100713 live kidney transplant from an unrelated donor

8/12/2019 100713 Live Kidney Transplant From an Unrelated Donor

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12 Nursing Times 10.07.13/ Vol 109 No 27 / www.nursingtimes.net

Nursing PracticeReviewOrgan donation

Keywords:Live organ donation/Renal

failure/Kidney care

This article has been double-blind

peer reviewed

AuthorSharon Smith is principal lecturer;

Vimala Sinniah is senior lecturer; both in

pre-qualifying nursing at Buckinghamshire

New University.

Abstract Smith S, Sinniah V (2013) Live

kidney transplant from an unrelated donor.

Nursing Times; 109: 27, 12-15.

This article provides an insight into the

experience of live donation from the

donor and recipient perspectives from

diagnosis until 18 months after

transplantation. The lead author details the

diagnosis of end-stage renal failure in her

partner and their decision for her to

donate a kidney.

Howard is 58 years old and, incommon with many men, iskeen to have as little as possibleto do with healthcare pro-

viders. In April 2011, I had become con-

cerned about a small wound on his nosecaused by ill-fitting glasses; the wound didnot appear to be healing as expected and Ipersuaded him to visit our GP. During this

visit the GP measured his blood pressure,which was 161/96 and, in accordance withNational Institute for Health and ClinicalExcellence (2011) guidelines for stage 1hypertension, blood tests were requested(Table 1).

The blood results strongly indicatedthat Howard was suffering from renalinsufficiency. He was immediatelyadmitted to hospital, initially for the treat-ment of his hyperkalaemia (raised serumpotassium levels in the blood) and for fur-ther investigation to establish the reasonfor his abnormal blood results.

Reducing the potassium level was a

5 keypoints

1Live donation

addresses theproblem that there

are too few kidneys

available for

deceased donors

2Without akidneytransplant people

with end-stage

renal failure need

haemodialysis

3Researchsuggests thatsurvival rates of

transplanted

kidneys is greater

than those of

cadaveric organs

4Polycystickidney diseasecan profoundly

enlarge the

kidneys, replacing

much of the normal

structure and

reducing kidney

function

5Around half ofpatients with

the most common

type of PKD will

progress to

end-stage renal

failure

primary concern at this time, as untreatedhyperkalaemia can lead to cardiac arrhyth-mias and arrest (Hudak et al, 1998). This

was treated with salbutamol via a nebu-liser, which was supplemented with intra-

venous infusion of glucose and insulin.The insulin promotes movement of potas-sium from the extracellular space backinto the cells (Gross and Pistrosch, 2004).Salbutamol may not lower potassiumin all patients, and some studies showthat up to 40% of those who have a degreeof kidney failure requiring renal replace-ment therapy (those who are dialysisdependent) are resistant to salbutamol(Gross and Pistrosch, 2004). AlthoughHowards full blood picture indicatedthat he was likely to require dialysis,this treatment succeeded in reducing his

blood serum potassium level from6.2mmol/L to 4.9mmol/L (Table 1). He

started on a low potassium diet in the firstfew days following diagnosis.

The kidneys filter waste and excess fluidfrom the blood, which are excreted asurine, thereby regulating the levels ofpotassium, urea and creatinine.

An ultrasound scan showed bilateralpolycystic kidney disease (PKD), which is agenetic disorder causing the growth ofnumerous cysts in the kidneys (Jacob,2012). These cysts fill with fluid and canprofoundly enlarge the kidneys andreplace much of the normal structure,resulting in reduced kidney function andleading to renal failure.

Howard was diagnosed with end-stagerenal failure (ESRF) secondary to PKD.

Without a transplant, he would need threefive-hour haemodialysis sessions a week.

In this article... Signs and symptoms of renal failure

Assessments for both donor and recipient Process and follow-up care for transplant patients

Impact of live donation

A kidney donor describes and reflects on her experience, from her partner'sdiagnosis with kidney failure, through assessment to transplantation and recovery

Live kidney transplantfrom an unrelated donor


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14 Nursing Times 10.07.13/ Vol 109 No 27 / www.nursingtimes.net

overcome by medical intervention beforetransplant. Where the donor and recipienthave different blood groups for exampleone has group A and the other group B plasma exchange can be used to removeconflicting antibodies. These are known asABO-incompatible kidney transplants. Ifthe level of antibody incompatibilitycannot be overcome, willing donors canhave the option of being entered into ascheme where they donate a kidney to acompatible stranger so that their loved onecan receive a kidney from a stranger.

I underwent MRI and ultrasound scansto look at the anatomy of my kidneys, asthis varies from one person to another. Thedonors left kidney is the preferred one touse, because the left renal vein is usuallylonger than the right one, and is thereforeeasier to join to the recipients vein.

Nuclear medicine tests were required tolook at the glomerular filtration rate (GFR)of each of my kidneys as my left one wassignificantly larger than the right. This testdemonstrated that my overall kidney func-

tion was split 50/50 between each kidney,despite the difference in size. Had there

been a 60/40 differential (or more) thetransplant would not have taken place asthe kidney with the lesser function wouldnot have been enough to sustain satisfac-tory renal function in either Howard ormyself. I also underwent tests to establishmy fitness for anaesthetic.

To ascertain Howards fitness for trans-plant, he underwent routine cardiac andrespiratory investigations, and a brainscan to rule out cerebral haemorrhage,

which is one of the complications of PKD(Jacob, 2012). As he has a close family his-tory of bowel cancer, he also underwent acolonoscopy. It was important to establishif Howard had any pre-existing cancer asthe drugs he would need to take for the rest

of his life could exacerbate this condition.Immunosuppressive drugs, such as tac-rolimus, are given to suppress lymphocyteproduction.

Once all these tests had establishedHowards fitness for transplant and myappropriateness as a donor, together withmy fitness for surgery, non-medical assess-ment was required. This involved us beinginterviewed together by an independentassessor, who then saw me on my own to

verify that I was not being coerced todonate my kidney. This is in accordance

with UK Human Tissue Authority regula-tions (HTA, 2013).

I had made up my mind that I wanted tobe a donor before I understood all thephysical implications of having this sur-gery. The risks were explained to me and Iunderstood that my renal function wouldnot be compromised by having one kidney,although I might experience some fatigue

initially while the lone kidney adapted. Ivery much wanted to be able to giveHoward a kidney and trusted the renalteam to not put me at any undue risk.

During the build-up to the transplant,my anxiety was far more focused onhoping we would be able to have the sur-gery than on its implications.

Live kidney transplantationThe investigations caused a high degree ofanxiety for us both, but we finally made itto the operating theatre on 15 September2011. Fig 1 shows the position of a trans-planted kidney. It is normal to not removethe diseased kidneys unless they growexcessively large (Jacob, 2012).

After surgery, we both spent two days inthe renal high dependency unit. My renalfunction was closely monitored until itreached satisfactory levels of a GFR over70ml/min and creatinine below 120mol/L.

We were discharged home after twoweeks when Howards creatinine wasbelow 200mol/L, his wound appeared to

be healing and the pharmacist was satis-fied that he understood his drug regimen.

Following discharge, Howard con-tinued to be closely monitored by the renaloutpatients department. In the first coupleof weeks after discharge, this meant visitsthree times a week, then twice weekly andgradually reducing to once every six weeks.On each visit, his creatinine level wastested, as a significant rise could indicatesigns of rejection (Thomas, 2008). If pickedup early, this can be rectified by adjustingthe dose of anti-rejection drugs.

Howard also had a biopsy of the trans-planted kidney at three months and againone year after the transplant. This is

because this tissue can show signs of earlyrejection before creatinine levels change(Thomas, 2008).

Nursing PracticeReview

A short article by the lead author on her

feelings about being a live donor

www.nursingtimes.net/livedonation

National Kidney Federation

www.kidney.org.uk

Kidney Patients Association

www.britishkidney-pa.co.uk

NHS Blood and Transplant(organ

donation) www.organdonation.nhs.uk

You can join the NHS Organ Donor

register by filling in a form online or

calling the NHS Donor Line on 0300 123

23 23. Lines are open 24 hours per day

all year. Calls are charged at your

contracted rate for local calls.

BOX 1. RESOURCES

TABLE 3. SUMMARY OF THE INVESTIGATIONS IN PREPARATION FOR TRANSPLANT

Recipient (Howard) Donor (myself)

Coronory investigation: ECG and percutaneous coronaryintervention

Routine chest X-ray

Ultrasound scan of the kidneys

Blood test

Blood group (ABO)

Full blood count, urea and electrolytes, renal profile, liver

screen, bone screen, glucose

Human leucocyte antigen (HLA)

Virology (hepatitis, CMV)

MRSA swabs

Brain magnetic resonance imaging (because PKD diagnosis

would make Howard prone to cerebral haemorrhage)

Colonoscopy (family history of bowel cancer)

Ultrasound of kidneysMagnetic resonance angiogram (MRA)

Nuclear medicine test for glomerular filtration rate total

function and nuclear medicine test for GFR each kidney

Exercise ECG test

Chest X-ray

Routine blood tests

ABO blood group and HLA compatibility

24-hour urine collection

MRSA swabs


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100713 live kidney transplant from an unrelated donor

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