Pre- And Post-transplant Care

AIMThe aim of this continuing education article is to enable thenephrology nurse to assess, plan, implement and evaluate the caregiven to patients admitted to hospital for renal transplantation.

LEARNING OUTCOMESAfter reading this CE article the reader should be able to:

• Discuss the assessment, planning, implementation and eval-uation of the care given to patients admitted for renaltransplantation.

• Discuss the importance of post-transplant observations andthe significance of any changes.

• Discuss the management of the common complicationspost-transplantation.

107Journal of Renal Care 2012 © 2012 European Dialysis and Transplant Nurses Association/European Renal Care Association

Trevitt R., Dunsmore V., Murphy F., Piso L., Perriss C., Englebright B., Chamney M. (2012). Pre- and post-transplant care:nursing management of the renal transplant recipient: part 2. Journal of Renal Care 38(2), 107-114.

SUMMARYThis is the second article in a three part continuing education series on renal transplantation which addresses the specialisedknowledge and skills required in order to prepare a patient admitted to hospital for renal transplantation and then how tocare for that patient afterwards. The first article in this series addressed patient health and well-being while waiting for a renaltransplant. The third article will look at the long-term care of kidney recipients.

KEY WORDS Education • Nursing • Renal transplantation

Ray Trevitt1, RGN, MSc, Victoria Dunsmore1, RGN, Fiona Murphy2, RGN, RNT, BSc (Hons) Renal Nurs, BSc (Hons)Health Stud, PGDip Adv Nurs Scie, PGDip CHScieEdu, MA, MSc, Lilibeth Piso1, BSc RN, Charlotte Perriss1, RGN,Belinda Englebright1, BSc RN, Melissa Chamney3, RGN, MN (Nephrology), Grad.Dip.Ac.Practice, Renal Cert1Barts and The London NHS Trust. 2School of Nursing & Midwifery, Trinity College, Dublin. 3Renal Programme, City University, London.

BIODATA

RRaayy TTrreevviitttt is a Living Kidney Donor Coordinator at Barts and The London NHS Trust. His previous EDTNA/ ERCA roles include Consultant onTransplantation issues and Chair of the Transplant Interest Group.

VViiccttoorriiaa DDuunnssmmoorree is a Clinical Nurse Specialist, and has worked in transplantation for over 20 years. She is currently studying for an MSc in Nursing.

FF iioonnaa MMuurrpphhyy is a Lecturer and Renal Educational Facilitator. Fiona is the former Education Officer of the Irish Nephrology NursesAssociation and was a member of the former Education Research Board of the EDTNA/ERCA.

LLii ll iibbeetthh PPiissoo is a Clinical Nurse Specialist in Renal Transplantation working with pre and posttransplant patients.

CChhaarrlloottttee PPeerrrriissss is a Clinical Nurse Specialist in Renal Transplantation with special responsibilityfor paediatric transition patients.

BBeell iinnddaa EEnngglleebbrr iigghhtt is a Living Kidney Donor Coordinator and is studying for a BusinessDiploma.

MMeell ii ssssaa CChhaammnneeyy is a Senior Lecturer of Renal Care & Programme Manager at City University, London. She was a member of the former Education Research Board of the EDTNA/ERCA.

CCOORRRREESSPPOONNDDEENNCCEERay Trevitt,Department of Nephrology andTransplantation,Royal London Hospital,London E1 1BB, United KingdomTel.: 020 7377 7000Fax: 020 7377 [email protected]

CE: Continuing Education ArticlePRE- AND POST-TRANSPLANT CARE: NURSING MANAGEMENT OF THERENAL TRANSPLANT RECIPIENT: PART 2

This continuing education article, which is based on the best available evidence, includes various learning activities aimed atdeveloping your knowledge and understanding of pre and post transplant care of the patient. After reading this article and oncompletion of the learning activities you will have achieved 3 hours of learning in accordance with the EDTNA/ERCA criteria forcontinuing professional development.

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108 Journal of Renal Care 2012

CE: Continuing Education ArticlePRE- AND POST-TRANSPLANT CARE: NURSING MANAGEMENT OF THE RENAL TRANSPLANT RECIPIENT: PART 2

© 2012 European Dialysis and Transplant Nurses Association/European Renal Care Association

INTRODUCTIONFor patients undergoing renal transplantation it is a time ofgreat uncertainty. While it is acknowledged that there is a largenumber of healthcare professionals caring for patients who arewaiting for a transplant, it is the renal nurse who is at the cen-tre of their care delivery (Murphy 2007a). The renal nurse needsto assist the patient and their relatives to deal effectively withthis situation and also to manage the patient’s pre- and post-operative care to maximise the success of the graft. A goodstart for the transplant is a predictor of a good long-term out-come (Hariharan et al. 2002). The importance of patient well-being while waiting for transplantation was highlighted in thefirst of this series of articles (Murphy et al. 2011). Psychologicaland social support is vital for patients, their spouses/partnersand family members especially as patients endure their dialysistreatment and wait for that call for renal transplantation. Thissupport process must be continued throughout the pre-trans-plantation phase right through to discharge and beyond so thatthey can effectively manage this life-changing event.

ADMISSION TO HOSPITALWhen a patient is active on the transplant list it is importantthat they remain fit and well, and that they inform the centreof any changes in contact details. This is because it is usual forthe patient to receive a telephone call from the transplant cen-tre to inform them that there is a kidney available. They will beadvised to come to the hospital straight away, within a fewhours. Although they are warned that there is no guaranteethat they will receive the kidney, they should be advised to pre-pare to be admitted to hospital and bring personal things withthem. They will be instructed not to eat or drink from this pointonwards in order to be ready for surgery.

Upon arrival in the transplant ward, the admission proceduresand orientation are carried out by the nurse. Observations or vitalsigns are taken to help ensure that the patient will be fit for sur-gery and fit for the immunosuppression therapy they will receive.The nephrologists will also examine the patient and review his/hermedical history. It is important at this stage to establish that thepatient is free from infection and that any comorbidities present,such as vascular disease, would not cause undue risk. The patientwill be informed about the forthcoming procedures for theimmediate future and the surgeon and anaesthetist will assesswhether the patient is fit enough to undergo transplantation. Thesurgeon will explain in detail the risks and benefits of the surgeryitself. The aim is to reduce patient anxiety, provide appropriate

information and help him/her to prepare emotionally. The patientand their family members should be encouraged to ask questionsduring this time. At this point, the patient will be asked to pro-vide written consent for transplantation.

TESTSPre-operative preparation follows a similar process in all centres.The patient will have routine pre-operative blood tests and alsoa tissue type crossmatch to check if he/she has any antibodiesagainst the donor. Deceased donor kidneys are almost alwaysfrom a blood group compatible donor (see Table 1) so bloodgroup antibodies will not be an issue. With tissue type antibod-ies, if the patient has been negative for a period beforehand andhas not received a recent blood transfusion then some centresdo not require a prospective crossmatch. Crossmatching takesup to six hours to perform. In the past, a positive result meantthat the transplant could not proceed as the body would rejectthe kidney straight away. However, a positive crossmatch is nolonger a roadblock to kidney transplantation. Some degree ofpositivity may be acceptable depending on local policy. The sur-gery can still go ahead but the patient must receive additionalimmunosuppression such as antithymocyte globulin (ATG) todecrease antibody activity which is destructive to the graft(Danovitch 2009). A negative crossmatch means that there areno reactions between the donor and the recipient’s blood,meaning that the transplant can go ahead as the recipientshould not rapidly reject the kidney when immunosuppressiontherapy is given (Chamney 2009).

The patient may require renal replacement therapy (RRT)(haemodialysis or peritoneal dialysis) and other routine pre-operative tests such as ECG and chest x-ray. Once all theresults are back and are satisfactory, the transplant can pro-ceed. If not, the reasons for this negative outcome must bediscussed with the patient and they should be seen again inclinic for review. They may be suspended from the transplantlist pending further assessment.

Donor Recipient

A B AB O

A Yes Yes

B Yes Yes

AB Yes

O Yes Yes Yes Yes

Table 1: Compatible blood groups.

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CE: Continuing Education ArticlePRE- AND POST-TRANSPLANT CARE: NURSING MANAGEMENT

OF THE RENAL TRANSPLANT RECIPIENT: PART 2


In special circumstances, most commonly with living donors(LD), it is possible to transplant from a blood group incompat-ible donor (Wilpert et al. 2010).

THE DONATED KIDNEYDonors can fall into several categories which may have a bear-ing on expectations for the kidney due to the condition of thedonor at the time of retrieval (Gutiérrez 2009):• Donors after Brain Death (DBD) donor’s circulation contin-

ues up to point of retrieval;• Donors after Cardiac Death (DCD) donor’s heart stops

before retrieval commences;• Extended Criteria Donors (ECD), for example, donor may be

older with comorbidities;• LD give the best quality of kidney.

When a deceased donor organ becomes available, the nationalorgan procurement agency allocates it according to their regu-lations and matching criteria. For the United Kingdom, thesedetails can be found on the Organ and Donation website (NHSBT 2011a). Criteria for acceptance of kidneys may vary slightlyfrom hospital to hospital, as can local criteria for acceptingpatients for transplantation. Local criteria for acceptance of akidney include donor age, any transmittable disease, anatomicalabnormalities or damage and ischaemic time (NHS BT 2011a).

REMOVAL OF DECEASED DONOR KIDNEYSThe surgeon dissects each kidney with the vessels andureters intact. They are cooled and flushed whilst in situ tominimise warm ischaemic time. Multiple organ retrieval usu-ally begins with retrieval of heart, lungs then liver or pan-creas followed by kidneys. Cold ischaemic time (CIT), whenthe kidney is in cold storage, is far less damaging then warmischaemia. A CIT of greater than 20 hours may adverselyaffect outcome due to chronic damage to the kidney. In the

United Kingdom the median CIT in 2008–2010 was 16 hours(NHS BT 2011a)

THE TRANSPLANT RECIPIENTWhen anaesthetised and intubated the patient may have avenous line inserted into a peripheral vein and a doublelumen neck line. The kidney is place in the iliac fossa. Thegraft vein and artery are sewn to the recipient’s vein andartery and the ureter to the bladder. Ureteric anastamosis isusually to the recipient’s bladder or into the native ureter. Aurinary catheter is inserted to ensure continuous bladderdrainage and many centres use a ureteric stent, which is leftin place for several weeks, to protect and keep open theureteric anastamosis.

Drains may also be placed in the peritoneal space during sur-gery to drain any excess blood or lymph fluid. During this peri-od the patient needs to be well perfused to establish diuresisand graft function and maintain blood pressure.

Commonly used measures of success are patient and graft sur-vival and comparisons with patient outcome on RRT. In theUnited Kingdom, for the period 2005–2008, for first adult DBDdonor kidney transplants, one-year graft survival was 93%. Forthe period 2002–2004 the five-year graft survival rate is 85%(NHS BT 2011b). For the same groups the patient survival is96% and 87%, respectively.

POST-OPERATIVE COMPLICATIONSThe complications cited below are specific to renal transplantsurgery and are in addition to general complications post-abdominal surgery, for example, deep vein thrombosis (DVT),post-surgical ileus (temporary paralysis of a section of theintestines).

Time out activityFind a detailed account of renal transplant surgery (e.g.Trevitt 2008, Chamney 2009).

Try to find an aspect of care that interests you. It may besomething you do not understand the purpose of, or donot agree with, or differs from practice at your own centre.See if you can find evidence to support continuing with thisaspect of care using a search engine such as google scholaror Pub Med.

Time out activityFind out about different types of kidney donor and anyimplications for the transplant outcome. Why do livingdonor kidneys provide the best quality transplant?

Time out activityReview your hospital protocols for pre-operative prepara-tion. Are these the same as above?

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BLEEDINGSignificant post-operative bleeding occurs in up to 15% ofpatients post-transplant (Hernández et al. 2006). This compli-cation can be life threatening and requires immediate interven-tion. Bleeding can result from loosening of the suture at thearterial or venous anastomosis, from a mycotic aneurysm (ananeurysm resulting from infection in the vessel wall) at thearterial anastomosis or from rupture of the kidney due toaggressive early rejection. Monitoring of the patient’s wound,abdomen and vital signs including urine output are key indetecting this complication.

ACUTE VASCULAR THROMBOSISThis is the formation of a clot which blocks the flow of bloodin the kidney. Typically this occurs within 24 hours of surgeryin as many as 8% of patients and can involve either thetransplant renal artery or vein (Veale et al. 2009). Thepatient may complain of pain and swelling over the trans-plant site and have decreased urine output. UltrasoundDoppler is used to determine whether there is blood flow inthe renal artery and vein.

If detected straight away the graft may be saved by surgicalintervention, however in many cases this is not possible andthe graft is lost. The cause of acute vascular thrombosis isoften unknown but there are pre-disposing factors: technicalproblems at the time of surgery due to small vessels in therecipient or donor; pre-existing atherosclerotic vascular dis-ease in the recipient or donor; undiagnosed clotting disorderin the recipient.

URINE LEAKThis can occur in around 4% of patients (Hernández et al.2006). Urine leaks into the abdominal cavity due to uretericobstruction or necrosis. The patient may complain of abdomi-nal discomfort and have reduced urine output. Ultrasoundinvestigation of the abdomen can confirm a urinary leak.Treatment is usually insertion of an indwelling urinary catheterwhich remains in situ until the leak is healed. Occasionally sur-gical intervention will be necessary.

LYMPHOCOELEA collection of lymph fluid can accumulate following trans-plant surgery, occurring in approximately 18% of patients(Veale et al. 2009). A lymphocele can be present withoutadverse effects but can become problematic if large as it

may compress the iliac vein leading to swelling of the leg, or compress the transplant ureter leading to graftdysfunction. Presence of a lymphocele can be identified by ultrasound.

INFECTIONDue to the effects of immunosuppression transplant recipientsare at higher risk of infection from bacterial, viral and fungalsources. Prevention of chest infection can be ensured post-operatively by encouraging deep breathing, promoting earlymobility and physiotherapy. Close attention should be paid tothe surgical wound to prevent and/or detect infection.Monitoring of vital signs, particularly temperature is importantin order to detect signs of infection.

REJECTIONRejection rates of between 15% and 30% have been reportedin renal transplant recipients depending on immunosuppres-sive regime (Vincenti et al. 2008) and can be either cellular orvascular in nature. Rejection is suspected if the serum creati-nine rises (or fails to fall). Symptoms such as pyrexia, graft ten-derness and decreased urine output develop at a relatively latestage. If no obvious cause for the creatinine rising can be seen,then to confirm the diagnosis of rejection a biopsy of trans-plant tissue is taken under local anaesthetic and is examined inthe laboratory. Treatment depends on the type and severity ofrejection. Borderline or mild rejection (cellular) may be treatedwith an increase in oral immunosuppression or with intra-venous high dose Prednisolone. More severe rejection (cellularor vascular) can be treated as mentioned above or by addition-al administration of ATG.

IMMUNOSUPPRESSIONWithout medication to suppress the patient’s immunesystem the transplanted kidney would be rejected. This typeof medication is referred to as immunosuppression.Immunosuppressive medication used at the time of trans-plant surgery is referred to as induction. Once transplantedthe patient must continue to take immunosuppression for aslong as the organ functions, this is known as maintenanceimmunosuppression.

Time out activityWhat types of rejection are there? See Malhotra et al.(2011).

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POST-OPERATIVE OBSERVATIONSOn return to the ward the patient must have their vital signsmonitored as for any patient post major surgical procedureand general anaesthetic, observing for signs of shock andhaemorrhage. The anaesthetist’s instructions for oxygenadministration must be observed. It is important to monitorrespiratory function at this time as the patient will beimmunosuppressed, may be fluid overloaded to somedegree and susceptible to chest infection. Analgesia will berequired which also contributes to respiratory depression.Patients are encouraged to mobilise the day after transplantsurgery to minimise the development of DVT and chestinfection.

FLUID BALANCEEach patient will have a urinary catheter in situ on return fromtheatre; this enables accurate measurements of urine output tohelp ensure adequate hydration of the patient and to deter-mine the presence of bleeding and/or blood clots. A drop inoutput could signify problems with fluid balance, cardiac out-put, with the kidney itself or within the urinary tract.Intravenous fluid replacement may be titrated to centralvenous pressure (CVP) readings (via a central line) andurine/drain output. Alternatively a fluid replacement regimemay consist of adding an extra specified volume (e.g. 30 ml) tothe total urine output for the previous hour. The urinarycatheter is usually removed after several days, this allows ade-quate time for the anastomosis of the transplant ureter to thebladder to heal but urine output should still be monitored.

The patient will have peripheral access to enable administra-tion of intravenous fluids. Central and peripheral access shouldbe removed as soon as possible, when no longer required, inorder to minimise the risk of infection.

WOUND CAREThe surgical wound should be observed regularly for signs ofbleeding, redness and infection. It is the surgeons’ preferenceas to whether clips or stitches are used to close the wound;these are generally removed at 10–14 days post-operatively.In some centres patients will have an abdominal drain for the first few days; the surgical team will decide when thedraining output over 24 hours is sufficiently low to removethe drain.

RRTThe patient may require RRT initially after transplant surgeryuntil the kidney is working sufficiently. If the patient was ondialysis prior to the transplant their access may still be inplace, if this is a haemodialysis or peritoneal dialysis line thismay be removed prior to discharge or will need to bereviewed in out-patient clinic.

NUTRITIONAs with any abdominal surgery, the patient should remain nilby mouth (NBM) until bowel sounds are present then startedon fluids, proceeding to a light diet.

MEDICATIONS AND DISCHARGEPatients will have blood tests every day. Important resultsinclude serum creatinine for renal function, CRP and whitecell count for infection, and drug levels. These helpdetermine how effectively the kidney is working, indicatequickly the first signs of possible rejection or infection andshow whether drug levels are within the therapeuticrange. Each patient will be required to take a regimen of tablets called immunosuppressive medications (seeTable 2). Doses are decided by local policy and blood testresults.

Patients and donors will have been screened forcytomegalovirus (CMV) antibody before surgery. This virusremains a common cause of post-transplant morbidity. CMV–recipients receiving a CMV� kidney should receive prophylaxiswith valganciclovir for three months to reduce the risk of CMVdisease. In addition, CMV� patients receiving strong anti-rejection treatment such as ATG also receive prophylaxis. CMVdisease typically presents as a ‘flu-like illness but can also causelocalised damage in the graft, gastrointestinal tract and lungs.Valganciclovir can be used at a higher dose for treatment(British Transplantation Society 2004).

Time out activityWhy do we need to maintain an accurate fluid balancechart post renal transplant surgery?

Time out activityThink about what information you would give to a patientfollowing transplantation regarding their medication, forexample, how to take their medication, when to stop andwhat side effects to expect?

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Drug class/group Use Side effects

Calcineurin inhibitor (CNI) Cyclosporin Tacrolimus (Tac)

Maintenance immunosuppression Raised creatinine (nephrotoxicty), hyperkalaemia, hyperlipidaemia,neurotoxicity, infection, glucose intolerance (Tac), hypertension

Corticosteroid Prednisolone Methylprednisolone

Induction, maintenance and treatment of rejection

Impaired healing, glucose intolerance, cosmetic changes, mood andbehaviour changes, adrenal suppression, infection, osteoporosis

Antimetabolite Azathioprine Mycophenolate Mofetil (MMF)

Maintenance immunosuppressionDiarrhoea & upper gastrointestinal disturbance (MMF), anaemia,leucopaenia, thrombocytopaenia, infection, increased incidence non-melanoma skin cancers

Mammalian target of rapamycin (mTOR) inhibitor Sirolimus Everolimus Maintenance immunosuppression Impaired healing, hyperlipidaemia, pneumonia, infection, rash,

proteinuria

Monoclonal antibody Muronomab CD3 (OKT3) Induction & treatment of rejection Infusion reactions common (fever, shivering, rash), leucopaenia,

neutropaenia, pulmonary oedema

Polyclonal antibody Rabbit antithymocyte globulin (rATG) Induction & treatment of rejection Infusion reactions common (fever, shivering, rash), leucopaenia,

neutropenia

Interleukin (IL)-2 receptor antagonist Daclizumab Basiliximab

Induction Hypersensitivity reactions can occur

Patients need to be familiar with taking all of their medicationsbefore being discharged home.

Patients can expect to be in hospital for 6–10 days on averageand will receive close follow-up in a nephrology out-patientsetting thereafter.

DISCHARGE ADVICEPatients can face many challenges when discharged into theprimary care setting following the renal transplant. They willneed intensive support from the transplant clinic and the pri-mary care setting when discharged (Murphy 2011). Educationremains the cornerstone in the care of these patients. They mustbe taught how to manage the care of their transplant and becompetent in self-care skills (Murphy 2007b). It is importantthat patients are assessed in terms of their ability to learn andcomprehend this new knowledge and skills. These teaching ses-sions must be conducted on an individualised basis using aninformal, non-threatening manner. There may be physical diffi-culties such as visual or hearing impairments or language andliteracy challenges when assessing these patients. These can bemanaged through various means such as electronic blood pres-sure screening equipment, use of diagrams, daily dosette boxes,translation services and involving family members in teachingsessions as applicable (Trevitt 2008).

The issues regarding concordance to treatment, especially withmedication, must be addressed, as poor concordance increas-es the risk of acute rejection and graft loss. There must be pro-vision of education, prevention and treatment methods toaddress non-concordance in patients, and family members/car-ers must be involved (Murphy 2011). Kidney Disease ImprovingGlobal Outcomes (KDIGO 2010) asserts that there should bemore levels of screening for those patients that are at greaterrisk for non-concordance towards their medication.

After discharge from the ward the patients must attend the trans-plant clinic on a continuous outpatient basis. This can all be a veryoverwhelming timeframe for patients and their familymembers/carers who are adapting to this new life changing cir-cumstances (Wilkinson 2009). It is important that patient care ismanaged holistically. They should be empowered to managetheir rehabilitation from a psychosocial perspective and not justregarded in terms of their renal function and the progress of theactual transplant (Trevitt 2008). Psychosocial concerns must be

Time out activityWhat do patients need to be educated about prior to beingdischarged post renal transplantation? What tools are avail-able to help educate patients could you improve on this?

Table 2: Immunosuppressive drugs in current use including short-term side effects. Note: Adapted from Meier-Kriesche and Lodhi (2010) and Danovitch (2009).

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addressed with patients and their family members/carers as theybegin to adapt to life post-transplantation. These may include thefreedom from their dialysis regime and the associated lifestylerestrictions and the learning of a new regime for their transplant.Relevant issues such as financial (potential changes to their cur-rent welfare payments and the impact that this can have on thefamily) and vocational concerns must be addressed with theapplicable social care worker with a view that patients may getthe opportunity to re-enter the workforce for the first time in anumber of years. The revised role of patients within their families,and their relationships with spouses/partners and children shouldbe addressed as patients may have adapted to the ‘sick role’ inthe past whilst living with their chronic illness. They may, there-fore, find it challenging to move away from this concept and seethemselves as a valued member of the family. Patients can worryabout potential graft loss. All of these overwhelming emotionsmay result in patients becoming distressed and anxious whichcould lead to depression (Murphy 2011). This change in circum-stances may cause additional difficulties in the family home astheir spouses/partners and family members try to assist them toadapt. The family members also need time to adapt to theseevents. It is vital that patients and family members are providedwith the opportunity to discuss their concerns and are actively lis-tened to. The majority of transplant units should have counsellingsupport services to assist patients in this new dynamic life chang-ing event. They should be encouraged to attend these servicesbut also to engage with the nurses and voice their concerns(Murphy 2011). See Table 3 for some of the discharge advice thatpatients require post-transplant. Other relevant discharge advice

includes the importance of a healthy balanced diet, avoidingweight gain and exercise. Skin care advice is necessary due to thehigher risk of malignancies from the immunosuppression regime.Fertility and lifestyle issues must also be discussed and reiteratedwith patients and their family members. Long-term aspects ofrenal transplantation will be addressed in the third article of thisthree part continuing education series on transplantation.

CONCLUSIONThe renal nurse needs to support and assist the patient andtheir relatives to cope with transplantation in the best way pos-sible and to manage the pre- and post-operative care to max-imise the success of the graft. Nurses caring for these patientsrequire specialist knowledge to reduce problems in the earlypost-transplant period by prevention or anticipation and earlyintervention to maximise short- and long-term graft outcome.Patients (and relatives) who are engaged with the process arebetter equipped to care for themselves and this also con-tributes to the success of the graft.

Author contributions:RT: concept and design of paper and drafting of sections onadmission, surgery, post-operative and final approval paper.

Key Learning Points

• Nurses caring for pre and post-renal transplant patients require specialistknowledge and skills.

• Minimising problems in the early post-transplant period by prevention oranticipation and early intervention maximises transplant outcome.

• It is important that nurses empower patients to be involved in their caredelivery.

Time out activityStandards are an important tool to improve the care ofpatients. Examples from the United Kingdom are theNational Service Framework for Renal Services (Departmentof Health 2004); a strategy to improve the outcomes andexperiences of people with kidney disease, and there is alsothe National Institute for Health and Clinical Effectivenessguidance on both clinical and cost effectiveness of trans-plantation (NICE 2004).

Have a look at these national documents and see if youagree or disagree with how they should apply to local trans-plant centres.

Table 3: Discharge advice post-transplant.Note: Adapted from Trevitt (2008).

• Be able to recognise, comprehend and report the significance of any changes inthe following�Blood pressure�Pulse�Temperature�Respirations�Weight�Urinary output

• Identify the signs & symptoms of the following:

�Rejection�Infection

• Comprehend the action, dose and side effects of medication regime and thenecessity for concordance

• Have the contact details for the transplant unit and the key personnel to contactshould there be any issues as listed above

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VD: concept and design of paper and drafting of section onpost-operative complications and immunosuppression andfinal approval of paper. FM: concept and design of paper anddrafting of sections on discharge advice and final approval ofpaper. LP: concept and design of paper and drafting of sec-tions on pre-transplant period and final approval of paper. CP:concept and design of paper and drafting of sections on post-

operative observations and final approval of paper. BE: conceptand design of paper and drafting of sections on the donor kid-ney and final approval of paper. MC: contribution to design ofpaper, revising article for important intellectual content andfinal approval of paper.

All authors confirm no conflict of interest.


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