The role of the nurse in pre-renal transplantation

Abstract The following two articles explore the role of the nurse in caring for and educating the patient both pre- and post-renal transplantation. The nurse plays a pivotal role in assisting the patient facing the many challenges that are associated with transplantation. Renal transplantation is considered the optimal treatment of choice for patients with end stage renal failure (ESRF) and who are receiving dialysis. This first article will explore the role that nurses play regarding the care of the patient pre-transplant, including the physical, psychological and educational support required to assist the patient and family members deal with the many challenges associated with transplantation.

Key words: Renal • Dialysis • Transplantation • Nursing Role

,...--; rgans for kidney transplant are ~ from two source~: either living or

~ ....ii J deceased (cadavenc) donors. In the ""'_. United Kingdom (UK) there are

currently 6360 patients on the waiting list for a cadavenc kidney transplant (UK Transplant, 2006a). There 1s an mcreas111g rccogmtton of the shortage of cadaveric donors and demand continues to outstrip supply.

Organ procurement in both the UK and Ireland 1s based on a voluntary g1fung system whereby md1v1duals choose to donate or 'opt 111' to organ donat10n after suffenng brainstem death (Haddow, 2005). Dunng the year 2005-2006 in the UK, 1203 individuals received a cadaveric kidney only transplant while 590 received a kidney transplant through live donation. In the Republic of Ireland 126 patients received a cadavenc kidney only transplant 111 2005-2006, although there were only three transplants conducted through hve donation (UK Transplant, 2006a).

A live transplant programme has been developed recently m the Republic oflreland. It must be acknowledged that the increased numbers of hvmg donor transplants has not

Fiona Murphy 1s Lecturer. School of Nurnng ~nd

M1dw1fery, Trin1ry College, Dublin

,1cceptrd for p11b/icatio11 April 2007

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compensated for the increased numbers waiting for a tran\plant (Trevitt, 2004), therefore patients can watt for extended penod of tunes before being offered a transplant.

However, the Human Tissue Act 2004, which came into bemg at the start of September 2006, gives pnonty to the wishes of the 13.5 nullion people on the NHS organ donor register, donor card earners and others who have said they want to help others to hve m the event of their death. This new Ac.t makes it clear that if an md1v1dual wishes to donate that their wishes should be fulfilled (UK Transplant, 2006b).

This article explores the pivotal role that nurses play regarding the care of the patient pre-transplant mcludmg the physical, psychological and educational support required to assist the patient and farrn ly members deal with the many challenges associated wrth transplantation.

Transplantation Chronic kidney disease (CKD), care on dialysis and transplant care are all interdependent (Siddq1 et al, 2005).While it must be recogmzed that there ts a wide mult1d1sc1plinary team that cares for paoents, 1t 1s the nurse who 1s at the centre of the patients' care throughout. These include the specialist nurses who work w1thm the dialysis and transplant units along with the out· paaents departments and who share the connnuum of care for patients as

Fiona Murphy

they move forward from <l1alym trl·atment to transplantation and beyond elm to long term management.

Renal transplant:rnon has the gn:,tte\t potential for restoring a healthy produrnve hfe for most panents with renal f,ulure (Goodman and Oanov1tch, 2005). Auer (2002) merts that, for numerous pattems, rece1v111g <l1alr1s 1s a period of marl.mg tune while awa1t111g transplantation. Chmtemen et .11 (2000) identifies that a funwon.11 renal graft offers the patient the potenttal tor freedom from numerous, t11ne-consu111111g. and occ.1,1on:illy pa111ful or uncomfortJble d1,1lys1s treatments. While FrJnkhn (2002) concurs with tlm, a uccessful tramplant presents the p.ltlent with

freedom from the psychological d1fficulnes and physical restncnom assoc1atrd with long-term dialysis, 111clud111g freedom from dietary and fluid rest11ct1om, return ot 'exual funct1on111g and fertility with the potl'nttal opportumty for parrnthood.

Tramplamat1on rema1m the 1110\t cost­effecttve treatment option for end st,1ge renal failure (ESRF). The Jverage l mt of d1alys1s 1s £30 800 per p.ltlent per year, while the cost of a transplantat1on 111clud111g the 1mmtmosuppress1on needed by the p.1tient costs on average £22 000. The owr.111 sav111g-. to the N I IS in dialysis costs as a result of the kidneys transplants in the year 2005 2006 was £46.1 million. I lowever, this figure 1s the savmgs that the N I IS make e.1ch year for every year that the kidney funct1om (UK Transplant, 2007).

Kidney transplantation 1s not a pt·rmanent cure for patients with E RF {St.1rzmmk1 and Hilton, 2000). Anecdotally. tele'.is1on soap operas m the past have highlighted actors playmg ind1v1duals receivmg kidney transplantations and miraculously they .1ppe,1r to recover w1th111 a few days pmt -surgery. However, realistically 111 order for patient to mamtam the1r renal graft function they will require medical care for the rest of their lives and will need to acqwre ne,.,, sdf care skills to recognize for example the signs and symptoms associated with mfecnon and re3ecnon (Luk, 2004).

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Transplantation ~hould be offered to all suitable patients. Unfortunately not all patients with ESRF are medically or surgically fit for a kidney tr,msplant, and there are a number of contramd1cations (Table /). All of these contraindications may require mod1ficat10ns in situations that alter the balance of mks between d1alys1s and transplantation (UK Transplant, 2003). The survival rate for transplant patients 1s over 95% for the first year and that of the kidney is around 90%. The average lifespan of a transplanted kidney from a cadaver 1s 12 years while organs from hve donors average 15 years; however, these figures are related to the characteristics of both recipients and donors (Force and Andreu, 2005).

Preparation of the patient pre­transplantatlon Transplantation should be discussed as a treatment opnon ideally when patients are diagnosed with CKD or chronic renal failure. CKD patients that are better managed both before and after commencing dialysis make better transplant candidates (Siddqi et al, 2005). Patients will be added to the UK transplant national list by their transplant centre following 111dividual pre-transplant assessment, the process of which w1ll be discussed later. It 1s established by a computer protocol the best matched patient for an allocated kidney which 1s based mamly on blood group, degree of nssue matching and tune spent on the waiting hst. This database will also identify the transplant centre to which the organ is to be offered if the best matched patient 1s not found.

Over the past 20 years the transplant national allocation scheme has evolved progressively to improve outcomes, ensure equity of access to transplanraaon and also to maxinuze the number of transplants performed. Live donor kidneys and non-hcartbeanng donor kidneys are not allocated through the national scheme and are utilised by local transplant units (UK Transplant, 2006c).

One of the standards set by the Nat1011al Sen1icc Framework for Renal Services (Department of Health, 2004) is that all patients likely to benefit from a kidney transplant are to receive a high quality service which supports them in managmg their transplant and facilitates them co achieve the best possible quality of hfc.

There are three key stages in the patients' pathway to transplantation according to The Renal Association (2002): • Psychological and physical preparation • Pre- and postoperative care • Long-term follow up.

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Table l. Contraindications to renal transplantation

·rredlcted patient survlval of less than 5 years

• M alignant d isease not amenable to curative treatment. o r remission for greater than 5 years. HIV infection not treated with highly active antlretroviral therapy or already progressed to AIDS.

• Cardiovascular disease - ischaemlc heart d isease, the prognosis of which cannot be Improved by

revasculariz.ation and/or cardiac failure w ith a predicted risk of death greater than 50% at 5 years

• A history of non-compliance and , In particular, graft loss from non-compliance. Reasons for non­compliance should be Investigated

• Patients w ith poorly controlled psychosis or regular use of class A d rugs

lmmunosuppresslon predicted to cause llfe-threatenlng compllcations

• Unresolved chronic bacterial Infection • Persistent vi ral infection

Both the potential risks as well as the benefits of transplantation must be fully explamed to patients as these factors might influence their quality of life post-transplantation. If patients are well informed they may also demonstrate adherence with their treatment regime (Farmer et al, 2004).

Psychological preparation Patients undertaking dialysis can experience a variety of emotions trymg to cope with the everyday reality of living with a chronic illness. Denial, guilt, depression, fear, regress10n, resentment and disbelief are common defence mechanisms that patients may present with. They may feel that their hopes for the future are altered and may demonstrate hostility or helplessness. Nurses can assist patients by discussing their feelings with them and allowing them to grieve for what they have potentially lost. They should determine the patients' attitudes towards their condition and its meaning for them. They should build up a positive relationship with patients while on dialysis and assist them to begin to adapt and cope with their dialysis treatment while supporting them make an informed choice regarding the issue of transplantation.

Murphy (2005) maintains that the extent to which patients became familiar to medical treatment before the onset of ESRF is an important variable wluch affects their psychological response co transplantation. While patients await a transplant they may experience feelings of anxiety, fear of the unknown, not obtaining a donor, pain

Source: UK Transplant (2003)

from surgery, and possible long-term health problems (Wallace, 2003). Other specific pre-transplant anxieties and fears include: acceptance of the transplant as part of the patients' 'self' and guilt over benefitmg from traumatic death (Franklm. 2002), rejection and body image changes due to the effects of the immunosuppressive therapy (Scarzomsla and Hilton, 2000). It must be recognized that patients who receive a transplant arc facmg a life-changing event and it 1s important that they have the support systems in place to cope. The nurse should assess the patients' copmg abilita:s and what support systems they have in place, which include the renal counsellor, family members and friends (Wallace, 2003).

Corley et al (2000) assert that although there may be possible conflict or stress associated with hvc donation, the maJOnty of both potential donors and recipients are very comfortable with the selected donors and that relationships can improve following transplantation. It 1s the role of the nurse to ensure that the potennal donor has made an educated and mformed choice without coercion about donating a kidney to a loved one. The donor should feel able to discuss any issues without fear or embarrassment and needs to have emotional support with regards making the difficult decision to donate (Fisher et al, 2005).

Physical preparation There are various physical assessments that a patient must have established before bemg considered for transplantation (sec Talile 2). It

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1s important to ascertain the patient's primary renal disease as with some cases they can recur and destroy the new kidney, an example

being focal segmental glomerulosclerosis which cause massive proteinuria and scarring

of the glomeruli of the kidney. Vasculitic illnesses need to be completely treated before progressing ahead with transplantation (Franklin, 2002).

One of the leading causes of ESR F 1s diabetes mellitus, particularly type 2, and the treatment of choice for end-stage diabetic nephropathy is kidney transplantation alone, or combmed with pancreas transplantation. As cardiovascular disease is the leading cause of death following renal transplantation, patients with ESR.F are at high cardiac risk. However diabetic patient~ are a higher risk and should therefore be assessed pre­rransplantation includmg being reviewed by a cardiologist. They may undertake furtht.!r cardiac investigations, mcluding an assessment of vessel patency to exclude severe atherosclerosis (Franklin, 2002; Pirsch et al, 2005, Siddq1 et al, 2005).

The upper age limit for a transplant patient must be considered and can be viewed as a potential risk coupled with other increased risk facrors associated with older ,1dults. These risk factors include: advanced cardiovascular disease, longer initial hosp1ralization post­surgery, the metabolism of immunosuppressive drugs may be slower along with increased risk of infection and malignancy related to 1mmunosuppression. Older adults should be assessed n:garding their cognitive abilities along wJth their ability to care for themselves and mobilize post-transplant (Siddqi et al, 2005). The revised UK transplant national allocation scheme slightly reduces the chances of receiving a kidney for patients over the age of 60 (UK Transplant, 2006b). However, the nurse, along with the rest of the transplant team, must discuss the issue of transplantatrnn and its potential risks and benefits with the older patient and their family members as each case must be looked at on an individual basis.

The issue of obesity must alo;o be considered as a potential risk post-transplantation, including higher risk of delayed graft function, potentially more surgical complicat1ons including more wound infections (Siddqi er al, 2005). It must be recognized that for many patients the renal diet can be highly restrictive and adding on add1t1onal restrictions to lose weight can seem overwhelmmg for patients. They should be encouraged and provided with assistance and support to lose weight

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Table 2. General medical and physical examination pre-transplantation

-• Complete history and full assessme nt of cardiovascular. respiratory, gastrointestinal symptoms

if present • Histo ry of chronic or recurrent infections • Ascertain if the patient smokes. amount of alcohol intake or drug taking • Serum biochemistry • Tissue typing • Full blood examination (FBE), blood type and coagulation profile • Serological examinations, including Hepatitis A. B, C and human Immunodeficiency virus (HIV)

status, cytomegalovirus (CMV) titres and the presence of sexually-transmitted diseases and herpes simplex virus (HSV)

• Chest X-ray • Electrocardiogram • Dental evaluation • Smear test for women • Ascertain if any problems with the bladder and ure thra. or if history of urinary tract infections • Abdominal assessme nt to ascertain If previous surgery, Tenckhoff site • Vascular assessme nt to assess pulses • History of polycystic kidney disease

through tailored weight loss progranm1es (Pans1, 2002) supervised by the renal dietician and the nurse.

With regard to tht' immunological aspects of transplantation, the major obstacle to a successful renal transplantation is the body's ability to recognize and reject foreign tissue. Each individual has at least six important human leukocyte antigens (HLA) which are complex proteins located on the surface of immune system cells and are used to ascertain compatibility between a kidney donor and the recipient. When the donor's six antigens match those of the recipients this results in a perfect match. This is established through tissue typing. With living donors such as siblings, since they have the same parents, they would have th e greatest chance of being a perfect match (Wallace, 2003).

It is important to regularly screen patients on the transplant waiting list in order to maintain knowledge of their current antibody status as antibodies can be induced to blood transfusions, pregnancies or prev10us transplants (Franklin, 2002). The cross-match test 1s the final pre-transplant im111unolog1cal screenmg step whereby the potential donor's lymphocytes serve as the target cells for the patient's serum. A strong contraindication to tramplantation is the presence of cytotoxic lgG antidonor HLA (Cecka and R.eed, 2005) whereby there is a positive cross-match and the recipient is sensitized to the donor and therefore the transplant cannot proceed as it will be rejected (Franklin, 2002).

From: Franklin (2002); Terrill (2002)

Educational preparation lt must be acknowledged that the educational preparation of potential transplant candidate\ is just as important as the physical and psychological preparation (Terrill, 2002). The purpose of patient educ.won 1s to mcn:ase the competence and confidence of patients for self-management with the mO'lt important goal bemg to prepart' patients and their families for 111dependenc~· (13.lstablc, 2006).

Parient education 1s not simply a matter of repeating d1rect1ons to patients or hand111g out printed materiah. It i~ a process involv111g the health professional\ precise chmcal \kills 111 terms of data gathering, indiv1duahz,H1011 of instructions. prompting and support, ;md

evaluation and follow-up of the p.itient\ success 111 implcment111g the treatment pl.tn (Falvo, 2004).

The transplant team, 1nclud111g the mme, will meet up with the transplant rec1p1enrs and their families to discuss the mrgery and what to expect both pre and post the actual operation, the issues mrrounding rCJCCt1on and the complications that can oct ur postoperatively. The immunosuppress1ve medication must be explored and it must be explained that patients will rema111 on tlus med1 cat1011 for the re111a111der of their lives. l t can be difficult for patients to grasp all of the 111formatio11 regarding transpl,rntation, and during the various educational sessions 1t 1s important that these sesrn>ns are tailored to their individual needs. The nurse 'ihould attempt to ascertain the patients ' thoughts and

fl·dinh" concern111g tr,mspl.mtation and to rcassun: them and reiterate educational advice ,1s nel'essary. Through good communication and a chorough a''es,ment of the patients' learning neeth thl· mir'e c.1n establish \Vh,tt educat1on.1l tool, can .mist patients further, for ex,tmpk. the ll\e of tr,1mplantat1on DVDs, various p.n1ent education le.1flets, authonzcd vetted llltl'rlll't 'ttcs, and possibly mcctmg tr,111splant pancnts who h.tvc gone through the cxpcncnn·

J'he IS\Ue surrounding the relaCtve adv.1ntagcs of liv111g donor and cadavenc donor tr.111spl.1nt.1t1on should be compared and tontrastcd 111 the context of the prolonged \\Jic chat is expected for a cad,weric transplant in tht• t'\'Cnt th.it .t h\'lng donor 1s not a\.1il.1ble. The 1m1e of live donation must be explored, thi' can c.ll!se stre" on a farrnly .ind .1g.11n the nur'e mu\t 'upport p.itients and their f.1111ihes 111 their mformed dec1siom made P,u1ents should be strongly advised that a transpl.1nt 111.1} not I.1st forever and there m,1y come a time m the future whereby ,1 return to d1.1lym 1s a poss1b1hty. The issue of c ompltam e or adherence to treatment with reg.ml to d1.tlys1s .111d dietary regimen, \\ h1le waiting to be c.tlled for ,1 transplant. as well ·" che 1mporc.mcc of takmg the vanous immuno,upprc"ivc regimcm without fail post-tr.111Spl.mt. mmt be explored (S1ddqi ct ,1), 2005). h.1nklm (2002) 1denttfies the importarH:e of offering extensive prc­tra11Spl.1nt counsdltng to explore the rationak for not ,1dhcring \\ ith healthcare advice and

to otfrr further 'upport post-transplant to factlit.nc .1dherenCl' to 111ed1c.1tiom and post­transplant lifestyle.

Preoperatlvely K1dm·y transplant.ltlon diffors from that of he.1rt .md hvcr tr.in,pbntation 111 that chrome d1.ilym .tllow' pat1c1m to be maintamed in optim.11 condition .rnd provides time to addrc'' potentially comphcatmg medical .111d 'urgic.11 is\Ue\, whereas the condition of the pJtlCnt\ facmg both .1 heart and liver trJnspl.int t\lll often deteriorate rapidly m the pre-tr.1mpl.mt timefrJmc (~mgcr et al, 2005). There .ire nuny c·hallcnge' \\ ith the actual ren.ll tr.rnspl.111t.1t1on procedure as there are two p.itienb .md two sets of fanuly members th.It mmt bl· cared for. The approaches to

surgery .Jrl' \aried depend111g on \\ hethcr it is ,i hve don.mon or a dy111g patient whose fanuly member\ have opted to donate Im or her orgam (Wall.Kc. 2003). lemll (2002) also 1dcnt1fics that the \Urcess or failure of the tramplant.ltlon pn>cc\\ often is deterrrnned by

llnthh Jourll.ll ot N1m111g • .!(M17,\'ol lh, Nn Ill

che .mention to detail chat occurs throughout the perioperat1w period.

It c.111 be .1 vcrv stressful time for both patient, and their fanuly members awaiting that phone call from the transplant unit 1dent1fying that a suitable donor kidney has become a\atlable. Terrill (2002) asserts that when pat1e1m receive the call. they cxpcnl·ncc .1 1111xture of cmouons, mcludmg anttc1p.1t1on and exntcmcnt :it the potermal of life wtthout d1alym, cmouons sue h as fear of thl· 11npend111g surgery should the transplant not be succes•iful, along wtth sadness regarding the fact that they are be111g provided with this opportunit) through the de.1th of .111othcr human being. Patient' are mformed on the phone to present to the transpl.111t unit .1\ soon as possible. to not cat or dnnk . • 1Jong with a brief discussion to l'\t,1bhsh the p.ment\ current he.11th st:itus to

exclude any potential 111fcct10n or potential problerm that could exclude transplamatton. C oncurrcntly .• mother patient may ren•1vc a wmlar call adv1s111g him or her to present also to the tramplant umt; some transplant units may contact two patients in case a positive cross match 1s present with one of the p.men ts, therefore the other patient 1s also prep.ired so as to reduce the cold 1scluem1a tune (franklin. 2002). Terrill (2002) maintains th.it although this method can be viewed a' medic.1lly efficient. one of the p.ttients called will leave the hospital without a tramplant.

Nurses play .1 vital role during elm 1mmcthate preoperative stage. The} would usu.illy be the first potnt of contact that the pJt1ent .111d family members would meet on adm1ss1on to tht• umt and would therefore be able to discuss with the patient and fan11ly his or ht•r fears and anxieties of what to

expect on .1dmM1on, 111clud111g the various 1mpcnd111g medical invemganons and the gt•neral preopcr.ltlve procedure. Throughout the nursing admi\\1011 1t can be established whether the patient had any recent mfectton or received any blood transfusions. wh.tt the current and past medical lmtor} 1c;, mcluding renal d1sc.tst', .iny .1llerg1es, \\hat the normal urine output if present, the measurement of v1t.1I sigm and the patients' sonal history and support. The medic.ti invcmgat1om, including blood tests, such .1, tissue typmg crms-match. urea .md electrolyte. liver function tests, v1r.1I screen and cross match for ,1 number of units of blood for the impend mg transplant surgery should be undertaken. Additionally. chest X rJ}. dectrm.ard1ogram (ECG). urinalysis (includmg .1 1md-stre,1m spenmen of urine).

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skm. nose. throat, .1x1ll.1 and gro111 '\'abs, along with \W.tbs t.ikcn from eitht•r the pt•ritoneal di.1lysis or subclavian catheters exit sites for mcthinlhn-resistant tapliyfoc11cws t111rc11~. \'ir,11 and b.1cterial screemng. should .1ll bl· undert.1king.

Thl· p.1t1t•nt n1.1y rl·quire d1alvs1s depcnd111g on the results from the blood tests .ind follow111g medic.ii .mcssment 111dud111g wh.tt the p.1t1cnts' drv and current weight 1s, tht• relevant dialysis history mvolving type of dialy'1' mmbht) .ind the d.tte and tlllll' of I.1st d1aly,1s tre.ttmcnt and \ital s1gm. lsrnes such .ts electrolyte imbal.mc es and fh11d overload can cause d1fficult1l'' during and pmc-trampl.111tation. Thereforl'. should haemod1ah·,1s be required. rmnimal hep.irin is med 'rnml.uly, 1f the panent nornully receives pcntoneal dialym. he or she would nt•ed to t.t rry out the necessary exch.1nge': following \\hich the peritoneal cavity should be dramcd ,rnd the catheter capped .1ft:er this tin.ti cxch.rngc. A thud speomen would need rn be wnt to the l.tboratOr} for m1t roscopy, culture and sensitivity, V;mou' members of the 111ult1d1sc1plmary team will v1s1t the p.1t1ent pre-surgery, mcludmg the nephrologist, the transplant surgeon and co­ord111.1tor, the anae,thet1st, che physiotherapist to .mist \\Ith tkcp breathing and coughing exern,cs. Onrc the tl\'ille typing cross· nutch comes b.ll k negan\'e the last st.1gc of the prcopcrat1\"C prepar.1tion can begm (Franklin, 2002; kmll. 2002).

Other preoperat1w preparation mdudcs comem, n.unc badge. bath or shower, me of an l'l1l'ma. theatre gown, the mark111g and drc,s1ng to protect the Jrtcnovenom fi,tula from 111.1dvertent use of mvasive monitoring, ,111t1 thro111bos1s stock111gs along with the co Ill 111l'nlc111cnt of 1111 mun os u pp rcss 1 ve ther.1py .is per the applicable tr.impl.111t umt' · pohcv. Other med1cat1ons given preopent1wly include the pre mcd1cat1on (such as tcmazapam). and ,hould the p.menc be di.1bl·tic a 'liding \Cale of msulin would be rcqum·d a' prescribed (Fran klin. 2002: Terrill. 2002).

Transplantation technique The 'ucccssf'ul m.1gc of donor tMue relies on r.1p1d org.111 re,cct1on and cool mg \\ ith a 111i11i111.tl period of tune to develop 1sch.1c1111.1 It i' therefore vttal to preserve the donor gr.th 1mmed1att'ly "d11le wa1tmg to establish a possible donor mate h. The patient will be c.ichetenzed betore rnrgcry, allowmg tht· bladder to drain thmughout the operation .ind allow the .idm1111stratton of anttb1ottc-t) pc

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Figurt 1. Location of rhe trasplantt d kidnty.

Diseased kidneys

Artery

Bladder---=---

solutions which will assist in the viewing of the bladder when the ureter is reimplanted.

Singer et al (2005) asserts the importance of meticulous surgery techniques,attention tO detail, strict aseptic technique and ideal haemostasis as essential throughout the transplant surgery. The surgeon will make a curved incision in either of the patients' lower quadrant for a first transplant (Figure 1). This recroperitoneal space is entered and a pocket is made for the donor kidney, any bleeding 1s managed with clamps, ties and eleccrosurgery. The renal vein will be sewn to the recipients' external iliac vein as sinlilar to suture material that is utilized for the arterial anatomises, while the donor renal artery may be sewn to the external iliac artery. Care must be taking to prevent kinking or angulations of the donor vessels which may compromise renal blood flow.

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Vein

Transplanted kidney

Transplanted ureter

Following the anatomises the donor kidney usually turns pink quickly and may produce urine rapidly. The ureter can be anatomised to the bladder of the recipient and a Stent may be used if the surgeon believes that the patient may be more at risk regarding urological complications. Closed drains such as the Jackson-Pratt type may be placed through a separate small incision into the perirenal space to drain blood, urine or lymph.

Copious amount of sterile saline solution is used to irrigate the wound, and it is observed closely for any leaks or bleeding, the wound is closed at the end of the surgery. It is important that there is adequate perfusion of the newly transplanted kidney which is vital for the establishment of an immediate postoperative diuresis and also to avoid the delay of graft function. A large dose of methylprednisolone

(an immunosuppress1ve corticosteroid) is usually given before the release of the vascular clamps. Verapamtl, a calcium channel blocker, is directly admirustered into the renal artery which reduces capillary spasm and improves renal blood flow. Fluid replacement is maintained accordingly along with the administration as prescribed of Mannitol and frusemide. The patients cardiac statm must be closely monitored with the central venous pressure should be maintained at around 10 mmHg with the usage of isotonic solution and infusions of albumin. The \ystohc blood p ressure should be mamtained above 120 nunH g.The patient will spend time being closely monitored in the theatre recovery area initially after this major surgery before returning back to the transplant unit (Franklin, 2002; Singer et al, 2005; Wallace, 2003).

It must be acknowledged that there are many challenges facing patients pre-transplant mcluding the physical, psychological .111d educational preparation along with the watt for an actual transplant itself. Nurses can support patients to cope with this difficult process and assist them along their journeys as they wait for transplantation.

In the next article there will be a discussion of the continued challenges facing patients including the compli cations that can occur post-transplant along with the long­term implications of living with :i kid~

transplant. Wil

Auer J (2002) Psychological pe"pecavcs. In. Thomas N, ed. Ad1u11tcd Renal Carr. Bl~ckwell Publt,h1ng, Oxforo: 75-102

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Cecka MJ, Reed EF (2005) I fotornmpaubtlny tl"ltmg, cross-niatchmg, and allocaoon of k.1dncy rr:insplanc.. In· Danovitch GM, ed. Handbook of K1d11cy Tramp/..,111111011 4th edn. L1ppmcon Williams&.. Wilkins, Plul.iddph1a: 43-71

Christensen A, Ehlen. S, RaichJc K, 13crtolaru' J, Lawton W (2000) Predtcong change m depression followmg renal transplancaoon; effect of paaenc coping preforcnce<:. Hea/rll Psyr 19: 348-53

Corley M, EISW1ck R, Sargenr C, Scott S (2000) Amtudc, 1elf-1mage, and quabry of hfe of hv111g kidney donor\. NeplirolOJIY Nurs J 27(1): 43-50

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Farmer C, Duniapp L, O'Sullivan H ct al (2004) A mulomedia trauung sy>tem for rcn.il transplant p.mentJ; Br] Re11 Med 9(2): 9-12

Fisher PA, Kropp DJ, Flemmg EA (2(X)5) Impact on ltvmg ladi1ey donors: qualtry of life, <clf-1111age and family dynanucs. Nep/1rolOJIY Nrmj 32(4): 489-500

Franklm PM (2002) Renal tramplantaaon. In: Thom;t< N. ed. Advatll'l'd Re11al Carr. Blackwell Publt>hmg. Oxforo 337-402

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llrmsh Journal o( Nu""'~· 2(XJ7. Vol 16, No 10

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Haddow G (2005) The phenomt'nology of dt'ath, cmboduncm and organ cramplanuoon . • '>« Health a11d Tl/111" 27(1) 92-113

Luk S-C W (2004) Tht' HRQoL of renal transplant paoents. J C/111 "''"' 13: 201 -9

Murphy KJ (2005) l\ych1atrac a'pccts of kidney tramplamJUOn. In: DanoVJtch GM, ed. Ha11dbook of K1d11ry Jh111.•plm11t1t1011 4th t'dn. Lappmcott Williams and W1lk111s, Ph1IJddph1a: 451-<>6

Pama M (2lKl2) Wt•1ghcmg the mks pnor to kidney tramplant fomp /Vnvs and Ism 3(2): S 13--S 14

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St.lrlo1mk.i R. Htlton A ('.!lKlO) P.mcm am! fanllly ad1usanent m kidney tr.tn,pLmunon \Vlth .md "'1thout ID mtenm pcn<XI of d1.il,...1s. t\

0

171/m1/,'m' \"1m j 27(1): 17-32 Terrill 13 (21Xl2) Rm.1/ \;1m111~ a C111,Jr lo Praau~ Radcliffe

Medical Pn."-'· Oxon I he Ren.ii A'!>oc1aoon (2W2) faatmmt of Adults a11d

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CRITICAL CARE

uktr.11"plant org. uk I ukt/1t<~w,room I nc\\ ,_rdea'e'/ art1cll'.J>p?releJ-cld=!50 Oa\t Jcce..o,ed 14 M.iy 2007)

UKTrampLmc (200(,.;) 1-n.-qucntly .i.,kt'J qu~onsabout k1dnli' tramplmcaoon UK Tran,plun. Bn\tol. Ava1Llbll' Jt: W"-"'\

ukcra mp Ian t. org. u k I u kt/ a bout .. tr.uu.pla m,/ fi-«qucntl} _ ;i,kcd_quc-,oons_alx1u1 __ uan.'pbnt,1 (._a_q-._about_ 1..idnt)_ tran,pl.u1uoonJ'P (Li.\t an~ .... -.i 14 M.iy 2<Wl7)

UK Transpl.un (21Kl7) NcwmlOm Fact Sheet,, C<M cffccovcnC\\ of tran,planLluon UK Tra111pl.mt, Bmtol. Ava1bble .n- www.uktr.implant.org.uk 'uktinew,rooml fan_ \hecc./rn,t _effernvcnc'\s_of_tnrupbnuaonJ'P (la>t acn,..,ed 14 M.1y 2007)

Wallace MA (2CKl3) Wh.n j, nc'W \Vlth renal transpl.lnwuon? JIOR.llJ J 77(5) 946-<>6

KEY POINTS

• Renal transplantation has the greatest potential for restoring a healthy productive life for

the majority of patients with end stage renal failure.

• There are many challenges that present for the patient and family members pre-renal

transplant, lnduding psychological, physical and educational preparation.

• The nurse plays a pivotal role in assisting the patient and family members face these

challenges.

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