Renal Nursing

School of Nursing & Allied Health Sciences

SEMESTER: 2
INTAKE: JANUARY 2012

NBNS3504

COURSE: BACHELOR OF NURSING SCIENCE WITH HONOURS

COURSE TITLE: RENAL NURSING

MATRICULATION NO: 871001305396001
IDENTITY CARD NO. : 871001305396
TELEPHONE NO. : 0166695545
E-MAIL : annbukutty0110@gmail.com
LEARNING CENTRE: PPW Melaka

CONTENTS

NO | TITLE | PAGES | 1 | INTRODUCTION * URINARY SYSTEM * WHAT DO NORMAL KIDNEYS DO? | 3 | 2 | RENAL REPLACEMENT THERAPY * HEAMODIALYSIS * PERITONEAL DIALYSIS | 4 - 7 | 3 | RENAL TRANSPLANTATION * TRANSPLANT PROCEDURE * TISSUE TYPING * CONTRAINDICATION OF TRANSPLANTATION * TYPES OF TRANSPLANT * DONOR WORK UP * RECIPIENT WORK UP | 8 - 14 | 4 | PRE OPERATIVE MANAGEMENT | 14 - 15 | 5 | INTRA OPERATIVE MANAGEMENT | 16 | 6 | POST OPERATIVE MANAGEMENT | 16 - 17 | 7 | COMPLICATIONS OF KIDNEY TRANSPLANT | 17 - 18 | 8 | NURSING PROCESS | 18 - 21 | 9 | HEALTH EDUCATION FOR PATIENT | 22 | 10 | CONCLUSION | 23 | 11 | REFERENCES | 24 |

INTRODUCTION
URINARY SYSTEM
The urinary system consists of the kidneys, ureters, urinary blabber and urethra. The kidneys produce the urine and account for the other functions attributed to the urinary system. The ureters convey the urine away from the kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to outside of the body.
WHAT DO NORMAL KIDNEYS DO? * Remove extra water. * Remove waste products. * Balance chemicals in the body. * Help control blood pressure. * Help make red blood cell. * Help build strong bones.
When the kidneys no longer able to perform normal functions and starts to deteriorate, renal failure will occur, this condition may be acute or chronic. Then the following problems will occur: * Retention of waste and toxic products and excess water. * Nausea * Vomiting * Loss of appetite * Tiredness * Swelling of feet and body * High blood pressure * Upset in the internal balance of acid and base leads to a build-up of acid in the body. * Acidosis * Inadequate production of hormones. * Lack of vitamin D – Bone disease * Lack of Erythropoietin – Anaemia
There are two measures that can help to slow down the rate of kidney: * Control of blood pressure by restricting low salt diet and observation of high blood pressure medications. * Protein restriction diet by reducing the intake of meat and soya products.
When the kidneys function falls to about 10%. Then haemodialysis and peritoneal dialysis is required to sustain life.

RENAL REPLACEMENT THERAPY
HEAMODIALYSIS
Haemodialysis removes blood from the body and sends it across a special filter with solutions. The filter helps remove harmful substances. The blood is then returned to the body. If you have haemodialysis, your health care team will need a way to get to the blood in your blood vessels. This is called access. You may need this for a little while (temporary) or for a long time (permanent). Temporary access involves putting a hollow tube (called a catheter) into a large vein, usually in your neck, chest, or leg near the groin. This is most often done in emergency situations for short periods of time. However, some catheters can be used for weeks or even months. Permanent access is created by surgically joining an artery to a vein, usually in the arm. There are two ways to do this: * An artery and a vein are directly connected to each other. After a few months, they form a connection called a fistula (an arteriovenous fistula, or AVF). This type has a lower risk of infections and lasts longer. * A human-made bridge (arteriovenous graft or AVG) can also be used to connect the artery and vein. An AVG can be used for dialysis within several weeks. * When you have dialysis, one or two needles are placed into the access area. PERITONEAL DIALYSIS
The peritoneum is a thin membrane lining the abdominal cavity with its organs like the liver, gall bladder, gut, female reproductive tract, etc. There are numerous tiny blood vessels in the peritoneum, making it suitable for filtering blood. A small incision is made in the abdomen, and a catheter, which is a small flexible tube, is inserted into the peritoneal cavity, which is the space lined by the peritoneum. The dialysate is then allowed to flow into and out of the abdominal cavity for a specified period of time, during which the abdomen may feel fuller than usual. With the movement of blood through the blood vessels of the peritoneum, waste products and excess fluid move out of the blood and into the dialysate, which is removed from the abdominal cavity at the end of the dialysis. There are two main schedules of peritoneal dialysis: * Continuous ambulatory peritoneal dialysis (CAPD) * Continuous cycling peritoneal dialysis (CCPD).
CAPD involves filling the abdominal cavity with dialysate, leaving it in the abdominal cavity, and later draining away the dialysate through the effect of gravity. Three or four exchanges are needed during the day and one during sleep. One is free to carry out daily activities during the time the dialysate is in the abdominal cavity. CCPD involves a device called a cycler, which automatically fills the abdominal cavity with dialysate three to five times at night, allowing the dialysate to remain in the abdominal cavity and then draining it away into a sterile bag which is emptied in the morning. Although attached to the cycler for 10 to 12 hours at night, the patient is not connected to the device during the day, thereby allowing greater flexibility with activities during the day. The choice of CAPD or CCPD is influenced by the patient’s medical condition, lifestyle and personal preferences. Some people use a combination of both methods to customise their dialysis programme. Peritoneal dialysis is different from haemodialysis. The former can be done at work or home. It is more suitable for patients who cannot tolerate the changes in the fluid balance in haemodialysis. In addition, the need for medicines and diet restriction may be less as compared to haemodialysis. Not everyone with renal failure is a suitable candidate for peritoneal dialysis. One requires manual dexterity or a reliable caregiver and the ability to care for oneself at home. It is unsuitable for patients who have extensive surgical scars in the abdomen or who suffer from inflammatory bowel disease. In deciding on the mode of dialysis, the factors that have to be considered include the general health status of the patient, the functional state of the kidneys, the situation at home, personal preferences and financing. (Dr MILTON LUM- THE STAR 5/1/11).

If the kidneys are unable to recover the despite treatment, end stage renal failure results and transplantation is needed.

RENAL TRANSPLANTATION
Renal transplantation is the organ transplant of a kidney into a patient with end-stage renal disease. It means replacement of the failed kidneys with a working kidney from another person, called a donor. Kidney transplantation is not a complete cure, although many people who receive a kidney transplant are able to live much as they did before their kidneys failed. People who receive a transplant must take medication and be monitored by a physician who specializes in kidney disease (nephrologist) for the rest of their lives. The healthy kidney (the "graft") takes over the functions of your nonworking kidneys. You can live normally with only one kidney as long as it functions properly.
The first renal transplantation in humans was carried out in Ukraine, in 1933, but the graft was not successful. In the beginning of 1950’s, several renal transplantations were carried out in Paris and Boston, but no drug was used to prevent ejection and only one patient survived. In Brazil, the first living donor renal transplantation was carried out in Rio de Janeiro, in 1964, and with a cadaver donor in the countryside of São Paulo State, in 1967. (Hospital Israelite, Albert Einstein – HIAE, São Paulo (SP), Brazil)
In Malaysia, there are a total of 25,000 renal disease patients and these numbers are on the rise with four to five thousand new cases each year. One of the ways in which end stage renal disease can be treated is through renal transplantation either from a living donor or diseased donor (also known as cadaver donor). This can be done with one main condition; blood type of the donor must be compatible with the kidney patient. The shortage of cadaver donors or non-compatible living donors remains as a major issue for those suffering from renal failure. However, a procedure known as “ABO Compatible Kidney Transplantation” marks a new chapter in treating renal failure. With this technique, patients whose blood type did not match the donors are still able to undergo renal transplantation. In July 2011, the first operation using this novel technique was performed in Malaysia. The ABO incompatible transplantation is one of the best options for patients who have no compatible donors in their family. This technique breathes new hope to patients for a chance of survival. (MAHKOTA MEDICAL CENTRE-august2011)

TRANSPLANT PROCEDURE
The transplantation itself is a surgical operation. The surgeon places the new kidney in your abdomen and attaches it to the artery that supplied blood to one of your kidneys and to the vein that carries blood away from the kidney. The kidney is also attached to the ureter, which carries urine from the kidney to the bladder. Your own kidneys are usually left in place unless they are causing you problems, such as infection. Every operation has risks, but kidney transplantation is not a particularly difficult or complicated operation. It is the period after the surgery that is most critical. Your medical team will watch very carefully to make sure that you’re new kidney is functioning properly and that your body is not rejecting the kidney.

TISSUE TYPING
Before kidney transplant, tests that should be done: * ABO blood group typing for compatible blood transfusion. (Bartucci, 2006) * Human Leukocyte antigen (HLA) studies. (Smeltzer & Bare, 1992) * To match transplant recipient with compatible donors, * The more similar the antigens of the donor are to those of the recipient, the more likely it is that the transplant will be successful and immunologic rejection will be avoided. (Danovitch, 2005, Coates et al, 2007)
CONTRAINDICATION OF TRANSPLANTATION * Malignancy * Hepatitis virus and human immunodeficiency virus * Recurrent disease * Diabetes mellitus and severe cardiovascular disease * Hypertension * Drug abuse * Mental disorder/psychiatric diseases * Pregnancy * Chronic infections
TYPES OF TRANSPLANT * LIVING RELATED TRANSPLANT * Donor is from the family members, parents or siblings.

* LIVING NON-RELATED TRANSPLANT * Donor is patient’s spouse or friend.

* CADAVERIC TRANSPLANT * Kidney is taken from a brain death patient or a person who recently died from an accident.

DONOR WORK-UP * SELECTION CRITERIA * Siblings/ parents are the best donor. If no relative, consideration can be given emotionally related donor such as spouse/ close friend. * Age of donor must be above 18 years old and not more than 65 years old. Biological age is more important than chronological age. * ABO compatibility with recipient. * Tissue typing matching donor should have 1 or 2 haplotype match.

* INFORMATION ON TRANSPLANT * The surgical risk and the complications of nephrectomy must explain to donor to reduce the fear and anxiety. * The common early complications are atelectasis, nerve injury tract infection & wound infection.

* PSYCHOLOGICAL ASSESSMENT * Referral to a psychiatrist is necessary to assess the mental stability and willingness in giving the kidney. * Minor feelings of depression are common in the immediate post-operative period. * Must explain to donor that if the graft fails to function it cannot give back to donor. * Give assurance to donor that he/she may withdraw at any stage of pre-transplant assessment.

* CARDIOVASCULAR ASSESSMENT * ECG, CXR, fasting triglycerides and cholesterol. * Referral to cardiologist is indicated if donor above 45 years old, donor who are 35 years or older with coronary risk factors e.g. smoking, obesity, dyslipidaemia and family history.

* RESPIRATORY ASSESSMENT * Potential donor with chronic smoking history and symptoms chronic lung disease should be refer to chest physician and anaesthetist assessment.

* RENAL ASSESSMENT * A full assessment and examination should be carried out to identify any primary renal disease. * Among the examinations are : * Renal profile * Fasting blood glucose * Serum calcium phosphate, uric acid * Urine microscopy (FEME), culture and sensitivity (C&S) * 24 urine for urea, creatinine calcium, uric acid, protein * 24 urine creatinine clearance * Ultrasound of kidney * Radiography for KUB, IVP * Renal angiogram

RECIPIENT WORK UP * CONTRAINDICATION TO TRANSPLANTATION * Age above 55 years, but consideration can be given on an individual basis. * HIV infection * Malignancy * Severe cardiovascular disease * Diabetes mellitus with multiorgan failure * Psychiatric illness * Non-compliance to treatment * Chronic active hepatitis or cirrhosis * Secondary glomerulonephritis due to systemic lupus erytheromatosus

* ADEQUATE DIALYSIS AND NUTRITIONAL STATUS * Potential renal recipient should be adequately dialysed to achieve good control of blood pressure, optimum of fluid status balance, achieve dry weight and satisfactory nutritional status. * The assessment on body weight, body mass index and mid arm circumference, serum albumin should be done to assess the nutritional status.

* ASSESSMENT OF CARDIOVASCULAR SYSTEM * Full history and examination, CXR, ECG * Referral to cardiologist is indicated if donor is above 45 years old, donor is 35 years or older with coronary risk factors e.g. smoking, obesity, dyslipidaemia and family history.

* RESPIRATORY ASSESSMENT * Potential donor with chronic smoking history and symptoms chronic lung disease should be refer to chest physician and anaesthetist assessment.

* ASSESSMENT OF GASTROINTESTINAL SYSTEM * Upper gastrointestinal endoscopic examination should be done to detect peptic ulcer disease.

* UROLOGICAL ASSESSMENT * Patients with suspected urological disorder problem, referral to urologist is required for further assessment and investigation. * Kidney, ureter and bladder (KUB) * Ultrasound of kidney

* ASSESSMENT OF LIVER STATUS * Routine blood test on liver enzymes, Hepatitis B and C antigen and antibody. * Liver biopsy for patient with HCV Ab or HCV positive with or without raised liver enzymes. If patient have chronic hepatitis, renal transplant is contraindicated.

* ASSESSMENT OF HAEMOTOLOGICAL SYSTEM * Haemoglobin level at least 8 g/dl before transplant. * Blood transfusion for anaemia is discouraged. * Anaemia should be treated with erythropoietin.

* DENTAL ASSESSMENT * All potential recipients should be assessed by a dentist for dental clearance.

* SCREENING FOR INFECTION * Cultures should be taken from ear, nose and throat * CXR prior to transplantation * Urine culture and sensitivity

PRE OPERATIVE MANAGEMENT * PRETRANSPLANT DIALYSIS * Fluid overload and electrolyte must be corrected, as this may enhance post transplantation complications. * Haemodialysis with minimal or no heparinisation is carried out to reduce fluid overload and serum potassium levels

* IMMEDIATE PRE-TRANSPLANT INVESTIGATION * Renal profile * FBC, FBS, PT/PTT/APTT * Urine C&S * Swab for nasal, throat, ear * Cytomegalovirus serology * Chest radiography * CA2+, PO4, LFT * ECG * Cross match 4 units packed cells * Cyclosporine level

* PREOPERATIVE MEDICATION * Immunosuppressive drugs are given before the operation to reduce the risk of rejection. * The common medications given are: * Cyclosporine * Azathioprine * Prednisolone

* NURSING MANAGEMENT * Monitor blood pressure, pulse, temperature and respiration. * Check weight by ensuring that dry weight is achieved. * Assess past medical history that is the cause of renal disease. * Dialysis history by checking the date and time of last dialysis done. * Assess current health status whether there any signs of infection. * Urine output if any. * Check on drug allergies * Provide information on the transplant procedure and medication. * Offer emotional support to reduce fear and anxiety. * Cover and mark the arteriovenous fistula to prevent for invasive monitoring. * Give routine preoperative care such as: * Consent * Fasting the patient * Bowel preparation * Shower * Premedication given

INTRAOPERATIVE MANAGEMENT * Central line to be inserted in OT * To maintain CVP at 10-15 cnH2O2 * Urinary catheter to be inserted * Anaesthetist to document clamp and release time * Measures to decrease the likelihood of delayed graft function entail maintenance of adequate blood pressure and fluid status with IV colloid or crystalloid. In living related transplant, it is common practice to administer mannitol before the kidney is perfused, which helps to trigger an osmotic diuresis.

POST OPERATIVE MANAGEMENT * Isolation nursing until all tubes and drains are removed. * Proper hand washes before and after nursing or examines patients. * Monitor hourly fluid balance by correct document of * Intake output * Central venous pressure * Daily weight * Daily investigations: * Biochemistry * Haematology * Microbiology * Urinalysis * Aggressive fluid replacement is essential to keep patient well hydrated so that the newly transplanted kidney will function and produce urine immediately after operation. * If patient is adequately hydrated with good graft function, replace previous hours’ urine output and if is adequately hydrated but remains anuric, restrict intravenous fluid to 500-1000 ml/day. * Use normal saline alternate with dextrose 5%, if potassium (K+) is < 4, use Hartmann’s solution or supplement with vitamin K+ and replace fluid loss based on hourly urine output and central venous pressure. * Urinary catheter is inserted in OT, monitor urine output hourly. If urine output is declines
(< 100 mls/ hour) or blood clot present, inform the doctor immediately. * Bladder washout should be only done under strict aseptic technique by urologist if deemed necessary. * Catheter usually will be removed at Day 5 post-operative or pending on the urologist. * Wound drain will be removed at the discretion of urologist. * Removal of internal J stents will be done 3 months post-transplant or early if infection occurs. * Examination of the renal profile twice daily for 48 hours then daily: * Daily FBC * Liver function test, calcium and phosphate three times per week * Cyclosporine / tacrolimus level three times per week * DPTA (diethylenetriamine penta acetate) scan usually done on Day 2-4 * Chest radiography * Doppler US Day 1, or immediately if primary non-function, delayed graft function or sudden drop in urine output. * Patients medications: * IV ranitidine 50mg tds for 2 days then change to oral ranitidine 150mg bd for 3-6 months. * Nystatin 250000units gargle and swallow qid for 3 months * Cotrimoxazole 480mg at night to commence when renal function is stable. * Enforce patients on follow up.

COMPLICATIONS OF KIDNEY TRANSPLANT * Rejection of the new kidney * Hyper acute rejection which occurs immediately within minutes or hours after transplant. This may cause by presence preformed cytotoxic antibodies in the recipients blood or ABO incompatibility. * Acute rejection – usually occur between 4 days and 2 months after transplant. The clinical signs of rejection are: * Pyrexia * Weight gain * Reduced urine output * Swelling and tenderness of the graft * Ankle oedema * Flu-like symptoms * Chronic rejection – occurs months or years later the exact cause is still uncertain, it may be due to immunological factors. The early signs are reduced renal function or increase creatinine or presence of proteinuria. * Acute tubular necrosis may is due to prolonged hypotension in the donor or ischemia during the surgery. * Severe infection * Common occur due to the immunosuppressive medications. * Bacterial infection to the chest, fungal infection to the oral cavity and cytomegalovirus.

NURSING PROCESS 1. EXCESS FLUID VOLUME RELATED TO FUNCTION OF TRANSPLANTED KIDNEY
Objective
* Patient will not experience fluid retention
Intervention
* Weigh patient daily and monitor blood pressure. * Compare both to baseline values. * Auscultate lungs for crackles. * Monitor RAP and PAWP if indicated. * Notify physician of indications of fluid volume excess including 3 pound weight gain in three days. * Collaborate with physician and patient to determine fluid allotment and medication or dialysis management of volume excess. * Monitor serum Sodium and potassium levels.

Rationale * Following renal transplantation from a deceased donor, the kidney may not function optimally at first resulting in fluid volume excess. * Fluid volume excess may also develop from use of steroids and from decreased cardiac output in any transplant recipient. * The nurse must identify the volume excess and collaborate with the patient and physician return the patient to neutral state.
Evaluation
* Weight and blood pressure will return to baseline. * Lungs will remain clear to auscultation. * RAP and PAWP will return to baseline. * Serum Sodium will remain within normal limits.

2. RISK FOR INFECTION RELATED TO IMMUNOSUPPRESSION
Objective
* Patient will remain free of infection.
Intervention
* Maintain a clean patient environment; wear a mask in patient’s room if policy indicates. * Follow strict hand washing technique. * Limit the number and duration of invasive devices. * Encourage incentive spirometer, deep breathing and ambulation. * Assess patient’s mouth for white lesions characteristic of oral candidiasis. * Apply topical antifungal as directed.

Rationale * The high level of immunosuppression in the first month post-transplant predisposes the patient to develop nosocomial infections. * However, the patient has not been immunosuppressed long enough to develop opportunistic infections. * After the first month the patient may develop candidiasis.
Evaluation
* Patient will be afebrile, WBC count will be within normal limits, there will be no infiltrates on chest x-ray, IV sites will be benign, no evidence of UTI, fatigue, anorexia, diarrhoea, or candidiasis.

3. DISTURBED BODY IMAGE RELATED TO EFFECTS OF STEROID THERAPY
Objective
* Patient will develop a realistic sense of self.
Intervention
* Provide an empathetic environment so that patient can discuss her concerns about her changed body. * Collaborate with patient to develop strategies to cope with changes such as: * Help female patients to find a way to manage excessive facial hair. * Encourage exercise and appropriate diet to limit weight gain. * Encourage patient to socialize with family and peers.
Rationale
* Encouraging the patient to describe her concerns will assure that the nurse is addressing the patient’s concerns. * Jointly developed strategies are more likely to be successful.
Evaluation
* Patient will identify strategies to respond to the changes in her body. * Patient will verbalize that her body “feels like her own.”

4. ACUTE PAIN RELATED TO FREQUENT INVASIVE PROCEDURES AND SURGERY
Objective
* Patient’s pain level will be less or reduced.
Intervention
* Establish rapport on the client. * Monitor the vital signs. * Provide pharmacologic agents to reduce or eliminate pain as prescribed by the physician. * Help patient focus on activities rather than on pain and discomfort by providing diversion through radio and visitor * Provide health teaching on the client regarding the pain associated to her surgery.
Rationale
* To establish trust and cooperation on the client * To obtain the baseline data. * To help in reduction of pain. * To focus more on activities and reduce the pain. * To maintain the healthy habit of the patient. * To provide adequate knowledge on the client.
Evaluation
* After 2 hours of nursing intervention, goal met, the patient was able the pain from level 3.

HEALTH EDUCATION FOR PATIENT * The length of stay in the hospital for uncomplicated kidney transplant is from 5 to 10 days for a living-donor kidney and up to 25 days for a cadaveric kidney. I. Avoid injury to the transplant site. Nurses will examine and clean your incision site three times a day. II. Measure your urinary output. For a man, this means urinating in a urinal, for a woman, a plastic "hat" placed under the toilet seat. III. Plan to cough and take deep breaths regularly to prevent pneumonia. Walk at least four times a day around your hospital room and halls. IV. Learn the proper ways to take your medicines and how to prevent organ rejection and infection once you go home. V. Look for signs of rejection such as: * Fever * Flulike symptoms * Decrease in urine production * Changes in blood pressure * Weight gain * Pain around your new kidney. VI. Note signs of infection such as: * Redness around your incision site * Fever * Pus like drainage * Flulike symptoms * Pain around your new kidney. VII. Learn everything you can about your medicines because you may be on immunosuppressant drugs for the rest of your life. They prevent your body from releasing antibodies meant to attack your new kidney.

CONCLUSION
Almost everyone feels that they have a better quality of life after the transplant. Those who receive a kidney from a living related donor do better than those who receive a kidney from a donor who has died. (If you donate a kidney, you can usually live safely without complications with your one remaining kidney.) People who receive a transplanted kidney may reject the new organ. This means that their immune system sees the new kidney as a foreign substance and tries to destroy it. In order to avoid rejection, almost all kidney transplant recipients must take medicines that suppress their immune response for the rest of their life. This is called immunosuppressive therapy. Although the treatment helps prevent organ rejection, it also puts patients at a higher risk for infection and cancer. If you take this medicine, you need to be screened for cancer. The medicines may also cause high blood pressure and high cholesterol and increase the risk for diabetes. A successful kidney transplant requires close follow-up with your doctor and you must always take your medicine as directed.

REFERENCES * Kidney Transplantation, Surgical Complications [retrieved on 25 FEB 2012] http://emedicine.medscape.com/article/378801-overview

* Medline Plus: Kidney transplant [retrieved on 27 FEB 2012] http://www.nlm.nih.gov/medlineplus/ency/article/003005.htm * emedicinehealth.com: Kidney Transplant [retrieved on 29 FEB 2012] http://www.emedicinehealth.com/kidney_transplant/article_em.htm * UCSF Medical Centre: Kidney Transplant [29 FEB 2012] http://www.ucsfhealth.org/adult/medical_services/organ_transplants/kidne... * Gupta A, Upadhay BK, Khaira A, Bhowmik D, Tiwari SC. Chronic diarrhea caused by Hymenolepis nana in a renal transplant patient. Clin Exp Nephrol 2009; 13(2): 185-6

* Barry JM, Jordan ML, Conlin MJ. Renal transplantation. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 40.

* Hooi LS. HIV infection in recipients of living unrelated donor renal transplants - a report of 4 cases. Med J Malaysia 1993; 48: 232 – 35

* The Council of the Transplantation Society. Commercialisation in transplantation: the problems and some guidelines for practice. Lancet 1985; 2: 715-16.

* NBNS3504 Renal Nursing. Open University Malaysia. [retrieved on 11 MAC 2012] http://lms.oum.edu.my/myvle/index.php?gauser=annbukutty0110&gaulevel=5