Module 7: Acute Kidney Injury and Chronic Kidney Disease

Question 1

Kidney (Renal) Failure

Answer 1

Partial or complete impairment of kidney function
that results in inability to excrete metabolic waste
products and water

Question 2

Acute Kidney Injury

Answer 2

Ranges from slight deterioration to severe
impairment
 Rapid loss of kidney function with:
 Rise in serum creatinine and/or reduction in urine
output
 Elevated BUN and K+
 Azotemia—accumulation of nitrogenous waste
products
 High mortality rate; other life-threatening conditions

Question 3

Etiology and Pathophysiology of AKI - Prerenal

Answer 3

Prerenal
 Causes: factors that reduce systemic circulation
causing reduction in renal blood flow which leads to
oliguria
* Severe dehydration, heart failure, decreased CO
 Autoregulatory mechanisms attempt to preserve
blood flow
 Prerenal azotemia results in Na+ excretion, increased
Na+ and H2O retention and decreased urine output

Question 4

Etiology and Pathophysiology of AKI - Intrarenal

Answer 4

Intrarenal
 Causes: problems that cause direct damage to kidney
tissue
* Prolonged ischemia
* Nephrotoxins
* Hemoglobin released from hemolyzed RBCs
* Myoglobin released from necrotic muscle cells
* Kidney diseases—acute glomerulonephritis and SLE

Intrarenal
 Acute tubular necrosis (ATN)
* Results from ischemia, nephrotoxins, or sepsis
* Severe ischemia causes disruption in basement
membrane and patchy destruction of tubular epithelium
* Nephrotoxic agents cause necrosis of tubular epithelial cells—clog tubules
* Potentially reversible

Question 5

Etiology and Pathophysiology of AKI - Postrenal

Answer 5

Postrenal
 Causes: mechanical obstruction of outflow which
results reflux into renal pelvis, impairing kidney
function
* Benign prostatic hyperplasia, prostate cancer, calculi,
trauma, and extrarenal tumors
 Bilateral ureteral obstruction—hydronephrosis; relieve obstruction in 48 hours increased chance of recovery

Question 6

Acute Kidney Injury
Clinical Manifestations: Oliguric phase

Answer 6

Three phases: oliguric, diuretic, and recovery
 RIFLE classification (Table 51.3 in the textbook)
 Risk (R)
 Injury (I)
 Failure (F)
 Loss (L)
 End-stage renal disease (E)

Oliguric phase
 Urinary changes—*oliguria
* Urinary output less than 400 mL/day
* Occurs within 1 to 7 days after injury
* Lasts 10 to 14 days (longer is poor prognosis)
* Urinalysis—casts, RBCs, WBCs, protein
* Specific gravity 1.010
* Osmolality 300 mOsm/kg
 50% patients nonoliguric; greater than 400 mL
urine/day

Oliguric phase
 Fluid volume
* Hypovolemia may exacerbate AKI
* Decreased urine output leads to fluid retention
 Neck veins distended
 Bounding pulse
 Edema
 Hypertension
* Fluid overload can lead to heart failure, pulmonary
edema, and pericardial and pleural effusions

Oliguric phase
 Metabolic acidosis
* Impaired kidney cannot excrete hydrogen ions or acid
products of metabolism
* Serum bicarbonate production is decreased
 Reabsorption and regeneration defective
* Severe acidosis develops
 Kussmaul respirations—increasing exhaled CO2

Oliguric phase
 Sodium balance
* Increased excretion of sodium—damaged tubules
* Hyponatremia can lead to cerebral edema
 Potassium excess
* Impaired ability of kidneys to excrete K+
* Increased risk with massive tissue trauma
* Usually asymptomatic
* ECG changes—peaked T waves, widened QRS, ST
depression

Oliguric phase
 Hematologic disorders
* Leukocytosis—infection may be fatal
 Urinary and respiratory infections
 Waste product accumulation
* Increased BUN and *serum creatinine levels
 Neurologic disorders
* Fatigue and difficulty concentrating
* Seizures, stupor, coma

Question 7

AKI Diagnostic Studies

Answer 7

Diagnostic studies
 Thorough history
 Serum creatinine, BUN, electrolytes
 Urinalysis
 Renal ultrasound
 Renal scan
 CT scan
 Renal biopsy

Diagnostic studies
 Contraindications for contrast medium
* MRI or MRA with gadolinium contrast medium—may be fatal
* Contrast-induced nephropathy (CIN)
* Diabetics taking metformin: hold 48 hours before and
after use of contrast medium; risk of lactic acidosis
* If contrast is needed for high-risk patients—use low-
dose and optimal hydration

Question 8

AKI Care

Answer 8

Ensure adequate intravascular volume and cardiac
output
 Loop diuretics (e.g., furosemide [Lasix])
 Osmotic diuretics (e.g., mannitol)
 Closely monitor fluid intake during oliguric phase
 Fluid restriction calculation: All fluid losses for
previous 24 hours + 600 mL

Hyperkalemia therapies
 Temporary—move K+ into cells
* Insulin and sodium bicarbonate
  dysrhythmias—stabilizes myocardium
* Calcium gluconate
 Remove K+ from body
* Sodium polystyrene sulfonate (Kayexalate) or
Patiromer (Veltassa)
* Dialysis
 Dietary restriction

Indications for renal replacement therapy (RRT)
 Volume overload
 Elevated serum potassium level
 Metabolic acidosis
 BUN level > 120 mg/dL (43 mmol/L)
 Significant change in mental status
 Pericarditis, pericardial effusion, or cardiac
tamponade
 Clinical status of patient

Renal replacement therapy (RRT)
 Peritoneal dialysis (PD)
* Not frequently used
 Intermittent hemodialysis (HD)
* Emergent therapy
 Continuous renal replacement therapy (CRRT)
* Cannulation of artery and vein
* Continuously 24 hours

Nutrition therapy
 Maintain adequate caloric intake
* Primarily carbohydrates and  fat
* Adequate protein to prevent breakdown
 Restrict sodium, K+, phosphate
 Calcium supplements or phosphate-binding agents
 Enteral/parenteral nutrition

Question 9

Gerontologic Considerations
Acute Kidney Injury

Answer 9

Decreased GFR with aging
 More susceptible to AKI
 Dehydration
* Polypharmacy- diuretics, laxatives
* Illness and immobility
 Hypotension, diuretic therapy, aminoglycoside
therapy, obstructive disorders, surgery, infection, and
contrast medium
 decreased reduced ability to recover
 RRT still an option

Question 10

Chronic Kidney Disease

Answer 10

Progressive, irreversible loss of kidney function
 Greater than 26 million American adults have
CKD; more common than AKI
 Increased prevalence related to aging population,
increased obesity, increased diabetes and HTN
 Over half a million Americans are receiving
treatment for ESRD; high mortality rate

Kidney disease improving global outcomes (KDIGO)
defines CKD as
 Kidney damage
* Pathologic abnormalities
* Markers of damage
 Blood, urine, imaging tests
 Low glomerular filtration rate (GFR)
* <60 mL/min/1.73m2 for longer than 3 months

Leading causes
 Diabetes—50%
 Hypertension—25%
 Other: glomerulonephritis, cystic diseases, urologic
diseases
 Persons with CKD are often asymptomatic; ~ 70%
aware
 Underdiagnosed and untreated

Course and prognosis are variable
 Medicare covers ~80% of the costs
 Considered a disability
 See Promoting Health Equity Box
 Increased incidence with Blacks, Native Americans,
and Hispanics

Question 11

CKD Clinical Manifestations

Answer 11

Result of retained substances
 Urea
 Creatinine
 Phenols
 Hormones
 Electrolytes
 Water
 Uremia

Early stages
 No change in urine output
 Polyuria may be present related to diabetes.
 CKD progression—increasing fluid retention; need
diuretic
 After a period on dialysis, patients may become
anuric

Waste product accumulation
 As GFR decreases, BUN and serum creatinine levels
increase
 BUN level increase
* From kidney failure and protein intake, fever,
corticosteroids, and catabolism
* N/V, lethargy, fatigue, impaired thought processes, and headaches occur
 *Serum creatinine clearance—most accurate indicator

Question 12

Uremia

Answer 12

Uremia
 Syndrome in which kidney function declines to the
point that symptoms occur in multiple body systems
 Often occurs when GFR is less than or equal to
15 mL/min
 Manifestations vary depending on cause, co-
morbidities, age, and adherence to medical regimen

Question 13

Defective Carb Metabolism

Answer 13

Altered carbohydrate metabolism
 Caused by impaired glucose metabolism
* From cellular insensitivity to normal action of insulin
* Mild-moderate hyperglycemia and hyperinsulinemia

Defective carbohydrate metabolism
 Patients with diabetes who develop uremia may
require less insulin than before the onset of CKD
 Excretion of insulin dependent on kidneys
 Insulin dosing must be individualized
 May improve after starting dialysis

Question 14

Elevated Triglycerides

Answer 14

Elevated triglycerides
 Hyperinsulinemia stimulates hepatic production of
triglycerides
 Altered lipid metabolism
* Decreased levels of enzyme lipoprotein lipase
– Important in breakdown of lipoproteins
 Increased VLDLs and LDLs, decreased HDLs
 Most patients with CKD die from CV disease

Question 15

Electrolyte Imbalances

Answer 15

Potassium (K+)
 Hyperkalemia
* Most serious electrolyte disorder in kidney disease
* Fatal dysrhythmias
 When serum potassium level reaches 7 to 8 mEq/L (7 to 8 mmol/L)
* Decreased excretion, breakdown of cellular protein,
bleeding, and metabolic acidosis leads to increased K+
 Other sources: food, dietary supplements, drugs, and IV infusions

Sodium (Na+)
 May be high, normal, or low
 Impaired excretion causes sodium and water
retention
 Dilutional hyponatremia may occur
* Edema
* Hypertension
* HF

Calcium and phosphate
 See section on Musculoskeletal System (CKD mineral
and bone disorder)

 Magnesium
 Hypermagnesemia
* Related to ingestion of magnesium (e.g., milk of
magnesia, magnesium citrate, antacids)
* Can result in absence of reflexes, decreased mental
status, cardiac dysrhythmias, hypotension, respiratory
failure

Question 16

Metabolic Acidosis

Answer 16

Metabolic acidosis
 Results from
* Impaired ability of kidneys to excrete excess acid
* Defective reabsorption and regeneration of bicarbonate
 Plasma bicarbonate level usually falls to
approximately 16 to 20 mEq/L (16 to 20 mmol/L)

Question 17

Anemia

Answer 17

Anemia
 Due to decreased production of erythropoietin
* Hormone stimulates bone marrow to make RBCs
 Other factors: nutritional deficiencies, decreased RBC
life span, increased hemolysis, blood sampling, GI
bleeding, HD, increased PTH
 Also decreased iron stores
 Folic acid lost in dialysis

Bleeding tendencies
 Defect in platelet function
 Infection
Changes in WBC function
 Altered immune response and function
 Hyperglycemia and external trauma

Question 18

Cardiovascular Disease closely linked

Answer 18

CV disease and CKD closely linked
 Death often related to MI, ischemic heart disease,
PAD, HF, cardiomyopathy, and stroke
 Traditional CV risk factors
* Hypertension and elevated lipids
 Nontraditional CV risk factors
* Vascular calcification and arterial stiffness

Calcium deposits associated with stiffness of blood
vessels
 Vascular smooth muscle cells change
* Chondrocytes or osteoblast-like cells
 High calcium and phosphate totals
 Impaired renal excretion
 Drug therapies to treat bone disease

Question 19

HTN

Answer 19

Hypertension
 Both a cause and a consequence of CKD
* Aggravated by sodium and water retention
* Increased renin production may contribute
 HTN, ECF volume overload, and anemia may
develop into left ventricular hypertrophy, which may
lead to cardiomyopathy and HF
* HTN can cause retinopathy, encephalopathy,
nephropathy

*BP control—one of most important goals
 Dysrhythmias
 Hyperkalemia and decreased coronary artery
perfusion
 Uremic pericarditis can progress to effusion and
tamponade
 Friction rub, chest pain, and fever

Question 20

Respiratory

Answer 20

Kussmaul respirations related to acidosis
 Dyspnea may occur with
 Fluid overload
 Pulmonary edema
 Uremic pleuritis
 Pleural effusions
 Respiratory infections

Question 21

GI

Answer 21

Every part of GI system is affected
 Cause: excessive urea
* Stomatitis with exudates and ulcerations
* Uremic fetor (urinous odor of breath)
* Anorexia, nausea, and vomiting
* Diabetic gastroparesis
* GI bleeding
* Constipation

Question 22

CNS Depression

Answer 22

CNS depression
 Lethargy, apathy
 Decreased ability to concentrate
 Fatigue, irritability
 Altered mental ability (late)
 Seizures
 Coma
 Hypertensive encephalopathy

Peripheral neuropathy
 Restless legs syndrome
 Paresthesias
 Motor involvement
 Footdrop
 Muscle weakness and atrophy
 Loss of deep tendon reflexes
 Muscle twitching, jerking, asterixis, and nocturnal leg
cramps

Question 23

Bones/Minerals

Answer 23

CKD mineral and bone disorder (CKD-MBD)
 Systemic disorder of mineral and bone metabolism
 Results in
* Skeletal complications (osteomalacia, osteitis fibrosa)
* Soft tissue complications (vascular calcifications)

Question 24

Other

Answer 24

Pruritus
 Calcium-phosphate deposits and sensory neuropathy
 Itching may be intense
 Leads to bleeding or infection

Uremic frost
 Urea crystalizes on skin
 BUN > 200 mg/dL

 Infertility and decreased libido
 Experienced by both sexes: low sperm counts;
amenorrhea
 Sexual dysfunction
 Physical, psychological, and medication side effects
 Pregnancy during dialysis poses significant risk to
mother and infant
 Personality and behavioral changes
 Emotional lability
 Withdrawal
 Anxiety, depression, and grief
 Fatigue, lethargy
 Changes to: body image, lifestyle, occupation,
finances, and family roles and responsibilities

Question 25

CKD Diagnostic Studies

Answer 25

History and physical assessment  Dipstick evaluation of protein  Albuminuria  Urinalysis  Renal ultrasound, scan, CT scan, biopsy  Albumin-to-creatinine ratio (1st am void)  Serum BUN, creatinine, creatinine clearance, electrolytes, lipids, hemoglobin, hematocrit  GFR

Question 26

CKD Care

Answer 26

Management  Stages 1 to 4  Control HTN, hyperparathyroid disease, CKD-MBD, anemia, and dyslipidemia  Correct of ECF volume overload or deficit  RRT  Treat CV disease  Nutritional therapy  Drug therapy Hyperkalemia  Restriction of high-potassium foods and drugs  Acute * IV glucose and insulin * IV 10% calcium gluconate  Sodium polystyrene sulfonate (Kayexalate) * Cation-exchange resin; bowel exchanges Na+ for K+ ions * Osmotic laxative action (diarrhea)  Patiromer (Veltessa)—binds K+ in GI tract * May bind other oral meds; take 6 hours before or 6 hours after ; delayed onset  Dialysis—most effective Hypertension  Weight loss (if indicated)  Therapeutic lifestyle changes  Diet recommendations (DASH Diet)  Antihypertensive drugs; often need 2 or more * If diabetic—give ACE inhibitors and ARBs CKD-mineral and bone disease (MBD)  Phosphate not restricted until patient requires renal replacement therapy * Phosphate intake then restricted to < 1 g/day CKD-MBD  Phosphate binders * Calcium acetate (PhosLo) * Calcium carbonate (Caltrate)  Bind phosphate in bowel and then excreted * Sevelamer hydrochloride (Renagel)  Lowers cholesterol and LDL levels Phosphate binders * Should be administered with each meal * Side effect: constipation CKD-MBD  Avoid aluminum and magnesium preparations  Supplementing vitamin D * Cholecalciferol * Serum phosphate level must be lowered before calcium or vitamin D is administered

Question 27

CKD Care Continued

Answer 27

Control secondary hyperparathyroidism * Calcimimetic agents  Cinacalcet (Sensipar) – Increase the sensitivity of calcium receptors in parathyroid glands * Subtotal or total parathyroidectomy Anemia  Erythropoietin (EPO) * Epoetin alfa (Epogen, Procrit) * Darbepoeitin alfa (Aranesp) * Given IV or subcutaneously * Increased hemoglobin and hematocrit in 2 to 3 weeks * Side effects: thromboembolism, hypertension * Use lowest possible dose; contraindicated in uncontrolled HTN Anemia  Iron supplements * If plasma ferritin level is <100 ng/mL * Side effects: gastric irritation, constipation * May make stool dark in color Anemia  Folic acid supplements * Needed for RBC formation * Removed by dialysis  Avoid blood transfusions * Increase the development of antibodies * May lead to iron overload Dyslipidemia  Statins (HMG-CoA reductase inhibitors) * Most effective for lowering LDL level * Atorvastatin (Lipitor)  Fibrates (fibric acid derivatives) * Used to lower triglyceride levels and increase HDLs * Gemfibrozil (Lopid)

Question 28

CKD Nutriton Therapy

Answer 28

Nutrition therapy  Designed to maintain good nutrition  Dietician referral  Calorie-protein malnutrition * Monitor laboratory parameters Protein intake  Normal for Stages 1 to 4 and HD patient  Increased for PD patient Fluid restriction with HD  Intake depends on daily urine output Sodium restriction  Diets vary from 2 to 4 g/day  Avoid high-sodium foods  Salt substitutes should be avoided because they contain potassium chloride Potassium restriction  Limit: 2 to 3 grams  High-potassium foods should be avoided with HD Nutrition therapy Phosphate restriction in ESRD  Limit: 1 gram per day  Foods high in phosphate * Meat and dairy products  Most foods high in phosphate are high in protein * Phosphate binders essential with dialysis

Question 29

Dialysis

Answer 29

Movement of fluid/molecules across a semipermeable membrane from one compartment to another  Used to correct fluid and electrolyte imbalances and removes waste products in kidney failure  Can be used to treat drug overdoses 2 methods of dialysis available  Peritoneal dialysis (PD)  Hemodialysis (HD) Started when patient’s uremia can no longer be adequately treated conservatively; GFR < 15 mL/min/1.73 m2  Nephrologist determines when to start  Uremic complications require dialysis ESRD treated with dialysis because  There is a lack of donated organs  Some patients are physically or mentally unsuitable for transplantation  Some patients do not want transplants  Age is not a factor in determining candidacy

Question 30

General Principles of Dialysis

Answer 30

Diffusion  Movement of solutes from an area of greater concentration to an area of lesser concentration Osmosis  Movement of fluid from an area of lesser concentration of solutes to area of greater concentration * Glucose in dialysate creates osmotic gradient to pull fluid from the blood Ultrafiltration  Water and fluid removal  Results when there is an osmotic gradient or pressure gradient across membrane * PD—glucose in dialysate * HD—pressure gradient  Excess fluid moves into dialysate

Question 31

Peritoneal Dialysis

Answer 31

Peritoneal access is obtained by inserting a catheter through anterior abdominal wall  Technique for catheter placement varies; usually done via surgery  PD may start right away or bed delayed until site healed  Aseptic technique important to avoid peritonitis Three phases of PD cycle (manual):  Inflow (fill)—2 to 3 L over 10 minutes  Dwell (equilibration) 20 to 30 minutes—8 hours  Drain 15 to 30 minutes Cycle is repeated  Called an exchange  Volume depends on size of peritoneal cavity  Dextrose—osmotic agent Automated peritoneal dialysis (APD)  Cycler delivers the dialysate during sleep Times and controls fill, dwell, and drain phases; alarms and monitors for safety  Continuous Ambulatory peritoneal dialysis (CAPD)  Manual exchange four times during the day

Question 32

Peritoneal Dialysis Complications

Answer 32

Exit site infection  Redness, tenderness, drainage  Treat with antibiotics Peritonitis—Exit site or tunnel infection  Abdominal pain, rebound tenderness, or cloudy effluent with increased WBCs or bacteria, may have fever GI: diarrhea, vomiting, distention, increased bowel sounds  Treat with antibiotics  Repeated infections may cause adhesions Hernias  Increased intrabdominal pressure from dialysate  Treatment: hernia repair Lower back problems  Intraperitoneal infusion increases pressure  Treatment: binders and exercise Bleeding  Common with initial catheter placement  New—active intraperitoneal bleeding; check BP and hematocrit  Pulmonary complications  Decreased lung expansion  atelectasis, pneumonia, or bronchitis  Elevate HOB, repositioning and deep breathing  Protein loss—monitor nutrition

Question 33

Hemodialysis Settings and Schedules

Answer 33

Most treated in a community-based center  Dialyzed for 3 to 4 hours, 3 days/wk  Other schedule options  Short daily HD  Long nocturnal HD  Home HD

Question 34

Hemodialysis Complications

Answer 34

Hypotension  Hypovolemia, decreased CO and SVR  Light-headed, nausea, seizures, vision changes, and chest pain  Treatment: decreasing volume of fluid removal and IV NSS  Muscle cramps  Decreased BP, hypovolemia, increased ultrafiltration, and low-sodium dialysate  Treatment: decrease ultrafiltration and IV fluids Loss of blood  Blood not rinsed from dialyzer, accidental separation of tubing, dialysis membrane rupture or bleeding after needles removed; heparin  Treatment: rinse all blood back, avoid excess heparin, and hold pressure to access sites  Hepatitis—8% to 10% hepatitis C  Infection control precautions  Hepatitis B—low incidence; administer vaccine

Question 35

Continual Renal Replacement Therapy

Answer 35

Method for treating AKI (acute kidney infection)  Means by which uremic toxins and fluids are removed  Acid-base status and electrolyte are adjusted slowly and continuously in hemodynamically unstable patients  Over 24 hours  Can used with HD Contraindication  Patient has life-threatening manifestations of uremia that require rapid treatment Various types of CRRT  Continuous venovenous hemofiltration (CVVH)  Slow continuous ultrafiltration (SCUF)  Continuous venovenous hemodialysis (CVVHD)  Continuous venovenous hemodiafiltration (CVVHDF) Infusion of replacement fluid determined by degree of fluid and electrolyte imbalance  Anticoagulants are needed to prevent blood clotting  Customized to patient’s needs CVVHD and CVVHDF  Uses dialysate  Dialysis fluid is attached to distal end of hemofilter  Can be continued as long as 30 to 40 days  Hemofilter should be changed every 24 to 48 hours  Able to obtain specimens  Ultrafiltrate should be clear yellow  If bloody, need to terminate

Question 36

CRRT versus HD

Answer 36

CRRT versus HD  Blood pump is slower than HD  Continuous rather than intermittent  Fluid volume can be removed over days versus hours  Solute removal by convection (no dialysate required) in addition to osmosis and diffusion  Less hemodynamic instability  Does not require constant monitoring by HD nurse (need ICU nurse)  Does not require complicated HD equipment

Question 37

CRRT Nursing Interventions

Answer 37

Specific nursing interventions  Obtain weights  Monitor and document laboratory values daily for fluid and electrolyte balance  Assess hourly intake and output, VS, and hemodynamic status  Care for site to prevent infection

Question 38

Wearable Artificial Kidney (WAK)

Answer 38

Recently developed and approved for use  Miniaturized dialysis machine; ~10 pounds  Carrier resembles a tool belt  Connects to patient via catheter  Designed to filter blood in ESRD  Can run continuously on batteries

Question 39

Kidney Transplant

Answer 39

More than 100,000 patients are currently awaiting kidney transplants  Average wait time for cadaver is 2 to 5 years  17,000 transplants take place every year Advances include:  Organ procurement and preservation Surgical techniques  Tissue typing and matching  Immunosuppressant therapy  Prevention and treatment of graft rejection Best treatment for ESRD  Very successful  1-year graft survival rate  Deceased donor transplants: 90%  Live donor transplants: 95%  Reverses pathophysiology of ESRD  Eliminates dialysis and dietary and lifestyle restrictions  Less expensive than dialysis after 1st year

Question 40

Kidney Transplant Recipient Selection

Answer 40

Candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers  Possible exclusions: obesity, smoker  Preemptive transplant (before dialysis is required) is possible if recipient has a living donor Contraindications to transplant  Advanced cancer  Refractory/untreated heart disease  Chronic respiratory failure  Extensive vascular disease  Chronic infection  Unresolved psychosocial disorders  HIV+ or hepatitis B or C are not contraindications Surgical procedures may be required before transplant  Coronary artery bypass or coronary angioplasty  Cholecystectomy  Bilateral nephrectomy

Question 41

Kidney Transplant Histocompatibility Studies

Answer 41

Purpose of testing is to identify HLA antigens for both donors and potential recipients

Question 42

Kidney Transplant Donor Sources

Answer 42

 Deceased donors with compatible blood type  Blood relatives  Emotionally related living donors  Altruistic living donors  Paired organ donation Live donor  Extensive interprofessional evaluation  Crossmatches—check antibodies  Advantages * Better patient and graft survival rates * Immediate organ availability * Immediate function/minimal cold time * Opportunity to have recipient in best possible medical condition since elective surgery Live donor sees nephrologist for H & P  Laboratory studies * 24-hour urine—creatinine clearance and total protein * Complete blood count, chemistry and electrolyte profiles * Hepatitis B and C, HIV, CMV testing

Question 43

Donor Sources: Live Donor

Answer 43

Diagnostic studies  ECG, chest x-ray  Renal ultrasound, arteriogram, 3-D CT scan Psychologist or social worker evaluation  Emotional stability  Risks and benefits  Cost covered by recipient’s insurance  No compensation for lost wages Paired organ donation  ABO incompatibility between donor and recipient  Find another donor/recipient pair with whom to exchange kidneys  Plasmapheresis—option to remove antibodies from recipient * After transplant, patient gets plasmapheresis

Question 44

Donor Sources Deceased Donors

Answer 44

Deceased (cadaver) kidney donors are relatively healthy persons that have suffered an irreversible brain injury and are brain dead  Must have effective CV functions and on ventilator to preserve organs  Permission of next of kin requested even with signed donor card  Kidneys removed and preserved up to 72 hours * Preferred cold time less than 24 hours

Question 45

Kidney Transplant Surgical Procedure - Live Donor

Answer 45

Live donor  Donor nephrectomy performed by a transplant surgeon  Begins 1 or 2 hours before the recipient’s surgery is started  Recipient is surgically prepared in a nearby operating room Laparoscopic donor nephrectomy * Most common approach for removing kidney in living donor * Minimally invasive  Fewer risks, shorter recovery time Open (conventional) nephrectomy * Lateral incision * Rib may need to be removed

Question 46

Kidney Transplant Recipient

Answer 46

Kidney transplant recipient  Transplanted kidney usually placed extraperitoneal in the iliac fossa  Right iliac fossa is preferred for anastomosis of blood vessels and ureter Before incision  Urinary catheter placed into bladder * Antibiotic solution instilled  Distends the bladder  Decreases risk of infection  Crescent-shaped incision Rapid revascularization critical  Donor artery anastomosed to recipient internal or external iliac artery  Donor vein anastomosed to recipient external iliac vein Kidney transplant recipient  When anastomoses are complete, clamps are released and blood flow reestablished  Urine may begin to flow from ureter immediately  Donor ureter tunneled through bladder submucosa (ureteroneocystotomy)

Question 47

Pre Op Care

Answer 47

Preoperative care  Emotional and physical preparation * Stress that dialysis may be required * Review need for immunosuppressive drugs and prevention of infection  ECG  Chest x-ray  Laboratory studies  Dialysis, if needed

Question 48

Post Op Care

Answer 48

Live donor * Care is similar to that for open or laparoscopic nephrectomy * Closely monitor renal function * Closely monitor hematocrit * Donors usually experience more pain than recipient * Acknowledge their gift! Kidney transplant recipient * Maintenance of fluid and electrolyte balance is the priority * Large volumes of urine may be produced soon after transplanted kidney placed due to  New kidney’s ability to filter BUN  Abundance of fluids during operation  Initial renal tubular dysfunction * Dehydration must be avoided * Assess for hyponatremia/hypokalemia * Acute tubular necrosis can occur * Monitor urine output; maintain catheter patency * Patient education: signs and symptoms of rejection, infection, and surgical complications; follow-up care

Question 49

Kidney Transplant Immunosuppressive Therapy

Answer 49

Goals  Adequately suppress immune response to prevent rejection  Maintain sufficient immunity to prevent overwhelming infection

Question 50

Kidney Transplant Complications - Rejection

Answer 50

Rejection  Hyperacute (antibody-mediated, humoral) rejection * Occurs minutes to hours after transplant  Acute rejection * Occurs days to months after transplant  Chronic rejection * Process occurs over months or years and is irreversible * May go back on transplant list

Question 51

Transplant Complications - Infection

Answer 51

Risk related to: suppression of normal defense mechanisms, immunosuppressive drugs, and effects of ESRD; compounded by systemic illnesses  Most common infections observed in 1st month: pneumonia , wound infections, IV line and drain infections, and UTIs Fungal infections * Candida * Cryptococcus * Aspergillus * Pneumocystis jiroveci Viral infections * CMV  One of most common * Epstein-Barr virus * Herpes simplex virus (HSV) * Varicella-zoster virus * Polyomavirus (e.g., BK virus)

Question 52

Transplant Complications - CVD

Answer 52

Cardiovascular disease  Transplant recipients have increased incidence of atherosclerotic vascular disease  Immunosuppressants can worsen hypertension and hyperlipidemia  Patients need to adhere to antihypertensive regimen

Question 53

Transplant Complications - Cancer

Answer 53

Cancers  Primary cause— immunosuppressive therapy  Most common * Skin cancers * Posttransplant lymphoproliferative disorder  Regular screening is important  Preventive care * Protective clothing and sunscreen

Question 54

Transplant Complications - Recurrence of Kidney Disease

Answer 54

Recurrence of original kidney disease  Glomerulonephritis  IgA nephropathy  Diabetic nephropathy  Focal segmental sclerosis