Chapter 20 Transplantation
Nephrology nurses who primarily care for patients undergoing dialysis treatment have several roles involving transplantation. They educate and counsel patients regarding the option of transplantation, and they may assist patients undergoing the pretransplant evaluation. They also may need to provide dialysis treatments for transplant recipients who experience temporary loss of renal function from acute tubular necrosis (ATN) or a rejection episode and for patients with permanent loss of a transplanted kidney. Nephrology nurses and technicians also may provide dialysis for recipients of transplanted nonrenal organs, such as a liver or heart, who are experiencing acute kidney injury (AKI) or chronic kidney disease (CKD). Currently there are approximately 85,000 patients waiting for a renal transplant (United Network for Organ Sharing [UNOS], 2010) and the average waiting time for a kidney transplant is five to seven years according to the U.S. Renal Data System (USRDS, 2007). In 2008, 16,520 kidney transplants and 837 combined kidney-pancreas transplants were performed (NKF, 2010). The shortage of kidneys available for transplantation is quite severe. The average cost to Medicare for the first year post renal transplantation is $106,000. The average cost to Medicare for an individual with a functioning kidney transplant is $17,000 annually. Approximately 17,000 kidney transplants are performed annually and Medicare is the primary payer for more than half of these (NKF, 2009). The estimated cost of a kidney failure is $137,930 per patient for the first year after failure (Page & Woodard, 2008–2009).
What are the advantages of renal transplantation?
The most important advantage of renal transplantation is improved quality of life. Patients with a successful kidney transplant report a higher quality of life compared to patients receiving other forms of renal replacement therapy. With no need for dialysis treatment and more complete resolution of uremic symptoms, successful transplant recipients can experience a more “normal” lifestyle that includes family, social, and vocational activities. Another benefit is cost. Although the initial year post transplantation is more costly than one year of dialysis treatment, the subsequent years’ costs are significantly less. Finally, although the long-term survival rate for patients undergoing dialytic therapies has vastly improved, transplantation may offer patients the opportunity for longer survival. Since the introduction of cyclosporine, survival rates for transplant recipients are longer than for dialysis patients. This difference is most pronounced in individuals with diabetes mellitus.
What are the disadvantages of renal transplantation?
The process of transplantation—from evaluation and waiting for a donor organ to the surgical hospitalization and threatened or actual rejection—places a great deal of stress on both the patient and family members. Again, strong social support is a crucial component of successfully coping with the stress of transplantation. Table 20-1 summarizes the risks and benefits of transplantation.
Table 20-1 The Transplantation Trade-off
| Benefits | Risk |
|---|---|
| Improved quality of life | Lifelong immunosuppression |
| Freedom from dialysis | Necessity for daily medication |
| More normal lifestyle | Increased risk of infection |
| Longer survival rate | Increased risk of malignancy |
| Increased ability to pursue normal activities: work, home, school More complete resolution of uremic symptoms: | Loss of sick role Steroid bone disease Potential medication side effects: |
| Less costly than dialysis | Difficulty paying for costly medications |
What are the risks and benefits of combined kidney-pancreas transplantation?
• Euglycemia, which may halt or slow the progression of diabetic sequelae
• Freedom from frequent insulin injections and finger sticks for glucose measurement
• Exocrine drainage of the pancreas. Many transplant surgeons choose to drain amylase, a digestive enzyme made by the pancreas, to the urinary bladder using a piece of donor duodenum as a conduit. Although this procedure allows for monitoring of pancreatic function by measuring urinary amylase, the amylase may cause acute or chronic cystitis or urethritis. In addition, patients lose a great deal of bicarbonate and fluid and thus have a tendency to develop acidosis and dehydration.
• Increased immunosuppression-associated risks. The transplanted pancreas is much more prone to stimulate the body’s immune system than is a transplanted kidney, thus greater amounts of immunosuppression are required.
Who should be considered as a transplant candidate?
In general, all patients should be offered the option of consultation with a transplant team to determine their eligibility. Box 20-1 summarizes absolute and relative contraindications to transplantation.
Can patients who are positive for human immunodeficiency virus receive a kidney transplant?
The USRDS (2008) reports that approximately 800 new CKD patients initiated dialysis treatment between 2002 and 2008 with a diagnosis of human immunodeficiency virus–associated nephropathy (HIVAN). HIVAN is the most common cause of renal failure in those with human immunodeficiency virus (HIV) (Carlson, 2008). In the past HIV was an absolute contraindication to transplantation because of concerns that the immunosuppressant therapy used in transplants might exacerbate the patient’s HIV infection. Other reasons were the shortage of organs available for transplantation and the shortened life expectancy rates of those infected with HIV. Today, most transplant centers do not perform transplants on HIV-positive patients; however, new findings suggest that it may be safe to perform transplants on some HIV-positive patients. Several transplant centers across the U.S. now perform renal transplants on carefully selected HIV-positive patients.
What is the immunological basis of transplantation?
The immune system protects the body from foreign invasion by identifying the invaders and then destroying them. Anything that produces this response is called an antigen. The basis of immunology in transplantation is to identify how the body recognizes foreign antigens. Transplant immunologists have identified two main antigen systems that affect the acceptance or rejection of a transplanted organ or tissue. These two systems are blood groups and the human leukocyte antigen (HLA). Blood groups are the first determinant of compatibility for solid organ transplantation. In general, an organ must be ABO compatible with the recipient to be transplanted. For this reason, transplant recipient waiting lists are arranged by ABO group. The rhesus (Rh) factor is not applicable to solid organ transplantation. The four blood groups are O, A, B, and AB. Blood group O is the universal donor and blood group AB is the universal recipient. Blood group O can receive organs only from blood group O donors; recipients from blood group A can receive a kidney from blood groups A and O; recipients from blood group B can receive a kidney from blood groups B and O; and recipients from blood group AB can receive a kidney from blood groups A, B, AB, and O.
What is crossmatching?
Monthly serum samples from potential recipients are used to perform crossmatching tests. Crossmatching tests are blood tests that determine whether a recipient has acquired immunity to a given donor organ tissue. The tests are performed when a donor organ becomes available. Serum from all eligible recipients is tested with donor lymph cells. A positive crossmatch means that the recipient has memory or acquired immunity to the donor and therefore cannot receive the organ. The routine test is the Amos antiglobulin test, which takes about six hours to complete, although more sophisticated and time-consuming tests, such as flow cytometry crossmatches, may sometimes be performed. In living donor transplantation, an additional test called a mixed leukocyte reaction (MLR) may be ordered, although this test takes several days to complete and has not proven to be of great value.
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