Care of the renal transplant recipient

30 Care of the renal transplant recipient




Overview/pathophysiology


Individuals with end-stage renal disease (ESRD) have several treatment modalities from which to choose—hemodialysis, peritoneal dialysis, no treatment, and renal transplantation. Diabetes is the leading cause of renal failure in the United States, and there is an increasing number of simultaneous kidney-pancreas transplants. In order for a solid organ transplant to survive, patients need to take immunosuppressive medications for the life of the graft. Renal transplantation is not a cure for renal failure. It can only be done in a hospital that has a Medicare provider agreement (Centers for Medicare and Medicaid Services, 2007), and in order to receive organs for transplant, facilities must be a member of the Organ Procurement and Transplantation Network (OPTN). There are several types of donors for renal transplant patients: deceased (formerly cadaveric), living related, living unrelated, voluntary nondirected (anonymous), directed, paired kidney exchange, domino, and expanded-criteria donors. Postoperatively, patients are sent to specialized units where nephrology nurses monitor them on an hourly basis for the first 24-36 hr. Subsequent admissions may occur at any hospital for treatment of a rejection episode, infection, medication complication, or unrelated illness. Rejection is the major complication of renal transplantation. Long-term complications occur secondary to use of immunosuppressive agents and include infection, hypertension, hyperlipidemia, cardiovascular disease, chronic liver disease, bone demineralization, cataracts, gastrointestinal (GI) hemorrhage, and cancer.



Health care setting


Transplant center; acute care surgical unit or critical care unit for complications or rejection



Immunosuppression


With the exception of identical twin donors, all transplant recipients must take drugs that suppress their immune system to prevent graft rejection. Each transplant center has a drug protocol outlining which combination of medications will be given to each patient. Note: A complete list of patient’s medications, including herbal remedies, should be included on patient’s chart. Some herbs interfere with absorption of immunosuppressive medications, causing patients to have lower levels of medications in their systems and potentially resulting in episodes of graft rejection and/or loss of the graft. Check the herbal Physicians’ Desk Reference (PDR) if unsure about interactions.



Rejection



Acute:


May begin weeks to 1 year after surgery; potentially reversible; treated with increased immunosuppression.



Chronic:


Usually classified as starting 1 year after transplant; irreversible; managed conservatively with diet and antihypertensive agents until dialysis is required.



Indicators of rejection:


Oliguria, tenderness over graft site (located in iliac fossa), sudden weight gain (2-3 lb/day), fever, malaise, hypertension, and increased blood urea nitrogen (BUN) and serum creatinine. In addition, hyperglycemia will develop with combined kidney-pancreas transplants.





Nursing diagnosis:


Risk for infection

related to invasive procedures, exposure to infected individuals, and immunosuppression


Desired Outcomes: Patient is free of infection as evidenced by normothermia; heart rate (HR) 100 bpm or less (or within patient’s normal range); respiratory rate (RR) 12-20 bpm with normal depth and pattern; and absence of erythema, edema, increased local warmth, tenderness, or purulent drainage at wounds or catheter exit sites. Patient is free of signs and symptoms of oral, esophageal, respiratory, gastrointestinal (GI), genitourinary, and cutaneous infections. Patient verbalizes indicators of infection and importance of reporting them promptly to health care provider or staff.



















ASSESSMENT/INTERVENTIONS RATIONALES
Assess for low-grade temperature elevation, fever, and unexplained tachycardia. These are indicators that might signal infection in a transplant recipient.
Assess for indicators of cytomegalovirus (CMV), including fever, malaise, fatigue, and muscle aches. CMV is a common infectious agent among these patients. Other infectious complications include Legionella pneumophila; cutaneous herpes zoster (shingles); varicella (chickenpox); Epstein-Barr virus (EBV); oral, esophageal, deep fungal, or mycotic pseudoaneurysm caused by Candida; and Pneumocystis jiroveci (formerly called Pneumocystis carinii).
When caring for these patients, increase your sensitivity to any indicator of infection as a cue to increase depth and frequency of assessments for infection. Transplant recipients are taking large doses of immunosuppressive agents, and their immune response and thus response to infectious agents will be muted. Infections therefore are potentially life threatening in an individual who is immunosuppressed.
Instruct patient to be alert to signs and symptoms of commonly encountered infections and importance of reporting them promptly.
Infections and their indicators include urinary tract infection (UTI)—cloudy and malodorous urine; dysuria, frequency, and urgency; pain in the suprapubic area, buttock, thighs, labia, or scrotum; upper respiratory tract infection (URI)—productive cough, malodorous, purulent, colored, and copious secretions, chest pain or heaviness; pharyngitis—painful swallowing; otitis media—malaise, earache; impetigo—inflamed or draining areas on the skin.
< div class='tao-gold-member'>

Related posts:

  1. Psychosocial support
  2. Urinary diversions
  3. Pneumothorax/hemothorax
  4. Bronchiolitis

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 18, 2016 | Posted by in NURSING | Comments Off on Care of the renal transplant recipient

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access