Delayed Graft Function (DGF)
Delayed graft function in the pediatric kidney transplant patient represents a significant adverse event for the graft with
repercussions in both short-term and long-term graft survival and compromising the post-op management significantly.
Every possible effort should be exerted to avoid DGF and to pursue constant surveil ance of the patient’s status to make
changes immediately, before complications arise.
Anticipation of incipient DGF
• Prolonged laparoscopic or open donor nephrectomy, based on surgical report.
Diagnosis of established DGF:
• Requirement for dialysis in the first week post-transplant, but dialysis should only be initiated as a last resort to
Approaches to Prevent DGF for Every Patient
a. Give only 1 pre-op dose of TACROLIMUS.
b. Keep TACROLIMUS target levels 8-10 for 3 days, then reevaluate.
b. Keep TACROLIMUS target levels 10-12 for 3 days, then reevaluate.
3. Continue Daclizumab / Thymoglobulin and MMF per protocol.
4. At the time of kidney revascularization:
a. Renal dose dopamine at 3mcg/kg/min may need higher levels to support systolic blood pressure in
b. Single dose of IV Mannitol with dosing as fol ows:
5. Baseline ultrasound within 24 hours post-op.
6. Keep CVP >10cm in the first 72 hours post-op.
7. Consider post-op IV Lasix infusion to maintain high urine output.
8. Consider operative 2mg/kg solumedrol in anticipation of possible DGF. May be continued at post-op days 1 and 2
Approaches to Minimize Possible DGF
1. If < 25% decline in serum creatinine or oligoanuria in the first 36 hours post-transplant, reduce TACROLIMUS
2. If no clinical response at 36 hours, fol ow DGF management protocol below.
3. Ultrasound with Doppler to fol ow RIs and rule out surgical complications.
4. Renal dose dopamine at 3mcg/kg/min; may need higher levels to support systolic blood pressure in infants and
Management of DGF
1. Give thymoglobulin for a period of 3-5 days.
2. Premedicate thymoglobulin with 2mg/kg, tapering to 1mg/kg of Solu-Medrol.
3. During period of thymoglobulin, hold TACROLIMUS.
4. If steroid-free, no steroids fol owing course of thymoglobulin and return to steroid-free protocol.
5. At anticipated last day of thymoglobulin, restart TACROLIMUS.
6. Continue daclizumab and MMF per protocol.
7. If DGF persists for 5 days, consider biopsy to rule out acute rejection and confirm DGF diagnosis.
8. Follow donor-specific antibody titers post-transplant.
9. Ultrasound with Doppler to fol ow resistive indicies and rule out surgical complications.
10. Reduce fluids to insensible plus output.
11. Renal y dose al medications to calculated creatinine clearance.
12. Renal dose dopamine at 3mcg/kg/min; may need higher levels to support systolic blood pressure in infants and
13. Blood pressure MUST be maintained at pre-dialysis baseline levels throughout dialysis. Blood pressure stability
takes precedence over ultrafiltration and fluid removal on dialysis.
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