Dialysis-1.pptx

Dialysi s Copyright © 2020 by Elsevier, Inc. All rights reserved. 1 Objectives Discuss Hemodialysis Discuss Peritoneal dialysis Discuss complication for HD and PD. Discuss general principles of Dialysis. Dialysis (1 of 3) Movement of fluid/molecules across a semipermeable membrane from one compartme...

Dialysi s Copyright © 2020 by Elsevier, Inc. All rights reserved. 1 Objectives Discuss Hemodialysis Discuss Peritoneal dialysis Discuss complication for HD and PD. Discuss general principles of Dialysis. Dialysis (1 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 3 Dialysis (2 of 3) Two 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 4 Dialysis (3 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 5 General Principles of Dialysis (1 of 3) Diffusion  Movement of solutes from an area of greater concentration to an area of lesser concentration Copyright © 2020 by Elsevier, Inc. All rights reserved. 6 Osmosis and Diffusion Across Semipermeable Membrane (Fig. 46-4) Copyright © 2020 by Elsevier, Inc. All rights reserved. 7 General Principles of Dialysis (2 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 8 General Principles of Dialysis (3 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 9 Case Study (9 of 13) K.W., a 35-year-old man, received a diagnosis of chronic glomerulonephritis He now has stage 5 chronic kidney disease Copyright © 2020 by Elsevier, Inc. All rights reserved. 10 Case Study (10 of 13) K.W.’s laboratory values:    BUN 72 mg/dL Serum creatinine 6.5 mg/dL GFR 12 mL/min What are his treatment options at this time? Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 Peritoneal Dialysis (1 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 12 Peritoneal Dialysis (2 of 3) Fig. 465 Copyright © 2020 by Elsevier, Inc. All rights reserved. 13 Peritoneal Catheter (3 of 3) Fig. 466 Copyright © 2020 by Elsevier, Inc. All rights reserved. 14 Case Study (11 of 13) K.W. decides to use peritoneal dialysis (PD) as his treatment. He has a Tenckhoff catheter placed for PD. He asks many questions about when he can begin using the catheter, as well as how he will manage his dialysis schedule. Copyright © 2020 by Elsevier, Inc. All rights reserved. 15 Peritoneal Dialysis Dialysis Solutions and Cycles 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 16 Peritoneal Dialysis Systems 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 17 Automated Peritoneal Dialysis Fig. 467 Copyright © 2020 by Elsevier, Inc. All rights reserved. 18 Peritoneal Dialysis Exit siteComplications infection (1 of  Redness, tenderness, drainage 3)  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, ⭡ bowel sounds  Treat with antibiotics  Repeated infections may cause adhesions  Copyright © 2020 by Elsevier, Inc. All rights reserved. 19 Peritoneal Dialysis Complications (2 of 3) Hernias Increased intrabdominal pressure from dialysate  Treatment: hernia repair  Lower back problems Intraperitoneal infusion increases pressure  Treatment: binders and exercise  Bleeding Pulmonary complications Protein loss Copyright © 2020 by Elsevier, Inc. All rights reserved. 20 Peritoneal Dialysis Complications (3 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 21 Peritoneal Dialysis Effectiveness of Chronic PD Short training program; 3 to 7 days Advantages      Simplicity Home-based program Increasing patient participation No need for special water systems Equipment set-up is relatively simple Copyright © 2020 by Elsevier, Inc. All rights reserved. 22 Case Study (12 of 13) K.W. has difficulty managing his P.D. because of progressive visual limitations. He develops a catheter infection, and it is determined that he should be switched to hemodialysis (HD). Copyright © 2020 by Elsevier, Inc. All rights reserved. 23 Hemodialysis (HD) Vascular Access Sites HD requires rapid blood flow and access to a large blood vessel. Obtaining vascular access is one of most difficult problems  Types of access Arteriovenous fistulas and grafts Temporary vascular access Copyright © 2020 by Elsevier, Inc. All rights reserved. 24 Arteriovenous Fistulas and Grafts Created in forearm or upper arm— preferred access for HD Fistula allows arterial blood to flow through vein; becomes “arterialized; ⭡ vein size and wall thickness Placed 3 months before HD; needs to mature Feel “thrill” or hear “bruit” due to high velocity of blood flow Copyright © 2020 by Elsevier, Inc. All rights reserved. 25 Vascular Access for Hemodialysis Arteriovenous Fistula (Fig. 46-8) Copyright © 2020 by Elsevier, Inc. All rights reserved. 26 Arteriovenous Fistula Created by Anastomosing an Artery and a Vein (Fig. 46-8) Copyright © 2020 by Elsevier, Inc. All rights reserved. 27 Arteriovenous Grafts (AVGs) (1 of 2) Synthetic material surgically placed under the skin to form a “bridge” between artery (brachial) and vein (antecubital) Healing time—2 to 4 weeks More likely to get infected or form clots  If infected, may need removed Copyright © 2020 by Elsevier, Inc. All rights reserved. 28 Arteriovenous Graft (2 of 2) Fig. 468B Copyright © 2020 by Elsevier, Inc. All rights reserved. 29 HeRO Graft (Hemodialysis Reliable Outflow) (1 of 2) access used when other Special bridge access options are exhausted Two pieces    Reinforced tube to bypass blockages Dialysis graft anastomosed to an artery; placed under skin Bypasses venous system; blood flows from target artery to heart Copyright © 2020 by Elsevier, Inc. All rights reserved. 30 HeRO Graft (Hemodialysis Reliable Outflow) (2 of 2) Fig. 468C Copyright © 2020 by Elsevier, Inc. All rights reserved. 31 AV Fistulas and Grafts Risks:  Distal ischemia (steal syndrome) Pain distal to access site Numbness or tingling of fingers Poor capillary refill  Aneurysms Safety alert for AVF and grafts  No BP, venipunctures, or IV lines Post signs in room or labeled arm band  Prevent infection and clotting Copyright © 2020 by Elsevier, Inc. All rights reserved. 32 Temporary Vascular Access Catheter insertion of internal jugular or femoral vein when immediate access is needed Double lumen   Blood removal Blood return Risks: high infection, dislodgment, and malfunction Copyright © 2020 by Elsevier, Inc. All rights reserved. 33 Temporary Double-Lumen Vascular Access Catheter Fig. 4610AB Copyright © 2020 by Elsevier, Inc. All rights reserved. 34 Right Internal Jugular placement for a Tunneled, Cuffed Semipermanent Catheter Fig. 4611 Copyright © 2020 by Elsevier, Inc. All rights reserved. 35 Temporary Hemodialysis Catheter Fig. 4611 Copyright © 2020 by Elsevier, Inc. All rights reserved. 36 Temporary Vascular Access Long-term cuffed catheters are used when waiting for AVF or other forms failed    Exit on upper chest and tunneled to internal or external jugular vein Tip is in right atrium One or two cuffs that prevent infection and anchor catheter Copyright © 2020 by Elsevier, Inc. All rights reserved. 37 Long-term Cuffed Hemodialysis Catheter Fig. 4611C Copyright © 2020 by Elsevier, Inc. All rights reserved. 38 Hemodialys is Plastic cartridgeDialyzers that contain thousands of parallel hollow tubes or fibers; semipermeable membranes Blood is pumped from top into fibers Dialysate pumped from bottom and bathes the outside of the fibers Ultrafiltration, diffusion and osmosis occur When blood reaches end—returned via single tube to patient Copyright © 2020 by Elsevier, Inc. All rights reserved. 39 Hemodialysis Procedure (1 of 3) Before HD treatment  Assess fluid status Weight, BP, peripheral edema, heart and lung sounds Weight from last postdialysis and current weight predialysis determines how much fluid will be removed Assess vascular access  Assess temperature  Monitor VS every 30 to 60 minutes  Copyright © 2020 by Elsevier, Inc. All rights reserved. 40 Hemodialysis Procedure (2 of 3) Two large bore needles placed in fistula or graft   One needle is placed to pull blood from circulation to HD machine Other needle is used to return dialyzed blood to the patient Heparin is added to prevent clotting Dialysate delivery and monitoring system is used Copyright © 2020 by Elsevier, Inc. All rights reserved. 41 Components of Hemodialysis System Fig. 4612 Copyright © 2020 by Elsevier, Inc. All rights reserved. 42 Hemodialysis Procedure (3 of 3) Dialyzer/blood lines primed with saline solution to eliminate air Terminated by flushing with saline to return all blood to patient Needles removed and firm pressure applied Copyright © 2020 by Elsevier, Inc. All rights reserved. 43 Case Study (13 of 13) K.W. has a left arteriovenous fistula placed. After 1 month, he is ready to begin HD. What assessment data should be obtained before a dialysis treatment is initiated? Copyright © 2020 by Elsevier, Inc. All rights reserved. 44 Hemodialysis Settings and Schedules 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 45 Home HD Fig. 4613 Copyright © 2020 by Elsevier, Inc. All rights reserved. 46 Hemodialysis Complications (1 of 2) 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  Copyright © 2020 by Elsevier, Inc. All rights reserved. 47 Hemodialysis Complications (2 of 2) 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  Copyright © 2020 by Elsevier, Inc. All rights reserved. 48 Hemodialysis Effectiveness (1 of 2) Cannot fully replace normal functions of kidneys Can ease many of symptoms Can prevent certain complications CV disease carries high mortality rate Infectious complications 2nd leading cause of death Copyright © 2020 by Elsevier, Inc. All rights reserved. 49 Hemodialysis Effectiveness (2 of 2) Individual adaptation Positive  Ambivalent  Depressed  Nursing goals: help the patient to: have a healthy self-image  return to highest level of function  Copyright © 2020 by Elsevier, Inc. All rights reserved. 50 Continual Renal Replacement Therapy (CRRT) (1AKI of 9) Method for treating 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 51 Continual Renal Replacement Therapy (CRRT) (2 of 9) Contraindication  Patient has life-threatening manifestations of uremia that require rapid treatment Copyright © 2020 by Elsevier, Inc. All rights reserved. 52 Continual Renal Replacement Therapy (CRRT) (3 of 9) Various types of CRRT     Continuous venovenous hemofiltration (CVVH) Slow continuous ultrafiltration (SCUF) Continuous venovenous hemodialysis (CVVHD) Continuous venovenous hemodiafiltration (CVVHDF) Copyright © 2020 by Elsevier, Inc. All rights reserved. 53 Continuous Venovenous Therapies Fig. 4614 Copyright © 2020 by Elsevier, Inc. All rights reserved. 54 Continual Renal Replacement Therapy (CRRT) (4 of 9) Infusion of replacement fluid determined by degree of fluid and electrolyte imbalance Anticoagulants are needed to prevent blood clotting Customized to patient’s needs Copyright © 2020 by Elsevier, Inc. All rights reserved. 55 Continual Renal Replacement Therapy (CRRT) (5 of 9) CVVHD and CVVHDF   Uses dialysate Dialysis fluid is attached to distal end of hemofilter Copyright © 2020 by Elsevier, Inc. All rights reserved. 56 Continual Renal Replacement Therapy CRRT (CRRT) versus HD (6 of 9)      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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 57 Continual Renal Replacement Therapy CRRT (CRRT) versus HD (7 of 9)   Does not require constant monitoring by HD nurse (need ICU nurse) Does not require complicated HD equipment Copyright © 2020 by Elsevier, Inc. All rights reserved. 58 Continual Renal Replacement Therapy (8long ofas9)30 to 40 days Can be(CRRT) continued as Hemofilter should be changed every 24 to 48 hours Able to obtain specimens Ultrafiltrate should be clear yellow  If bloody, need to terminate Copyright © 2020 by Elsevier, Inc. All rights reserved. 59 Continual Renal Replacement Therapy (CRRT) (9 of 9) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 60 Wearable Artificial Kidney (WAK) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 61 Audience Response Question (1 of 2) A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patient’s diet? a. Fat b. Protein c. Calories d. Carbohydrates Copyright © 2020 by Elsevier, Inc. All rights reserved. 62 Audience Response Question (2 of 2) Answer: B Protein Copyright © 2020 by Elsevier, Inc. All rights reserved. 63 Kidney Transplantation Copyright © 2020 by Elsevier, Inc. All rights reserved. 64 Kidney Transplant (1 of 2) 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. Copyright © 2020 by Elsevier, Inc. All rights reserved. 65 Kidney Transplant (2 of 2) 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 first year Copyright © 2020 by Elsevier, Inc. All rights reserved. 66 Kidney Transplant Recipient Selection (1 of 3) determined by a variety of medical Candidacy 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 67 Case Study (1 of 6) C.L., a 49-year-old woman, has a history of type 1 diabetes. She was recently diagnosed with chronic kidney disease. She is interested in pursuing preemptive kidney transplant to avoid long-term effects of dialysis. Copyright © 2020 by Elsevier, Inc. All rights reserved. 68 Kidney Transplant Recipient Selection (2 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 69 Kidney Transplant Recipient Selection (3 of 3) procedures may be required Surgical before transplant    Coronary artery bypass or coronary angioplasty Cholecystectomy Bilateral nephrectomy Copyright © 2020 by Elsevier, Inc. All rights reserved. 70 Kidney Transplant Histocompatibility Studies Purpose of testing is to identify HLA antigens for both donors and potential recipients Copyright © 2020 by Elsevier, Inc. All rights reserved. 71 Kidney Transplant Donor Sources (1 of 3) Deceased donors with compatible blood type Blood relatives Emotionally related living donors Altruistic living donors Paired organ donation Copyright © 2020 by Elsevier, Inc. All rights reserved. 72 Case Study (2 of 6) C.L. is married with 2 school-age children. She has a very supportive extended family. Her husband and 2 sisters are tested to see if they are a compatible match to donate. Copyright © 2020 by Elsevier, Inc. All rights reserved. 73 Case Study (3 of 6) It is determined that C.L.’s 39-year-old sister is a compatible donor. What information does C.L.’s sister need about the preoperative diagnostic studies and surgery? Copyright © 2020 by Elsevier, Inc. All rights reserved. 74 Kidney Transplant Donor Sources (2 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 75 Kidney Transplant Donor Sources (3 of 3) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 76 Donor Sources: Live Donor (1 of 2)  Diagnostic studies ECG, chest x-ray  Renal ultrasound, arteriogram, 3D CT scan Psychologist or social worker evaluation   Emotional stability Copyright © 2020 by Elsevier, Inc. All rights reserved. 77 Donor Sources: Live Donor (2 of 2) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 78 Donor Sources Deceased Donors 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 Copyright cold ©time less Inc. than 2020 by Elsevier, All rights24 hours reserved. 79 Kidney Transplant Surgical Procedure (1 of Live7) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 80 Kidney Transplant Surgical Procedure (2 of Live7) donor  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 81 Kidney Transplant Surgical Procedure (3 of 7) transplant recipient Kidney   Transplanted kidney usually placed extraperitoneal in the iliac fossa Right iliac fossa is preferred for anastomosis of blood vessels and ureter Copyright © 2020 by Elsevier, Inc. All rights reserved. 82 Kidney Transplant Fig. 4615A Copyright © 2020 by Elsevier, Inc. All rights reserved. 83 Case Study (4 of 6) C.L. and her sister arrive together the morning of surgery. Her sister is taken to the OR first and has a laparoscopic nephrectomy. C.L. is taken into the OR to begin preparing to receive the kidney. Copyright © 2020 by Elsevier, Inc. All rights reserved. 84 Kidney Transplant Surgical Procedure (4 of 7) transplant recipient Kidney Before incision  Urinary catheter placed into bladder Antibiotic solution instilled ⮞ ⮞  Distends the bladder Decreases risk of infection Crescent-shaped incision Copyright © 2020 by Elsevier, Inc. All rights reserved. 85 Kidney Transplant Surgical Procedure (5 of 7) transplant recipient Kidney    Rapid revascularization critical Donor artery anastomosed to recipient internal or external iliac artery Donor vein anastomosed to recipient external iliac vein Copyright © 2020 by Elsevier, Inc. All rights reserved. 86 Kidney Transplant Surgical Procedure (6 of 7) transplant recipient Kidney    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) Copyright © 2020 by Elsevier, Inc. All rights reserved. 87 Kidney Transplant Nursing Management (7 of 7) care Preoperative  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 88 Case Study (5 of 6) C.L. and her sister are transferred to a progressive care unit. C.L. is resting comfortably after IV analgesics were administered. Her sister continues to report discomfort after two doses of analgesia. Copyright © 2020 by Elsevier, Inc. All rights reserved. 89 Kidney Transplant Nursing Management (1 of 3) Postoperative care  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! Copyright © 2020 by Elsevier, Inc. All rights reserved. 90 Kidney Transplant Nursing Management (2 of 3) Postoperative care  Kidney transplant recipient Maintenance of fluid and electrolyte balance is first 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 91 Kidney Transplant Nursing Management (3 of 3) Postoperative care  Kidney transplant recipient 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; followup care Copyright © 2020 by Elsevier, Inc. All rights reserved. 92 Kidney Transplant Immunosuppressive Therapy Goals   Adequately suppress immune response to prevent rejection Maintain sufficient immunity to prevent overwhelming infection Copyright © 2020 by Elsevier, Inc. All rights reserved. 93 Kidney Transplant Complications (1 of 8) 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 94 Case Study (6 of 6) C.L.’s sister is discharged on postoperative day 3. C.L. is scheduled to be discharged 3 days later. What are the priority teaching needs for C.L.? Copyright © 2020 by Elsevier, Inc. All rights reserved. 95 Kidney Transplant Complications (2 of 8) Infection   Risk related to: suppression of normal defense mechanisms, immunosuppressive drugs, and effects of ESRD; compounded by systemic illnesses Most common infections observed in first month: pneumonia , wound infections, IV line and drain infections, and UTIs Copyright © 2020 by Elsevier, Inc. All rights reserved. 96 Kidney Transplant Complications (3 of 8) Infection  Fungal infections Candida Cryptococcus Aspergillus Pneumocystis jiroveci Copyright © 2020 by Elsevier, Inc. All rights reserved. 97 Kidney Transplant Complications (4 of 8) Infection  Viral infections CMV ⮞ One of most common Epstein-Barr virus Herpes simplex virus (HSV) Varicella-zoster virus Polyomavirus (e.g., BK virus) Copyright © 2020 by Elsevier, Inc. All rights reserved. 98 Kidney Transplant Complications (5 of 8) Cardiovascular disease    Transplant recipients have increased incidence of atherosclerotic vascular disease Immunosuppressants can worsen hypertension and hyperlipidemia Patients need to adhere to antihypertensive regimen Copyright © 2020 by Elsevier, Inc. All rights reserved. 99 Kidney Transplant Complications (6 of 8) Cancers   Primary cause— immunosuppressive therapy Most common Skin cancers Posttransplant lymphoproliferative disorder   Regular screening is important Preventive care Protective clothing and sunscreen Copyright © 2020 by Elsevier, Inc. All rights reserved. 100 Kidney Transplant Complications (7 of 8) Recurrence of original kidney disease     Glomerulonephritis IgA nephropathy Diabetic nephropathy Focal segmental sclerosis Copyright © 2020 by Elsevier, Inc. All rights reserved. 101 Kidney Transplant Complications (8 of 8) Corticosteroid-related complications        Aseptic necrosis of hips, knees, and other joints Peptic ulcer disease Diabetes Cataracts Dyslipidemia Infections Cancers Copyright © 2020 by Elsevier, Inc. All rights reserved. 102 Audience Response Question (1 of 2) Six days after kidney transplant from a deceased donor, a patient develops a temperature of 101.2°F (38.5°C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate: a. acute rejection, which is not uncommon and is usually reversible. b. hyperacute rejection, which will necessitate removal of the transplanted kidney. c. an infection of the kidney, which can be treated with IV antibiotics. d. the onset ofCopyright chronic rejection of the kidney © 2020 by Elsevier, Inc. All rights reserved. 103 Audience Response Question (2 of 2) ANS: A Acute rejection, which is not uncommon and is usually reversible. Copyright © 2020 by Elsevier, Inc. All rights reserved. 104