**7.2. Graft function**

• Infections: they are frequent in this group of transplant recipients (80% throughout the first year), and they play an important role in the patient and graft survival. Diabetes, surgery, and immunosuppression are factors that predispose these patients to suffer infections of all types. Pancreas transplantation presents a risk of infection by CMV of 13–17%, largely due to the use of potent induction immnunosuppression. CMV infection is associated with increases in mortality, the rate of rejection, and the presentation of other types of infections. The incidence of intra-abdominal infections is 10–30%, most of them polymicrobial, with fungi present in less than 10% [29]. The current prophylaxis schemes (against bacterial, viral, and fungal infections), established from the moment of intervention, have managed to reduce its incidence in the short term. However, they still need to be monitored in the

Recipients of pancreas transplantation are diabetic patients most often with a disease vintage over 10 years and frequently with secondary macro- and microvascular complications. The cardiovascular risk is superior to those of general population or recipients of kidney transplant alone. The perioperative management is of crucial importance not only to avoid the risk of hemodynamic instability and periods of low perfusion of the graft, but is also vital for

Volume and electrolytes should be monitored closely during the first 48 h and fluids administered accordingly to avoid hypovolemia or acid-base and electrolyte inbalances. Although an individualized assessment should be performed in each case, it is considered appropriate to maintain a central venous pressure between 5 and 10 mmHG. The administration of fluids

Since most patients are also recipients of a kidney transplant, close monitoring of urinary output must be performed simultaneously. In the event of polyuria (urinary output >150 ml/h), aggressive volume reposition should be perfomed, usually at a rate of 1:1 during the first 24 h, and thereafter at a rate of 0.7:1 to avoind prolonging the polyuria. Fluid solution should be selected according to acid–base and electrolyte homeostasis, with 0.9% or 0.45% sodium

In the event of delayed graft function and oliguria (urinary output <50 ml/day), fluids should be restricted to those needed for the minimum daily calories and electrolyte intake to avoid hastening the need for dialysis intended for volume management. When needed, dialysis modality (continuous vs. intermittent) should be discussed with the nephrologist and risk benefits must be weighed—intermittent dialysis may be performed with the need for anticoagulation, and with low ultrafiltration volumes, reducing the risk of surgical complications, while continous dialysis reduces hemodynamic instability and therefore decreases the risk of

**7.1. Volume, acid-base and electrolyte, and hemodynamic stability**

with dextrose should be avoided, as it may prolong the need for insulin.

longer term.

**7. Perioperative management**

276 Organ Donation and Transplantation - Current Status and Future Challenges

organs such as brain and heart.

chloride often being the first line of treatment.

reducing organ perfusion.

The immediate evaluation of the graft (both pancreatic and renal, in the case of SPK) can be monitored in various ways. The protocol accepted by most centers combines the use of laboratory parameters together with image tests. The decrease in blood levels of blood urea nitrogen (BUN), creatinine, amylase and lipase is required, together with blood glucose levels within normality, to consider that the grafts function correctly (in case of SPK). Blood levels of amylases and lipases provide additional information regarding pancreatic injury. In the immediate postoperative period, blood levels of pancreatic enzymes may be elevated, with normal blood glucose levels, which translates into an ischemia-reperfusion injury, and usually resolves spontaneously. In cases of exocrine drainage to urinary bladder, the level of amylases in urine can be monitored. A decrease of 50% or more is suggestive of rejection or pancreatitis.
