I. INTRODUCTION
Thousands of patients in countries worldwide are awaiting a new kidney.
Table 14-1 provides data on patients awaiting renal transplantation in the United States, Australia, Eurotransplant, and the United Kingdom.1,2,3,4
In the United States, there are also 1,971 individuals awaiting simultaneous kidney-pancreas transplantation.1
Thousands of others throughout the world are in the process of being evaluated or scheduled for living donor transplantation.
To have a clear understanding of both the pre- and the postrenal transplant process, it is necessary to have knowledge of renal function, causes of chronic kidney disease (CKD), and the manifestations of abnormal renal function.
In most cases, early kidney disease is a silent and insidious process.
Patients accommodate to their worsening physiological condition without realizing they are doing so and often without being aware they have a health problem.
Renal failure often is not recognized until the patients have irreversibly lost a significant percentage of their kidney function and have multiple manifestations of renal disease.
The state where all or most kidney function has been lost and dialysis is indicated has traditionally been referred to as end-stage renal disease (ESRD).
The current term used to describe this state is chronic kidney disease (CKD), and this term will be used throughout this chapter.
TABLE 14-1 Patients Awaiting Renal Transplant (as of August 2015) | ||||||||||||||||||
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Are paired organs
Sit behind the peritoneum at approximately the level of the first lumbar vertebra
Receive their blood supply via the renal arteries and are drained via the renal veins
It is not uncommon to have two to three renal arteries supplying each kidney.
It is less common to have multiple renal veins.
Perform numerous functions (see Table 14-2)8
Primary product, urine, is drained via the ureters into the urinary bladder.
On occasion, there may be two ureters from a single kidney.
The bladder is a hollow muscular organ that is readily distensible and has a capacity of 500 mL.
The urine produced contains waste products, electrolytes, and other substances outlined in Table 14-3.8
Abnormalities in the urine composition such as the presence of protein, blood cells, glucose, or other substances can indicate renal or systemic disease.
The nephron is the basic structural and functional unit of the kidney, with each kidney having approximately 1 million nephrons.9
Each nephron is capable of carrying out all of the functions of the kidney.
About 50% of the nephrons must be impaired before the creatinine will rise.
When the kidneys fail, dialysis or transplantation is required to sustain life.
TABLE 14-2 Major Kidney Functions | ||
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TABLE 14-3 Urine Composition | ||
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II. CHRONIC KIDNEY DISEASE
The causes of CKD are many (Table 14-4), but diabetes mellitus (DM), hypertension, and glomerulonephritis account for the majority of patients with CKD.
These three diseases account for almost 80% of all patients on dialysis.10
DM is the most common cause of CKD.
Although all forms of glomerulonephritis may recur, focal segmental glomerulosclerosis has the highest rate of recurrence.
Other causes of CKD that may recur include Henoch-Schönlein purpura, amyloidosis, hemolytic-uremic syndrome, and oxalosis.11
TABLE 14-4 Major Causes of Chronic Kidney Disease
Most common causes of CKD:
Diabetes mellitus
Hypertension
Glomerulonephritis
Cystic disorders:
Polycystic kidney disease
Medullary cystic disease
Acquired cystic diseases
Urinary tract abnormalities:
Reflux nephropathy
Posterior ureteral valves
Neurogenic bladder
Tubular disorders:
Renal tubular acidosis
Fanconi’s syndrome
Obstructive disorders:
Renal calculi
Retroperitoneal fibrosis
Prostatic hypertrophy
Autoimmune disorders:
Goodpasture’s disease
Wegener’s disease
Systemic lupus erythematosus
IgA nephropathy
Hemolytic disorders:
Hemolytic-uremic syndrome
Thrombotic thrombocytopenic purpura
Nephrotoxic agents:
Cyclosporine
Gentamicin
Nonsteroidal anti-inflammatory drugs
Analgesics
Intravenous contrast dyes
Cancers:
Multiple myeloma
Renal cell cancer
Congenital disorders:
Renal agenesis
Renal aplasia
Others:
Amyloidosis
Oxalosis
Henoch-Schönlein purpura
Interstitial nephritis
Nephrotic syndrome
Focal segmental glomerulosclerosis
Human immunodeficiency virus nephropathy
Pyelonephritis
HIV, human immunodeficiency virus.
From Whittier WL, Lewis EJ. Pathophysiology of chronic kidney disease. In: Gilbert SJ, Weiner DE, Gipson DS, et al., eds. National Kidney Foundation’s Primer on Kidney Diseases. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014:448-457; Jennette JC, Falk RJ. Glomerular clinicopathologic syndromes. In: Gilbert SJ, Weiner DE, Gipson DS, et al., eds. National Kidney Foundation’s Primer on Kidney Diseases. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014:152-163.
Patients with polycystic kidney disease may require bilateral nephrectomy before or at the time of transplant if the cysts are large, cause frequent infection or bleeding, impinge on surrounding structures, or fail to allow sufficient room for the new kidney.
In most cases, CKD occurs over months to years, although some diseases such as rapidly progressive glomerulonephritis can cause permanent damage within weeks or months.
CKD is differentiated from acute disease in that the damage to the kidney lasts for more than 3 months in CKD.
TABLE 14-5 Stages of Chronic Kidney Disease
Stage
Description
GFR (mL/min)
1
Kidney damage with normal or increased GFR
≥90
2
Kidney damage with mild decrease in GFR
60-89
3
Moderate decrease in GFR
30-59
4
Severe decrease in GFR
15-29
5
Kidney failure
<15 (or dialysis)
Data from National Kidney Foundation (NKF). K/DOQI Clinical Practice Guidelines For Chronic Kidney Disease: Evaluation, Classification, and Stratification. Available at http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm. Accessed September 29, 2014.
Gradual loss of kidney function is described in five stages (Table 14-5) that have been clearly defined in the clinical practice guidelines by the Kidney Disease Outcomes Quality Initiative (KDOQI).12
The staging of CKD enables clinical practice guidelines and performance measures to be used as tools for improving the evaluation and management of CKD.
The two primary markers used to define the stages of disease are
Damage to the kidneys as manifested by abnormalities in blood and/or urine (BUN, creatinine, etc.)
Level of kidney function as measured by the glomerular filtration rate (GFR)
The stages also indicate how soon renal replacement therapy may be required.
Those in stage 4 should be preparing for dialysis by having access placed or seeking a living donor for preemptive transplant.
Those who have reached stage 5 are in need of immediate renal replacement therapy.
As it progresses, CKD leads to a syndrome known as uremia, which literally means urine in the blood and refers to the buildup of waste products, excess electrolytes, and toxins in the blood.
Physical signs and symptoms develop due to the presence of unfiltered waste products and the loss of kidney function.
CKD can affect the most elemental of patient parameters, the vital signs.
Despite an increased susceptibility to infection, CKD patients may have a subnormal temperature as BUN acts as a hypothermic agent.
Tachycardia is often present in response to cardiac and volume changes.
Tachypnea can be present as a compensatory response to metabolic acidosis.
Blood pressure (BP) can be normal but is often elevated due to the cardiovascular changes that occur in many diseases that cause kidney disease.
CKD disease evolves into a multisystem disease affecting many aspects of bodily function.
TABLE 14-6 Systemic Effects of Chronic Kidney Disease
System
Effect of Disturbance
Cardiovascular disturbances
Hypertension
Left ventricular hypertrophy
Congestive heart failure
Pericarditis
Pericardial effusion
Pericardial tamponade
Edema of extremities
Gastrointestinal disturbances
Uremic fetor
Nausea
Vomiting
Gastritis
Diarrhea
Anorexia
Gastrointestinal bleeding
Stomatitis
Gastritis
Peptic ulcer disease
Musculoskeletal disturbances
Renal osteodystrophy
Osteitis fibrosa/osteomalacia
Muscle wasting
Muscle irritability
Bone pain
Bone fractures
Pulmonary disturbances
Pulmonary edema
Pleuritis
Dyspnea
Pneumonia
Tachypnea
Hematologic disturbances
Anemia
Impaired platelet function
Infection
Neurologic disturbances
Drowsiness, fatigue
Muscle twitching
Headache
Confusion
Delirium
Tremors
Seizures
Coma
Peripheral neuropathy
Sleep disturbances
Paresthesias
Restless legs syndrome
Motor weakness
Genitourinary disturbances
Oliguria
Anuria
Urinary tract infections
Proteinuria
Metabolic/electrolyte/acid-base disturbances
Hyperkalemia
Hyperlipidemia
Acidosis
Hypo-/hypercalcemia
Hypoalbuminemia
Hyperphosphatemia
Carbohydrate intolerance
Waste product accumulation
Endocrine disturbances
Altered insulin metabolism
Reduced insulin requirements
Peripheral insulin resistance
Thyroid abnormalities
Hyperparathyroidism
Reproductive disturbances
Amenorrhea
Impotence
Infertility
Integumentary disturbances
Uremic frost
Pallor, pigmentation changes
Pruritus, dry/scaly skin
Ecchymosis
Excoriations
Calcium-phosphate deposits
Psychologic disturbances
Anxiety
Depression
Noncompliance
Denial
Psychosis
From Hall JE. Guyton & Hall Textbook of Medical Physiology. 13th ed. Philadelphia, PA: WB Saunders; 2015; Patton KT, Thibodeau GA. Anatomy and Physiology. 7th ed. St. Louis, MO: Mosby; 2010; Inker LA, Levey AS. Staging and management of chronic kidney disease. In: Gilbert SJ, Weiner DE, Gipson DS, et al., eds. National Kidney Foundation’s Primer on Kidney Diseases. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014:458-466; Hain DJ, Haras MS. Chronic kidney disease. In: Core Curriculum for Nephrology Nursing. 6th ed. Pitman, NJ: ANNA; 2015:153-182.
Although dialysis can improve fluid and electrolyte balance and remove waste products, other measures are necessary to prevent and treat the many symptoms and complications of CKD:
Dietary restrictions/modifications
Antihypertensive therapy
Iron replacement
Stimulation of red blood cell production
Control of calcium and phosphate levels
As described earlier, CKD is defined by stages that enable the application of guidelines for treatment and management.
In order to determine the stage of CKD and the underlying cause of the CKD, patients typically undergo radiologic and invasive testing in addition to routine lab work.
Imaging of the kidneys provides information on the size and structural abnormalities of the kidneys:
Renal or abdominal ultrasound
Computed tomography (CT)
Magnetic resonance imaging (MRI)
A renal biopsy provides tissue for histological classification of the disease.
A 24-hour urine for creatinine and protein may be collected. This test provides information regarding the severity of the kidney disease.
An excellent test to determine the degree of renal dysfunction is a nuclear medicine glomerular filtration rate.
These diagnostic studies provide information regarding the potential causes and reversibility of the kidney disease and help guide treatment and prevention of further loss of function.
III. EVALUATION FOR KIDNEY TRANSPLANTATION
Patients who may be considered acceptable candidates by one program may be deemed unacceptable by another.
There is no one set of definitive acceptance or rejection criteria or methodology for assessment.
Physiologically, the potential candidate must be able to undergo and withstand the transplant procedure itself and have a low risk of long-term morbidity and mortality.
Cardiovascular function, respiratory status, body mass index, and the absence of defined contraindications form the basis of the assessment.
Major contraindications are listed in Table 14-7.16
Although some of these criteria and/or contraindications will exclude a patient at the time of initial assessment, if they can be resolved, the patient can be reassessed.
Examples of this would be obese patients who complete a weight reduction program or patients with symptomatic coronary artery disease who undergo coronary artery bypass graft surgery.
Older age, in itself, is not a definitive contraindication because physiologic age is more important than chronologic age.
Physical assessment is aimed at determining a patient’s potential morbidity and mortality in both the short term and long term.
A battery of laboratory, tissue and blood-typing, and radiologic and diagnostic tests are required to determine the state of a potential candidate’s health (see Table 14-8).
Certain patients may require additional tests and procedures depending on their medical history.
TABLE 14-7 Contraindications to Kidney Transplantation
Active or current malignancy
Active infection
Significant peripheral vascular disease (that would interfere with surgical anastomoses)
Untreatable end-stage diseases of other organs, for example, inoperable coronary artery or valvular disease, severe cardiomyopathy, end-stage emphysema
Active inflammatory disease (systemic)
Noncompliance
Active substance abuse; current recreational drug abuse
Untreated psychiatric illness or mental incapacity without an adequate support system
Active peptic ulcer disease
Irreversible rehabilitative potential
Primary oxalosis
From Bunnapradist S, Danovitch GM. Evaluation of adult kidney transplant candidates. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:157-180.
Based on the evaluation results, the interdisciplinary team members will determine if a candidate falls within the range of acceptable risk.
It must be understood that if a patient is deemed not a candidate on one occasion, periodic reevaluation may be considered to determine if there have been changes such that the patient may now meet physiological and/or psychosocial eligibility criteria for transplantation.
The psychosocial assessment of patients is of particular importance to the long-term success of kidney transplantation.
Major components of the psychosocial evaluation include
Psychiatric history
Adherence history
Substance abuse history
Mental status
Social history
Availability of social support
Family social and mental health history
Perceived health, coping style, and quality of life17
Presence of any religious or cultural concerns
Are there any objections to receiving blood or blood products?
Certain religious faiths such as Jehovah’s Witnesses do not accept blood products under any circumstances.
The risks associated with this belief must be carefully discussed before proceeding.
Consideration must be given as well to cultural norms and values.
When the nursing assessment indicates that cultural or religious norms could be a concern, they should be fully investigated, seeking experts as needed to ensure that no cultural norms or values are violated. Examples include
Dietary restrictions
Use of herbal or alternative therapies
TABLE 14-8 Pretransplant Tests and Investigations for Potential Kidney Transplant Recipients
Laboratory tests: blood and urine
Hematology:
Complete blood count (CBC) with differential
PT, INR, PTT
Chemistry panel:
Sodium, potassium, carbon dioxide, chloride, creatinine, blood urea nitrogen, blood glucose
Liver function tests
Urine: (If patient is able to produce urine)
Culture, urinalysis, 24-hour urine for protein and creatinine
Serology:
Hepatitis B surface antigen and antibodies
Hepatitis C PCR
CMV, EBV, HSV, VZV
HIV
VDRL
Others:
Papanicolaou (PAP) smear
Prostate-specific antigen (men 50 or older)
PPD
Hemoglobin A1C (diabetics)
Pregnancy test (females)
Tissue- and blood-typing tests
ABO blood typing
Tissue typing
Panel reactive antibodies (PRA)
Crossmatch
Radiologic/diagnostic tests
Physical exams
Full history and physical by a transplant nephrologist and surgeon
Psychosocial assessment by CSW
Gynecologic exam (females)
Prostate exam (males)
* If indicated by exam or other studies.
aPTT, activated partial thromboplastin time; CMV, cytomegalovirus; EBV, Epstein-Barr virus; HIV, human immunodeficiency virus; HSV, herpes simplex virus; INR, international normalized ratio; PCR, polymerase chain reaction; PPD, purified protein derivative; PT, prothrombin time; VDRL, venereal disease research laboratories; VZV, varicella-zoster virus.
From Bunnapradist S, Danovitch GM. Evaluation of adult kidney transplant candidates. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:157-180.
Psychosocial support
Patients need to be able to care for themselves posttransplant or have a support network in place that is capable of assisting them.
Posttransplant self-care is critical to graft and, at times, patient survival.
Regular attendance at posttransplant clinics, adherence to all aspects of the posttransplant medical regimen, and awareness of the signs and symptoms of rejection and infection are all a shared responsibility among the transplant center, the patients, and their support network.
Adherence
As well as assessing patients’ and their support systems’ ability to cope with the rigors of posttransplant life, an assessment of patients’ history of adherence to medical management must be done.
Patients should demonstrate reliability in this regard before being allowed to proceed.
For patients who have not been able to demonstrate consistent adherence, contracts of varying lengths can be established. These contracts provide detailed criteria patients must meet to be accepted for transplantation in the future.
This may not be an accepted practice at all centers and in all countries.
Patients who are actively abusing illegal or legal substances or have an untreated psychiatric disorder do not meet eligibility criteria for transplantation.18
For all patients, ensuring that they have a current and long-term source of income to cover hospitalization, their medications, and posttransplant costs is essential.
In a large number of Western countries, organ transplant services and medications are provided to patients either free of charge or with minimal charge through National Health Services or National Social Insurance Plans.
In the United States, the coverage for transplantation and posttransplant medications can be provided by a wide variety of private and governmental insurance programs.
For those patients with adequate insurance, the appropriate approvals and authorizations are obtained.
Patients who are uninsured or underinsured are assisted in completing the paperwork necessary to obtain adequate coverage.
No kidney patients are ever refused transplantation on the basis of inability to pay.
Psychosocial evaluations must be completed by a trained professional such as a licensed social worker.
Additional assessment by a psychologist or psychiatrist familiar with transplantation may be necessary in cases where the initial assessment is equivocal or for individuals with a history of significant psychiatric or compliance issues.
In the United States, there are regulatory standards that require the availability of psychiatric and social support services in transplant programs.
For additional information, see chapters on Solid Organ Transplantation: The Evaluation Process and Psychosocial Issues in Transplantation.
IV. PRETRANSPLANT EDUCATION AND THE EVALUATION PROCESS
The transplant evaluation process
Responsibilities while awaiting transplant
National and center-specific transplant outcome data
Transplant surgery
Posttransplant management and responsibilities
Importance of adherence with the medical regimen
Potential complications
Options of living versus deceased donor transplantation
Options such as Kidney Paired Donation, blood type incompatible transplant, or desensitization protocols if the patient has a willing but incompatible donor
Early education provides benefits to both the patients and the transplant team.
Introduce patients and families to other patients who have undergone transplantation
Provide patients with ample time to ask questions
Provide patients and families with information on support groups and continuing education on transplantation
TABLE 14-9 Benefits of Early Patient Education | |
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V. LIVING VERSUS DECEASED DONOR TRANSPLANTATION
Living donor assessment may entail the evaluation of a number of potential donors.
The general assessment requirements for living donor transplantation are provided in Table 14-10.
See Chapter 7 on Care of Living Donors for additional information.
VI. DECEASED DONOR WAITING LIST PATIENT MAINTENANCETABLE 14-10 Required Testing for Living Donors As per United Network of Organ Sharing (UNOS)/OPTN Policies optn.transplant.hrsa.gov/ Accessed August 14, 2015 | ||
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VII. TRANSPLANT SURGERY
Kidney transplantation is considered an elective procedure although it may be considered an urgent procedure in deceased donor transplantation.
Live donor transplantation has a number of advantages over deceased donor transplantation.
The condition of the candidate can be maximized prior to transplantation.
Organ cold ischemic time is minimized prior to the transplant.
Incidence of delayed graft function is decreased.
Short- and long-term outcomes are better.
The organ is not subjected to the physiological insults that accompany brain death.
The candidate can be dialyzed prior to final preparation for surgery.
Allows for a planned date that is mutually convenient for both the donor and candidate who will receive the organ.
All relevant tests and investigations can be completed.
Deceased donor transplantation, in comparison, provides a much shorter time for patient preparation.
When an organ becomes available, the candidate is contacted and detailed information is obtained regarding recent medical history, date of last dialysis, and whether the patient has received any recent blood transfusions.
Questions are directed at ascertaining if there are any impediments to transplantation:
Any cardiovascular events (myocardial infarction, stroke)
Recent infections or fevers
New diagnoses of cancer or any other major medical or surgical events
If no contraindications are identified, the patient is asked to proceed to the hospital.
Upon admission:
Vital signs are checked.
Blood samples are taken.
If not anuric, a urine sample is sent for analysis and culture.
Full history and physical.
Chest radiograph.
Electrocardiogram (EKG).
The patient is dialyzed, if necessary.
Table 14-11 provides a list of preoperative tests for kidney transplantation.
Careful attention should be paid to the results that are critical to patient survival and transplant outcome.
If the patient is febrile or has an elevated white blood cell count, infection must be ruled out before proceeding to transplantation.
TABLE 14-11 Preoperative Tests for Kidney Transplantation
History and physical including vital signs, weight, height, and oxygen saturation
Routine blood tests: CBC, chemistry panel, calcium, phosphate, magnesium, liver function tests, PT, INR, aPTT
Routine urine tests: urinalysis, pregnancy test (females)
Type and crossmatch for blood (2-4 units)
ABO typing
Tissue typing and final crossmatch with donor
Chest x-ray
Electrocardiogram
aPTT, activated partial thromboplastin time; CBC, complete blood count; INR, international normalized ratio; PTT, partial thromboplastin time.
If the potassium level is elevated, dialysis will be required to prevent intraoperative arrhythmias.
Coagulation study results such as the partial thromboplastin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT) must be reviewed given that clotting dysfunction may be present.
A prolonged PT, INR, or PTT may necessitate the use of vitamin K or fresh frozen plasma to minimize intraoperative bleeding.
Anticoagulants and antiplatelet agents such as warfarin (Coumadin), aspirin, and clopidogrel (Plavix) must be discontinued and reversed when possible.
Although a low hemoglobin level is common in renal failure patients, a hemoglobin level of 8 to 8.5 g/dL may predispose patients to cardiac ischemic events and necessitate preoperative transfusion.
Untreated pneumonias or suspicious lesions on the chest radiograph or serious EKG abnormalities may result in cancellation of the case.
The candidate’s cytomegalovirus (CMV) status should also be determined as more aggressive antiviral therapy may be needed postoperatively for CMV-negative recipients who receive kidneys from CMV-positive donors.
Confirmation of tissue typing, compatibility of ABO blood group between donors and recipients, and a negative donor/recipient crossmatch result is of utmost importance to a successful outcome.
Incompatibility of ABO blood groups and/or a positive crossmatch can lead to an immediate hyperacute rejection of the organ.
These results must be ascertained and promptly reported prior to going to surgery.
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