Major Cations Targeted Fluid Therapy In Renal Transplantation.
Major Cations Targeted Fluid Therapy In Renal Transplantation.
English Summary And Abstract

 The overall anesthetic goal for the newly transplanted kidney is to maintain intravascular
 volume and avoid decreased perfusion by maintaining main arterial blood pressure (MAP). The
 participants with end-stage renal disease(ESRD) present with electrolyte and metabolic
 abnormalities such as hyponatremia, hyperchloremia, hyperkalemia, hypocalcemia,
 hypermagnesemia and metabolic acidosis. With fluid therapy for the participants with (CKD),
 electrolytes are potentially affected. So there is a progressive metabolic acidosis. The
 debate about the type of fluid to be used in renal transplant participants is on-going.

 Material and methods Place of research is the Department of Anesthesia and Surgical ICU,
 Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura,
 Egypt.Total duration will be assumed to conduct the search over one year. A prospective
 cohort study and sample size 50 participants aged18 to 40 years. Written informed consent
 will be obtain from the participants with chronic renal failure scheduled for living-related
 kidney transplantation surgery .

 Basal Serum major cations Na,K,Ca,Mg and Cl, Albumine and after completion of the vascular
 anastomosis.Fluid therapy volume 40ml/kg From the start of surgery until the renal vessels
 are unclamped after completion of the vascular anastomosis. and the type of fluid is
 determined by major cations values. Heart rate ,Systolic, diastolic, mean arterial blood
 pressure,will be record after induction of anesthesia, every 30 minutes till at the time of
 renal artery clamping in the donor, at unclamping of the vessels , after completion of the
 vascular anastomosis and at the end of surgery.the investigator also record renal ischemia
 time.Time of onset of urine production on unclamping of the renal artery .Total urine output
 from unclamping of the renal vessels to the end of the surgery.Kidney turgidity will
 evaluated .

 All participants transfer to post-anaesthesia care unit then to ICU .Daily serum creatinine,
 creatinine clearance, a total urine output and any renal complications will be record for
 first 5 days postoperatively .
Material and methods Place of research the Department of Anesthesia and Surgical ICU, Urology
 and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt.

 Total duration assumed to conduct the search over one year.

 Preoperative management Will be that

 -  All transplantations in this study will be performed by the same surgical team. All
 undergo participants preoperative hemodialysis 24 hours before renal transplant surgery.

 -  Full medical and surgical history will be taken, and

 -  Routine laboratory investigations (eg. blood Hb, plasma proteins, coagulation studies,
 serum electrolytes, blood glucose, arterial blood gases, chest radiograph, and
 echocardiography).

 -  Basal Serum major cations Na,K,Ca,Mg and Cl, Albumine

 Intraoperative management will be

 -  On the morning of surgery intra muscular injection of Morphine 0.1mg\kg and diclofenac
 Na 0.6mg/kg. ketamine infusion by rate 0.1 mg /kg/ h

 -  Monitoring before induction of anesthesia, 5-lead electro cardio gram, pulse oximetry,
 and noninvasive arterial blood pressure are record. Central venus catheter will be
 aseptically inserted into the right internal jugular vein ,

 -  Induction of general anesthesia is with IV midazolam 0.15 mg/kg ,fentanyl 1micogram /kg,
 and sodium thiopental 5% 5mg/ kg. Endotracheal intubation is facilitated by rocuronium
 0.5 mg/kg Anesthesia is maintained by sevoflurane (MAC )minimal alveolar concentration
 (1%) with 40% O2. Minute volume is adjusted to keep end-tidal CO2approximately 35 mm Hg.

 -  Fluid therapy volume 40-50 ml/kg From the start of surgery until the renal vessels are
 unclamped after completion of the vascular anastomosis. and the type of fluid is
 determined by major cations values.

 K > 4.0 ml Eq/dl the investigator use saline 0.9% K<3.5ml Eq/dl us the investigator ringer
 acetate . k> 5.0ml Eq/dl the investigator use glucose 25% 8gm+ 10 unite insulin in saline
 0.9%+salbutamol 200mg.

 G Na >140ml Eq/dl the investigator use ringer acetate . Na <135ml Eq/dl the investigator use
 saline 0.9%. and Na bicarbonate (Na H2CO3) with dose = body weight x base deficit x 0.4 x 1/2

 Cl >105 ml Eg/dl the investigator use ringer acetate. Mg<2ml Eq/dl investigator use Mg
 sulfate 10mg/kg infusion Ca <9ml Eq/dl investigator use Ca gluconate 10% 0.25ml/kg infusion.

 -  From the start of surgery until the renal vessels are unclamped after completion of the
 vascular anastomosis. Norepinephrine will infused using infusion pump with started rate
 0.01ml/ h and will be adjusted to maintain arterial blood pressure within 25% of the
 basal value after unclamping at the end of vascular anastomosis or mane arterial blood
 pressure <60 ml mercury.

 -  During vascular anastomosis, all recipients will receive 500 mg prednisolone as prepared
 by the attending nephrologist. After completing the renal vascular anastomosis,
 furosemide was given in20mg increments to enhance diuresis post vascular anastomosis

 -  Serum major cations Na,K,Ca,Mg and Cl,Albumine and arterial blood gases will be sampled.

 -  Heart rate ,Systolic, diastolic, mean arterial blood pressure,will be record after
 induction of anesthesia, every 30 minutes till at the time of renal artery clamping in
 the donor(onset of ischemia), at unclamping of the vessels after completion of the
 vascular anastomosis (end of ischemia),and at the end of surgery.

 -  The investigator also record renal ischemia time.

 -  Time of onset of urine production on unclamping of the renal artery in minute.

 -  Total urine output from unclamping of the renal vessels to the end of the surgery.

 -  Kidney turgidity will evaluated by the surgical team members, 3-point scale: score I
 (soft graft), score II (moderate turgid graft), and score III (highly turgid and firm
 graft).

 Post operative management,

 -  All participants will be assessed for the presence of tissue edema, especially in the
 conjunctiva, eyelids, face,and upper airway

 -  All participants had a routine postoperative chest radiograph to look for signs of
 pulmonary edema and to exclude pneumothorax.

 -  Daily serum creatinine, creatinine clearance, and total urine output will be record for
 5 days postoperatively.

 -  the investigator also will record any renal complications in the first 5 days (e.g.,
 acute graft rejection, acute tubular necrosis, or need for hemodialysis).

 Statistical Analysis

 The calculated sample size of the study will be 23 at 5% participants level of significance
 and 80 % power, using the following formula:

 N= (Z1-α/2+Z1-β) ² σ1* σ2 / δ Z1-α/2 = 1.96 Z1-β= 0.842 σ = (Standard deviation δ = Expected
 difference to be detected between the sample and population α = Level of acceptability of a
 false positive result (level of significance=0.05) β = Level of acceptability of a false
 negative result (0.20)

 1- β= power (0.80) The sample size will be increased to 50 participants to compensate for
 drop outs or protocol failures with incomplete data and to increase the study power.
Inclusion Criteria:-

 - Participants with chronic renal failure scheduled for living-related kidney
 transplantation surgery

 Exclusion Criteria:-

 -  participants with severe left ventricular dysfunction.

 -  cardiomyopathy with ejection fraction 50%.

 -  severe anemia (blood hemoglobin Hb5g\ dL).

 -  bleeding tendency .

 -  previously received transplants.

 -  experienced any surgical complications (e.g., excessive bleeding or resistant graft
 arterial spasm.

 -  any surgical difficulty such as the presence of multiple renal vessels.