Current management issues of immediate postoperative care in pediatric kidney transplantation

Abstract

The number of pediatric kidney transplants has been increasing in many centers worldwide, as the procedure provides long-lasting and favorable outcomes; however, few papers have addressed the immediate postoperative care of this unique population. Herein, we describe the management of these patients in the early postoperative phase. After the surgical procedure, children should ideally be managed in a pediatric intensive care unit, and special attention should be given to fluid balance, electrolyte disturbances and blood pressure control. Antibiotic and antiviral prophylaxes are usually performed and are based on the recipient and donor characteristics. Thrombotic prophylaxis is recommended for children at high risk for thrombosis, although consensus on the optimum therapy is lacking. Image exams are essential for good graft control, and Doppler ultrasound must be routinely performed on the first operative day and promptly repeated if there is any suspicion of kidney dysfunction. Abdominal drains can be helpful for surveillance in patients with increased risk of surgical complications, such as urinary fistula or bleeding, but are not routinely required. The immunosuppressive regimen starts before or at the time of kidney transplantation and is usually based on induction with monoclonal or polyclonal antibodies, depending on the immunological risk, and maintenance with a calcineurin inhibitor (tacrolimus or ciclosporin), an anti-proliferative agent (mycophenolate or azathioprine) and steroids.

Intensive Care of the Child After Kidney Transplantation

“…Immediate postoperative care of the pediatric kidney transplant recipient focuses on hemodynamic monitoring and fluid and electrolyte management to maintain optimal graft function in the first 24-48 h following transplantation (Torricelli 2014). Pediatric kidney transplant recipients, especially those receiving kidneys from living donors, can experience significant polyuria, require massive fluid replacement, and can develop rapid electrolyte shifts or osmolar changes.…”

“…Fluid management begins with replacement of presumed daily insensible losses [400 mL/m 2 of body surface area (BSA)] for at least the first 24 h. The volume of urine output should be fully replaced hourly with an equivalent volume of crystalloid. The composition varies by center and can include saline, lactated Ringer's solution, a bicarbonate-containing solution, or a combination to maintain electrolytes in a safe range (Hoorn 2016;Torricelli et al 2014).…”

“…Electrolyte derangements should be anticipated, and monitoring of intermittent metabolic profiles should take place every 4-6 h on the first postoperative day and until stability is demonstrated (Torricelli et al 2014;Drake et al 2015;Hoorn 2016). Urine may be sent for electrolyte analysis, and this information can also be used to calculate the proper electrolyte content of the replacement fluids.…”

Common challenge topics in pediatric transplantation

“…Torricelli et al ( 6 ), from the University of São Paulo, review the current immediate postoperative care management of kidney transplantation patients. In addition, Tannuri and Tannuri ( 7 ) describe and discuss specific aspects of liver transplantation methods that can avoid potential complications.…”

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“…Torricelli et al (6), from the University of São Paulo, review the current immediate postoperative care management of kidney transplantation patients. In addition, Tannuri and Tannuri (7) describe and discuss specific aspects of liver transplantation methods that can avoid potential complications.…”