TY  - CHAP
M1  - Book, Section
TI  - Allograft Function
A1  - Bhaskaran, Madhu
A1  - Clement, Damian
A1  - Duncan, Aaron T
A1  - McCann-Molmenti, Alexia
A1  - Molmenti, Ernesto P
A2  - Molmenti, Ernesto Pompeo
Y1  - 2023
N1  - 
T2  - Molmenti’s Kidney and Pancreas Transplantation: Operative Techniques and Medical Management, 2e
AB  - Most  transplant  allografts  with  short  cold  ischemic  time  begin  to  produce  urine  in  the  operating  room  or  soon  thereafter.We  monitor  graft  function  in  the  first  24  hours  by:Hourly  urine  outputSince  polyuria  is  common  during  this  period,  we  maintain  volume  status  with  a  combination  of  maintenance  crystalloid  at  1  mL/kg/hour  and  a  replacement  crystalloid  measured  1:1  for  hourly  urine  output.In  cases  of  very  high  urine  output,  a  fluid  warmer  is  useful  to  maintain  body  temperature.Close  and  continuous  monitoring  prevents  complications  within  the  first  24  hours.Vital  signs:  The  newly  implanted  kidney  is  susceptible  to  hypotension.  We  aim  for  systolic  blood  pressure  >120  mm  Hg  during  this  period  (we  prefer  to  follow  systolic  rather  than  mean  pressures).If  urine  output  declines  abruptly:Suspect  a  vascular  compromise  until  proven  otherwise,  and  act  rapidly.A  duplex  Doppler  ultrasound  should  be  obtained  immediately.A  quick  initial  approach  is  to  irrigate  the  urinary  catheter  and  verify  that  it  is  placed  and  working  correctly.Hematuria  is  common  after  surgery,  and  if  significant,  blood  clots  are  possible.It  is  also  important  to  confirm  the  correct  placement  of  the  urinary  catheter,  since  twists,  kinks,  and  obstruction  by  a  partially  inflated  balloon  or  residue  from  the  bladder  may  account  for  obstruction.In  instances  of  possible  urinary  catheter  dysfunction,  we  prefer  to  remove  the  dysfunctional  one  and  place  a  new  one  (disruption  of  a  fresh  ureter–bladder  anastomosis  is  unusual  with  such  replacement).Urgent  renal  ultrasound  (US)  with  arterial  and  venous  Doppler  duplex  studies  to  evaluate  for  surgical  complications,  including:Vascular  thrombosisInflow/outflow  vascular  compromiseOutflow  urinary  obstructionMechanical  or  functional  obstructionExtravasation  of  blood  and/or  urineRenal  US  can  detect  perinephric  fluid  collections.  Differential  diagnoses  include:–  Hematoma–  Lymphocele–  UrinomaFluid  draining  from  the  wound  or  aspirated  from  a  collection  can  be  evaluated  for  creatinine  concentration  to  differentiate  between  urinary  leaks,  urinomas,  or  lymphoceles.In  urine  leaks  and  urinomas,  the  creatinine  concentration  is  similar  to  that  in  urine  (which  is  much  higher  than  that  in  the  serum).In  non-urinoma  collections,  the  fluid  creatinine  resembles  that  in  serum.In  order  to  be  able  to  compare,  it  is  useful  to  obtain  simultaneously  the  creatinine  concentrations  in  the  serum.  In  instances  of  delayed  graft  function,  especially  when  the  recipient  is  undergoing  dialysis,  the  serum  creatinine  will  be  elevated.Urgent  electrolyte  and  complete  blood  count.  Hyponatremia  and/or  hyperkalemia  may  be  early  signs  of  obstruction.  Hyponatremia,  hyperkalemia,  high  chloride,  and  low  bicarbonate  levels  in  blood  are  suggestive  of  a  urinary  leak,  with  urine  being  reabsorbed  in  the  retro-peritoneum  or  intra-peritoneally.Graft  function  postoperative  day  1  (POD  #1)Hourly  urine  output  and  daily  weights.Once  the  patient  is  ambulatory,  we  discontinue  the  urinary  catheter.The  day  of  removal  of  the  urinary  catheter  is  based  on  how  confident  the  surgeon  feels  with  the  ureter–bladder  anastomosis.Good  surgical  technique  with  full-thickness  anastomoses  can  tolerate  removal  of  urinary  catheters  within  24  hours  of  transplantation.Otherwise,  urinary  catheters  are  removed  72  hours  (3  days)  after  transplantation.In  order  to  minimize  pressure  at  the  ureteral  anastomosis,  the  patient  is  instructed  to  void  every  60  minutes.If,  after  a  1  to  3  hour  trial  of  void,  the  patient  is  unable  to  void,  an  initial  bladder  catheterization  is  undertaken.  This  procedure  may  be  repeated  on  ...
SN  - 
PB  - McGraw Hill
CY  - New York, NY
Y2  - 2024/04/18
UR  - accesssurgery.mhmedical.com/content.aspx?aid=1194187782
ER  -