Postoperative monitoring after kidney transplantationmed.swu.ac.th/surgery/images/kidney_2560... · Handbook of Kidney Transplantation, 5th Edition • Management depends on urologist

Postoperative monitoring after kidney transplantationkidney transplantation

Bundit sakulchairungrueng ,MDVascular and Transplantation Unit

Faculty of Medicine Ramathibodi HospitalMahidol University

Reference

Introduction

• A successful long-term outcome for a new kidney transplant recipient depends on the early perioperative management and course after surgery.after surgery.

Cecka JM. The UNOS scientific renal transplant registry – tenyears of kidney transplants. Clin Transpl 1997;1–14

Perioperative Assessment

• Assessment of pretransplant fluid status of recipient to determine the need for dialysis

• Careful physical examination recipient (e.g. active • Careful physical examination recipient (e.g. active

ischemic heart disease, active infection, vascular disease)

• Knowledge of the donor status (e.g. living related

donor ,expanded criteria donors )

DANOVITCH, GABRIEL M. , chapter 9 Handbook of Kidney Transplantation, 5th Edition

• Technical considerations include the need for vascular reconstruction , anatomical considerations that complicate the surgery

Perioperative Assessment

• Recipient factors : Significant risk factors for early posttransplant dysfunction (e.g. obesity, younger or older age)


Perioperative Management

• Early perioperative period, attention to fluid and electrolyte balance is crucial.

• Careful monitoring of urine output is • Careful monitoring of urine output is essential.


The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines

• Recommend measuring urine volume every 1–2 hours for at least 24 hours after transplantation and daily until graft function is transplantation and daily until graft function is stable .

KDIGO clinical practice guideline for the care of kidney transplantrecipients. Am J Transplant 2009;9(Suppl. 3):S1–155.

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines

• Serum creatinine should be measured at least daily for 7 days or until hospital discharge.

• Creatinine should then be measured two to • Creatinine should then be measured two to three times per week for a month, and a tapering frequency of measurements in ensuing weeks.

KDIGO clinical practice guideline for the care of kidney transplantrecipients. Am J Transplant 2009;9(Suppl. 3):S1–155.

DANOVITCH, GABRIEL M. , chapter 9 ,table 8.1Handbook of Kidney Transplantation, 5th Edition

Postoperative Assessment

• Urine output early graft recovery

• Hemodynamic and respiratory stability

• Assessment of volume status

• Intraoperative immunosuppressive protocols• Intraoperative immunosuppressive protocols

• Control blood glucose concentration (facillitaterecovery of allograft ,promote healing)


• Operative record information to assess- Fluid and blood loss and fluid replacement

- Intraoperative events

- Intraoperative perfusion characteristics of the kidney

Postoperative Assessment

- Intraoperative perfusion characteristics of the kidney

- Intraoperative urine volume

- Details of the surgery (e.g., multiple donor vessels, recipient vascular condition, type of ureteral anastomosis)


• Most common aspect is to ensure sufficient fluid replacement

- maintain hemodynamic stability

- urine output

Fluid Replacement

- urine output


Fluid Replacement

Maintenance fluid-Insensible loss ~30 mL/h

Replacement fluid-Urine output-Any Nasogastric fluid loss

*Half- normal saline


Fluid Replacement

• Keep euvolemic or mildly hypervolemic

• Estimate volume losses at the operative site

• Urine volume must be monitored hourly and replaced accordingly replaced accordingly


Hemodynamic Evaluation

• An adequate blood pressure and volume status is necessary to establish good graft function.

• Many patients are hypertensive after surgery


• In acute setting , mild elevated blood pressure (systolic pressure < 180 mmHg) is acceptable.

Hemodynamic Evaluation


Assessment and management of urine output

• Oliguria in the posttransplant situation usually refers to urine outputs of less than approximately 50 mL per hour.


DANOVITCH, GABRIEL M. , chapter 9 figure 9.1Handbook of Kidney Transplantation, 5th Edition

Hemodynamic assessment Duplex ultrasound

Hypovolemia Euvolemia/ hypervolemia

250-500 ml Fluid load

No Urine Furosemide 250 mg IV.

Good Kidney Purfusion

Poor/No Kidney Purfusion

Bladder Ultrasound/Scan

No UrineIn Bladder

UrineIn Bladder

Irrigate

Post transplant oliguria/anuria

Urine

Immediateexploration

No Urine

Treat AKI

Irrigate Bladder

Urine

Protocol Kidney transplantation, Ramathibodi hospital Mahidol University

Duplex ultrasound

Duplex ultrasound

• If the flow study reveals no demonstrable blood flow, a prompt surgical reexploration is necessary to attempt to repair any vascular technical problem. technical problem.


• Polyuria- amounts of urine (greater than 500 mL per hour) in the early posttransplantperiod.

• Potassium and calcium may need to be

Assessment and management of urine output

• Potassium and calcium may need to be replaced in the polyuric patient.


Postoperative Bleeding

• Most hematomas will spontaneously tamponade

• Any combination of the triad of Hypotension , • Any combination of the triad of Hypotension , a decreasing hematocrit and pain significant postoperative bleeding

• Perinephric drain may fill with blood



• If bleeding continues can ‘t maintain blood pressure with intravenous fluids or blood replacement ,

• Surgical exploration may be required to


• Surgical exploration may be required to find source of persistent bleeding.


Postoperative Hemodialysis

• If serum potassium concentration is elevated or if the patient is compromised by overhydration , dialysis should be performed for correct condition for correct condition


• Sudden onset of severe pain or pain that appears to be aggravated by voiding ,suggests the possibility of a urine leak.

• Urine wound / Drain

The first postoperative week

• Urine wound / Drain


Urine leak

• Urine leaks usually occur at the ureteric anastomosis, most frequently in the first 72 hours.

• location vesicoureteric anatomosis , calyx • location vesicoureteric anatomosis , calyx (area of ischemia)

• Complication infection ,abscess, urinoma

• Ultrasound , Renal scan


• Management depends on urologist surgical practice.

• If the leak persists, or if it is considered

Urine leak

• If the leak persists, or if it is considered unlikely to heal , then re exploration is indicated to reimplant the ureter.


Delayed Graft Function

• DGF is defined as the need for dialysis during the first week after transplantation, and is the most frequent early posttransplantcomplication.complication.

Siedlecki A, Irish W, Brennan DC. Delayed graft function in thekidney transplant. Am J Transplant 2011;11(11):2279–96.

• Diagnosis of DGF is apparent during the first 24hours after transplantation.

• Clinical scenario is a decline in urine output unresponsive to a fluid challenge.


unresponsive to a fluid challenge.

• Usual time course of DGF is 10–14 days.

Chapter 14 , 7 th Kidney transplantation ,peter J.Morris

• The major differential diagnostic consideration

an acute vascular or urological complication.

• Can be evaluated with urgent ultrasound


Typically, a transplant with DGF shows good renal perfusion


• Kidney transplant biopsy is the “gold standard” for diagnosis.

• When the diagnosis of DGF is established, careful attention to fluid status is paramount


careful attention to fluid status is paramount to decrease the frequency and necessity for

dialysis.


Allograft function

• The creatinine and the urine output can be used as measures of changes in kidney function and as markers of the development function and as markers of the development of new problems


• Rejection

• Problem with blood flow to the kidney

• Obstruction to urine flow

• CNI toxicity

Problem of Allograft function

• CNI toxicity

• Infection



Thank you

Documents

Postoperative monitoring after kidney transplantationmed.swu.ac.th/surgery/images/kidney_2560... · Handbook of Kidney Transplantation, 5th Edition • Management depends on urologist