CARE OF THE KIDNEY CARE OF THE KIDNEY TRANSPLANT RECIPIENTTRANSPLANT RECIPIENT

(Cadaveric and Living Donor(Cadaveric and Living Donor)

Kimberly KenneyKimberly Kenney

Nurse Clinician Nurse Clinician

November 12, 2009November 12, 2009

OBJECTIVESOBJECTIVES

Upon completion of this lesson you will be able Upon completion of this lesson you will be able to:to: Identify leading causes of end stage renal diseaseIdentify leading causes of end stage renal disease Describe expected physical findings in a stable post-Describe expected physical findings in a stable post-

op kidney recipientop kidney recipient Identify problems with the foley catheter and Identify problems with the foley catheter and

implement appropriate interventionsimplement appropriate interventions Administer correct I.V. fluids to replace urine outputAdminister correct I.V. fluids to replace urine output Manage a hypertensive recipientManage a hypertensive recipient Identify signs and symptoms of post-op Identify signs and symptoms of post-op

complicationscomplications State purpose and side effects of prograf and neoralState purpose and side effects of prograf and neoral

THE KIDNEYTHE KIDNEY Each processes 1700L of blood per Each processes 1700L of blood per

dayday Nephron is functional unit and has Nephron is functional unit and has

glomerulusglomerulus Glomerulus is where materials are Glomerulus is where materials are

selectively reabsorbed or filteredselectively reabsorbed or filtered Large blood flow needed for efficient Large blood flow needed for efficient

GFRGFR

FUNCTIONS OF THE FUNCTIONS OF THE KIDNEYKIDNEY

Regulate sodium and potassiumRegulate sodium and potassium Regulate pHRegulate pH Eliminate urea and uric acidEliminate urea and uric acid Eliminate certain drugsEliminate certain drugs Secrete reninSecrete renin Erythropoietin productionErythropoietin production Activate vitamin DActivate vitamin D

CREATININECREATININE Reflects glomerular filtration rate and Reflects glomerular filtration rate and

renal functionrenal function Filtered in glomeruli, but NOT reabsorbed Filtered in glomeruli, but NOT reabsorbed

into bloodinto blood If the creatinine doubles this indicates that If the creatinine doubles this indicates that

the kidney function is reduced in halfthe kidney function is reduced in half If the GFR is less than 5% then If the GFR is less than 5% then

hemodialysis or a kidney transplant is hemodialysis or a kidney transplant is needed for survivalneeded for survival

LEADING CAUSES OF END LEADING CAUSES OF END STAGE RENAL DISEASE IN STAGE RENAL DISEASE IN

USUS Polycystic kidney diseasePolycystic kidney disease GlomerulonephritisGlomerulonephritis DiabetesDiabetes HypertensionHypertension

Polycystic Kidney Polycystic Kidney DiseaseDisease

Results from autosomal dominant Results from autosomal dominant inherited traitinherited trait

Genetic mutation on chromosomes 4 & 16Genetic mutation on chromosomes 4 & 16 Fluid filled cysts form on functioning Fluid filled cysts form on functioning

nephronsnephrons Tubular dilatation occursTubular dilatation occurs Kidneys become enlargedKidneys become enlarged Slow progressive renal failureSlow progressive renal failure

CLINICAL MANIFESTATIONS CLINICAL MANIFESTATIONS AND DIAGNOSISAND DIAGNOSIS

Pain from enlarging cystsPain from enlarging cysts Gross hematuriaGross hematuria Infected cysts from UTIInfected cysts from UTI HTN from compression on vesselsHTN from compression on vessels Diagnose with CT scan, ultrasound, Diagnose with CT scan, ultrasound,

genetic workupgenetic workup

GLOMERULONEPHRITISGLOMERULONEPHRITIS

Inflammation of glomerulusInflammation of glomerulus Can be primary conditionCan be primary condition Can result from diabetes, lupus, viral Can result from diabetes, lupus, viral

infection, staph, or streptococcusinfection, staph, or streptococcus Many cases have immune originMany cases have immune origin

GLOMERULONEPHRITISGLOMERULONEPHRITIS

Nephritic SyndromeNephritic Syndrome Inflammatory process damages Inflammatory process damages

capillary wall and decreases capillary wall and decreases permeabilitypermeability

RBCs in urine, decreased GFR, RBCs in urine, decreased GFR, nitrogenous waste in blood, nitrogenous waste in blood, oliguria, water retention, HTNoliguria, water retention, HTN

GlomerulonephritisGlomerulonephritis

Nephrotic SyndromeNephrotic Syndrome Inflammatory process increases Inflammatory process increases

capillary permeabilitycapillary permeability Massive loss of protein and lipids in Massive loss of protein and lipids in

urineurine Edema due to Na and H20 retention Edema due to Na and H20 retention

and decreased albuminand decreased albumin Dyspnea due to water retentionDyspnea due to water retention

GLOMERULONEPHRITISGLOMERULONEPHRITIS

Nephrotic Syndrome (cont.)Nephrotic Syndrome (cont.) Infection due to loss of globulinsInfection due to loss of globulins Drug toxicity since binding proteins Drug toxicity since binding proteins

are lostare lost Thrombotic complicationsThrombotic complications Atherosclerosis due to liver Atherosclerosis due to liver

producing lipoproteinsproducing lipoproteins

DIABETESDIABETES Glomerulus is commonly affected structureGlomerulus is commonly affected structure Elevated glucose alters development of Elevated glucose alters development of

glomerular membraneglomerular membrane Leads to thickening and sclerosing of Leads to thickening and sclerosing of

glomerulusglomerulus Elevated glucose may increase capillary Elevated glucose may increase capillary

pressurepressure Large proteins escapeLarge proteins escape Tubules overworked and nephrons destroyedTubules overworked and nephrons destroyed

HYPERTENSIONHYPERTENSION Cause and effect of kidney functionCause and effect of kidney function Sclerotic changes in glomerular Sclerotic changes in glomerular

structuresstructures Vascular structures thicken and Vascular structures thicken and

perfusion decreasesperfusion decreases Nephrons less able to concentrate Nephrons less able to concentrate

urineurine

FACTORS CONSIDERED FACTORS CONSIDERED DURING TRANSPLANT DURING TRANSPLANT

WORKUPWORKUP Basic lab workBasic lab work ABO bloodtypingABO bloodtyping Hepatitis and HIV screeningHepatitis and HIV screening Cardiovascular workupCardiovascular workup Psychiatric historyPsychiatric history Metastatic historyMetastatic history Current infectionCurrent infection Drug abuseDrug abuse

THE TRANSPLANT THE TRANSPLANT PROCEDUREPROCEDURE

ASSESSMENTASSESSMENT Dressing intactDressing intact Jackson-Pratt drainJackson-Pratt drain Urine output at least 100 mL/hrUrine output at least 100 mL/hr Urine bloody at first, but clears with Urine bloody at first, but clears with

hydrationhydration Look for any clots, complaints of feeling Look for any clots, complaints of feeling

full, sudden drop in urine outputfull, sudden drop in urine output ******MD or NP MD or NP ONLY ONESONLY ONES who flush foley who flush foley

FLUID REPLACEMENTFLUID REPLACEMENT D5 ½ normal saline at 50 mL/hr D5 ½ normal saline at 50 mL/hr

for maintenancefor maintenance Replace urine output mL per mL Replace urine output mL per mL

with 0.45% normal saline with 0.45% normal saline

BLOOD PRESSURE BLOOD PRESSURE REGULATIONREGULATION

Too high: urine leak and bleedingToo high: urine leak and bleeding Too low: vascular thrombosis and ATNToo low: vascular thrombosis and ATN Systolic should be 110-160Systolic should be 110-160 Consider pain managementConsider pain management Labetolol and hydralazine Labetolol and hydralazine Avoid ACE inhibitorsAvoid ACE inhibitors ******Ca+ channel blockers increase Ca+ channel blockers increase

cyclosporine levelscyclosporine levels

OTHER POST-OP OTHER POST-OP CONSIDERATIONSCONSIDERATIONS

Wean for extubationWean for extubation Pulmonary toiletingPulmonary toileting SCDsSCDs LabsLabs Donor information kept Donor information kept

confidentialconfidential POU or Transplant ICUPOU or Transplant ICU

POST-OPERATIVE POST-OPERATIVE COMPLICATIONSCOMPLICATIONS

BleedingBleeding Sanguinous drainage on dressing or in JPSanguinous drainage on dressing or in JP Bloody urine continues despite hydrationBloody urine continues despite hydration Increasing abdominal painIncreasing abdominal pain Firm, distended abdomenFirm, distended abdomen Ultrasound ordered to rule out bleedUltrasound ordered to rule out bleed Possible return to ORPossible return to OR

POST-OPERATIVE POST-OPERATIVE COMPLICATIONSCOMPLICATIONS

Urine LeakUrine Leak Increased yellow serous drainage in JP Increased yellow serous drainage in JP

or on dressingor on dressing Check creatinine of JP drainCheck creatinine of JP drain Decreased urine output in foley bagDecreased urine output in foley bag Increased serum creatinine Increased serum creatinine Ultrasound to rule out leak Ultrasound to rule out leak Possible return to ORPossible return to OR

POST-OPERATIVE POST-OPERATIVE COMPLICATIONSCOMPLICATIONS

Acute Tubular Necrosis (ATN)Acute Tubular Necrosis (ATN) Due to ischemic injury or preservation Due to ischemic injury or preservation

injuryinjury Oliguric or anuricOliguric or anuric Urine appears very concentrated or bloodyUrine appears very concentrated or bloody Increased serum creatinineIncreased serum creatinine Days to weeks to resolveDays to weeks to resolve Hold prograf and neoral Hold prograf and neoral Hemodialysis Hemodialysis

POST-OPERATIVE POST-OPERATIVE COMPLICATIONSCOMPLICATIONS

Vascular ThrombosisVascular Thrombosis Urine output suddenly dropsUrine output suddenly drops Tenderness over graft siteTenderness over graft site Increased serum creatinineIncreased serum creatinine Ultrasound done to view vesselsUltrasound done to view vessels Possible return to ORPossible return to OR

POST-OPERTIVE POST-OPERTIVE COMPLICATIONSCOMPLICATIONS

InfectionInfection Post-op cephalosporinPost-op cephalosporin Check CMV status of patient Check CMV status of patient

before giving bloodbefore giving blood Hand washing and being Hand washing and being

mindful of environmentmindful of environment

IMMUNOSUPPRESSIONIMMUNOSUPPRESSION

Prograf Prograf OROR Neoral (NOT Neoral (NOT BOTH)BOTH)

Simulect 20mg in ORSimulect 20mg in OR Solumedrol 1000mg in ORSolumedrol 1000mg in OR Solumedrol taper post-opSolumedrol taper post-op

Prograf (tacrolimus)/Neoral Prograf (tacrolimus)/Neoral (cyclopsporine)(cyclopsporine)

Prevent rejectionPrevent rejection Inhibit T-lymphocytesInhibit T-lymphocytes Doses based on trough and renal Doses based on trough and renal

functionfunction Troughs drawn 6am and 6pmTroughs drawn 6am and 6pm Cardizem CD given with Neoral to Cardizem CD given with Neoral to

potentiate levelpotentiate level

SIDE EFFECTSSIDE EFFECTS

******HypomagnesmiaHypomagnesmia****** HyperkalemiaHyperkalemia HyperglycemiaHyperglycemia HypertensionHypertension TremorsTremors NephrotoxicityNephrotoxicity NeurotoxicityNeurotoxicity dyslipidemiadyslipidemia

QUESTIONSQUESTIONS????????????????

THANK YOU!!!!THANK YOU!!!!