405.3 Using a cardiac-output guided hemodynamic therapy algorithm reduces intra-operative fluid administration while achieving good renal outcome in LDKT with large donor-recipient size mismatch
Tuesday May 07, 2019 from 10:00 to 11:00
Bayshore D
Presenter

Elisabeth Cornelissen, Netherlands

Pediatric nephrologist

Ped Nephrology

Amalia Children's Hospital Radboudumc

Abstract

Using a cardiac-output guided hemodynamic therapy algorithm reduces intra-operative fluid administration while achieving good renal outcome in LDKT with large donor-recipient size mismatch

Elisabeth Cornelissen1, Marieke Voet2, Anneliese Nusmeier3, Joris Lemson3.

1Pediatric Nephrology, Amalia Children's Hospital Radboudumc, Nijmegen, Netherlands; 2Pediatric Anesthesiology, Amalia Children's Hospital Radboudumc, Nijmegen, Netherlands; 3Pediatric Intensive Care, Amalia Children's Hospital Radboudumc, Nijmegen, Netherlands

Introduction: A living donor kidney transplantation (LDKT) in young children requires a substantial increase in cardiac output (CO) to maintain good perfusion of the relatively large kidney. To achieve this, intra-operative hemodynamic therapy protocols commonly advise liberal fluid administration guided by high target central venous pressure (CVP) and arterial blood pressure (ABP). However, ABP and CVP are known to poorly estimate CO or organ blood flow. Such therapy may lead to good renal outcomes, but inherits the risk of severe fluid overload leading to substantial complications.

Goal of our study was, first, to evaluate the feasibility of using a gold standard CO monitor for children, the transpulmonary thermodilution (TPTD) technique, during LDKT with large donor-recipient size mismatch. Second goal was to evaluate whether a CO-guided hemodynamic therapy algorithm could induce a reduction in fluid administration, while achieving increased target CO and ABP.

Methods: Twelve consecutive LDKT recipients were studied. Heart rate (HR), ABP and CVP were measured continuously. A thermistor tipped catheter was inserted in the left arteria femoralis which was used to measure perioperative CO by TPTD measurements (PiCCO device, Pulsion). A CO-guided hemodynamic therapy algorithm steered hemodynamic management. Data on patient characteristics, fluid administration and vasoactive medication were collected. Hemodynamic values were obtained before (t0), during (t1) and after (t2) transplantation and were analyzed with repeated measurements ANOVA.

Results: Age and weight of recipients was 3.2 (1.6-4.9) yr and 14.1 (10.4-18) kg, respectively. Donor-recipient weight ratio was 0.18 (0.11-0.28). No complications related to the TPTD-CO monitor were reported. Between t0 and t2, indexed CO increased with 31% (95% CI=15-48%). HR appeared to be the main contributor to the augmented CO and increased with 22% (95% CI=9-34%). Increase in indexed SV (stroke volume) was non-significant. Mean arterial pressure increased with 66% (95% CI=34-98%). Between t0 and t1, CVP did not change despite fluid administration. Mean fluid administration reduced from 166 ml/kg in the first two to only 59 ml/kg in the last ten patients. All kidneys showed diuresis shortly after reperfusion. Patient and graft survival were 100% with excellent kidney function at 6 months post-transplantation.

Conclusion: In LDKT with large donor-recipient size mismatch TPTD-CO monitoring is a safe and feasible technique to guide hemodynamic therapy. Using a CO-guided hemodynamic therapy algorithm reduces intra-operative fluid administration while achieving increased CO and ABP and preserving good renal outcome. This might prevent fluid overload and subsequent tissue edema.


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