A kidney transplant is an operation that places a healthy kidney in your body.

The transplanted kidney takes over the work of the two kidneys that failed, and you no longer need dialysis. During a transplant, the surgeon places the new kidney in your lower abdomen and connects the artery and vein of the new kidney to your artery and vein. Often, the new kidney will start making urine as soon as your blood starts flowing through it. But sometimes it takes a few weeks to start working. Many transplanted kidneys come from donors who have died. Some come from a living family member. The wait for a new kidney can be long. People who have transplants must take drugs to keep their body from rejecting the new kidney for the rest of their lives. The names of the different types of transplants refer to the kidney donor. There are three sources of transplant organs: Cadaveric Living donation Living related Living unrelated Cadaveric A cadaveric transplant is a kidney removed from someone who has died. More than 90% of transplant kidneys in the UK come from this source. Cadaveric kidneys are only removed after a series of tests have established that the donor is brain dead. This means that the part of the brain called the brainstem, which controls breathing, has permanently stopped working. A brain-dead patient is only being kept alive by a life-support machine. Living donation In a living donation, one of a donor's two healthy kidneys are removed. This kidney is transplanted into the kidney patient. A donor who is fit and well before the operation will be able to live a completely normal life with the remaining healthy kidney. The most successful transplants come from living donors. Living donors, may either be related or unrelated to the transplant recipient. Living related transplant In living related transplants, a living relative donates a kidney for transplant. A living related transplant is more likely to work than a cadaveric transplant because it is more likely to be a better match than from an unrelated donor.

The relative needs to consider the decision to donate a kidney very thoroughly especially since there is no guarantee the transplant will work. Most donors and recipients receive in-depth counseling before a final decision is reached. If a kidney patient has a relative who is at least 18 years old, healthy, and willing to donate a kidney, they should speak to the transplant coordinator at their unit. A number of tests will then need to be arranged for both the patient and the donor. Living unrelated Sometimes an unrelated person will donate a kidney for transplant. It is usually someone close to the patient, such as a husband, wife, partner or close friend. Before a living unrelated transplant can take place, an agreement must be obtained from a government body called ULTRA (Unrelated Live Transplant Regulatory Authority). It is illegal in many countries to buy or sell organs. As with a living-related transplant, both the donor and recipient will be given a number of tests and will receive in-depth counseling. INDICATIONS FOR KIDNEY TRANSPLANTATION Criteria have been established to help determine if a patient is a candidate for transplantation. The criteria explain the reasons for inclusion in, or exclusion from pancreas and/or kidney transplantation. Inclusion Criteria for kidney transplantation: Patients must have chronic irreversible kidney disease which has not responded to other medical or surgical treatments, and who are on dialysis or may require dialysis in the near future. Patients must qualify for and be able to tolerate major surgery. Patients and their family members/support system must be able to understand the risks and benefits of transplantation, including the longterm need for close medical follow-up and life-long need for anti-rejection therapy. Patients/families must be able to accept the responsibility to be involved in the long-term care required after transplantation including the financial responsibilities. Exclusion Factors and considerations that may result in exclusion from transplantation include:

The presence of some other life-threatening disease or condition that would not improve with transplantation. This would include certain cancers, infections that cannot be treated or cured or severe, uncorrectable heart disease. History of chronic non-compliance including but not limited to medical treatments, medications, or other behaviors that would affect the patient's ability to fully care for themselves after transplantation. History of chronic and ongoing drug and/or alcohol abuse that cannot be successfully treated before transplantation, putting the patient at risk for continued harmful behavior after transplantation.

Nursing Interventions: Kidney Transplant 1. Prepare the patient for transplantation and a prolonged recovery period and offer him ongoing emotional support. 2. Encourage the patient to express his feelings. 3. Describe routine preoperative measures, such as thorough physical examination and a battery of laboratory tests to detect any infection. 4. Tell the patient the hell undergo dialysis the day before surgery to clean his blood of unwanted fluid and electrolytes. 5. Teach the patient the proper methods for performing coughing, turning, deep breathing and, if ordered incentive spirometry. 6. Administer blood transfusions as ordered. 7. Ensure the patient or a responsible family member has signed a consent form consenting to transplantation. 8. Throughout the recovery period, watch for signs and symptoms of tissue rejection. 9. Assess the patient for pain and provide analgesics as ordered. 10. Carefully monitor urine output. 11. Connect the patients indwelling catheter to a closed drainage urinary catheter to a closed drainage system to prevent overextension of the bladder. 12. Review daily results of renal function test. 13. Stress strict compliance with all prescribed medication regimens.

CHAPTER 27 / Nursing Care of Clients with Kidney Disorders 783

NURSING CARE OF THE CLIENT HAVING A KIDNEY TRANSPLANT PREOPERATIVE CARE Provide routine preoperative care as outlined in Chapter 7. Assess knowledge and feelings about the procedure, answering questions and clarifying information as needed. Listen and address concerns about surgery, the source of the donor organ, and possible complications. Addressing concerns and reducing preoperative anxiety improve postoperative recovery. Continue dialysis as ordered. Continued renal replacement therapy is necessary to manage fluid and electrolyte balance and prevent uremia prior to surgery. Administer immunosuppressive drugs as ordered before surgery. Immunosuppression is initiated before transplantation to prevent immediate graft rejection. POSTOPERATIVE CARE Provide routine postoperative care as outlined in Chapter 7. Maintain urinary catheter patency and a closed system. Catheter patency is vital to keep the bladder decompressed and prevent pressure on suture lines. A closed drainage system minimizes the risk for urinary tract infection. Measure urine output every 30 to 60 minutes initially. Careful assessment of urine output helps determine fluid balance and transplant function. Acute tubular necrosis (ATN) is a common early complication, usually due to tissue ischemia during the period between removal of the kidney from the donor and transplantation. Oliguria is an early sign. Monitor vital signs and hemodynamic pressures closely. Diuresis may occur immediately, resulting in hypovolemia, low cardiac output, and impaired perfusion of the transplanted kidney. Maintain fluid replacement, generally calculated to replace urine output over the previous 30 or 60 minutes, milliliter for milliliter. Fluid replacement is vital to maintain vascular volume and tissue perfusion. Administer diuretics as ordered. Loop and/or osmotic diuretics such as furosemide or mannitol may be used to promote postoperative diuresis. Remove the catheter within 2 to 3 days or as ordered. Encourage to void every 1 to 2 hours and assess frequently for signs of urinary retention following catheter removal. The bladder may have atrophied prior to surgery, reducing its capacity. Urinary retention places stress on suture lines and increases the risk of infection. Monitor serum electrolytes and renal function tests. These tests are used to monitor graft function and fluid and electrolyte status. Electrolyte imbalances may develop as the transplanted kidney begins to function and diuresis occurs. Elevated serum creatinine and BUN levels may be early signs of rejection or graft failure. Monitor for possible complications: a. Hemorrhage from an arterial or venous anastomosis can be either acute or insidious. Indicators include swelling at the operative site, increased abdominal

girth, and signs of shock, including changes in vital signs and level of consciousness. Hemorrhage is a surgical emergency, requiring prompt recognition and treatment to preserve the graft. b. Ureteral anastomosis failure causes urine leakage into the peritoneal cavity. It may be marked by decreased urine output with abdominal swelling and tenderness. Failure of the ureteral anastomosis requires surgical intervention. c. Renal artery thrombosis is characterized by an abrupt onset of hypertension and reduced GFR. Renal artery thrombosis can result in transplant failure. d. Infection due to immunosuppression is an immediate and continuing risk. The inflammatory response is blunted, and infection may not significantly elevate the temperature. Monitor for signs such as change in level of consciousness, cloudy or malodorous urine, or purulent drainage from the incision. Prevention and prompt treatment of infections is particularly important in the immunosuppressed client. Include the following in predischarge teaching for the client and family: a. The use and effects of prescribed medications, including antihypertensive medications, immunosuppressive agents, prophylactic antibiotics, and others as ordered. b. Monitoring vital signs (including temperature) and weight. c. Manifestations of organ rejection, such as swelling and tenderness over the graft site, fever, joint aching, weight gain, and decreased urinary output. Stress the importance of promptly reporting signs and symptoms to the physician. d. Ordered or recommended dietary restrictions such as restricted carbohydrate and sodium intake, and increased protein intake. e. Measures to prevent infection, such as avoiding crowds and obviously ill individuals. The client and family will manage care after discharge, and therefore need a good understanding of what to expect, how to monitor graft status, and measures to reduce the adverse effects of medications. Provide psychologic support, address concerns, and provide information as needed. The client knows that transplant success is not guaranteed. In addition, the client has often been managing a chronic disease independently and is used to having a degree of control. Providing information and allowing the client to retain control relieves anxiety and improves recovery. Subjective: complaints of anorexia, nausea, weight gain, or edema; current treatment (if any), including type and frequency of dialysis or previous kidney transplant; chronic diseases such as diabetes, heart failure, or kidney disease Objective: mental status; vital signs including temperature, heart and lung sounds, and peripheral pulses; urine output (if