Article

Nursing Care for Kidney Transplant Patients:
A Scoping Review^*

Cuidados de enfermería al paciente trasplantado renal:
scoping review^**

Cuidados de enfermagem ao paciente transplantado renal: scoping review^***

10.5294/aqui.2021.21.3.6

Cintia Capistrano Teixeira Rocha¹
Alcides Viana da Lima Neto²
Ana Beatriz Pereira da Silva³
Victor Alexandre Silva Farias⁴
Aurean D'Eca Junior⁵
Richardson Augusto Rosendo da Silva⁶

¹ 0000-0002-3755-8978. Universidade Federal do Rio Grande do Norte, Brazil. cintia.capistrano@ebserh.gov.br

² 0000-0001-6191-9465. Universidade Federal do Rio Grande do Norte, Brazil. alcides.neto@ebserh.gov.com

³ 0000-0001-8339-6482. Universidade Federal do Rio Grande do Norte, Brazil. ana.beatriz.pereira.700@ufrn.edu.br

⁴ 0000-0002-5173-7331. Universidade Federal do Rio Grande do Norte, Brazil. victor.farias.091@ufrn.edu.br

⁵ 0000-0002-7675-412X. Universidade Federal do Rio Grande do Norte, Brazil. aurean.junior@ufma.br

⁶ 0000-0001-6290-9365. Universidade Federal do Rio Grande do Norte, Brazil. richardson.augusto@ufrn.br

^* This article is derived from the ongoing doctoral thesis entitled “Construction and validation of an educational technology for nursing care in renal transplant recipients”, which will be presented to the Graduate Program in Nursing at the Federal University of Rio Grande do Norte, Brazil.

^** Este artículo se deriva de la tesis doctoral en construcción titulada "Construcción y validación de una tecnología educativa para el cuidado de enfermería en receptores de trasplante renal", que se presentará al Programa de Posgrado en Enfermería de la Universidade Federal do Rio Grande do Norte, Brasil.

^*** Este artigo é derivado da tese de doutorado em andamento intitulada "Construção e validação de uma tecnologia educativa para o cuidado de enfermagem em receptores de transplante renal", que será apresentada ao Programa de Pós-Graduação em Enfermagem da Universidade Federal do Rio Grande do Norte, Brasil.

Received: 01/03/2021
Sent to peers: 15/06/2021
Approved by peers: 01/07/2021
Accepted: 13/08/2021

Theme: Chronic care.

Contribution to the discipline: In this study, knowledge for nursing care to transplanted patients is mapped, in which a care practice based on scientific evidence, quality, and safety, is mapped, which allows better decision-making of the nurse. Added to the importance of this theme is the identification of nursing care that permeates the three levels of complexity in health: primary, secondary tertiary, considering the different scenarios of the nursing team's performance. Therefore, it is configured as an instrument that induces co-responsibility and care quality with the objective of continuous improvement of health effects, essential for the maintenance of the graft in the transplanted patient.

Para citar este artículo / To reference this article / Para citar este artigo: Rocha CCT, Neto AVL, da Silva ABP, Farias VAS, D'Eca Junior A, Silva RAR. Nursing Care for Kidney Transplant Patients: A Scoping Review. Aquichan. 2021;21(3):e213X. DOI: https://doi.org/10.5294/aqui.2021.21.3.6

ABSTRACT

Objectives: Mapping nursing care in kidney transplant patients.
Materials and method: A scoping review was conducted according to the recommendations of the Joanna Briggs Institute Reviewers' Manual. Data were collected through 13 national and international databases from December 2020 to January 2021, following scientific rigor in the selection of the material. The pre-selection was made by reading the title, abstract and introductory text in advance; the materials included in this stage were read in full to define the content for the study.
Results: Fifteen studies were included. Of these, 60% are articles; dissertations, manuals, protocols, guidelines and bulletins totaled 40%> of the material studied. 86.6% of the material has a quantitative approach. Regarding the methodological design, 73.3% were descriptive/transversal character studies. Regarding the mapping of nursing care, it was possible to divide them into two categories: nursing care after kidney transplantation (immediate, mediated and late) and nursing care after kidney transplantation in primary health/ extra-hospital care.
Conclusions: It is concluded that the study allowed mapping nursing care to kidney transplant patients in the immediate, late and primary health care periods.

KEYWORDS (Source DeOS): Kidney transplantation; nursing; nursing care; postoperative period; review literature as topic.

RESUMEN

Objetivos: mapear los cuidados de enfermería en pacientes trasplantados renais.
Materiales y método: scoping review conducida conforme las recomendaciones del Joanna Briggs Institute Reviewers' Manual. Se recolectaron los datos por medio de 13 bases de datos nacionales e internacionales de diciembre del 2020 a enero del 2021, siguiendo rigor científico en la selección del material. La preselección se dio mediante lectura previa de título, resumen y texto introductorio; los materiales incluidos en esta etapa se leyeron en la íntegra con el fin de definir el contenido para el estudio.
Resultados: se incluyeron 15 estudios. De estos, el 60 % es artículo; tesis, manuales, protocolos, directrices y boletines suman 40 % del material estudiado. El 86,6 % del material presenta enfoque cuantitativo. En cuanto al diseño metodológico, el 73,3 % son estudios de tipo descriptivos/transversales. Con relación al mapeo de los cuidados de enfermería, se logró dividirlos en dos categorías: cuidados de enfermería post trasplante renal (inmediato, mediato y tardío) y cuidados de enfermería post trasplante renal en la atención primaria a la salud/extra hospitalaria.
Conclusiones: se concluye que el estudio permitió mapear los cuidados de enfermería al paciente trasplantado renal en los posoperatorios inmediato, mediato, tardío y en la atención primaria a la salud.

PALABRAS CLAVE (Fuente DeOS): Trasplante de riñón; enfermería; atención de enfermería; periodo posoperatorio; literatura de revisión como asunto.

RESUMO

Objetivos: mapear os cuidados de enfermagem em pacientes transplantados renais.
Materiais e método: scoping review conduzida conforme as recomendações do Joanna Briggs Institute Reviewers' Manual. Os dados foram coletados por meio de 13 bases de dados nacionais e internacionais de dezembro de 2020 a janeiro de 2021, seguindo rigor científico na seleção do material. A pré-seleção se deu mediante a leitura prévia de título, resumo e texto introdutório; os materiais incluídos nessa etapa foram lidos na íntegra a fim de definir o conteúdo para o estudo.
Resultados: foram incluídos 15 estudos. Destes, 60 % são artigos; dissertações, manuais, protocolos, diretrizes e boletins somaram 40 % do material estudado. 86,6 % do material apresenta abordagem quantitativa. Quanto ao desenho metodológico, 73,3 % eram estudos de tipo descritivos/transversais. Quanto ao mapeamento dos cuidados de enfermagem, pôde dividi-los em duas categorias: cuidados de enfermagem pós- transplante renal (imediato, mediato e tardio) e cuidados de enfermagem pós- transplante renal na atenção primária à saúde/extra-hospitalar.
Conclusões: conclui-se que o estudo permitiu mapear os cuidados de enfermagem ao paciente transplantado renal nos pós-operatórios imediato, mediato, tardio e na atenção primária à saúde.

PALAVRAS-CHAVES (Fonte DeOS): Transplante de rim; enfermagem; cuidado de enfermagem; período pós-operatório; literatura de revisão como assunto.

Introduction

Chronic kidney diseases (CKD) are quickly increasing worldwide and represent important events for public health, as a significant percentage of affected individuals progress to death. Thus, this population demands a health system organized in terms of the appropriate process and structure, so that qualified care occurs, with treatment for such diseases, according to their needs ⁽¹⁾.

In the publication of Ordinance 389/2014, which defines the criteria for the organization of the care line of the person with CKD, replacement therapies for kidney function are peritoneal dialysis, hemodialysis and kidney transplantation, when the individual has advanced CKD ⁽²⁾.

Kidney transplantation is a safe and successful surgical strategy consisting of the removal of a healthy kidney from one individual (living or deceased donor) to another (recipient), to maintain lost or ineffective kidney functions. Kidney transplantation, although not the definitive "cure" for the disease, provides, among the therapeutic options, a better quality of life for chronic kidney patients ^(3-9).

Thus, considering kidney transplantation a substitute therapy, that is, a treatment for CKD, the kidney transplant recipient is still a person living with CKD. Thus, it is necessary to understand that, throughout its treatment, it permeates the three levels of complexity of health care: primary, secondary and tertiary, according to the organization of the care line of the person with CKD. The success of kidney transplantation is directly linked to the health and support network in which the transplanted person is inserted. Thus, during therapy, hospital admissions, high complexity procedures, follow-up of the specialized outpatient clinic and follow-up of primary care in its home location may be necessary ^{(2, 10, 11)}.

In this perspective, because it is a highly complex treatment, kidney transplantation requires specificities from the nursing team during their care ^(12-14). For this, nurses must systematize their actions, their care provided and interventions with periodic evaluation of patients. Thus, the health care provided to the transplanted becomes quality and safe care, since this performance is based on scientific evidence ^{(15, 16)}.

In this sense, the nurse, being the leader of the nursing team, actively participates in all stages of the organ transplantation process, since his activities are broad and specialized, and the satisfactory evolution of the patient is related to the care provided to him and directly to the technical-scientific quality of the professional nurse. It has the task of coordinating the nursing service, early diagnosing problems, proposing solutions and developing health education activities in daily work focusing on technical-scientific deficiencies ^(17-23).

When we think of nursing care for transplanted patients, the entire postoperative period stands out until outpatient and home care for graft maintenance ⁽²⁴⁾. It is emphasized that, in this process, health professionals, patients and their families are involved.

It is believed that follow-up should be performed both in primary health care (PHC) and in specialized care. However, it is perceived, in practice, that transplanted patients are followed by PHC from their municipalities in a non-effective way and that many professionals have disabilities regarding the competencies and skills in this theme.

This care, besides being important for the strengthening of PHC and being configured as an instrument that induces co-responsibility and quality to continuously improve health outcomes, is essential for the maintenance of the graft in the transplanted patient, because it allows better adhering to drug treatment as an action to protect health; promotion and prevention actions for diseases such as opportunistic infectious diseases; promotion of sexual health; health recovery actions such as reducing anxiety about doubts and treatment difficulties, and greater emotional support for the user and family involved; health rehabilitation actions ^(25-27).

Therefore, research on this theme is of great relevance to the health area, especially for nursing because they contribute to the quality of care provided to this patient audience, assistance that is still very specialized and little widespread in undergraduate studies. Thus, it is essential to awaken, in nursing professionals, the care of the transplanted patient at any level of complexity in health.

From the above, the study aims to map nursing care in kidney transplant patients through the scoping review.

Materials and method

A scoping review was carried out that followed the methodology recommended by the Joanna Briggs Institute ⁽²⁸⁾. This methodological strategy is considered a robust approach to synthesize the relevant literature on health, being used to answer comprehensive questions and map evidence for practical decision-making and research ⁽²⁹⁾.

To this end, the following steps were performed in the study: 1) elaboration of the guiding question of the scoping review; 2) identification of relevant studies; 3) sorting of studies; 4) analysis of the collected data and 5) treatment, synthesis and presentation of the results.

A protocol was elaborated for the structuring and development of the research, which contained the objective of the study, the research question, the eligibility criteria, the research strategy, the databases used for data collection, the definition of variables for data extraction and how the data would be presented. The entire protocol was based on the parameters of the participants, concept and context (PCC) strategy, in which "P" is population, "C", concept and "C", context. The scoping protocol was registered in the public domain (https://osf.io).

Thus, for the study in question, the defined population consisted of patients submitted to kidney transplantation; the concept is related to nursing care in kidney transplant recipients, and the context, to the postoperative period of kidney transplantation in hospitals and PHC. All the results found in the scoping review on the subject were included from the PCC strategy. Thus, the study has as a guiding question to identify which nursing care is described in the national and international literature to patients undergoing kidney transplantation. In addition, it has as inclusion criteria texts available in full - in Portuguese, Spanish and English - and texts that address nursing care in kidney transplant patients.

Initially, the descriptors were identified through the Descriptors in Health Sciences (DeCS) — words in Portuguese — and the Medical Subject Headings (MESH) — terms in English — which make up the mnemonic PCC of this research. They are: (P) kidney transplantation OR (C) nursing OR nursing care AND (C) postoperative period.

The second and third stage of the scoping review that corresponds to the identification and selection of studies that fall under the research occurred from December 2020 to January 2021. PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), Web of Science, Latin American and Caribbean Health Sciences (LILACS) and SciELO databases were performed in the Databases. for the research of studies in the grey literature, such as theses,  dissertations, manuals, protocols, guidelines and bulletins, we use the Scientific Repository of Open Access of Portugal (RCAAP), the Thesis Bank of the Coordination for the Improvement of Higher Education Personnel (Capes), to the National ETD Portal, Theses Canada, the National Health Surveillance Agency (ANVISA), the Brazilian Ministry of Health, the Federal Nursing Council, the Brazilian Organ Transplant Association and the Brazilian Society of Nephrology.

As a search strategy used for the research, we have (Kidney Transplantation) OR (Nursing OR Nursing Care) AND (Postoperative Period) for the databases in Portuguese and (Kidney transplantation) OR (Nursing OR Nursing Care) AND (Postoperative Period) for the international databases.

Scientific articles, dissertations, theses, manuals, guidelines, protocols and bulletins were defined as eligibility criteria; published and available in full online; in Portuguese, Spanish and English; and that address nursing care in kidney transplant patients. In turn, they were not included in the editorial scope and experience reports. There was no temporal delimitation in the search performed.

By evaluating the titles and abstracts of the identified studies, the preliminary selection was made. Then, the selected publications were read in full, according to Figure 1. The relevance of the articles for the review was analyzed by two independent reviewers.

Figure 1. Scheme of the study selection process.Natal, Brazil, 2021.

Souce: Flowchart for the scoping review (adapted from Prisma)

The fourth stage of the scoping review aimed at the treatment, synthesis and presentation of the results was performed by collecting the data contained in the publications included in the final sample, in a spreadsheet built-in Microsoft Excel Office 365, with support for the variables listed in the research protocol: type of document, year of publication, journal, country of origin, language, study objective, type of research, study sample, main results about nursing care in kidney transplant patients identified and conclusion of the study.

After data analysis, they were synthesized and presented using tables. To facilitate the understanding and visualization of the data, the studies were coded as follows: "E" (study), followed by Arabic numerals 1, 2, 3, ... 15, to assume representation E1, E2, E3, ... E15.

The level of evidence and the level of recommendation of the studies were classified according to the proposal of the Joanna Briggs Institute ⁽²⁸⁾.

To facilitate the reader's understanding and through the materials selected in the scoping review, nursing care for kidney transplant patients was classified as: nursing care to kidney transplant recipients in the immediate, middle, and late postoperative periods, and nursing care for kidney transplant recipients in PHC.

Results

The final sample of the scoping review consisted of 15 publications (100%). Among these, there are articles (60 %), manuals (6.6 %), dissertations (6.6 %), protocols (6.6 %), guidelines (13.6 %) and bulletins (6.6 %). Most publications have a quantitative approach (86.6 %); on methodological design, 60% of the studies are descriptive, 13.3 %, transversal character, 6.6 %, observational and 20.1 %, others.

As for the country of origin, 93.3 % of the material comes from Brazilian studies. In view of the sample found, the publications started in 2006 and ended in 2021. Most publications were in 2006, followed by 2007, 2013 and 2016, each year with two publications on the subject, according to Table 1.

Table 1. Characterization of the included studies. Natal, Rio Grande do Norte, Brazil, 2021.

Source: Own elaboration.

Table 2 gathers the main findings, classifying them in nursing care after kidney transplantation (immediate, mediated and late) and PHC.

Table 2. Main nursing care in kidney transplant patients mapped in the scoping review.
Natal, Rio Grande do Norte, Brazil, 2021.

Among nursing care after kidney transplantation (immediate, mediated, late), the material studied has as main findings to control hemodynamic status, blood pressure, respiratory function and capillary glucose levels; monitor the hydration situation; perform volume replacement, diuresis control every hour; fasting weigh; evaluate abdominal circumference and laboratory results related to fluid retention; monitor systemic signs and symptoms and sites of infection such as the surgical wound; care with an indwelling urinary catheter for the prevention of urinary tract infections; detect early complications related to the surgical procedure; initiate guidance on treatment/follow-up and inform about side effects resulting from immunosuppressive agents or rejection (Table 2).

On the extra-hospital care that also involves PHC, it was identified to encourage healthy habits, such as feeding with less sodium and proteins, with many fibers and fluid intake; guide to avoiding alcohol and smoking, in addition to hygiene care and infection control; guide care with medications and the importance of adhering to the use of medications, especially immunosuppressants; check the vaccine card and guide the one that is up to date; evaluate signs and symptoms suggestive of cytomegalovirus infection, especially in the first three months; evaluate signs and symptoms of chronic rejection (progressive worsening of kidney function, presence of proteinuria, less than 1.0 g/day in 50% of cases); the presence of hypertension (> 90°%), as observed in Table 2.

Discussion

Given the predominance of descriptive studies developed in Brazil, in the final sample of the scoping review, it is evident the need for studies related to this theme focused on clinical practice and with scientific productions with a better level of evidence, making reliable publications that empower the care nurse and assist him in decision making.

Nursing care for kidney transplant patients is essential for the maintenance and preservation of the graft and quality of life of the patient. This care constitutes the basic structure for the patient in the post-transplant period because nursing is the category that is present 24 hours next to the patient during hospitalization and that also monitors and monitors the responses of the organism along with the three levels of health complexity ⁽⁴⁰⁾.

Research developed on the culture of patient safety in kidney transplantation showed the need for continuous improvement of the nursing professional in the face of theoretical and practical knowledge related to transplantation. It is noteworthy that the nursing professional must be trained and have the skills and competence to assist the transplanted patient to enable safe care for patients and staff, a better quality of care provided, a higher graft survival and better quality of life for kidney transplant recipients ⁽⁴²⁾.

Considering the classification used in the review of the scope in question for nursing care for kidney transplant recipients in the immediate, middle and late postoperative periods, and nursing care for kidney transplant recipients in PHC, results were found for each classification.

For this, nursing care in the immediate postoperative period is vital, being considered a care for critical care. In the first 24 hours after kidney transplantation, nursing actions aim to prevent complications and prioritize the continuous evaluation of general health status with noninvasive monitoring of vital signs and evaluation of the nursing team of 1 hour/1 hour in the first 12 postoperative hours, which allows early and appropriate interventions for each type of worsening. This period of great potential for hemodynamic instability, cardiovascular and neurological complications, important metabolic alterations and the need for replacement of parenteral fluids in large volumes that require intensive care for the maintenance of life ^{(5, 23, 43, 44-49)}.

The main complications of this period are related to the surgical procedure of kidney transplantation, such as: kidney artery thrombosis, hemorrhage, kidney surgery, urinary obstruction; and non-surgical complications such as acute graft rejection ^{(37, 41)}. Therefore, the care of the nursing team should be based on clinical evaluation based on physical examination and laboratory tests for monitoring kidney function, pulmonary and cardiovascular function, with emphasis on monitoring the hydroelectrolytic balance and signs and symptoms of kidney injury ^{(5, 23, 33, 50)}.

Nursing care in the middle postoperative period is a continuity of the surveillance of these patients. The main complications in this period are kidney vein thrombosis, bladder fistula, urinary fistula, kidney shop hematoma, urinary infection and hypertension.

The emphasis of care in this period is the monitoring of the hydro-electrolytic balance, care for infection prevention, pain control, maintenance and stimulation of pulmonary function, early ambulation, restoration of gastrointestinal functions and restoration of kidney function ^{(37, 51-53)}.

In this moment of care still in the hospital environment, it is extremely important to create the bond between professionals and the patient, because the longevity of the graft, the quality of life of the recipient and self-care are associated with his/her treatment' and the latter, directly linked to the relationships established throughout the health network. Thus, the professional must establish a dialogical relationship with the client, with a clear language, holistic treatment, individualized, considering their socioeconomic, cultural, religious and cognitive condition ^{(37, 41, 53-58)}.

How far from the surgical procedure, surgical complications are more difficult to happen, but they may still be present, coming to light, more predominantly, clinical complications ⁽⁵⁹⁾. Thus, we can say that, in the late postoperative period, the most common complications are lymphocele, urinary infection, cytomegalovirus infection, systemic arterial hypertension, diabetes mellitus, rejection of the acute or chronic graft ^{(32, 37, 41, 60-65)}.

However, late nursing care is based on the care of the surgical wound, the scores of laboratory results of the general state of health and kidney function, but the care of guidance to the recipient and family members regarding the use of immunosup-pressants, the importance of returning to consultations and the performance of scheduled tests, maintenance of dietary recommendations and physical activity, among others ^{(15, 32)}.

This study highlights the inclusion of nursing care for kidney transplant recipients in PHC. As important as the follow-up of kidney transplant recipients in secondary care, that is, in the specialized outpatient clinic, it is the follow-up of it in PHC in the basic units and in the family health strategy in the municipalities of origin.

It is important to highlight that the kidney transplant patient is still a patient with CKD and should be inserted in the health care network at the three levels of complexity, according to their need.

Published in March 2014, Ordinance 389 defines the criteria for the organization of the care line of the person with CKD. Thus, it is the responsibility of PHC to perform educational activities and support self-care, expanding the autonomy of the person with CKD, such as stimulating and guiding therapeutic adherence, updating the vaccination card, personal and home hygiene care, and care for the prevention of opportunistic infections due to immunosuppression ⁽²⁾.

It is the responsibility of specialized outpatient care to maintain communication with the multidisciplinary teams of the other components of the Health Care Network (2). This shows that networking among the levels of complexity of care for patients with CKD is extremely important.

Moreover, the potential of studies of this nature is considered by synthesizing and mapping knowledge that ensures a care practice based on scientific evidence and allows decision-making. Added to this theme and the evidence summed up for nursing professionals working with kidney transplant patients in a perspective of guidance and support to safe nursing care practices.

The heterogeneity of the selected studies and even the possibility of vice-studies in individual studies described are uncontrolled characteristics in this type of study and is considered as a limitation of the research. Another limiting feature would be the non-inclusion of material published and available in full in a non-free online medium that could add scientific value to this scoping review. The scarcity of studies focused on nursing care in the international literature was listed as a complicating feature, but not controlled in this type of study.

Conclusion

It was concluded that the study allowed mapping nursing care to kidney transplant patients in the immediate, immediate, late and PHC postoperative periods.

The mapping of nursing care to kidney transplant recipients provides the strengthening of the care offered in the health care network and is configured as an instrument that induces co-responsibility and quality intending to continuously improve health outcomes. An important driver for the praxis (action-reflection-action) of science and for the valorization of nursing.

Given the complexity that the patient submitted to kidney transplantation presents, it is necessary that the nurse who assists this public be trained to conduct care efficiently in the face of the complex situations resulting from the clinical profile of patients, developing their practice of competent care for safe decision-making, ensuring patient safety and based on scientific evidence.

The insertion of primary health care in the care of kidney transplant patients becomes a differential of this study. In addition, this care is considered essential in the process for graft maintenance in transplanted patients, as it allows better treatment support, promotion and prevention of diseases such as opportunistic infectious diseases, reduction of anxiety regarding doubts and difficulties of treatment and greater emotional support for the user and the family.

Conflicts of interest: None declared.

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