Selective Pre-Transplant Nephrectomy: Indications and Perioperative Management

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Abstract
From May 1977 to June 1983, 198 patients were accepted as candidates for renal transplantation. Experience with 14 consecutive patients who underwent selective pretransplant nephrectomy during this interval were reviewed. Indications for this procedure included recurrent or chronic pyelonephritis, structural abnormalities of the urinary tract predisposing the patient to infection, malignant or renin-dependent hypertension, Goodpasture''s disease, certain cases of rapidly progressive glomerulonephritis and selected patients with polycystic kidneys. All patients underwent dialysis 1 day preoperatively. Perioperative fluid losses were measured carefully with prompt and vigorous replacement therapy. Patients received an average of 5890 ml fluid replacement before postoperative dialysis. All patients underwent dialysis within 29 h postoperatively. There were no postoperative deaths and 8 complications. Selective pretransplant nephrectomy has spared 93% of potential renal transplant candidates from a major surgical procedure. No patient has required removal of the original kidneys during the posttransplant period. The reluctance to hydrate these patients may be unwarranted and that prompt postoperative dialysis, if required, is safe. Since some end stage kidneys are physiologically active and the associated surgical risk is high, pretransplant nephrectomy should be performed only in carefully selected patients. In contrast to previous reports, which advocated minimal fluid administration and delayed postoperative dialysis, recent experience indicates that vigorous fluid replacement therapy, carefully monitored with serial vital signs, weights, serum electrolytes and central venous pressure readings, will avert many of the complications encountered previously.