Transcript ANNA’S NEPHROLOGY REVIEW COURSE PRE TRANSPLANT

CARE OF THE KIDNEY
RECIPIENT PATIENT
Hany Elbarbary
MD,MRCP
Nephrology Lecturer
Preparation for Kidney Transplantation
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Application phase
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Evaluation phase
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Funding?
Eligible for transplant evaluation?
Medical
Psycho/Social
Maintenance phase
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From listing … until transplant
Preparation for Kidney Transplantation
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Application phase
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Funding source covering transplant
evaluation at transplant center of patient’s
choice?
Kidney function declined enough to
warrant transplant evaluation?
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Private insurance
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Medicare/Medicaid
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> 20 ml/min Creatinine clearance
20 ml/min or less Creatinine clearance
Transplant information & Health History
review
Preparation for Kidney Transplantation
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Evaluation phase
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Healthy enough for the surgery?
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Healthy enough for the medication
afterwards, being immunosuppressed?
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Cardiac, vascular, BMI, urological, etc.
Infection, cancer, liver status
Can they cope with it?
Risk for surgical complications …
 Risk for DM, side-effects of all medications …
 Cost of medicines, clinic visits, hospital
admissions …
 Support available …
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Preparation for Kidney Transplantation
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Maintenance phase
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Keeping an eye on the patient while on the
waiting list
Average waiting time for donor is 4-5 years,
but can happen any time!
Regular evaluation can catch problems before
they are called in for a kidney offer
Communication with the dialyses unit –
essential!!
Placing patients “on hold” and “off hold”
PREOPERATIVE CARE
An organ donor has been located and
tested….Happy News in Transplant Unit
The organ bank enters the tissue typing of
the donor into the UNOS Waiting List ...
A list of potential recipients is compiled,
ranked by a point system based on
urgency, time, HLA matching, antibody
levels, age, and/or previous organ donation
…
IMMUNOLOGY AND GENETICS
Tissue Typing … ?
HLA matching … ?
Antibody levels … ?
IMMUNOLOGY AND GENETICS
The Immune System
Protects the body from invasion by foreign
substances; bacteria, virus, even a transplant
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Antigens – substance on all living cells, cell
markers, able to initiate immune response
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Antibody – immunoglobulin that attach to
foreign antigens, aids in the destruction
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Leucocytes – White Blood Cells
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Nonspecific/inflammatory response by granulocytes
and monocytes
Specific response/acquired immunity by B and T
lymphocytes, very important in transplantation
IMMUNOLOGY AND GENETICS
Acquired Immunity
 B Lymphocytes – Humoral Immunity
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Foreign antigen found
B cells activated, start making plasma cells
Plasma cells makes specific antibodies until
the antigen is destroyed (IgM)
Macrophages and “helper” T-cells help in
stimulation of antibody production
Memory B cells remains as part of the
immune system for a faster secondary
response to that specific antigen (IgG)
IMMUNOLOGY AND GENETICS
Acquired Immunity
 T Lymphocytes – Cellular Immunity
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Differentiate self through expression of antigen
receptors
Provide immunity against viruses, fungi, TB, cancer,
and TRANSPLANTS
Killer T cells (CD8) – kill directly or through
lymphokines (interferon and interleukins)
Helper T cells (CD4) - assists B cells in antibody
production, produce lymphokines
Memory T cells – for a faster second response
Suppressor cells – inhibit B cells and killer T cells
IMMUNOLOGY AND GENETICS
Histocompatibility
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Two antigen system impacting transplants
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ABO - A and B antigens on red blood cells
 Safe transplant follows blood transfusion rules
HLA - Human Leukocyte Antigens
 Group of genes on Chromosome 6 that are
involved in immune response
 4 gene sites important Class I - A, B, (C)
Class II – DR, (DQ, DP)
 This gene grouping, haplotype, is inherited, one
from the mother, one from the father
 Perfect match – 2 haplotypes, “0 mismatch”,
or “6 out of 6” match
IMMUNOLOGY AND GENETICS
HLA Matching:
Mom A 2, 5
B 5, 15
Dad A 1, 30 B 75, 21
DR 15, 17
DR 1, 7
3/6
3/6
#1
#2
#3
#4
#5
DR
DR
DR
DR
DR
self
0/0
3/6
3/6
6/6
A
A
A
A
A
2,
5,
2,
5,
2,
1
30
30
1
1
B
B
B
B
B
5, 75
15, 21
5, 21
15, 75
5, 75
15,
17,
15,
17,
15,
1
7
7
1
1
IMMUNOLOGY AND GENETICS
Tissue Typing …
Finding out a person’s HLA antigens - A ?,?, B ?,?, DR ?,?
HLA matching …
Compare the HLA with the potential donor’s HLA antigens to
get the match or mismatch – in haplotype, or 0-6/6
Antibody levels …
How many antibodies towards other people’s antigens they
have – measured as a % of common antigens in the
Panel-Reactive Antibody test (PRA)
PREOPERATIVE CARE
Organ bank call out the organ offer
Surgeon on call accepts or decline the offer
Locate the patient within 1 hour of the call from
the organ bank
interview with the patient to determine current
status and contraindications for transplantation
Plan NPO to start 6-8 hours before estimated time
of surgery
PREOPERATIVE CARE
After patient has arrived at the hospital –
medical clearance and preparation for
transplant have to be done quickly to keep
the cold ischemia time as short as possible
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Infections?
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Cancer?
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Cardiovascular problems?
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Compatible donor kidney?
PREOPERATIVE CARE
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History & physical, chart review
Laboratory testing:
 Hematology
 Chemistries
 Urine cultures
 Final cross match
 Type & Cross for 2 units PRBC
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PREOPERATIVE CARE
Chest X-ray
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ECG
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Vital signs
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Pre op dialysis as needed
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Weight after dialysis
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Pre and post operative teaching for
patient and family
Shower, skin preparation, and access care
PREOPERATIVE CARE
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Signed OR consent form and final cross
match report on the chart
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Placement of IV lines
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Placement of Foley catheter
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Preop immunosuppressive medication?
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Preop antibiotics?
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Calcium channel blocker (Verapamil)?
POSTOPERATIVE CARE
AFTER THE SURGERY
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Circulatory and pulmonary functions
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Fluid and electrolyte balance
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Administer pain control as needed
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Immunosuppressive regimen - provide
and monitor for side effects
Psychosocial management of the
recipient and the family
POSTOPERATIVE CARE
MAINTAIN CIRCULATORY FUNCTION
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Frequent monitoring of vital signs
blood pressure, pulse, respirations,
central venous pressure
Monitor pulses
femoral, popliteal, pedal
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Monitor cardiac status
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Early ambulation is strongly encouraged
POSTOPERATIVE CARE
MAINTAIN PULMONARY FUNCTION
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Humidified oxygen if indicated
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cough, and deep breath R Ex
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Encourage ambulation
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Monitor temperature
POSTOPERATIVE CARE
MAINTAIN FLUID AND ELECTROLYTE
BALANCE
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Monitor fluid intake and output
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Daily weight
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Fluid replacement per protocol
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Daily laboratory testing
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Monitor vital signs frequently
POSTOPERATIVE CARE
Physical assessment of fluid imbalance
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Hypotension/Hypertension
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Dry mucus membranes
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Poor skin turgor
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Concentrated urine
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Shortness of breath
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Presence of edema
POSTOPERATIVE CARE
MONITOR FOR COMPLICATIONS
• Infection
• ATN
• Rejection
• Renal artery stenosis
• Renal artery thrombosis
• Renal vein thrombosis
• Urologic complication
• Graft rupture
• Wound complications
POSTOPERATIVE CARE
PREVENTION OF INFECTION
Careful hand washing
 Adequate nutrition for wound healing
 Meticulous pulmonary toilet
 Encourage good oral and skin hygiene
 Isolate patients with leukopenia
 Assess patients for signs and symptoms
of infection
 Administer antiviral and antibiotics as
prescribed
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POSTOPERATIVE CARE
ACUTE TUBULAR NECROSIS ( ATN )
Etiology
 Prolonged cold ischemia time
 Prolonged warm ischemia time
 Severe rejection episode
Symptoms
 Decreased urine output
 Elevated BUN and Creatinine
 Often high output ATN - high urine
volume with low clearance
POSTOPERATIVE CARE
Treatment for ATN
 Alteration of diet
Decreased protein intake
Decrease fluid intake
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Manage hyperkalemia
Dialysis as indicated
Patience …
POSTOPERATIVE CARE
RENAL ARTERY STENOSIS
• Bruit over graft site is diagnostic
evidence - confirmed by
arteriography
• Results in hypo perfusion of the kidney
which then produces more rennin to
compensate causing hypertension
• Symptoms - hypertension and renal
dysfunction
• Treatment – antihypertensive therapy,
surgical repair or balloon angioplasty
POSTOPERATIVE CARE
RENAL ARTERY THROMBOSIS
 Uncommon
- usually occurs in early
post transplant period
 Requires
early detection for treatment
to be effective
 Signs
and symptoms – sudden anuria
and graft tenderness
POSTOPERATIVE CARE
RENAL VEIN THROMBOSIS
 Symptoms
swelling of the graft, thigh, and leg
decreased urine output, proteinuria,
and hematuria
 Treatment
anticoagulation therapy
 May require nephrectomy
POSTOPERATIVE CARE
GRAFT RUPTURE
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Signs and symptoms
swollen and painful graft,
hematuria
Usually caused by the swelling of the
graft during a severe rejection episode
Surgical repair or graft nephrectomy is
always required
POSTOPERATIVE CARE
UROLOGIC COMPLICATIONS
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Urine leak results from ureteral leakage,
ureteral disruption, or leak from the
bladder.
Related to poor tissue healing, ureteral
stenosis, or poor vascularity with tissue
necrosis
POSTOPERATIVE CARE
WOUND COMPLICATIONS
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Perinephric hematomas, urinomas,
lymphoceles, and abscesses can exert
pressure on the kidney or ureters
resulting in deterioration of renal
function
Wound infection
Signs and symptoms:
Swelling and tenderness over the graft,
fever, and possible wound drainage
POSTOPERATIVE CARE
TEACHING AND DISCHARGE PLANNING
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General post-op care
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Medications
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Signs of rejection
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Record keeping
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Prevention of infection
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Whom to call
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Where to go in case of an emergency
POSTOPERATIVE CARE
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Schedule post-op visits with the referring
physician and/or clinic
Be sure patient has a month’s supply of all
necessary medications