Critical Care of Kidney Transplant Recipients
Brian J. Gallay
I. GENERAL PRINCIPLES
Patients with chronic kidney disease have multiple comorbidities that affect transplant outcomes. Consider underlying disease to guide pretransplant evaluation and postoperative management.
II. IMMEDIATE PRETRANSPLANT EVALUATION
A. Cardiovascular assessment.
1. Assess history of coronary artery disease, symptoms of angina or congestive heart failure, recent change in exercise tolerance, new ischemic changes on ECG, decreased pulse or bruit, or pathologic heart murmur on physical examination.
2. Prevention.
a. Continue perioperative β-blocker therapy for patients already on β-blockers. Monitor for hyperkalemia, bradycardia, and hypotension.
b. Continue or start aspirin if bleeding risk is acceptable.
c. Continue clopidogrel to minimize risk of drug-eluting stent thrombosis.
B. Infectious disease assessment.
1. Assessment: Obtain history of recent febrile illness or recurrent infection. Examine for signs or symptoms of active infection, including lymph nodes, oral mucosa, skin (especially intertrigal areas and feet), hemodialysis or peritoneal dialysis catheters, and hemodialysis access grafts. Obtain peritoneal fluid sample from peritoneal dialysis catheter for cell count and culture. Peripheral blood neutrophil count and urinalysis for evidence of active infection. Check chest radiograph for mass, nodules, or cavitary lesions.
2. Prevention: Postpone transplant if active infection is identified. Use routine preoperative antibacterial prophylaxis.
C. Malignancy assessment.
1. Careful skin examination for melanoma.
2. Oral examination for squamous cell epithelial cancer.
3. Complete lymph node examination.
D. Preoperative dialysis assessment.
1. Assess volume status, looking for jugular venous distension, pulmonary and peripheral edema.
2. Dialyze for (i) hypervolemia to minimize risk of postoperative pulmonary edema and hypertension, and (ii) hyperkalemia (K+ >5 mEq/L) to minimize risk of cardiac arrhythmia.
E. Other issues.
Determine and document pretransplant urine output to facilitate interpretation of postoperative kidney graft function.
III. INTRAOPERATIVE CARE
A. Avoid hypotension that impairs perfusion and increases risk of delayed graft function (i.e., need for dialysis therapy during the first week after transplant).
B. Maintain euvolemia. Use central venous pressure (CVP) monitoring to maintain CVP at 5 to 10 cm H2O.
