Veterinary Medicine - February 2008 - (Page 99) derangements are present in transplant patients including anemia, acidemia, hyperphosphatemia, hypocalcemia, and uremia. Identi cation of any dysfunction within these body systems should be performed preoperatively so that correction may be attempted if possible. Preoperative management of the transplant patient includes parenteral uid diuresis with balanced electrolyte solutions. If treatment with recombinant human erythropoietin and subsequent transplant delay is inappropriate, anemic patients are given blood transfusions to achieve a PCV of > 30% before surgery. Immunosuppressive therapy is continued the day of surgery, as described earlier. Placing a jugular catheter is ideal to monitor hemodynamic parameters before, during, and after surgery. A standard premedication and anesthetic protocol including an anticholinergic, an opioid, and an inhalant anesthetic agent is used based on the preoperative evaluation and an individual anesthesiologist’s preference. Perioperative broad-spectrum antibiotics are administered for the duration of the procedure. Atracurium besylate is used as needed to maintain muscular relaxation during microvascular anastomosis. Dopamine may be administered as a continuous-rate infusion to ensure adequate systolic blood pressure. Mannitol may be given to induce osmotic diuresis in all donor cats before nephrectomy, as well as in recipient cats after vascular anastomosis.38 Administering mannitol may minimize acute tubular necrosis associated with temporary ischemia that occurs during transplantation. A recent report demonstrated that preserving nephrectomized kidneys in cold sodium gluconate or phosphatebuffered sucrose solutions for up to seven hours had no negative impact on patient survival.41 Intraoperatively, standard physiologic parameters are measured continuously, and drug adjustments are made if needed. Arterial or venous blood gas and electrolytes are assessed periodically, and imbalances are corrected as necessary. Surgery Donor cats. The donor kidney is removed through a ventral midline celiotomy. Vascular dissection is assisted by using magnifying loupes or a dissecting microscope. Assessment of both donor kidneys is performed, although the left kidney is preferred because of the increased length of the vascular pedicle.42 The donor kidney must be supplied by a single artery (some cats have two arteries supplying a single kidney), and a minimum length of 0.5 cm is generally required to complete the arterial anastomosis.42 The accompanying renal vein is measured to create a sterile template to guide the creation of the donor phlebotomy site. The entire length of the ureter is isolated from the kidney to the urinary bladder before nephrectomy. Several techniques for vascular anastomosis and ureteral implantation in cats have been described in the literature. Recent reports detail anastomosis of the donor kidney vessels to the postrenal aorta and vena cava.43 Cats in previous studies suffered rear limb complications when the external iliac vessels were used for anastomosis.43 Recipient cats. The surgical approach in the recipient cat is similar to that in the donor cat. The area between the left renal artery and caudal mesenteric artery is isolated and exposed in preparation for the graft. The donor kidney is harvested only after the recipient vessels are prepared for graft implantation. The donor renal artery is anastomosed end-to-side to the aorta by using 8-0 to 10-0 nylon in a simple interrupted pattern.42 The renal vein is anastomosed to the caudal vena cava with two rows of simple continuous sutures with 7-0 silk.43 Several techniques for implanting VETERINARY MEDICINE February 2008 99 http://www.meridiananimalhealth.com
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