complex phenomenon that requires meticulous care from the nurse.
This paper allowed me to gain an in depth understanding of the kidney transplant patient and the
pathophysiology that occurs with organ rejection. The information acquired in this paper will
impact my nursing practice because I have gained a complete understanding of the
pathophysiology of organ rejection, the importance of immunosuppression, and the components

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to management of the kidney transplant patient. The learning gained from this paper will allow
me to better alter my care to the kidney transplant patient.

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Retrieved March 29, 2016, from https://www.duo.uio.no/handle/10852/36110