Renal Transplantation

By:
Wilson Y. Bautista, RN
 History

 1954: The first successful kidney

transplant was performed by Dr. Joseph
Murray and Dr. Hartwell Harrisonin at
Peter Bent Brigham Hospital in Boston.

 1962: Tissue typing became the

accepted procedure to match donor
and recipient.
 History

 1970s: Used of deceased organ donors

became accepted practice, and the
concept of brain death was
established.

 1978: Cyclosporine was first used in

clinical trials as an immunosuppressant
 Organ Transplantation

AUTOGRAFT: Transplantation of a person’s

own tissue from one body site to another.

ISOGRAFT: Transplantation of tissues

between monozygotic identical (same
genetic make up) twins.
 Organ Transplantation
ALLOGRAFT OR HOMOGRAFT:
Transplantation of tissues between of the
same species (from one person to
another with different genetic make up).

XENOGRAFT: Transplantation of tissues

between members of the different
species.
 DONOR

A. Living Donor B. Deceased Donor

 ORGAN DONATION AND
PRESERVATION
LIVING DONOR
 Related or biologically related:

 Unrelated or biologically
unrelated:
 ORGAN DONATION AND
PRESERVATION
LIVING DONOR
1. Information / explanation of process
2. Medical Assessment
3. Chest X-ray
4. EKG
5. Hematology, chemistries, serologies
and cultures
 ORGAN DONATION AND
PRESERVATION
LIVING DONOR
6. Urine Studies to assess kidney function
7. Spiral CT scan or MRI/MRA to
document anatomy of kidneys,
ureter, bladder
 LIVING DONOR PROCEDURES
1. Pretransplant cytotoxiccrossmatch
2. Surgical procedure

a. Open Nephrectomy: Flank Incision, Left

Side preferred but dependent on
anatomy, Procedure usually takes 4 – 6
hours
 LIVING DONOR PROCEDURES

b. Laparoscopic Donor Nephrectomy:

Minimally invasive, 3 small incisions, Less
operative morbidity, less pain, shorter
hospital stay

b. Hand-assisted laparoscopic donor:

A small abdominal incision is created for the
surgeon to place his/her hand through a
pneumosleeve to remove the kidney.
 LIVING DONOR PROCEDURES
3. Postoperative nursing care
 Frequent monitoring of VS
 Meticulous pulmonary toilet
 Early ambulation
 Maintenance of Fluid & Electrolyte
balance
 Record intake and output
 LIVING DONOR PROCEDURES
3. Postoperative nursing care
 Monitor for signs of bleeding
 Daily weights
 Prevent infection
 Pain control
 Emotional support
 Patient education
 DECEASED DONOR
CRITERIA
A. Heart beating donor must have
irreversible cessation of
spontaneous brain function (brain
death)
B. Expanded criteria donors
I. Non-heart-beating. Controlled
situation, Irreversible brain injury,
but not a brain death
 DECEASED DONOR
CRITERIA
II. Uncontrolled situation:
 Cardiopulmonary arrest occurs
 No response to CPR and death is
declared;
 Family gives informed consent;
 Organs are recovered immediately to
minimize warm ischemic time;
 DECEASED DONOR
CRITERIA
A. Older donors (60 years old or greater)
B. Donors aged 50-59 with history of
cerebral vascular accident,
hypertension
C. The kidneys are usually biopsied prior to
transplantation
 Medical Criteria for deceased
donors
D. Absence of malignancy except for
some primary brain tumors or skin
cancers
E. Absence of active systemic infections
or transmissible disease
F. Absence of significant kidney disease
or uncontrolled HTN
G. Generally less than 70 years of age
H. Evaluation of organ function
 Advantages of Living versus
Cadaveric donation
1. Better short-term and long-term results
2. More consistent early function and ease of
management
3. Avoidance of brain death stress
4. Minimal incidence of delayed graft function
5. Avoidance of long wait for cadaveric transplant
6. Capacity to time transplantation for medical
and personal convenience
7. Immunosuppressive regime may be less
aggressive
8. Helps relieve stress on cadaver donor supply
RECIPIENT
 WORKUP & SELECTION OF
POTENTIAL RECIPIENT
CONTRAINDICATIONS
1. Current or recent malignancy
(excluding noninvasive skin cancers)
2. Active or chronic untreated infection
3. Severe irreversible extrarenal disease
4. Active autoimmune disease
5. Morbid obesity (BMI >35)
 WORKUP & SELECTION OF
POTENTIAL RECIPIENT
CONTRAINDICATIONS
6. Current substance abuse
7. Psychiatric illness
8. Significant history of nonadherence to
treatment regimens
 WORKUP & SELECTION OF
POTENTIAL RECIPIENT
HISTORY AND PHYSICAL EXAMINATION
1. AGE
 Physiologic age is more important
than chronologic age.
 Patients over age 70 are accepted at
some hospitals
2. Etiology of renal disease
 WORKUP & SELECTION OF
POTENTIAL RECIPIENT
HISTORY AND PHYSICAL EXAMINATION
3. Urinary Tract
4. Cardiovascular system
5. Pulmonary system
6. Neurologic System
7. Gastrointestinal system
8. Endocrine system
 WORKUP & SELECTION OF
POTENTIAL RECIPIENT
HISTORY AND PHYSICAL EXAMINATION
9. Dental system
10. Cancer screening
11. Infection
12. Immunologic system
13. Psychosocial system
 Immediate preoperative care of
the kidney transplant recipient
Preparation for Surgery
a. Communication with referring
physician regarding patient’s
candidacy.
b. NPO for 6-8 hours before surgery
c. History and physical examinations are
performed.
 Immediate preoperative care of
the kidney transplant recipient
Preparation for Surgery
d. Laboratory Testing.
e. Chest X –ray to assess for fluid overload,
pneumonia or new lesions
f. EKG
g. Vital signs and baseline weight
h. Shower and skin preparation
 Immediate preoperative care of
the kidney transplant recipient
Preparation for Surgery
i. Vascular access or peritoneal dialysis
catheter assessment.
j. Insertion of intravenous lines,
peripheral and or/central lines
k. Immunosuppression may be ordered
to be given prior to the operation
 Immediate preoperative care of
the kidney transplant recipient
Preparation for Surgery
l. Antibiotics are ordered
perioperatively
m. Patient and family education
n. Final cytotoxic crossmatch performed
o. Pretransplant dialysis may be done
 The Kidney transplant surgical
procedure

The kidney is usually placed in

the anterior iliac fossa,
extraperitoneally.
 Postoperative management of
the kidney transplant recipient
A. Maintain circulatory function
B. Maintain pulmonary function
C. Monitor fluid and electrolyte balance
D. Prevention of infection
E. Provide and monitor
immunosuppressive regimen
F. Assess and assist with treatment for
complications.
 Postoperative management of
the kidney transplant recipient
G. Administer pain medication as
needed
H. Discharge planning
I. Scheduling for posttransplant patient
follow up
J. Communicating with referring
physician
K. Rehabilitation
 Short Term Complications

 Renal Artery Thrombosis

 Renal Vein Thrombosis
 Graft Rupture
 Urologic Complications
 Delayed Graft Function (DGF)
 Acute Tubular Necrosis (ATN)
 Wound complications
 Long term complications
 Chronic allograft nephropathy (CAN)
also known as chronic rejection.
 Gastrointestinal
Ulcers, liver disease, cholecystitis,
pancreatitis
 Metabolic
 HTN, immunosuppresion induced DM,
disorders of calcium and phosphorus
metabolism
 Long term complications
 Renal Artery stenosis
 Cardiovascular
 Malignancy.
Squamous cell skin , cancer (most
common), solid organ tumors,
lymphomas
 Long term complications
 Osteoporosis
 Posttransplant chronic kidney disease
 Pregnancy after transplantation
 Obesity
 Types of rejection
1. Hyperacute rejection
 Onset is minutes to hours
 As a result of preformed antidonor
antibodies and complement
 This process usually involves memory B
lymphocytes
 Irreversible and untreatable
 Types of rejection
1. Hyperacute rejection
 Can be prevented by performing
crossmatch prior too transplant
 Transplant nephrectomy is necessary
for treatment
 Types of rejection
2. Accelerated Rejection
 Onset is days
 Cause by reactivation of sensitized T
lymphocytes, similar to hyperacute
rejection
 Types of rejection
2. Accelerated Rejection
 Clinical signs and symptoms:
 Profound oliguria
 Fever
 Rapid loss of transplanted kidney
function
 Systemic toxicity
 Types of rejection
2. Accelerated Rejection
 Can be prevented by performing
crossmatch prior to transplant
 Transplant nephrectomy is usually
necessary for treatment, although
plasmapheresis is sometimes attempted
 Types of rejection
3. Acute rejection

 Onset is days to weeks

 Caused by activation of T lymphocytes
 Types of rejection
3. Acute rejection
 Signs and symptoms:
 Fever
 Elevated leukocyte count
 Malaise
 Increased creatinine and BUN
 Decrease urine output
 Electrolyte imbalances
 Edema
 Graft tenderness
 Types of rejection
3. Acute rejection
 Acute rejection can usually be treated
with increased immunosuppresion
 Types of rejection
4. Chronic Rejection
 also known as chronic allograft
nephropathy
 Onset is months to years
 Cause is unclear, but is likely a
combination of T lymphocyte and B
lymphocyte mediated rejection
 Types of rejection
4. Chronic Rejection
 There is no successful treatment
 IMMUNOSUPPRESION
NOTE:
The goal of immunosuppresion is
to modify the immune system
enough to prevent rejection, but
not so much as to allow infection,
malignancies, and other side
effects.
 Immunosupppresive drugs
1. Glucocorticoids
2. Mycophenolate mofetil, mycophenolic acid
3. Sirolimus
4. Azathioprine
5. Cyclosporine
6. Tacrolimus
7. Polyclonal preparations (e.g., antilymphocyte
globulin, thymoglobulin)
8. Monoclonal preparations: muromonab CD3
9. Interleukin-2 receptor antagonists: basiliximab,
daclizumab