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Graft failure in Renal transplant patients: non-compliance with medication and patient education

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Graft failure in Renal transplant patients: non-compliance with medication and patient education

Category: Critical Thinking

Subcategory: Nursing

Level: Academic

Pages: 14

Words: 3850

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Graft Failure in Renal Transplant Patients
Introduction.
My prime in the topic of graft failures in the renal transplant patients due to medical noncompliance is due to the numerous cases of transplant rejection in the medical field. There have been pursuits to deflate the occurrences of these renal transplant rejection although studies have shown a new increment in the cases over the past decade. Noncompliance with the medication offered prior and post-transplantation procedures in renal patients is a particular cause of the presence of allografts. Studies have shown that there exist variables affecting both the likeliness of compliance with medication as well as the distinctions amongst noncompliance patients.
During the study’s survey that was carried out by an estimated number of 2500 renal transplant patients in the United States, compliance with the medication offered was said to rely upon the patient responses during the transplantation period. The induction of drug meant to suppress the immune systems of the patients was evaluated as one of the critical factors causing failures in the renal transplantation. The variables factored in during the study considered the transplant characteristics as well as memories of dialysis. More so, the activities that followed surgery procedures in the renal transplant patients that dealt with the symptoms and beliefs of efficiency were evaluated in the study. Later in the same survey, the results revealed that the incidence of noncompliance from the patients in the study was an estimate of 22.4%. A regression model constructed to factor in age, occupations and the periods within which the transplant procedures underwent.
Three medication beliefs rooted out to be most predictive of patient compliance. Other factors such as the donor types and the histories involved with the presence of diabetic disease medication entered into the multivariate model. However, the inclusion of these elements was made only in the cases where the belief related variables were excluded. A further cluster analysis revealed that there existed three distinct profiles that belonged to the noncompliance patients. Namely, the accidental noncom pliers, the invulnerable patients, and finally the significant noncom pliers. The study further concluded that there were roughly three times more patients than in the previous survey report that had been credited as the largest at the time (Cochat, 235-316).
The following article can be used by clinicians in the identification of patients likely to fall within the non-compliant category as well as the researchers in developing randomized clinical trials of the interventions designed to increase the compliance rates of patients. More likely, educators can find the study of graft failures in this piece useful in educating patients in the renal transplant programs.
Body
Chronic renal allograft rejection.
The factors involved in renal transplant failures amongst patients have been recorded to contribute in the attempt to enhance risk cases although a substantial consistency in the failure occurrences has proven challenging to clinicians.
In 2004, a study meant to analyze the first renal transplant failures performed between the years of 1995 and 2000 revealed that although a substantial reduction in the numbers of failures existed there had been close to zero improvements over the past decade in the long term allograft survivals. The rates of a decrease in the kidney allograft functions appeared to have slowed down due to the improvement occurrence in the results that related to long-term allografts survivals. The survival rates ranged from the existence of different ethnic groups. This fact explained that a presence in the higher numbers of risk factors that related to the failures although there were disproportionate variables among the population of patients as well as the differences in access to health care services.
The distinction of short term and long term determinants is to some point vague because most of these risk factors affect both short term and long term graft survivals. For instance, a short-term event occurrence that predisposes to symptoms of acute failures in turn leads to higher chances of graft loss. Also, many of the risk factors are seen to affect each other in almost all cases of graft failures. An example of this factors is that human leukocyte antigen mismatch increases the chances that deal with renal rejections and consequently prematurity in renal allografts leading to failure. Discussions on the patient survival chances after renal transplant procedures are presented separately.
The short-term risks in renal transplant procedures have been split into early, high-risk periods, and later periods of constant low risks. The major improvements in the renal allografts survival risk factors in the previous two decades has to do with the elimination of the early risk period symptom occurrence in the patients. The factors found to play significant roles in the short-term graft survival include the delayed allograft functions and the presence of human leukocytes antibodies. Moreover, the types of kidney donors and the infections of renal organs from the donors resulting to illness prior the transplant affect this short term period successes together with other varying medical center factors (Joosten & Simone, 36-54).
Renal transplant outcomes.
The detection of a complement split product C4d in the renal allograft biopsies plays a critical role in the understanding of the alloimmune responses in a transplant patient. In particular, this detection assists in the diagnosis of antibody-mediated rejection component. C4d is a production for degradation in the classic complement pathway where after an antibody-antigen complex fixes with this complement, a flow of events follows with the activation of several proteins that complete the process. The compliment is known as the C4; that is split into C4a and C4b. The C4b is later converted into a C4d, which contains unique properties of forming covalent bonds with the endothelial and collagen basement membranes. This event avoids removal and raises the possibilities of service as an immunologic footprint of complement activation and antibody activities in the renal organs. As for normal kidneys, the detection of C4d is smooth in the glomerular mesangium as well as the vascular poles that emphasize the existence of a constitutive turn out of immune complexes. Once the burden of the immune complexes raises with the immune complex deposition diseases the depositions of the C4d overflows from the mesangium and vascular poles to the glomerular capillaries. The C4d deposition in the glomerular mesangium the glomerular basement membranes, the tabular basements, arterioles and intima can be demonstrated by the monoclonal antibody staining while the immunofluorescent of frozen tissue sections.
The deposition of peritubular capillaries has selectively been analyzed in renal allografts that are meant to represent the donors whose organs would undergo rejection. However, the reasons behind the staining of the peritubular capillaries are not entirely clear. This factor is the reason the donor specific antibodies directly engage with the human leukocyte antigens found in the glomerulus and the peritubular capillaries. Well, known is the fact that anti-complement protection in the peritubular is weaker than in the glomerulus due to the incidence that the glomerulus has at the very least four cell surface complement inhibitors that decay another accelerating factor, CD55 as well another membrane cofactor protein, CD46. More of the factors that are decayed in this process are the complement receptor 1(CR1)-Cd35 and protectin- CD59. However, the only protectin is consistently expressed in the peritubular capillaries. This factor inhibits the formulation of complement membrane attack component, C5-9, and the result is that the generation of C4d is relatively unstoppable.
Despite the association between Cd4 and the immune complex components depositions, immunoglobin has not been detected in the peritubular capillaries in cases where the C4d is detectable. As the humoral rejection most likely is a result of direct attack on the target, the endothelial cells modulations from the entire surface could probably make the detection of antibodies difficult. The endothelial cells dislodge the surface antibodies through their shedding or otherwise termed as their internalization while the C4d resists this modulation from the surface due to the covalent bonds formed between the tissue structures (Willicombe, Michelle & Thomas).
Complications in the post-transplant immunosuppressant medication usage.
The candidates for renal transplantation are supposed to undergo a comprehensive evaluation so as to identify the components that may have an acute effect on the outcome. Vaguely, all transplant centers have a committee with which operations are discussed together with the evaluation results so as to select the candidates that are most suitable for the procedure and those to be injected into the waiting lists. An emphasis is installed upon the identification and treatment of all coexistent medical problems that may increase the mortality rates of the surgical procedures which in turn adversely impact the post-transplant medical course. In addition to a proper medical evaluation of patients in the program, social issues that affect the patient health are used in the determination of conditions that may jeopardize the outcome of transplantation to with travel restraints, financial overviews, as well as patterns of non-compliances (Myers).
A successful kidney transplant is supposed to offer a more enhanced quality and duration in the life span of the patient than long-term dialysis therapies provided to patients with chronic renal diseases. Transplantation in patients mainly occurs in those patients with diabetic nephropathy as well as pediatric patients. The patients whom these transplants are performed undergo an extensive evaluation procedure so that factors that may have enormous impacts on the outcomes are easily determined. All the transplant programs are led by formal committees that hold meetings on a regular basis to analyze the results from the patient evaluation procedures. Selection is carried out on the most suitable patients on the waiting lists starting from whoever is placed first. Moreover, an emphasis on identifying and treating all the coexisting medical problems that may increase the mortality as well as morbidity rates of the surgical procedures involved adversely impact the transplant procedures that fall in the post-surgical period. In addition to the proper medical evaluation of the transplant patients, the social issues concerned with the patient are also considered in an effort for the determination of the factors that may lead to failures in the entire procedure.
The laboratory studies in transplant studies mainly deal with: the blood chemistries, the liver functioning tests, the patient’s complete blood count, and the coagulation profiles. However, an infectious patient profile is meant to include: hepatitis B and C serologist, Epstein-Barr virus serologist, the cytomegalovirus serologist. Varicella zoster virus serologist, rapid plasma regain tests on the presence of syphilis, HIV antibodies, and the purified protein derivative that include a tuberculosis skin test with the energy panels during indication. More so, a urinalysis, urine culture, and cytosine should be ordered during this indication. Diagnostic procedures involve a complete cardiac workup that includes angiography that is not necessarily to be present in every patient category of transplants although patients with the significant histories and symptoms of type 1 diabetes or the hyper tensile renal diseases ought to undergo a thorough evaluation that rules out important coronary artery diseases.
The following procedures are credited mandatory in the transplant procedures. 12 lead ECG, a chest radiography, an exercise of the patient in the dipyridamole thallium scintigraphy, two-dimensional echocardiography that includes Doppler, and the coronary arteriography. A critical note is made of special procedures that may be indicated in selected patients based on the findings shown in the histories of physical examinations. Transplant ultrasonography that identify urinary obstructions as well as the fluid collections that suggest urine extravasation, abscess pyelonephritis or wounding infections are a significant inclusion of the studies in transplant recipients. The color flow Doppler ultrasonography as well is used in the identification of vascular occlusions and stenosis. Further on, renal biopsies usually required for the definitive diagnosis of numerous renal graft failures are included in the studies.
The occurrences of lumber punctures in cases of suspected meningitis mainly known to be caused by the Listeria species are a critical part of this study. An immunological evaluation of the transplant recipients is carried out during the transplant procedures which primarily serves the role of avoiding operations that are at a high risk of antibody-mediated hyperacute rejection. Immunologic evaluation comprises of the following four components: ABO blood group determination, human leukocyte antigen typing, serum screening for antibodies to HLA phenotypes, and crosshatching. The kidney transplant patients that have undergone a performance in donor specific antibodies are taken through a pretransplant decentering protocol. If the procedure proves to be successful, this protocol reduces the antibody levels to a point where the renal transplantation is credited feasible (Nikolopoulou).
Health promotion during long-term post-transplantation.
The re-transplant surgical interventions involve a workup that may reveal circumstances that necessities the surgical intervention process that prepares the patient for the kidney transportation process. Such interventions in this category include the following. Native kidney nephrectomies that are reserved for the specific indications such as large polycystic kidneys or the chronic reflux diseases, cholecystectomy in patients with gall bladder stones, and splenectomy. In addition to the surgical transplantation procedures, the management of the entire process involves an organ procurement, the provision of immune suppressive therapy to the recipient and a short to long term follow up on the affected patient for the possible indications of renal allograft dysfunctions as well as other complications.
The organ procurement process deals with the following procedures that are carried out on the patients undergoing the transplant. The identification of potential donors, the assessment of the donor suitability and the determination of donor brain death. Moreover, an extra mile to determine the medical management of the donor after the [procedure is undertaken. An immunosuppressive therapy prevents T cell alloimmune rejection response. The goals of the process are as follows: the prevention of acute and chronic rejection, minimization of drug toxicity and rates of infection as well as malignancy, the achievement of the highest possible rates of patient and graft survival. The medication used in the suppression of the immune system are split into two categories that are: the antirejection induced drugs agents and the maintenance immunotherapy agents.
However, complications may arise due to the usage of the medication that is meant to suppress the immune system. The outcome of the rejection action is as follows: renal artery thrombosis, the renal artery stenosis, urine leakage from the disruption of the anastomosis, the ureteral stenosis, and urinal obstruction that are mostly late complications, and finally, the lymphocele complication. The allograft dysfunction and rejection of the transplant may occur as follows: hyperacute rejection of the renal allograft within a few hours of the transplant surgery and nephrectomy is indicated, an appearance of acute rejection appearing within the first 6 months after the transplantation surgery, an occurrence of chronic rejection more than a year later after undergoing the entire procedure of transplantation, therefore, causing allograft loss. Other complications including the following also occur after and during the transplant procedures. Infections, malignancy, liver diseases, hypertension, and cardiovascular diseases.
Another article shows that the causes underlying kidney failures and infections are most likely to occur among patients with issues in their blood glucose levels such that when the blood sugar levels were leading to the occurrence of overproduction and underproduction of insulin that functions in the conversion of glucose into the blood. Over time, the appearance of too much glucose in the blood of a renal patient paves a way for the incidences involved in causing serious problems. Diabetes is a critical factor in the consideration of whether or not a renal transplant patient is to experiences graft failure during transplantation. The likelihood of allograft occurrence in the patient revolves around their normal behavior towards drugs administered during the curing process of prior diabetic histories mainly because the compounds of the medication are found in the patient’s blood. Drug tests are conducted in an attempt to discover diabetes conditions in the patients while exercise for weight controls are advocated those who intend to receive transplants. The prevention methods of diabetic conditions are also evaluated together with the patient needs (Frame).
Pregnancy after renal transplantation.
One of the critical factors to consider during the transplantation procedures on patients is that of the chances of pregnancies during long-term renal allograft functions. The aim of studies carried out in this field is to conduct the comparisons between long-term grafts as well as patient outcomes amongst pregnant and non-pregnant patients after the transplant surgical procedures have been done to both. A study consisting of 39 women who attended the perinatal division of the Rabin Medical Center; those who conceived under undergoing a renal transplantation was 55. These numbers were of those that mainly include live births. All were stated to have functioning allograft during the time that conception occurred. Each of the patients was matched with three control studies of twelve factors that were known to affect graft survivals.
The control studies were driven right from prior cohort studies of quarter a million transplant patients registered in the collaborative transplantation studies database. The groups in the study were compared with graft survivals, the long-term patient survival, and kidney functions. The results revealed that graft 61.6% and patient 84.8% survival from transplantation that were up to the end of follow-up fifteen years in the women who conceived after the transplantations did not seem to have distinct features in the rates observed in the 177 women in the matched control groups. There were no group to group differences in the long-term graft functions. The study concluded that in pregnant women, no adverse effects on long-term graft or patient survival occurred after renal transplantations (Chowdhury).
Patient education in renal transplant procedures.
The patient education system in the transplant system is meant to improve waitlisted patients, living donors, and transplant recipient outcomes. The goals of the education program systems are expected to define other measures of positive patient outcomes other than the yearly survival rate. More so, the aims of this systems deal with the provision of tools that promote self-assessment and member improvements. A further examination of practices that allocate organs in ways that support increased transplant benefits across the populations is conducted. There is another focus on the development and distribution of educational materials that assist with the intermediate care providers on the best practices used in partnering with the transplant center in the ongoing patient responsibilities. Minimally the systems also enroll in the activities toward the improvement of patient transplant literacy that facilitates self-management after the transplant procedures (McGinness).
The role of nurses in renal transplant procedures.
The roles of nurses in the preparation of renal transplantation procedures are addressed from both a physical and psychological perspective. Deeper into their role of the pre-renal transplant procedures is the fact that they have responsibilities in the patient’s educational support. This education support is critical to both patients and family members because the transplant is a life changing occurrence. Renal transplantation is considered as the optimal treatment of choice for patients with a dead end stage of renal failures among those receiving dialysis. The nurse plays a pivotal role in the assistance to the patient who faces numerous challenges associated with post renal transplantation stages. These challenges include complications that formulated during the long-term physical and psychosocial implications (Murphy).
Conclusion.
Transplantation is among the revolutionary fields of modern medicine that has been used to save thousands of lives. The continual refinement of surgical techniques and the squeak of potential in immune suppression medication has made the transplantation procedure most useful treatment option for patients with the end stage organ failure. A rough estimate of twenty-five thousand transplants is performed in the United States of America each year with survival rates that approach 90% during a period of a year while 75% over a five-year term. The central point of this successes is the administration of medication that suppresses the immune system during this time. The drug has been utilized extensively in the reduction of rejection cases of transplant organs. As a result, the occurrence of graft loss due to acute rejection has gone down dramatically in comparison to the early eras of transplantations.
The success of organ transplantation has played a role in the growth of immunosuppressed transplant patients who have experienced a prolonged survival with the functioning grafts. The exposures to medication side effects and complications that deal with chronic immunosuppression is also a factor to consider with the growth of immunosuppressant transplant patients. Post-transplant immunosuppressant burdens have become a steady concern among the transplant physicians. Although this impact is currently smaller in comparison to the past two decades, these actions have followed the introduction of new and less toxic suppressants. In contradiction to this, chronic immune suppression has been associated with severe morbidities, such as the fact that majority of patients treated with calcineurin inhabitants are bound to develop some levels of renal function impairments while only 10% progress to kidney failures that require dialysis or kidney transplants. The sequences of chronic immunosuppression on multiple organ systems have become progressively evident and often new symptoms or disordered have recorded to develop post-transplant as consequences of immunosuppressant medication use.
The onset of extreme post-transplant conditions that require separate treatment procedures has various implications regarding graft functions, patient compliance and total costs involved. Due to the above reasons, strategies that limit and prevent the complications of prolonged immune suppression after the transplant procedures are under demand. Moreover, current strategies that are focused on the management of complications of immunosuppression and ways that limit the burden of immunosuppression usage are highly considered (Jones).
Recommendation
The post care of the renal transplants can be summarized in the following forms that are focused on a kidney transplant recipient follow-up. First and foremost, there ought to exist a consultant level health care professional who should be available at every transplant clinic for the purpose of consultancy. This referral stage is critical for both patient and families of the recipients in matters concerned with renal transplant education. Secondly, the kidney transplant recipients should be reviewed in a dedicated outpatient area for the purpose of enhancing the transplantation regulations as well as procedures. The results of the patient blood tests ought to include an extensive overview of the drug levels in a short span of a day period. This act will enhance the achievement of a higher standard of compound accuracy during the recipient evaluation period to avoid occurrences of primary graft failures post transplantation. Another recommendation for the reduction of graft failures in renal transplant patients is taking note of the existence of a formal mechanism for the results review procedures by the health care professionals within twenty-four hours of clinic appointments. Furthermore, there should be a continuous access to a multidisciplinary renal team including a pharmacist, a dietician, and a formal social worker. In some cases, a psychologist should be made available in the event of any individual patient needs.
All the procedures used in ensuring patient care ought to be planned along principles that are set out in the National Services Frameworks. The uncomplicated patients also ought to be examined progressively with fewer frequencies as they exit the transplant system program. This practice assists in the detection of future complications that may arise in the patient’s allographs. The patient education systems have the abilities to provide online accesses to their results whenever they may wish regardless of their physical distance from the transplant clinics. Moreover, the patients should have access to the outpatient services as well as possess established points of contacts on any inquiries. The results gained from the evaluation procedures ought to be available to the active patient and family in both written and electronic formats. After considering the usage of immunosuppressive drugs, the medication should be started before or simply at the time of renal transplantation.
A further induction therapy with biological agents should be administered to all the kidney transplant recipients whereas patients at low immunological risks involve interleukin-2 receptor antagonists while those with higher immunological risks are considered for a T-cell depleting antibody induction. The above are injunctions that can be used in the improvement of the treatment plan for the patients suffering from the end stage renal diseases in frantic need of transplantation (McGinness).
Works Cited
A Jones.Web. 16 Nov. 2015. <http://connection.ebscohost.com/c/articles/71883061/foundation-good-nursing-practice-effective-communication>.
A Nikolopoulou, PD Mason. “Chapter 33.” Complications of Post-Transplant Immunosuppression. Web. 16 Nov. 2015. <http://www.intechopen.com/books/regenerative-medicine-and-tissue-engineering/complications-of-post-transplant-immunosuppression>.
Cochat, P., and J. Traeger. “Renal Allografts among Transplant Patients.” Immunosuppression under Trial Proceedings of the 31st Conference on Transplantation and Clinical Immunology, 3-4 June 1999. Dordrecht: Springer Netherlands, 1999. 768. Print.
D Myers. “Time to Prioritise Renal Patient Engagement.” : Journal of Renal Nursing: Vol 5, No 6. Web. 16 Nov. 2015. <http://www.magonlinelibrary.com/doi/abs/10.12968/jorn.2013.5.6.272>.
J Beer “Body Image of Patients with ESRD and following Transplantation.” ResearchGate. Web. 16 Nov. 2015. <http://www.researchgate.net/publication/15598628_Body_image_of_patients_with_ESRD_and_following_renal_transplantation>.
Joosten, Simone Anne. Pathobiology of Chronic Renal Allograft Rejection: Tissue Specific Humoral Immune Responses and Accelerated Ageing. S.l.: [s.n.], 2004. 476. Print.
M McGinness .”Transplant Education: Developing a Patient-centred Resource.” : Journal of Renal Nursing: Vol 6, No 4. Web. 16 Nov. 2015. <http://www.magonlinelibrary.com/doi/pdf/10.12968/jorn.2014.6.4.188>.
P Chowdhury, K Harding. “Pregnancy After Renal Transplantation.” Pregnancy After Renal Transplantation. Web. 16 Nov. 2015. <http://annals.org/article.aspx?articleid=689087>.
S-Frame .”Health Promotion in Long-term Transplant Patients.” : Journal of Renal Nursing: Vol 3, No 4. Web. 16 Nov. 2015. <http://www.magonlinelibrary.com/doi/full/10.12968/jorn.2011.3.4.162>.
Willicombe, Michelle, Thomas Cairns, and London College. Donor Specific HLA Antibodies and Renal Transplant Outcomes. Print.

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