Perioperative fluid management in kidney transplantation: a black box

Abstract

The incidence of delayed graft function in patients undergoing kidney transplantation remains significant. Optimal fluid therapy has been shown to decrease delayed graft function after renal transplantation. Traditionally, the perioperative volume infusion regimen in this patient population has been guided by central venous pressure as an estimation of the patient’s volume status and mean arterial pressure, but this is based on sparse evidence from mostly retrospective observational studies. Excessive volume infusion to the point of no further fluid responsiveness can damage the endothelial glycocalyx and is no longer considered to be the best approach. However, achievement of adequate flow to maintain sufficient tissue perfusion without maximization of cardiac filling remains a challenge. Novel minimally invasive technologies seem to reliably assess volume responsiveness, heart function and perfusion adequacy. Prospective comparative clinical studies are required to better understand the use of dynamic analyses of flow parameters for adequate fluid management in kidney transplant recipients. We review perioperative fluid assessment techniques and discuss conventional and novel monitoring strategies in the kidney transplant recipient.

Perioperative Goal-Directed Therapy during Kidney Transplantation: An Impact Evaluation on the Major Postoperative Complications

“…The fundamental role of health care professionals involved in perioperative fluid management of kidney transplantation is to identify the perfect balance of fluid therapy. Accumulating evidence supports the concept that fluid therapy should be individualized and based on dynamic indices of the intravascular volume [10]. Dynamic variation in the arterial waveform-derived parameters systolic pressure variation (SPV), pulse pressure variation (PPV), and stroke volume variation (SVV) in mechanically ventilated patients are currently the most precise predictors of fluid responsiveness, particularly when compared to static parameters [10,32].…”

“…Accumulating evidence supports the concept that fluid therapy should be individualized and based on dynamic indices of the intravascular volume [10]. Dynamic variation in the arterial waveform-derived parameters systolic pressure variation (SPV), pulse pressure variation (PPV), and stroke volume variation (SVV) in mechanically ventilated patients are currently the most precise predictors of fluid responsiveness, particularly when compared to static parameters [10,32]. This study revealed how the “tailored” approach, achieved through the implementation of PGDT strategies during kidney transplantation, might considerably decrease the incidence rate of major perioperative complications and increase the survival rate of the graft.…”

“…Moreover, each kidney transplantation candidate often has electrolyte imbalances and tends to oscillate between hypovolemia and hypervolemia [9]. This results in a very narrow margin of safety for intravenous fluid resuscitation and maintenance, so this may increase the risk of developing delayed graft function (DGF), acute kidney injury (AKI), and fluid overload after kidney transplantation [10]. Hypovolemia can lead to further kidney injury, but excessive fluid therapy can result in pulmonary edema, so optimal fluid management is mandatory to reduce perioperative complications, particularly in patients with concomitant comorbidities such as older age, diabetes, obesity, and arterial hypertension [8,11].…”

Modifiable Risk Factors for Delayed Graft Function After Deceased Donor Kidney Transplantation

“…Due to the lack of vascular autoregulation of the kidney transplant keeping the arterial blood pressure within physiological limits, this parameter gained increased attention during the last decade. 9,11 The mean arterial pressure (MAP) at the time of reperfusion is essential and should be kept higher than 80 mm Hg to avoid poor postoperative graft function. 8,11 It is still unclear which catecholamine to prefer.…”

Abdominal Organ Transplantation: Noteworthy Literature in 2018

“…24,25 Calixto Fernandes et al 14 suggested managing fluid therapy using a "flow-directed" model, where a positive response to 500 mL of crystalloid is defined as a 15% increase in cardiac output by noninvasive monitoring with a 2 mm Hg rise in CVP; however, this remains theoretical, and prospective studies are necessary. 14,26 Enhanced Recovery After Surgery. Halawa et al 27 described their experience implementing an enhanced recovery protocol for 286 kidney transplant recipients.…”