When does ischemic time begin & end w/ organ harvest?

It begins w/ the clamping of the donor's renal vessels and ends w/ the vascular anastomosis in the recipient.

When does diuresis begin if ischemic time is less than 30 minutes (donor in 1 rm, recipient in next rm)?

QUICKLY!

What happens if ischemic time is greater or equal to 2 hours?

There is a period of oliguria or anuria

How is the kidney preserved? For how long?

Its kept in cold preservation solution at 4 degrees C

Cadaver kidneys can be preserved for 36-48 hours w/ cold perfusion

Why is it important to use an adequate amount of balanced salt solution for donor preparation?

To ensure brisk diuresis from the donor kidney and offset the reduced venous return resulting from the use of the flank position.

What is the greatest risk for the donor?

HEMORRHAGE

Describe the flank position.

A lateral decub position

The bed elevates at the waist to form a gentle V shape

The head then is down slightly as is the lower extremities

Does the choice of anesthesia for a living related donor matter?

No, the choice of anesthesia is not critical

But make sure you have adequate IV access and available blood

What is the highest priority if the donor kidney is obtained from a brain dead patient?

Preservation of the graft!

With brain death, there is a loss of sympathetic tone that may produce what?

Hypotension despite adequate volume replacement

Brain death pts may come w/ many drips to maintain function, why do you often see high dose vasopressors?

-To reduce immediate allograft function and increase the risk for kidney damage.

What function is paramont to maintain in brain dead donors & how do you do that?

URINE OUTPUT!

-You can use diuretics or low dose dopamine.

Name some of the prepration associated w/ the recipient for organ donation.

-Free of acute illness and infection

(immunosuppressive therapy is used & can potentiate disaster if illness or infection is present)

-Correct fluid and electrolyte imbalances 24 hours before surgery

(pts should be dialyzed 24 hrs before procedure)

-Type & cross 2 units of WASHED PRBCs

Can a diabetic receive a kidney?

Yes-if insulin dependent Type I

NO-if insulin dependent Type II

(because of related comorbidity)

If the kidney fails, what will happen?

There will be an acute need to dialyze so make sure to maintain fistula patency!!

Fluid management is tricky-how is it typically handled?

w/ the history of renal failure, a dry regimen is typically employed initially followed by fluid bolusing'

-As the kidney is anastamosed, it is imperative that it is perfused.

-to do this the pt must be volume loaded

Can you use medications that are eliminated through the kidney?

Yes, but they may be used in reduced doses or if alternative exists, use it

What type of anesthetic should be used in the recipient? How are drugs chosen?

A regional or general can be used. Most prefer general.

Drugs are chosen by their impact on the procedure and kidney.

(Nitrous-bowel enlargement

Sevo-renal involvement Compound A)

Are NDMR that metabolize/eliminate via mechanism of kidney attractive choices?

YES-as a matter of fact they are =0)

-A newly transplanted but functioning kidney can clear NDMR drugs and anticholinesterase drugs at the SAME rate as a normal kidney-amazing...

When are vascular clamps removed and what does this produce?

Once the kidney is in place. This produces a vascular influx of metabolites and potassium into the system.

(The preservation fluid in the kidney contains high potassium content.)

How much blood volume is removed from the overall circulation when the reperfusion of the kidney occurs?

300 mls

When does acute immunlogic rejection of the kidney occur? What do you see?

As soon as the vascular clamp is released.

you'll see IMMEDIATE vascular reaction or collapse

What is the treatment for a rejected kidney?

Immediately cross-clamp the organ & take it out!

What symptoms will you see with a delayed rejection of an kidney?

Fever, local tenderness, loss of urine output

What is cyclosporin toxicity associated with?

ARF

Post transplant patients fall victim to opportunistic infections and are ________ times more likely to get _________.

They are 30-100 times more likely to get CANCER (large cell lymphoma is very common)

Name three procedures that use cystoscopy.

1) Diagnostic

2) Biopsy

3) Renal calculi removal

4) Stent placement in ureter

5) Retrograde pylograms

6) Direct lithotripsy

7) Resection of bladder tumors

How long is a cystoscopy? 

What type of anesthesia is utilized?

15-20 minutes

General which provides muscle relaxation

MAC sedation

Regional (epidural or spinal)

If your going to use a regional technique, what level do you need? What does it NOT abolish?

T-10 level

Regional does not abolish the obturator reflex (external rotation and adduction of the thigh) due to stimulation of the obturator nerve by electrocautery through the lateral bladder wall

What are your preoperative considerations for a transurethral resection of the prostate?

-BASELINE ELECTROLYTES!!

-Type and screen or cross (if coexisting anemia)

-Glands >40 ml may also require blood

-controlling bleeding w/ cystoscopy is difficult

Benign prostatic hypertrophy leads to what in men older than 60?

Asymptomatic bladder outlet obstruction