A rare renal transplant journey: nursing management of an elderly dialysis patient receiving a pediatric deceased donor

Swaminathan S1*, Shiva Kumar D2, Sowmya Sridharan3, Vijay Kumar R4, Nursing Team 5

1Transplant surgeon, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

2Nephrology consultant Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

3Consultant Infectious Disease, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

4Urology consultant , Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

5Nursing Team – Kauvery Hospital, Vadapalani ,Chennai, Tamil Nadu

*Correspondence

Abstract

Renal transplantation from pediatric deceased donors to adult recipients is an important option for patients with end-stage renal disease (ESRD), particularly in the setting of limited organ availability. Such transplantation requires meticulous perioperative assessment, close graft monitoring, infection prevention, and comprehensive nursing care.

Case Presentation

A 31-year-old female with hypertension and biopsy-proven chronic kidney disease progressed to ESRD and required maintenance hemodialysis from 2021. She remained dialysis-dependent and anuric for approximately four years before transplantation. Pre-transplant evaluation identified significant cardiovascular comorbidities, including severe left ventricular systolic dysfunction with an ejection fraction of 34% and severe pulmonary hypertension. Following multidisciplinary evaluation and counselling regarding the increased perioperative risk, she underwent en-bloc deceased-donor pediatric kidney transplantation to an adult recipient on 24 August 2026. The donor was a 1-year-7-month-old brain-dead pediatric donor, and both kidneys were retrieved and transplanted en bloc. Following reperfusion, both grafts became uniformly pink and turgid, with immediate urine output from both kidneys.

Intervention and Outcome

The patient received induction immunosuppression with antithymocyte globulin and methylprednisolone, followed by tacrolimus, mycophenolate mofetil, and steroids. Post-transplant complications included urinary catheter leakage, intermittent fever, a small-capacity urinary bladder, multidrug-resistant Klebsiella pneumoniae urinary tract infection, and a significant per-graft hematoma requiring surgical evacuation. In view of graft dysfunction and suspected acute allograft rejection, plasma exchange was initiated, followed by allograft biopsy for definitive evaluation.

Conclusion

This case demonstrates the complexity of pediatric deceased donor kidney transplantation in an adult recipient and highlights the critical role of nursing care in continuous graft surveillance, infection prevention, fluid and urine-output monitoring, immunosuppressive medication management, early identification of complications, and multidisciplinary coordination.

Keywords: En-bloc kidney transplantation; Pediatric deceased donor; Adult renal transplant recipient; End-stage renal disease; Nursing management; Graft dysfunction.

Fig (1): Anatomy of En-bloc Pediatric Kidney Transplantation

Case Presentation

A 31-year-old female with a history of hypertension and biopsy-proven chronic kidney disease (CKD) progressing to end-stage renal disease (ESRD) was evaluated for renal transplantation. She had been dependent on maintenance hemodialysis since 2021 and remained dialysis-dependent for approximately four years before transplantation.

Medical History and Clinical Course

The patient was initially diagnosed with hypertension during her first pregnancy in 2015, with no documented evidence of renal impairment at that time. During her second pregnancy, she developed hypertension associated with progressive deterioration of renal function. In 2019, she developed preeclampsia with worsening renal dysfunction, resulting in medical termination of pregnancy followed by emergency suction and evacuation.

Following this period, the patient discontinued conventional medical treatment and received various forms of alternative therapy, including Siddha, Ayurveda, acupuncture, and homeopathy, for approximately two years. During this period, her renal function progressively deteriorated. A renal biopsy performed in 2019 demonstrated global and segmental glomerulosclerosis with marked tubulointerstitial chronicity, consistent with advanced chronic renal parenchymal disease. Subsequently, she developed breathing difficulty and worsening clinical symptoms requiring hospitalization. In view of progressive renal failure, maintenance hemodialysis was initiated in 2021. She remained dialysis-dependent and subsequently became anuric. In 2023, the patient developed chest discomfort. Coronary angiography performed in April 2023 showed normal coronary arteries; however, left ventricular dysfunction was identified.

Comorbidities and Pre-Transplant Assessment

The major comorbidities identified during the pre-transplant evaluation were hypertension and significant cardiovascular dysfunction. Echocardiographic assessment demonstrated severe left ventricular systolic dysfunction with an ejection fraction of approximately 34%, along with severe pulmonary artery hypertension and tricuspid regurgitation. The patient underwent comprehensive pre-transplant evaluation, including anaesthetic, pulmonology, and cardiology assessments. Cardiology fitness was obtained after counselling regarding the increased perioperative cardiovascular risk. She was subsequently registered for renal transplantation in 2024, and the required transplant work-up was completed.

Given her ESRD, prolonged dialysis dependence, prolonged anuric state, and significant cardiovascular comorbidities, she was considered a high-risk renal transplant recipient requiring close perioperative monitoring and multidisciplinary management.

Renal Transplantation

The patient underwent en-bloc deceased-donor pediatric kidney transplantation on 24 August 2026. The donor was a 1-year-7-month-old brain-dead pediatric donor, and both kidneys were retrieved and transplanted en bloc into the adult recipient. Following reperfusion, both grafts became uniformly pink and remained turgid, with immediate urine output observed from both grafts following clamp release. The patient received induction immunosuppression with antithymocyte globulin (ATG) and methylprednisolone, followed by maintenance immunosuppression with corticosteroids, tacrolimus, and mycophenolate mofetil (MMF).

Post-Transplant Complications and Clinical Course

The patient underwent deceased donor renal transplantation (DDRT) with en-bloc pediatric kidney transplantation on 24.08.2026. Both pediatric kidneys were transplanted en bloc into the adult recipient. She received a cumulative dose of 75 mg antithymocyte globulin (ATG) as induction immunosuppression. The immediate postoperative period was uneventful, and she was discharged on 01.09.2026 with a serum creatinine of 0.6 mg/dL on postoperative day 7. Following discharge, the patient developed a suspected pericatheter urinary leak associated with reduced urine output, fever, and chills. She was readmitted on 02.09.2026 with acute graft dysfunction and decreased urine output. Urine culture was sent, and broad-spectrum intravenous antibiotics were initiated. Urology consultation was obtained, and she was treated with Mirabegron, Solifenacin, and an alpha blocker. A retrograde CT cystogram showed no evidence of urinary leak. A DTPA renal scan confirmed good perfusion of both transplanted kidneys without urinary leak.

Urine culture grew MDR Klebsiella, following which Infectious Disease consultation was obtained and antibiotic therapy was escalated to Aztreonam–Avibactam. The patient subsequently developed a progressive rise in serum creatinine with worsening oliguria. In view of previously documented Class I and Class II DSA positivity, empirical treatment for antibody-mediated rejection (ABMR) was initiated. The first session of plasma exchange (PLEX), followed by IVIG 10 g, was administered on 05.09.2026. MRI abdomen performed on 07.09.2026 revealed a perigraft hematoma with associated hemoperitoneum and mild mass effect on the urinary bladder, with a suspicious 5 × 6 mm outpouching/pseudoaneurysm in the inferior epigastric arterial region. Due to a serial fall in hemoglobin, she received 1 unit of PRBC. Re-exploration was performed on 07.09.2026, with evacuation of approximately 350 mL of hematoma. Two units of PRBC were transfused during the procedure. No active bleeding source was identified, and thorough washout and hemostasis were achieved. An allograft biopsy was also performed intraoperatively.

The biopsy was suggestive of acute antibody-mediated rejection with diffuse C4D positivity. The patient subsequently received two additional PLEX sessions as treatment for ABMR. Following PLEX therapy, urine output improved and serum creatinine progressively declined, indicating improving graft function. The DJ stent was removed on 10.09.2026. Tacrolimus trough levels were monitored regularly, and the dose was adjusted accordingly. The patient remained clinically stable with improving graft function and adequate urine output and was discharged on 11.09.2026 with advice for regular follow-up and monitoring of renal function, tacrolimus levels, infection, rejection, blood pressure, and graft function.

Fig (2): CT Abdomen Post-Transplant

 Investigations

InvestigationPre-operative LabsPost-operative Labs
Urea55 mg/dl44 mg/dl
Creatinine6.2 mg/dl0.60 mg/dl
Albumin3.54 mg/dl3.3 mg/dl
Hemoglobin8.5 gms7.7 gms

Recovery and Outcome

Following continued multidisciplinary management and close postoperative monitoring, the patient showed clinical improvement. The ureteric stent was successfully removed on 10 September 2026 without reported complications.

The patient remained clinically stable and demonstrated satisfactory recovery. She was subsequently discharged in a healthy and stable condition on 11 September 2026, with appropriate medications, follow-up instructions, and transplant-related education.

Post-Transplant Nursing Care

Following en-bloc pediatric deceased-donor kidney transplantation, comprehensive nursing care was provided to support graft function, prevent complications, promote recovery, and prepare the patient for safe discharge. Nursing management was individualized according to the patient’s prolonged dialysis dependence, anuric state, cardiovascular comorbidities, urinary complications, infection, hematoma, and graft dysfunction.

Wound and Drain Care

The surgical wound was assessed regularly for redness, swelling, warmth, tenderness, discharge, bleeding, and other signs of infection. Aseptic technique was maintained during wound dressing and drain care. Drain output was monitored for amount, colour, and characteristics and documented appropriately. Following hematoma evacuation, the operative site was closely monitored for recurrent bleeding, collection, wound infection, and delayed healing.

Medication and Immunosuppressant Monitoring

The patient received induction immunosuppression with antithymocyte globulin (ATG) and methylprednisolone, followed by maintenance therapy with corticosteroids, tacrolimus, and mycophenolate mofetil (MMF). Medications were administered as prescribed, and the patient was monitored for adverse effects and potential complications of immunosuppression.

Tacrolimus levels and relevant laboratory parameters were monitored according to the transplant team’s protocol. The patient was educated regarding strict adherence to immunosuppressive therapy and advised not to stop or modify medications without medical advice.

Infection Prevention and Neutropenic Precautions

Because immunosuppressive therapy increases susceptibility to infection, appropriate infection-prevention measures were maintained. Hand hygiene was emphasized for the patient, family members, visitors, and healthcare personnel. Aseptic technique was followed during invasive procedures, wound care, catheter care, and medication administration.

The patient was monitored for fever, chills, wound discharge, urinary symptoms, respiratory symptoms, and other signs of infection. Laboratory investigations, including complete blood count and microbiological investigations when indicated, were monitored.

When neutropenia or increased infection risk was identified, appropriate neutropenic precautions were implemented according to hospital protocol. Exposure to individuals with active infections was minimized, unnecessary visitors were restricted, and the patient was advised to avoid crowded or high-risk environments when clinically indicated.

Neutropenic Diet and Food-Safety Precautions

The patient and family were educated regarding safe food practices during immunosuppressive therapy. The prescribed diet was prepared using hygienic practices, with emphasis on preventing food-borne infections.

Education included:

  • Hand hygiene before handling or consuming food.
  • Consuming freshly prepared and thoroughly cooked food.
  • Avoiding raw or undercooked meat, poultry, seafood, and eggs.
  • Avoiding unpasteurized milk and dairy products.
  • Washing fruits and vegetables thoroughly before consumption.
  • Avoiding raw sprouts and foods from unhygienic or uncertain sources.
  • Avoiding improperly stored or expired foods.
  • Maintaining appropriate refrigeration and food-storage practices.
  • Using safe drinking water as advised by the transplant team.
  • Avoiding outside food when food hygiene cannot be assured.

The patient was encouraged to maintain adequate nutritional intake according to the renal transplant team’s dietary recommendations.

Rejection Surveillance

The patient was closely monitored for possible renal allograft dysfunction and acute rejection. Nursing surveillance included urine output, fluid balance, blood pressure, body weight, temperature, renal function parameters, and other relevant laboratory investigations.

Any significant reduction in urine output, unexplained fever, graft-site pain or swelling, fluid retention, or deterioration in renal function was promptly reported. In view of graft dysfunction and clinical concern for possible acute rejection, plasma exchange (PLEX) with FFP cover was performed, followed by allograft biopsy for definitive evaluation.

Patient and Family Education

The patient and family were educated regarding lifelong immunosuppressive therapy, medication adherence, infection prevention, hand hygiene, food safety, wound care, urine-output monitoring, scheduled investigations, and regular transplant follow-up.

They were instructed to promptly report fever, reduced urine output, graft-site pain or swelling, wound discharge, bleeding, breathlessness, vomiting, diarrhoea, or other new symptoms.

Psychological Support

Psychological support was provided throughout the postoperative period. The patient and family were given opportunities to express concerns regarding transplantation, prolonged dialysis, postoperative complications, infection, graft dysfunction, and recovery.

Clear explanations, reassurance, emotional support, and family involvement were provided to promote confidence and adherence to the long-term transplant-care plan.

Discharge Education

Before discharge, comprehensive education was provided regarding medication adherence, immunosuppressant monitoring, infection prevention, food safety, wound care, urine-output monitoring, body-weight monitoring, and follow-up requirements.

The patient was advised to maintain the prescribed medication schedule and attend all transplant follow-up appointments and laboratory investigations. The importance of promptly contacting the transplant team in case of fever, reduced urine output, swelling, breathlessness, wound discharge, bleeding, or other concerning symptoms was emphasized.

Following successful ureteric stent removal on 10 September 2026, the patient showed continued clinical improvement and was discharged in a stable condition on 11 September 2026 with prescribed medications, follow-up instructions, and comprehensive transplant education.

Discharge Medications

  • Tablet Prograf 4.5 mg BD
  • Tablet Dilzem 30 mg BD
  • Tablet CellCept 500 mg BD
  • Tablet Wysolone 20 mg OD
  • Tablet Met XL 12.5 mg BD
  • Tablet Urimax 0.2 mg BD
  • Tablet Pan 40 mg BD
  • Tablet Valocon 450 mg OD
  • Tablet Folvite 5 mg OD
  • Tablet Beplex Forte OD
  • Tablet Shelcal 500 BD

On Examination

  • Patient conscious, oriented, afebrile
  • Temperature – 98.4 °F
  • Blood pressure – 160/110 mmHg
  • Heart rate – 98.4 (bpm)
  • Respiratory rate / Oxygen saturation – 22/min: 99% room air
  • Cardiovascular system – S1 S2 (+), no murmurs
  • Respiratory system – bilateral air entry (+)

Conclusion

This case demonstrates the feasibility of en bloc pediatric kidney transplantation in a high-risk adult recipient with significant comorbidities and a prolonged history of hemodialysis. Postoperative complications included bladder dysfunction, multidrug-resistant Klebsiella pneumoniae infection, hematoma, and graft dysfunction; these were successfully managed through coordinated multidisciplinary care.

The patient recovered and was discharged in stable condition on 11/09/2026. Careful recipient selection, meticulous surgical technique, and close postoperative monitoring contributed to the favorable outcome.

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