We have had a couple of recipients recently who ran pre-transplant systolic in the range of 60-85. They both had sustained oliguric ATN for 2-3 weeks post-renal transplant, but eventually did OK.
We made sure they were well filled going into their operation, with no fluid taken off on dialysis on day before surgery. They had both been anuric prior to transplant, making the anaesthetists slightly nervous about intra-operative over-filling. We ran them on heparin infusion post-op because of increased risk of thrombosis. They were nursed on ICU post-op on noradrenaline titrated to MAP of 65 for couple of days, following which MAP dropped to 60.
Is there a threshold systolic BP below which transplant should not be considered? Is midodrine etc. useful (doesn't seem to be used so much in UK compared to when I worked in US)? Would you run heparin infusion or LMWH because of thrombosis risk? Are post-op pressors for target MAP useful, or does this just vasoconstrict the allograft and prolong ATN?
In my experience, the graft will not have any function in patients with postoperative systolic blood pressure of less than 90 mmHg. The most important factor in this topic, is the preoperative donor blood pressure, because the graft used to adjust itself according to the donor blood pressure, not the recipient's blood pressure. when we use a graft from a chronically hypertensive deceased donor, the graft will need a higher recipients blood pressure for a good function.
We start and continue dopamine and other vasopressors for all of our recipients to maintain the pressure above 90 for 2-3 days after the operation. Usually when the graft has a good function, the blood pressure will increase to the new "critical threshold" level and we can discontinue the vasopressors after that. One of our patient who didn't response to vasopressors died after 3 days without any known cause.
Hİ,
I have an experience about this issue.
Firtly, we gave dopamin for about 24 days, and we maintained the blood pressure above 110/70 mmHg. Secondly, we also gave LMVH (enoxaparin) for profilaxis of vascular trombosis. You can look our case report.
http://tndt.org/pdf/pdf_TNDT_970.pdf
see you...
Many thanks Mustafa + Farzad. Interesting to hear about your experience.
Dear James,our experience with this kind of receptors is that is very important the use of heparin to minimize the vascular trombosis and dopamina/NA tu reach a MAP above 70 for a few days post kidney transplant. These patient has autonomic disfunction and a long history of dialysis. Perhaps is the only chance that they have to be transplantated and we must optimize all condition for the good outcome of the intervention. Same team of transplant contraincated the procedure under this condition. This is not our opinion, and experience, the patient can be transplantaed with dopamina or NA/heparin and of course experticie of the surgical team
good lack
Dr. Hugo Petrone
Chief of Renal Unit- CRAI Sur, La Plata. Argentina
Based on my experience in Michigan, hypotensive patients do not seem eligible for transplant. One patient went into hepatorenal syndrome who was chronically hypotensive and required octreotide, midodrine, and albumin just to reperfuse the renal tissue. That patient made an amazing comeback from renal failure, but sadly died a few months later after a bout of aspiration pneumonia.
In answer to your question, it seems that hospitals in the Michigan area find chronically hypotensive patients less-than-ideal for transplant.
We usually look for Nephrogenic hypertension in our ESRD patients and if we find hypotension ( SBP
Many thanks Joseph, Hugo + Sina. These are certainly a high risk transplant cohort, and interesting to hear about the negative outcomes. Sounds like everyone uses heparin and titrated pressors. Makes sense to exclude a primary cardiac cause of hypotension versus uraemic autonomic neuropathic hypotension - I'm sure all units demand an echocardiogram prior to transplant.
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