The prognostic significance of early malfunction or delayed function after cadaveric renal transplantation is controversial. This study examines the influence of intraoperative management in 438 cadaveric renal transplant recipients on seven posttransplant outcome measures: (1) time of onset of urine output, (2) urine volume, (3) renal function, (4) incidence of delayed function, (5) never-functioning kidney, (6) graft survival, and (7) patient survival. Delayed function, defined as the need for hemodialysis during the first posttransplant week, decreased from 46% in 1982 to 15% in 1990 and was associated with a 25% lower 1-year graft survival rate and a mortality rate of 10% at 3 months, compared with 3% when immediate function was present. The most important factors influencing the outcome were cold ischemia time (P=0.007), intraoperative administration of albumin (P=0.0027), duration of surgery (P=0.020), and recipient age (JP=0.041). A high albumin dose (1.2-1.6 g/kg body weight) induced urine output within 30 min in 75% of patients and induced larger urine volumes (7.3 L/24 hr), as compared with the effects of a low dose (0-0.4 g/kg), which induced urine output within 30 min in 39% and only 3.7 L/24 hr. Serum creatinine at 1 week was 3.4 and 5.8 mg/dl for the high and low albumin doses, respectively (P<0.0001). Similarly, mean glomerular filtration rates at 1 and 7 days were 33 and 21 ml/min, compared with 47 and 28 ml/min, for the high and low albumin doses, respectively (P<0.01). The incidence of delayed function and of never-functioning kidneys declined from 34% and 9% for the low dose to 12% and 1% for the high dose, respectively. Finally, with increasing albumin dose, the graft survival rate at 1 year improved from 59 to 78% (P<0.002), and the patient mortality rate at 3 months dropped from 6% to 2%. For albumin dose intervals between the high (1.2-1.6 g/kg) and low (0-0.4 g/ kg), the effect on all seven outcome measures was intermediate, generally describing a linear relationship. Weighted least-squares analysis of the relationship of delayed function with high vs. low doses of albumin, mannitol, furosemide, and volumes of crystalloid solutions showed significance only for the albumin effect. High-dose albumin infusion likely produces intravascular volume expansion and achieves a prompt restoration of blood flow, minimizes hypoxic injury, and helps preserve renal tissue. The possibility of other beneficial effects of albumin unrelated to intravascular volume also exists. High-dose albumin infusion is associated with decreased nonfunction rates and improved outcome of cadaveric renal transplantation.
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