Kidney transplantation

Kidney transplantation is the most common type of organ transplantation; the main indication is the terminal stage of kidney failure. Absolute contraindications include concomitant diseases that can disrupt the survival of the transplant (eg, severe heart disease, malignant neoplasms) and are detected during examination. A relative contraindication is poorly controlled diabetes, which can lead to kidney failure. Patients over 60 years of age can be candidates for transplantation if they are generally healthy, functionally independent, with good social support, with a relatively good prognosis for life expectancy and if kidney transplantation is expected to significantly improve the quality of life without dialysis. Patients with type I diabetes may also be candidates for transplantation, provided that the pancreas and kidney or pancreas after the kidney are transplanted simultaneously.

More than 1/2 donor kidneys are obtained from healthy people with brain death. About 1/3 of these kidneys are marginal with physiological disorders or disorders associated with the procedure of transplantation, but they are used because the needs are very high. The remaining donor kidneys are taken from live donors; since the number of organs is limited, more and more implants are used from carefully selected live unrelated donors.

The main methods of treating patients in the terminal stage of chronic renal failure are program hemodialysis and kidney transplantation. The need for continuous passage of hemodialysis procedures for the purpose of detoxification forces the patient to visit a specialized clinic every two or three days and is often accompanied by significant iatrogenic complications (bleeding, anemia, dizziness, fainting, the possibility of infection with viral hepatitis, etc.). At the same time, kidney transplantation can give radically better results in case of successful operation, providing an almost optimal quality of life. The level of perioperative lethality and life expectancy after transplantation differ significantly from similar indicators in patients on hemodialysis. Therefore, a significant number of adults with end-stage renal disease are candidates for kidney transplantation.

[1], [2], [3], [4], [5]

Anatomico-physiological features of the urinary system and pathophysiological changes in terminal renal failure

There are many reasons for the development of the terminal stage of renal failure: diabetic nephropathy, glomerulonephritis of various etiologies, polycystic kidney disease, chronic pyelonephritis, obstructive uropathy, Alport syndrome, lupus nephritis and others, including cases of unknown etiology. Impaired renal function of any etiology eventually leads to the development of uremic syndrome. With uremia patients are unable to regulate the volume and composition of body fluids, which leads to fluid overload, acidemia and imbalance of electrolytes, such as potassium, phosphorus, magnesium and calcium. Developing signs of progressive secondary dysfunction in other body systems. Even in patients supported by hemodialysis, peripheral neuropathy, pericardial or pleural effusions, renal osteodystrophy, gastrointestinal and immunological dysfunction can be observed.

[6], [7]

Premedication

Diazepam v / m 10-20 mg, once for 25-30 minutes before the patient's delivery to the operating room or Midazolam IM 7.5-10 mg, once for 25-30 minutes before the patient's delivery to the operating room

Chloropyramamine IM 20 mg, once for 25-30 minutes before the patient's delivery to the operating room

Cimetidine in / m 200 mg, once for 25-30 minutes before the patient's delivery to the operating room

+

Betamethasone IV IM 4 mg, once for 25-30 minutes before the patient's delivery to the operating room.

Even before surgery, immunosuppressors can be prescribed to patients. There are various options for therapy, but mainly used are cyclosporine, azathioprine and GCS. Methylprednisolone is often given intravenously by induction of anesthesia or immediately before the restoration of blood flow through the graft. Immunosuppressors have many side effects, but the introduction of muromonab-CD3 (which is a monoclonal antibody against T-lymphocytes), which can cause pulmonary edema and convulsions, requires special attention.

Preoperative preparation and assessment of the patient's condition before surgery

When transplanting from a living related donor, a detailed donor survey is almost not limited to a time frame and should be carefully conducted in a planned manner.

Recipients of the cadaveric kidney can be urgently called into the clinic upon receipt of a suitable organ for them and in this case are treated as patients subject to an emergency operation. Major baseline studies include:

• determination of hemoglobin, creatinine, urea and electrolytes;
• ECG;
• chest x-ray.

Depending on the balance of fluids and metabolic status, patients can undergo hemodialysis before surgery - it is necessary to correct hyperkalemia and violations of CBS. After dialysis, it is important to establish the status of the patient's vollemic status, the final hematocrit, the level of electrolytes and bicarbonate, whether there is a residual effect of heparin. The levels of potassium and calcium plasma should be normal to exclude the occurrence of arrhythmias, cardiac arrhythmias and seizures. Hypovolemia should be avoided. Hypotension increases the possibility of acute tubular necrosis (OCN) in the transplant.

Patients with severe uremia even on dialysis have a hematocrit level of 6-8 g / dL. Prothrombin time and partial thromboplastin time are usually normal, but hypocoagulation remaining after dialysis should be corrected before surgery. It should be remembered that uremia leads to an extended bleeding time.

In many patients, prior to the use of recombinant erythropoietins, severe anemia was noted and blood transfusion was often required perioperatively. Now, treatment with erythropoietins is used to maintain Hb at a level of 9.5 g / dL to improve exercise tolerance. However, erythropoietins can increase hypertension and lead to increased coagulation.

If there are functional disorders due to the presence of pleural or pericardial effusions, their treatment may be required. Since there are many diabetic patients among adult recipients, the presence of concomitant ischemic heart disease is usually determined during exercise tests and coronary angiography is performed if necessary.

Candidates for kidney transplantation are characterized by delayed evacuation from the stomach, which is caused by diabetes, peripheral neuropathy and preoperative excitement. Before the operation, it is advisable to use antagonists of H2 receptors, antiemetics, metoclopramide or sodium citrate. Anticipation with anxiolytics, for example midazolam or diazepam, may be required. As in all emergency cases, rapid induction and intubation of the patient is necessary.

Basic methods of anesthesia

Currently, kidney transplantation uses a variety of options for general combined anesthesia, of which the constituent parts can be:

• IA;
• in / in anesthesia;
• RAA.

In general combined anesthesia, along with reliable analgesia, muscle relaxation and neurovegetative protection, control of the ventilator is provided, which becomes especially important in surgical manipulations near the diaphragm, therefore OA is usually the method of choice.

Kidney transplantation successfully uses the methods of RAA - epidural and spinal anesthesia as components of general combined anesthesia. However, the risk of neurological complications with long-term catheter placement in the epidural space may increase due to a combination of possible hypotension and hypocoagulation, especially against the background of initial excess heparinization after hemodialysis. RAA may complicate the assessment of intravascular volume and the situation with volume preload. Induction of anesthesia: Haecobarbital IV 3-5 mg / kg, single or Thiopental sodium iv 5 to 5 mg / kg, single dose

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Fentanyl IV 3.5-4 μg / kg, single dose

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Midazolam IV 5-10 mg, once-monthly

Propofol iv / 2 mg / kg, once

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Fentanyl IV 3.5-4 μg / kg, once.

Muscle relaxation:

Atracuria besylate IV 25-50 mg (0.4-0.7 mg / kg), once or Pipecuronium bromide IV 4-6 mg (0.07-0.09 mg / kg), once or Cisatracurium bezylate in / in 10-15 mg (0.15-0.3 mg / kg), once. Induction of anesthesia can be performed with propfol, thiopental or etomidate against a background of monitoring hemocinamic parameters. LS, which have a high affinity for proteins (eg, thiopental), should be given in reduced doses. Propofol is successfully used for TBAV, its advantage is the decrease in POND syndrome.

If suspicion of incomplete gastric emptying (especially in the presence of gastroesophageal reflux or in peripheral neuropathy), rapid induction and intubation are indicated.

Since most of these patients have AH, benzodiazepines (midazolam 5-15 mg) and fentanyl 0.2-0.3 mg are widely used to reduce the stress response to laryngoscopy and intubation of the trachea.

For intubation, non-depolarizing muscle relaxants (atracurium bezylate and cisatracurium bezylate) are predominantly used. Their use is justified, since the excretion of these drugs does not depend on the function of the kidney and they are destroyed by Hoffmann elimination. Atracuria bezylate and cisatracurium bezylate are preferred muscular relaxants because they are least dependent on renal metabolism, although patients with terminal stage of renal failure can accumulate laudanosine, atracurium metabolite. Laudanosine raises MAC galotan in laboratory animals, but does not cause a similar clinical result in humans. The response to vecuronium bromide may be unpredictable in renal lesions, and the restoration of the metabolic function of the kidney after transplantation is recommended for neuromuscular monitoring. The use of pipecuronium bromide and pancuronium bromide should be avoided. Their action can be prolonged due to the fact that 80% of these drugs are eliminated through the kidneys.

Transplantation of the kidney practically does not use depolarizing muscle relaxants. Suxamethonium chloride in a dose for intubation in patients with renal insufficiency can increase the level of potassium plasma by an average of 0.5 mmol / l (a maximum of 0.7 mmol / l). There are reports of cardiac arrest and fatal outcome in patients with initial hyperkalemia with repeated administration of suxamethonium chloride. The normal plasma potassium level provided by the last hemodialysis is not a contraindication to the use of suxamethonium chloride. It can not be administered to patients with a plasma potassium level greater than 5.5 mmol / l or to those who have uremic neuropathy. Under these conditions, the technique of successive rapid induction changes and suxamethonium chloride is not used.

Maintaining anesthesia:

(general balanced anesthesia based on isoflurane) Isoflurane inhalation 0.6-2 MAK I (in the minimal-flow mode)

+

Dinitrogen oxide with oxygen inhalation 1: 1 (0.25: 0.25 l / min)

+

Fentanyl IV bolusno 0,1-0,2 mg, the frequency of administration is determined by clinical feasibility +

Midazolam IV bolus 0.5-1 mg, the frequency of administration is determined by the clinical feasibility or (TBVA) I Propofol iv / 1.2-3 mg / kg / h

+

Fentanyl IV bolusno 0,1-0,2 mg, the frequency of administration is determined by clinical feasibility or

(general combined anesthesia based on an extended epidural block)

Lidocaine 2% rr, epidural I 2.5-4 mg / kg / h

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Bupivacaine 0.5% rr, epidurally 1-2 mg / kg / h

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Fentanyl IV bolusno 0,1 mg, the frequency of administration is determined by the clinical feasibility

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Midazolam IV bolusno 1 mg, the frequency of administration is determined by clinical feasibility.

Muscle relaxation:

Atracuria bezylate 1-1.5 mg / kg / h or Cisatracurium bezylate 0.5-0.75 mg / kg / h. Isoflurane is the drug of choice among inhalational anesthetics, because Only 0.2% of this drug is metabolized.

Isoflurane forms inorganic fluoride ions in very small amounts; in addition, it rarely causes arrhythmias of the heart. Isoflurane also has the least effect on CB and renal blood flow compared to other inhaled anesthetics.

Very promising for use in transplantology, sevoflurane due to the minimal effect on liver and kidney function. Studies of recent years have shown that it can be used without limits in the low- and minimal-flow regimes of fresh gases.

Enflurane does not have significant side effects on the graft function, but the levels of inorganic fluoride ions reach 75% of the nephrotoxic level, and therefore it is not recommended to use enflurane.

Halothane is still widely used, but it should be remembered that in patients with CRF, its arrhythmogenic potential may increase.

Dinitrogen oxide is often excluded from the composition of the gaseous drug mix to avoid bowel strains, especially in children.

Fentanyl is used in usual doses, because its excretion is mainly carried out by metabolism in the liver.

Morphine can be the cause of prolonged effects, such as sedation and respiratory depression in renal failure, due to the accumulation of its active metabolite, morphine-6-glucuronide.

[8], [9], [10], [11], [12], [13], [14]

Auxiliary therapy

In adults, the kidney is implanted retroperitoneally into the upper part of the pelvis, while using the paramedic lower abdominal access. Children weighing less than 20 kg usually use implantation in the abdominal cavity. With the revascularization of the graft in adults, an anastomosis of the renal vessels to the iliac vein and artery is performed. This may require clamping of the common iliac vessels, leading to limb ischemia duration of usually up to 60 min. After the anastomosis is performed, the blood circulation of the graft and limbs is restored.

After removing the vascular clamps, the renal preservative solution and the deposited venous blood from the limb enter the general circulatory system. This flowing blood is relatively rich in potassium and acid metabolites, which even in adults can have a pronounced systemic hypotensive effect. The final stage of the operation involves ureteral implantation for urinary drainage.

[15], [16], [17], [18]

Stimulation of the primary function of the kidney transplant

To stimulate renal perfusion, blood pressure is maintained at a level above normal, which can be achieved either by reducing the depth of anesthesia, or by bolus administration of crystalloids and temporary infusion of dopamine. The main components of the infusion therapy are crystalloids (sodium chloride / calcium chloride, isotonic sodium chloride solution, balanced saline solutions that do not contain K +), and CIP:

Dopamine iv / 2-4 mcg / kg / min, duration of administration is determined by clinical feasibility

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Sodium chloride, 0.9% r-r, IV 6-8 ml / kg / h, the duration of administration is determined by the clinical feasibility

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Freshly frozen plasma IV / 4-6 ml / kg / h, the duration of administration is determined by the clinical feasibility

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Albumin in / in 3 ml / kg, duration of administration is determined by clinical feasibility. As a rule, during operation in patients with terminal CRF it is recommended to minimize IV injection of fluids in order to prevent fluid overload and reduce the need for postoperative dialysis. Kidney transplantation is an important exception to this rule. When removing vascular clamps, a good perfusion of the new transplanted kidney is the main condition for the immediate functioning of the transplant, which directly depends on the adequate intravascular volume and the absence of hypotension. The target CVP should be equal to or greater than 10-12 mm Hg. Art. Or if there is a catheter in the pulmonary artery, the diastolic DLA should be greater than or equal to 15 mm Hg. Art. If these values are lower, then in the transplanted kidney more often appears OKH. However, to achieve relative hypervolemia, a much larger volume of fluid may be required. In some studies, typical volumes were 60-100 ml / kg, which emphasizes the need for monitoring CVP. In the opinion of most authors, the type of IV in the injected fluid is less important. Isotonic 0.9% solution of sodium chloride - L C of choice, t. It contains a large amount of sodium (which is especially important if mannitol is used) and does not contain potassium or lactate. In large volumes, FFP and albumin are transfused. Blood transfusion is performed only on indications. Intraoperative blood loss is usually less than 500 ml, but the possibility of sudden massive hemorrhage is not excluded. Sometimes withdrawal of vascular clamps leads to significant blood loss, which must be quickly replenished to maintain perfusion of the transplanted kidney.

In order to stimulate the immediate function of the transplanted kidney and increase the production of urine, diuretics are administered. Furosemide is administered by a one-stage bolus immediately before the removal of the clamps from the restored renal artery and vein at a dose of 2 mg / kg and then again at a dose of 6 mg / kg for an hour using a perfusor. It should be noted that with the successful inclusion of the kidney in the bloodstream with a favorable picture of filling it with blood and with the rapid restoration of urine production by the kidney, a second dose of furosemide may not be fully administered or canceled altogether. This is due to the danger of development of polyuria in the early postoperative period, which is especially important in related kidney transplantation.

Simultaneously with the infusion of the second dose of furosemide, the administration of dopamine in the "renal" dose of 2 μg / kg / min begins with a perfusor. Dopamine is often used to achieve two goals. There are theoretical grounds for using it as a DA2-receptor agonist at a dose of 2-3 mcg / kg / min in order to provide renal blood flow. However, it has not been proven that it improves the survival of the transplant, which may be due to vasoconstriction caused by cyclosporine. In doses of 5-10 μg / kg / min, beta-adrenergic effects can help in maintaining normotension. At higher doses, the alpha-adrenergic effects of dopamine prevail and the blood flow in the transplanted kidney can in fact be even lowered. If, in spite of adequate replenishment of BCC, hypotension remains a problem, it is preferable to use beta-agonists, such as dobutamine or dopexamine. Stimulation of diuresis:

Furosemide IV bolus 2 mg / kg, then intravenously for an hour with a perfusor of 6 mg / kg

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Dopamine iv in 2 mcg / kg / min after the start of blood flow through the kidney, the duration of administration is determined by clinical expediency.

Procedure for kidney transplantation

The donor kidney is removed by open or laparoscopic operation, perfusion is performed with chilled solutions containing relatively high concentrations of poorly penetrating substances (mannitol, heta-starch) and an electrolyte concentration close to the intracellular level; the kidney is stored in a frozen solution. With this method of preparation, kidney function is well preserved provided that renal transplantation occurs within 48 hours. If the kidney is not used during this time, it is possible to increase the viability of the kidney ex vivo up to 72 hours by continuous pulsating hypothermic perfusion with an oxygenated, plasma-based perfusion solution.

Before transplantation, dialysis may be required to ensure a relatively normal state of metabolism, but allografts of live donors survive better than those of recipients who did not begin long-term dialysis before transplantation. Nephrectomy is usually not required if there is no infectious process in your kidneys. It is not known whether blood transfusion is useful to patients with anemia who will receive an allograft; transfusion can sensitize patients to alloantigens, but the allograft can survive better in transfused but not sensitized recipients; perhaps this is due to the fact that transfusion induces some forms of tolerance.

The transplanted kidney is usually located in the iliac fossa. Form anastomoses of kidney vessels with iliac vessels, the donor ureter is implanted in the bladder or an anastomosis is formed with the ureter of the recipient. Bladder-urethral reflux is observed in 30% of recipients, but usually has no serious consequences.

The regimens of immunosuppressive therapy are diverse. Cyclosporine is administered intravenously intravenously during or immediately after transplantation, and then orally at doses at which toxicity and rejection risk are minimal, and its blood concentration is maintained at more than 200 ng / ml. On the day of transplantation, glucocorticoids are administered intravenously or orally; the dose is reduced to the minimum within the next 12 weeks.

Despite the use of immunosuppressants, most recipients have one or more episodes of rejection. Most cases may be minor, subclinical, so they are never detected; but they contribute to the development of insufficiency, damage to the graft or both. The signs of rejection vary depending on its type.

If the diagnosis is clinically unclear, rejection can be diagnosed by percutaneous puncture biopsy. A biopsy helps differentiate antibody mediated and T-cell-mediated rejection and identify other causes of graft failure or failure (eg, intoxication with calcineurin inhibitors, diabetic or hypertensive nephropathy, infection with Type I polyomavirus). More accurate tests to clarify the diagnosis of rejection include determining the level of mRNA encoding the mediators of rejection in the urine and the profile of genetic expression of biopsy samples using micro-DNA samples.

Chronic allotransplant nephropathy leads to insufficiency or damage to the transplant 3 months after transplantation. A greater number of cases arise for the reasons listed above. Some experts suggest that this term should be applied to a description of graft failure or damage when a biopsy establishes that chronic interstitial fibrosis and tubular atrophy do not occur for any other reason.

Intensive immunosuppressive therapy (for example, with the use of pulse therapy with high doses of glucocorticoids or antilymphocytic globulin) usually stops accelerated or acute rejection. If immunosuppressants are ineffective, their dose is reduced and hemodialysis resumes until another transplant is selected. Nephrectomy of the transplanted kidney is necessary in case of hematuria, soreness in the area of the transplant or the appearance of fever after stopping the use of immunosuppressants.

Kidney transplantation in children

Unlike adults, kidney transplantation in children uses an intra-abdominal organ arrangement. This allows the adult kidney, i. E. Organ of a large size, fit inside a very small child and thus increases the pool of possible donors. However, placing a chilled graft may cause acute hypothermia and take on a relatively large bcc of the child. The hypotension caused by these factors arises at the moment when adequate perfusion of the graft is necessary. To prevent hypotension and OKN as a direct consequence of it, vasoactive drugs are used to maintain blood pressure within normal limits. As a rule, the kidneys taken from living related donors usually function immediately, while for cadaveric kidneys a delayed function is characteristic - the urinary production resumes only after a few hours. When carrying out infusion therapy, this must be taken into account. In any case, the adult kidney will initially produce the volume of adult urine, which should be taken into account when carrying out maintenance infusion therapy.

Correction of violations

The time periods of oliguria or anuria, which are the consequence of OKN, are manifested in cadaveric transplantation in one third of cases. Thus, the volume of infusion therapy should be calculated in such a way that at a sufficient level of relative hypervolemia avoid the risk of intra- and postoperative pulmonary edema. The time of ischemia for organs obtained from living related donors is minimal, and usually the urination is immediately observed (the primary function of the transplant).

Waking up is often accompanied by pain and hypertension, which are especially dangerous in diabetic patients with concomitant IHD. In such cases, powerful analgesic drugs (opioids, tramadol or local anesthetics through the epidural catheter) and antihypertensive drugs should be used to avoid ischemia of the myocardium.

Other early postoperative complications include atelectasis, bleeding and thrombosis of vascular anastomoses, obstruction or incompetence of the ureter, and aspiration with gastric contents. Perhaps the development of a hyper-acute rejection, which leads to anuria; for final diagnosis, a kidney biopsy is required. This complication has become quite rare since routinely performed procedures for determining the compatibility of the ABO system and the cross-reaction ("cross-match") of the serum of the recipient to donor lymphocytes.

Immunosuppression with "triple therapy" (cyclosporine, azathioprine, prednisolone) usually begins before organ transplantation from living related donors or after transplantation of cadaveric kidneys.

[19], [20], [21], [22],

Kidney transplantation: contraindications

The main contraindications for kidney transplantation include active malignancy or infection, severe cardiovascular diseases, recent myocardial infarction and terminal stages of diseases in other systems. Relative contraindications specific for kidney transplantation are diseases in which recurrences in the transplanted kidney are possible, hemolytic uremic syndrome, membranous-proliferative glomerulonephritis, and metabolic disorders that cause toxic deposits in the kidney (eg, gout, oxalose). However, patients with such problems can be in good condition for many years after transplantation, and such a variant is often regarded as suitable. Diabetic nephropathy can also recur in the transplant, but diabetes mellitus is no longer considered a contraindication to transplantation, and the most successful and promising ones are one-stage kidney and pancreas transplantations. The presence of combined liver and kidney damage with a clinical manifestation of renal and hepatic insufficiency is no longer an insurmountable obstacle. A successful experience of combined simultaneous liver and kidney transplantation, incl. From a related donor, convinces of the wide possibilities of carrying out such operations.

What is the prognosis of kidney transplantation?

The greatest number of cases of rejection and other complications occurs within 3-4 months after transplantation; most patients recover their normal health and activity, but they must constantly take maintenance doses of immunosuppressants.

During the first year, the survival rate for transplantation from live donors is 98% for patients and 94% for transplants; when using a graft from donor corpses, this frequency is 94 and 88%, respectively. Further, the annual death of the transplant is 3-5% for kidney transplantation from live donors and 5-8% for kidney transplantation from donor corpses.

Of patients whose graft survival was more than 1 year, / is dying from other causes with a normally functioning transplant; y / develops chronic allograft nephropathy against the background of a transplant function failure within 1-5 years. The frequency of late disorders is higher in patients of the Negroid race than in white patients.

Doppler ultrasound measurement of peak systolic and minimal terminal diastolic current in renal segmental arteries after 3 months or more after such procedure as kidney transplantation can help to estimate prognosis, but the "gold standard" remains the periodic determination of serum creatinine.

Monitoring

Even before the induction of anesthesia, routine ECG monitoring should begin (preferably with ST-shift monitoring). Neuromuscular and temperature monitoring (central and peripheral temperature) should also be used. Hypothermia leads to vasoconstriction, increases bleeding, and when the patient warms up, fluid balance management is complicated. It is necessary to maintain and maintain the conditions of normothermy, using heated mattresses, air heaters and warming of fluids for intravenous administration.

Monitoring of CVP is mandatory, since this is the main available indicator in the assessment of intravascular volume, although central dialysis stenoses often occur in patients receiving dialysis through central venous lines. Pulmonary artery catheterization and invasive BP measurement may be required in patients with severe cardiovascular disease. Conducting continuous monitoring of systemic blood pressure can provide a guarantee that any of its dynamics will not go unnoticed. Sudden and extremely rapid changes in blood pressure, characteristic for patients with CRF, are unacceptable during acute reperfusion, because the degree and speed of hypotension significantly determine the frequency of occurrence of OKH in the postoperative period. The task of the anesthesiologist is the timely detection of the first signs of hypotension and their timely and adequate correction.

Assessment of the patient's condition after surgery

The duration of the operation (3-5 h), the use of drugs with predominantly extrahepatic metabolism suggest the possibility of early extubation on the operating table. Therefore, the main attention in the early postoperative period should be given to the prevention of nausea and vomiting, effective oxygenation through the constant supply of oxygen through Hudson's mask, the exclusion of the prerequisites for the development of hypothermia, the prevention of the occurrence of chills and muscular tremors. To this end, heated mattresses, thermoplids, wrapping the patient with blankets, foil, etc. Are used. Observance of an adequate temperature regime is of great importance, since the procedure for carrying out an early extracorporeal detoxification with plasmapheresis, which is often used recently in kidney transplantation, can significantly reduce body temperature. In the conditions of actively continuing infusion therapy, especially in the presence of paradoxical polyuria, constant monitoring of vollemia is very important, which is carried out by constant or periodic monitoring of CVP.

It should be noted the trend towards early activation of patients with a transplanted kidney. A large volume of movements and the ability to walk by the end of the first day of the postoperative period should imply extremely close monitoring of patients by the staff.

[23], [24], [25]