Is goal-directed therapy useful in kidney transplantation?

Introduction

Patients with end-stage renal disease (ESRD) are entitled to the kidney transplantation approach at surgery with various modifications of the volemic status. According to some studies [1, 2], acute tubular necrosis risk can be reduced by keeping a correct intravascular volume before graft reperfusion. The aim of this study was to evaluate goal-directed therapy in the early postoperative period in kidney transplantation.

Methods

We observed 50 kidney transplant recipients divided into two groups: 38 patients (Group A) underwent central oxygen venous saturation (ScVO₂) monitoring, and 12 patients (Group B) were controls. Continuous central venous pressure (CVP) and ScVO₂ were monitored the in ICU [3]. In Group A the volemic status by keeping CVP >5 mmHg and ScVO₂ >70% was optimized. We collected donors' and transplant patients' kidney parameters (age, sex, death cause, ischaemia time), recipients' parameters (age, sex, weight, height, BMI, duration of dialysis, ESRD, Simplified Acute Physiology Score II), intraoperative parameters (metabolic, respiratory and hemodynamic), hemodynamic and kidney functioning parameters in the ICU (heart rate, mean arterial pressure, CVP, ScVO₂, lactate, diuresis, blood urea nitrogen (BUN), creatinine, fluid balance), and outcome parameters (ICU length of stay, acute rejection at 28 days, mortality at 6 months).

Results

At each observation ScVO₂ was >70% in all patients of Group A. Diuresis was higher in Group A (at 6 hours, Group A: 1,082.6 ± 1,000.7; Group B: 757.2 ± 462.7; at 12 hours, Group A: 1,020.5 ± 921.5; Group B: 835.4 ± 517.8). The heart rate at 0 hours was higher in Group B (Group A: 85.2 ± 13.2; Group B: 97.7 ± 27.7; P < 0.05). Creatinine (at 0 hours, Group A: 6.9 ± 2; Group B: 8.2 ± 3; at 12 hours, Group A: 7.2 ± 2.5; Group B: 9.3 ± 0.07) and BUN (at 0 hours, Group A: 0.9 ± 0.4; Group B: 1.0 ± 0.3; at 12 hours, Group A: 1 ± 0.4; Group B: 1.1 ± 0.3) were higher in Group B. The creatinine (Group A: -0.2 ± 1.2; Group B: 0.4 ± 0.7) and BUN (Group A: 0.06 ± 0.1; Group B: 0.1 ± 0.04) reduction (12 to 0 hours) was higher in Group A. Diuretic stimulation was reduced in 10 patients of Group A and zero of Group B (P < 0.05) and was interrupted in eight patients of Group A and two of Group B.

Conclusion

Postoperative intensive monitoring and optimization of intravascular volume by CVP and ScVO₂ grant fast recovery of kidney functioning in transplant recipients, so reducing diuretic stimulation, creatinine and BUN values.