Renal Transplantation is the organ transplant of a kidney in patients with End-Stage Renal Disease. Renal Transplantation is classified as Deceased-Donor or Living-Donor Transplantation depending on the source of the recipient kidney. Complications after a transplant include Transplant Rejection, Infections, Post-Transplant Lymphoproliferative Disorder and Electrolytic Imbalance.
Nephrology Nurse Role
Nephrology nurses should be able to apply an in-depth knowledge of organ transplantation to assess, plan, implement, utilise an evidence-based practice approach to evaluate care interventions in the care of the transplant patient and analyse the biological, psychological and sociological effects of transplantation on the patient. This involves an ability to analyse the efficacy and validity of nurse-led therapeutic interventions and evaluation of quality assurance systems in the renal transplant setting. Diagnostic and Interventional Nephrology is a new subspecialty of nephrology, where, new opportunities are open for nephrology nurses in diagnostic and interventional nephrology (Merrill et.al, 2004).
A Kidney Transplant is the most commonly performed type of solid organ transplant (Kaufman, 2003). Nurse interventions in this process can be classified as pre- and post-renal transplantation interventions. In the pre-transplantation phase, the nephrology nurse plays a vital role in assisting the patient to tackle the challenges associated with Renal Transplantation. Pre-transplant interventions include physical, psychological and educational support to the patient and family members (Murphy, 2007). Since, Kidney Transplantation is an elective procedure, the entire procedure requires extensive pre-transplant evaluation and the patient is normally maintained on a schedule of pre-transplant dialysis (Barone et.al, 2004). Transplant is delayed with the onset of chest pain, infection, pneumonia, or gastrointestinal bleeding. If the serum potassium exceeds 5.5 mEq/l, the patient is put on dialysis preceding the transplant procedure.
Post-transplant nursing care for the patient begins in the post-anesthesia care unit (Cunningham et.al, 1992). Since the transplant is placed in a heterotropic retroperitoneal location in the lower pelvis, nurse's awareness of the transplant positioning in the operating room is vital for an effective postoperative care (Claudia, 2004). The patient's hemodynamic status and fluid volume need to be monitored to avoid post-transplant complications while maintaining central venous pressure at 10 mmHg and systolic blood pressure above 120 mmHg. Intravenous administration of steroids such as methyl prednisolone and diuretics such as mannitol or furosemide enhances diuresis. Urine output is replaced on an hourly milliliter-for-milliliter basis and recorded hourly. Reduced capillary spasms and normal renal blood flow is achieved by calcium channel blocker administration into the renal artery. It is important to keep the patient euvolemic or mildly hypervolemic by adequate intravenous fluid replacement which is usually 0.45% normal saline closely resembling the sodium content of a newly transplanted diuresing Kidney (Amend et al, 2001). Nurse assessment of hourly urine output includes assessment of Anuria where there is no urine output and Oliguria where the output is less than 50 ml per hour (Claudia, 2004).
Problems like Premature Graft Loss (Colaneri, 2002), Failing Renal Transplant (Neyhart, 2002) and Obstructive Uropathy pose serious challenges for the Nephrology Nurse in the post-transplantation phase. Renal Graft Rejection is a phenomenon where the transplanted Kidney is recognized as non-self by the immune cells of the patient. Rejection can be Hyperacute, Acute or Chronic (Danovitch, 2001). Hyperacute rejection occurs within minutes to hours of transplantation leading to Graft Loss. Acute rejection occurs days to weeks after the renal transplant and Chronic rejection occurs over months to years. The incidence of rejections within the first three months following transplantation has been reported as being seven to eighteen percent in the different risk groups. Hence, surveillance renal allograft biopsies are included into standard care procedures and biopsies are performed at three months and one year after transplantation (Golconda et.al, 2003). Immunosuppression in such cases can be classified as induction, maintenance, and rejection (Halloran et.al, 2003). Induction immunosuppressive medications are administered peritransplant and maintenance immunosuppression usually consists of a combination of steroids, a calcineurin inhibitor and a purine inhibitor (Halloran et.al, 2003). Since, malignancy is a significant risk in the transplant patient due to immunosuppression, Non-Hodgkins' Lymphoma, Cancers of the skin, liver, kidney, vulva, perineum and Post-Transplant Lymphoproliferative Disorder (PTLD) are frequent in transplant patients (Penn, 1999; Kahan and Ponticelli, 2000).
Urinary tract infections in the transplant patient are usually asymptomatic. Obstructive Uropathy has been identified as the cause of renal failure in 16.2% of pediatric patients who undergo Renal Transplantation (Hinds, 2004). Nurse care for patients with Obstructive Uropathy involves an understanding of the various congenital anomalies that create Obstructive Uropathy and the urological interventions used to treat them. Hypertension is one of the most common complications of Renal Transplantation when the Kidney is functional. Increased sodium and fluid retention associated with vasoconstrictive medications and corticosteroids predispose the patient to Hypertension (Braun, 2000). Transplant patients are also prone to Renal Stones, Necrosis of the failed Kidney and Interstitial Nephritis (Braun, 2000). Avascular Necrosis is a debilitating condition that is frequently observed in the transplant population and the patient experiences pain in major joints such as the hips, shoulders, and knees. Undetected Avascular Necrosis leads to Joint Necrosis (Kahan and Ponticelli, 2000). Post-Renal Transplant Compliance is an important aspect of the care process (Fiona, 2000).
Nurse Models in Renal Care
Development of protocols to aid nurses in the care of patients following a Kidney Transplant has been found useful to detect nursing problems at an early stage for immediate and appropriate action (Henderson and Prendergast, 1999). A Negotiated Care Model for the nursing role in the chronic health care context of Renal Replacement Therapy has been evaluated recently where the renal setting is conceptualized as a specialized social context with a dominant professional discourse and a contrasting client discourse. The model is based on the fact that the renal nurses develop a relationship with the patient based on responsiveness to their subjective experience reflecting the renal client discourse while performing specific therapeutic activities in accord with the dominant discourse. In this model, care is defined as the quality that nurses actively seek to create in their relationships with clients, through negotiation, in order to help them to live a complete life after a Renal Replacement Therapy (Polaschek, 2003). The incorporation of Nursing Theories into the clinical care of patients with end stage kidney disease has been shown to enhance the overall care that is administered and three Nursing Theories of Orem, Neuman and Peplau have been shown to assist renal nurses to articulate their practice (Graham, 2006).
Nurses caring Renal Transplant patients must have expertise not only in nephrology but also in immunology (Luquire, 1989). Management of medication, fluid balance and other problems often surrounded by complications such as Graft Loss, Failing Renal Transplant and Obstructive Uropathy pose serious challenges to renal nurses. Development of protocols and incorporation of Nursing Theories into the care process enhances nurse care for renal transplant patients.
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Agency San Francisco, Inc.
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Charles L. Berman
Liz Di Bernardo