The transplanted kidney needs to be well-perfused. Fluid management in the first 12 hours post operatively is critical and needs careful attention.
Please discuss any concerns with the nephrologist on call.
6.1 MEDICATION
The ward team will have prescribed relevant medication on HEPMA. Please transcribe onto the ITU prescription system. Appendix II contains all medications and doses needed.
6.1.1 Immunosuppression
The immunosuppression regimen will be documented on HEPMA. Typically this will be tacrolimus, MMF, and a short course of steroid.
6.1.2 CMV status
If the recipient is CMV negative and the donor CMV positive, then oral valganciclovir is given for at least the first 3 months, and consider treatment for 6 months total. This should be started when the patient is tolerating oral fluids (usually day 1 or 2 post transplant).
6.1.3 Analgesia / Sedation
This will have been started in theatre and usually includes a TAP block, an opioid (or equivalent) PCA/NCA, and regular IV paracetamol. If further analgesia is required, consider additional morphine (doses in Appendix II)
6.2 Investigations
On admission measure FBC, coagulation, U&E, LFTs, Bone, glucose, magnesium, CRP and urinalysis. Thereafter measure U&E, LFTs, glucose and FBC 4-6 hourly.
Monitor serum Na on blood gas machine 3-4 hourly.
Renal USS and Doppler shortly after admission to ITU if not already performed in theatre and repeated if clinical situation changes.
Daily Investigations
6.2.1 Check Tacrolimus level at 0800 each day. For Tacrolimus level send 1 x 0.5 ml K-EDTA (pink) which must be filled accurately.
6.2.2 Send daily urine (boric acid container) for culture.
6.2.3 Consider daily renal USS and Doppler if concerns about renal blood flow.
6.3 Monitor CVP, urine output, BP and core-peripheral temperature gap
Aim to keep CVP at 8-10 cm H20
Aim to keep systolic BP > 50th centile for donor age. For donors aged 17 and over this is 120/70 mmHg. For younger donors age-specific centile charts are available.
Aim to keep core-peripheral temperature gradient < 2oC
Measure the urine output hourly
6.4 Fluid and Electrolytes
Replace urine output ml for ml on an hourly basis with either Plasmalyte or 0.9% saline + 5% dextrose initially. This is the combined transplant and native urine output from the bladder.
6.4.1 If serum sodium rises change to 0.45% saline and 5% dextrose
6.4.2 Send a urinary sodium and dip urine for glucose
6.4.3 If combined urine output is >150 ml/hr, consider changing to 0.45% saline + 5% dextrose but be guided by urinary sodium losses.
6.4.4 Measure serum sodium frequently
6.4.5 If combined urine output is >200ml/hr, consider reducing the dextrose concentration.
- Insensible losses will generally be covered by infusions of inotropes, morphine, etc.
- Document drain losses - only replace, with 0.9% saline or blood, if losses are >4-5 ml/kg/day (discuss with nephrologist or surgeon on-call).
6.4.6 Blood transfusion can result in sensitisation, therefore transfuse only if actively bleeding or Hb <80 g/l and falling, or if there are concerns regarding adequacy of tissue oxygen delivery. Do not administer blood without discussion with nephrologist.
6.4.7 If clinically underfilled (CVP or BP low, large core-peripheral temp gap) Give 5% Albumin or 0.9% Saline at 5-10 ml/kg to keep CVP in the required range 8-10 cmH20. Measure serum albumin 6-8 hourly
6.4.8 If urine output falls to less than 1.5ml/kg/hr
- Check for a full bladder and flush urinary catheter (and stent if present).
- Check for hypovolaemia and give 5% albumin or 0.9% saline 5-10ml/kg as appropriate
- If well-filled then consider iv furosemide (initially 0.1- 0.25mg/kg). Start with a low dose as the response can be dramatic particularly with LD transplants. Discuss with renal consultant prior to first administration
6.5 Polyuria
Large urinary losses of sodium, calcium, magnesium and phosphate can occur with a high urine output. Monitor serum electrolytes closely. Check for glycosuria. SOPs are available for calcium, magnesium, and phosphate replacement.
6.6 Delayed Graft Function
If there is no urine output, mechanical or surgical causes should be discussed and ruled out. If there is no obstruction and no urine output despite adequate hydration and furosemide, then there is likely to be delayed graft function. Fluid replacement at this point should cover insensible losses, any other losses and any urine output that is present.