The postoperative care of the adult renal transplant recipient
Claudia P. Barone
Prior to the 1970s, little treatment available for patients with end-stage renal disease (ESRD) (Goodman & Danovitch, 2001). Most patients did not even receive dialysis because few centers had the capability to provide it. Kidney transplantation and the associated immunosuppression were in the elementary stages of development, with limited long-term success. In the 1980s, several factors improved survivability for patients with ESRD. Legislation that mandated Medicare payment for dialysis and transplantation opened a window of opportunity for affected patients as kidney transplantation offered the potential for restoring a healthier life. The prolonged survival of kidney transplant recipients today is due largely to improvements in immunosuppression, surgical methods, and specialized nursing care. In this article, the transplantation process and the nursing care needed by these patients in the postoperative period are reviewed.
A kidney transplant is the most commonly performed type of solid organ transplant (Kaufman, 2003). In 2003, some 15,123 renal trans plants (United Network for Organ Sharing, 2004) were performed, inclusive of 6,806 renal transplants from living donors. The term cadaveric renal transplant is a little misleading because the kidney is not procured in the morgue from a true cadaver. Rather, most cadaveric kidneys are obtained from brain-dead, heart-beating donors (Gritsch, Rosenthal, & Danovitch, 2001). Brain death is defined as cessation of brain activity, resulting in death if not supported by mechanical means. Typically, a neurosurgeon or neurologist declares the donor to have no cerebral and brain stem function. This can be a clinical diagnosis, correlated with nuclear cerebral blood flow studies and/or an electroencephalogram. The donors are maintained on mechanical support until the organs are procured.
Because of the worsening shortage of transplantable cadaveric kidneys, interest in other sources of kidneys includes organs from non-heart-beating donors (who die in the emergency department) and from other species (see Table 1) (Goodman & Danovitch, 2001). The organs are procured within 30 to 60 minutes of cardiac death, but they are of variable quality. Currently human kidney transplants are allo-grafts (from within the same species); however, grafts from pigs (xenografts) are currently being investigated as a source of transplantable kidneys. The majority of living kidney donors are siblings or parent-to-child (“related by blood”). With the significant shortage of transplantable kidneys and marked improvements in immunosuppression, however, the number of living unrelated donors is increasing (Gritsch et al., 2001). These donors include spouses, long-term friends, and even true altruistic donors who are complete strangers. Living-unrelated-donor kidneys appear to offer better renal survival than true cadaveric kidneys because there is less renal damage.
Kidney transplantation is an elective procedure, and the patient undergoes extensive preoperative assessment and evaluation. Typically, the patient is maintained on a routine schedule of dialysis. If a transplant candidate has been well prepared for surgery, cancellation rarely becomes necessary. However, a change in the patient’s condition, such as the recent onset of chest pain, infection, pneumonia, or gastrointestinal bleeding, could delay the transplant. Should the patient require anticoagulation to maintain dialysis access or mechanical valve function, fresh frozen plasma may need to be administered to correct the international normalized ratio to less than 2 prior to the start of the surgical procedure (University Hospital of Arkansas, 2004).
The patient may require dialysis immediately preceding the transplant procedure if the serum potassium is above 5.5 mEq/l. Hyperkalemia in the oliguric patient poses a significant intraoperative threat (University Hospital of Arkansas, 2004). Dialysis rarely needs to occur prior to the trans plant to facilitate fluid removal. However, if dialysis is done for this reason, it is important to maintain the patient close to his or her dry weight to facilitate postoperative diuresis. If the patient should need dialysis prior to transplantation, a 1 to 2 hour dialysis run should be sufficient to restore the patient to a normokalemic state and optimize hemodynamic status.
Renal Transplant Procedure
Strict aseptic technique and hemostasis of the operative site are extremely important aspects of the operative technique. Because all transplant patients receive immunosuppressive medications, the risk of infection is very high. The standard incision for the kidney transplant is an oblique incision made from the symphysis in the midline and curving in a lateral and superior direction to the iliac crest (see Figure 1). In a first transplant procedure, the incision may be located in either lower quadrant (Gritsch & Rosenthal, 2001).
[FIGURE 1 OMITTED]
The transplant is placed in a heterotropic retroperitoneal location in the lower pelvis (Gritsch & Rosenthal, 2001) (see Figures 1 & 2). This position provides easy access to the transplanted kidney for future biopsies. Except for grossly enlarged polycystic kidneys, the native kidneys are usually not removed. The oblique incision allows for exposure of the iliac vessels and the bladder. The transplant renal vasculature is anastomosed to the external lilac vessels, and the ureter is shortened (to minimize the potential for ureteral ischemia) (Kostopanagiotou et al., 1999) (see Figure 2) and anastomosed using an antireflux procedure. The nurse’s awareness of positioning in the operating room may affect postoperative care and the location for future biopsies.
[FIGURE 2 OMITTED]
Drains may or may not be placed to facilitate blood, urine, and/or lymph removal. The decision to use drains is generally based on the surgeon’s preference. If drains are used, a closed suction drain, such as the Jackson-Pratt, often is preferred over the open Penrose drain in order to minimize the potential for infection. Drains typically are removed as soon as there is minimal output, 24 to 48 hours after transplantation.
Following a stay in the post-anesthesia care unit (PACU), the patient should be transferred to a private room with the capabilities to monitor the patient’s hemodynamic status and fluid volume closely. Because the patient receives immunosuppressant medications, meticulous handwashing by all caregivers is essential to minimize the potential for infection. Several suggested postoperative nursing orders (see Table 2) are important for the viability of the kidney transplant (Drain, 2003).
Adequate perfusion of the newly transplanted kidney is a priority to assure postoperative diuresis and avoid acute tubular necrosis. Volume expansion should be consistent with the patient’s hemodynamic status (Drain, 2003). Central venous pressure will be measured through a central line and should be maintained at 10 mmHg; systolic blood pressure should be maintained above 120 mmHg. To minimize inflammation and maximize postoperative diuresis, steroids such as methylprednisolone (Solumedrol[R]) (up to 1 gram), and diuretics such as mannitol (Osmitrol[R]) (up to 12.5 grams) and furosemide (Lasix[R]) (up to 200 mg) are administered to the patient intravenously in the operating room. A calcium channel blocker such as verapamil (Calan[R]) (5 mg) also may be administered directly into the renal artery to reduce capillary spasm and improve renal blood flow. Caution should be exercised with using verapamil for patients who have a history of taking beta blocker antihypertensive medications (Deglin & Vallerand, 2003).
The nurse should be familiar with the patient’s pretransplantation blood pressure and antihypertensive medications. He or she should discuss with the surgeon the course of the operation and blood pressure management decisions. The initial blood flow to the transplanted kidney depends primarily on systemic arterial blood pressure, and the surgeon should report the intraoperative mean arterial pressure with the best urine output (Amend, Vincenti, & Tomlanovich, 2001). Postoperative hypertension may increase the risk for anastomotic leak, while hypotension increases the risk for both postoperative acute tubular necrosis and irreversible vascular thrombosis.
Hypertension is the leading cause of renal failure in this country (Leventhal & Schlueter, 2003). The most common causes of postoperative hypertension after renal transplant are hypothermia, pain, and hypoxia. The majority of people receiving renal transplants thus will require some type of anti-hypertensive medications postoperatively (Kaufman, 2003). If after correcting the identified problem the patient’s systolic blood pressure remains greater than 180 mmHg and/or diastolic blood pressure greater than 100 mmHg, intravenous labetalol (Normodyne[R]) is administered. Starting at 5 mg, the dose is doubled every 5 to 10 minutes as needed to control blood pressure, up to a total of 300 mg or when heart rate is less than 70 beats/minute (Deglin & Vallerand, 2003). Other intravenous medications that can be used include hydralazine (Apresoline[R]), fenoldopam (Corlopam[R]) (administered as an intravenous push), esmolol (Brevibloc[R]), or nitroprusside (Nitropress[R]) (administered as an intravenous drip). The patient may have missed the morning dose of antihypertensive medications, which could have a longer effect (Deglin, 2003). Also, as the patient becomes more euvolemic, blood pressure is often easier to control.
Central venous pressure (CVP) is often used to monitor a patient’s hemodynamic status and is especially helpful in the patient with an uncertain fluid balance. A manometer or monitor with CVP-monitoring capabilities is started in the operating room, with continued use for 24 to 48 hours after discharge from the PACU. The nurse should know the preoperative and intraoperative CVP readings, and interpret them in concert with insensible losses, postoperative third spacing, urine output, level of consciousness, blood pressure readings, and skin turgor.
Intravenous fluid replacement must be adequate to keep the patient euvolemic or mildly hypervolemic, as assessed through repeated CVP measurements. The choice of intravenous fluid will depend upon the transplant center’s protocol but is usually 0.45% normal saline, which closely resembles the sodium content of a newly transplanted diuresing kidney (60 to 80 mEq/L) (Amend et al., 2001). Urine output must be monitored and recorded hourly, with output replaced on an hourly milliliter-for-milliliter basis. If the patient is hypovolemic or an attempt is being made to increase urine output, 0.9% normal saline can he administered intravenously as fluid boluses of 250 to 500 ml over 1 hour.
In accordance with the transplant center’s protocol for acceptable hourly output, urine output in the operating room and PACU should be determined immediately upon the patient’s arrival in the unit. Establishment of acceptable output early in the postoperative period is crucial for the viability of the transplanted kidney. It is, however, important to understand that many factors (parenchymal, urologic, or perfusion) may influence the expected hourly urine output. Knowledge of the quality of the donor kidney and the source (cadaveric versus living donor) may influence the decision about the minimal acceptable hourly urine output by the surgeon or transplant team (Amend et al., 2001).
Assessment of hourly urine output should include assessment of anuria (no urine output) and oliguria (less than 50 ml/hour) (see Table 3). Before any intervention to increase output, the patient’s hemodynamic and fluid balance should be assessed thoroughly through measurements of recent heart rate, blood pressure and CVP, third spacing, insensible fluid losses, and intake (Amend et al., 2001). The indwelling urinary catheter should be irrigated gently with 30 ml of sterile normal saline solution because a clot may be preventing urine from exiting the bladder. Should irrigation fail to improve urine output, the surgeon may remove the catheter while using gentle suction in an attempt to remove a blood clot (Barone, Lightfoot, & Barone, 2003). Typically, a larger catheter is replaced. If the indwelling catheter is patent and the patient demonstrates signs and symptoms of hypervolemia (elevated CVP and blood pressure, edema, distended neck veins), up to 200 mg of furosemide should be administered intravenously. If the patient demonstrates signs and symptoms of hypovolemia (increased heart rate, decreased CVP and blood pressure, flattened neck veins), 0.9% normal saline should be administered intravenously in 250 to 500 ml boluses. Upon the patient’s return to an acceptable hourly urine output, fluid should be replaced on a milliliter-for-milliliter basis based on urine output. Some transplant center protocols permit infusion of furosemide at 5 to 10 mg/hour to maximize urine output (Kaufman, 2003).
Early Postoperative Bleeding
The following signs of postoperative bleeding should be reported to the surgeon immediately (Kaufman, 2003):
* Dressing over the transplant incision is soaked with blood.
* Blood is oozing from an incision that has been closed with surgical glue.
* Drains are filled with blood on an hourly basis.
* The hematocrit decreases.
* There is a palpable or a visible distention over the incision site (known as a perinephric hematoma).
* The patient exhibits signs and symptoms of blood loss such as tachycardia, hypotension, decreased level of consciousness, and/or decreased urine output.
Most perinephric hematomas resolve without surgical intervention; therefore, attention should be directed toward the patient’s fluid status (Kaufman, 2003). The diagnosis of bleeding is confirmed by hemodynamic instability, decreased hematocrit and hemoglobin, decreased urine output, elevated heart rate, and decreased blood pressure. Fluid should be 0.9% normal saline boluses, colloid solutions, and transfusions of packed red blood ceils from cytomegalovirus (CMV)-negative donors, especially in CMV-negative renal transplant patients.
Pain management in the transplant patient consists of morphine administered intravenously every 2 to 3 hours for the first 24 to 48 hours (Barone et al., 2003). Pain should be assessed using the self-reporting pain visual analog scale and compared with vital signs. Rarely does the patient require use of patient-controlled analgesia (G. Barone, personal communication, May 2003). Typically at the 48-hour period, the patient can be switched to oral analgesics such as oxycodone/acetaminophen (Percocet[R]) and propoxyphene napsylate/acetaminophen (Darvocet[R]). If the patient still requires intravenous pain medication 48 hours after transplant, the surgeon should be notified and the discomfort should be further investigated.
Pain associated with a transplant incision usually is managed easily. An epidural catheter is not routinely placed in renal transplant recipients. Morphine and fentanyl (Sublimaze[R]) are metabolized mainly by the liver into inactive metabolites which are then excreted by the kidneys. Meperidine (Demerol[R]) is also metabolized by the liver, and its metabolites have some activity that also must be excreted by the kidneys. Potentially nephrotoxic analgesics such as ketorolac (Toradol[R]) must be avoided.
Modern immunosuppression started in the 1980s with the introduction of cyclosporine (CSA) (Neoral[R], Sandimmune[R], Gengraf[R]. Prior to CSA, the only oral immunosuppressive medications were steroids and azathioprine (Imuran[R]). The introduction of CSA significantly improved the overall survival of both renal and extrarenal transplants. CSA and tacrolimus (TAC) (Prograf[R]) are both known as calcineurin inhibitors, and they act by blocking the production of interleukin-2 (IL-2) in the lymphocyte. IL-2 amplifies regulation of lymphocytes, the immune cells that cause an acute rejection of non-self tissues from the transplanted organ (Danovitch, 2001). Doses of CSA and TAC are adjusted based on 12hour post-medication trough levels (Danovitch, 2001).
Immunosuppression can be divided into induction, maintenance, and rejection (see Table 4) (Halloran, Batiuk, Goes, & Campbell, 2003). Induction immunosuppressive medications are administered peritransplant at the time when a hyperacute rejection may occur. Often an antibody agent such as basiliximab (Simulect[R]) that acts directly against the T-cells is administered. The agent can be given before, during, or just after the transplant. Nurses should become familiar with the agents used by the transplant program in their hospital. Along with these antibody agents, the patient usually receives steroids and azathioprine or mycophenolate mofetil (Imuran[R]) (both purine inhibitors which block the replication of Tceils). The patient also may have received CSA or TAC preoperatively (Halloran et al., 2003).
Maintenance immunosuppression usually consists of a combination of steroids, a calcineurin inhibitor (CSA or TAC), and a purine inhibitor (azathioprine or mycophenolate mofetil) (Danovitch, 2001). A renal transplant patient will receive only one drug from each group (for example, CSA or TAC, but not both). Rejection therapy is directed toward preventing acute rejection, which is typically seen 2 to 4 weeks after transplant (Danovitch, 2001). It usually follows a protocol consisting of high-dose steroids and/or antibody therapy (often OKT-3) directed at T-cell lymphocytes. All renal transplant programs have protocols indicating which immunosuppressive medications may he administered to the recipient in the hospital.
Renal graft rejection may be described as a process in which the transplanted kidney is recognized as non-self by the immune cells. The process involves both local and systemic responses. Rejection is classified as hyperacute, acute, or chronic on the basis of etiologic, clinical, and pathologic presentations (Danovitch, 2001).
Hyperacute rejection occurs within minutes to hours after the release of the vascular clamps to the transplanted kidney. In spite of aggressive treatment with anti-rejection medications, hyperacute rejection often leads to graft loss. Even with sophisticated cross-matching procedures, a hyperacute rejection episode still may occur in approximately 5% of patients (Danovich, 2001).
Acute rejection occurs days to weeks after the transplant and is manifested by signs and symptoms such as fever, chills, myalgias, and arthralgias (Danovitch, 2001). Approximately 90% of acute rejection episodes are cell mediated and are reversed pharmacologically with relative ease. Chronic rejection leads to late graft loss, occurs insidiously over months to years, and results in progressive loss of renal function. Chronic rejection can be due to noncompliance with immunosuppressive medications, the age of the transplant, and/or use of medications/herbal supplements (Barone, Gurley, Ketel, & Abul-Ezz, 2001; Barone, Gurley, Ketel, Lightfoot, & Abul-Ezz, 2000) that decrease immunosuppression medication levels.
Discharge instructions for the transplant recipient cover a variety of areas. Essential items that must be included are detailed instructions on how and when to take medications and what to do if a dose is missed. This is very important for the viability of the organ. Monitoring for and reporting fever, malaise, and sore throat are crucial because these symptoms may indicate an opportunistic infection is present. Urine output should be monitored with respect to quantity and concentration. Patients and their family members should be educated on using and reading a urine dipstick properly. Lastly, compliance with scheduled blood work is critical because levels of immunosuppressive medications must be monitored at frequent intervals, especially in the first few months following discharge (Darrikhuma, 1999).
The intense nursing care that transplant patients require is a direct result of improvements in the techniques of the surgical procedure and in immunosuppression. Nurses must consider many issues facing the transplant recipient such as medication management, infection prevention, chronic disease management, fluid balance, urine output, and the many psychological issues that surround receiving a transplant.
Origin of Organs
Autografts: Same person (Skin grafts)
Isografts: Identical twins
Allografts: Same species
Xenografts: Different species
Source: Taber’s cyclopedia medical dictionary (18th ed.). (1993).
Philadelphia: F.A. Davis.
Typical Postoperative Orders for the Kidney Transplant Patient
* Fluid: 0.45% normal saline cc: cc replacement per hour up
to 500 cc/hour.
* Vital signs and pulse oximetry: Every 1 hour times 12; every 2 hours
times 12, then every hour if stable.
* Incentive spirometer: Every 2 to 4 hours.
* Intake and output: Hourly first 12 hours then every 2 hours.
* Foley irrigation PRN if clots are present.
* CVP every hour times four, then every 2 hours times four, then
every 4 hours.
* Glucometer: If diabetic, check every 6 hours; AC and HS once eating.
* Diet: Clear liquids post operative day 1; advance as tolerated.
Diabetic diet if diabetic.
* Labs: CBC, chemistry, glucose, phosphorus, magnesium, calcium.
Postoperative day 3, immunosuppressive drug levels.
* Analgesia: Morphine 1-10 mg every hour for the first 48 hours then
oxycodon (Percocet[R]) or propoxyphene (Darvocet[R]) 1 to 2 tablets
every 4 to 6 hours PO.
* TEDs and compression device until ambulatory.
Source: University Hospital of Arkansas, Department of Surgery,
Division of Solid Organ Transplantation (2004). Little Rock, AR.
Causes of Poor Urine Output from a Transplanted Kidney
* Acute tubular necrosis
* Poor kidney quality (severe donor trauma)
* Renal artery thrombosis
* Renal vein thrombosis
* Kinked or obstructed ureter
* Kinked, clotted, or dislodged indwelling catheter
* Acute medication toxicity
Source: G. Barone (personal communication, May 2003)
Induction (administered in the first week following transplantation)
* Antibody agents (anti-thymocyte globulin [ATG])
* Steroids (prednisone)
* Purine inhibitors (azathioprine/mycophenolate mofetil)
* Calcineurin inhibitors (cyclosporine/tacrolimus)
Maintenance (administered during the first week and maintained
throughout viability of transplant)
* Steroids (prednisone)
* Purine inhibitors (azathioprine/mycophenolate mofetil)
* Calcineurin inhibitors (cyclosporine/tacrolimus)
Anti-Rejection (administered when rejection is identified, often
the first 2 to 4 weeks after transplant)
* High-dose steroids (solumedrol)
* Antibody agents (OKT-3)
Source: University Hospital of Arkansas, Department of Surgery,
Division of Solid Organ Transplantation (2004) Little Rock, AR.
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Barone, G., Gurley, B., Ketel, B., & Abul-Ezz, S. (2001). Herbal supplements: A potential for drug interactions in transplant recipients. Transplantation, 71, 239-241.
Barone, G., Gurley, B., Ketel, B., Lightfoot, M, & Abul-Ezz, S. (2000). Drug interaction between St. John’s wort and cyclosporine. The Annals of Pharmacotherapy, 34, 1013-1016.
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Halloran, P.F., Batiuk, T.D., Goes, N., & Campbell, P.M. (2003). Immunologic concepts. In F.P. Stuart, M.M. Abecassis & D.B. Kaufman (Eds.), Organ transplantation (pp. 1-43). Georgetown, TX: Landes Bioscience.
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Leventhal, J.P., & Schlueter, W.A. (2003). Early medical problems common to many recipients. In F.P. Stuart, M.M. Abecassis & D.B. Kaufmann (Eds.), Organ transplantation (pp. 426-436). Georgetown, TX: Landes Bioscience.
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University Hospital of Arkansas, Department of Surgery, Division of Solid Organ Transplantation. (2004). Little Rock, AR.
Claudia P. Barone, EdD, RN, LNC, CPC, is a Clinical Associate Professor and Associate Dean for Academic Administration, College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR.
Alice L. Martin-Watson, MNSc, RN, CPC, is a Clinical Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR.
Gary W. Barone, MD, is an Associate Professor of Surgery, Transplant Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
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