Return from theatre | Anuria | First days | Delayed graft function | Graft dysfunction | Renal biopsy
Return from theatre and Day One
Check FBC and Us & Es immediately post-op. Serum K+ must be known and result discussed with Registrar, if possible hyperkalaemia should be managed with Insulin/dextrose and nebulised Salbutamol rather than haemodialysis. Subsequent repeat Us & Es 12 hourly (more frequently if indicated or as decided by Registrar).
Arrange chest X-ray for position of central line, if not already performed in recovery.
Initial IV fluid replacement is Normal Saline at 40 mls/hr + last hour's urine output. This should be adjusted according to clinical assessment and CVP. Usual target CVP is 5-10 cm H20. Boluses of Normal Saline (or colloid) may be needed to raise a low CVP. Failure of the patient to respond to IV fluid with a rise in CVP or BP should raise possibility of bleeding. These measures should always be instigated by a senior member of staff. If there is a possibility of bleeding a transplant surgeon must be contacted.
Continuing IV fluid replacement should initially be maintained with alternating 5% Dextrose and Normal Saline.
Analgesia is by PCA fentanyl. Inadequate pain relief may herald serious pathology and should be discussed with a senior surgeon/Anaesthetist. NSAIDs are absolutely contraindicated. Live donors will receive an epidural infusion (see appendix VI).
Post-op anuria - check catheter function. Check with surgeon or operation note whether expected. Gentle catheter irrigation should only be performed after surgical consultation and preferably by the surgeon. If it continues, see Delayed Graft Function
Prescribing - see immunosuppression protocol and pre-op prescribing
First few days
Blood Tests
- U&E daily
- FBC daily
- LFTs, glucose, calcium, phosphate – daily
- Tacrolimus or Ciclosporin level - M/W/F
Chart all blood results on flow charts (creatinine on log creatinine graph)
MSU each Monday and at other times if clinically indicated.
Redivac drain removed at 24-48 hours at surgeon’s discretion.
Urinary catheter removed at day 5 unless: -
- the patient is anuric (removed earlier) or
- the patient is polyuric (removed later)
- advised differently by transplant surgeon
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Delayed graft function
In all cases of DGF an ultrasound and Doppler of the graft should be performed on day 1.
Due to prolonged ischaemic times/ATN etc., not all kidneys function immediately and some take a few days or even weeks before functioning. During this time the aim is to ensure that we are not missing concomitant rejection or other catastrophe.
- Day 1
Duplex scan
Routine immunosuppression - Day 5-7
If no evidence of improvement then biopsy to exclude rejection. - Around day 12
Repeat Duplex/biopsy.
Treat biopsy-proven rejection with iv pulsed methylprednisolone 3x500mg. Occasionally, 3 x 250mg given without biopsy on day 5, if particular reasons to avoid biopsy, e.g. risk of bleeding.
Graft dysfunction
Any drop in urine output or rise in creatinine should be discussed immediately with a senior colleague. Management will depend on the clinical situation. Fluid balance assessment is essential but acute rejection must always be suspected. Physical signs are often absent and urgent investigation is required. Think about ...
- Fluid balance - clinical assessment, weight, fluid charts
- Check tacrolimus (prograf) / ciclosporin result
- Graft tenderness, fever, or other signs of infection - MSU result; virus infections especially CMV
- Graft ultrasound scan - will exclude obstruction.
- Graft Doppler - assesses flow in renal artery and vein (may also comment on intra-renal vascular resistance).
- Graft biopsy - for definite diagnosis of rejection.
An increase in creatinine may be caused by a number of processes, but common causes are:
- Rejection
- Infection, e.g. urine, CMV
- Tacrolimus / Ciclosporin toxicity
- Altered fluid balance
Less common causes are:
- Vascular catastrophe
- Mechanical problem - urinary obstruction (less likely if ureteric stent present)
- Lymphocele
Renal Biopsy
Full allograft biopsy protocol. A routine graft biopsy is performed around day 5 if there is delayed graft function and subsequently at weekly intervals until function is established. This is to diagnose acute rejection co-existing with ATN.
Any deterioration in graft function may require a graft biopsy which will be requested by a senior member of staff. Refer to biopsy protocol.
Heparin should be stopped the evening prior to the planned biopsy.
Antibody samples should be sent to Tissue Typing on all patients receiving a biopsy.
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