Decongestion guided through Doppler Ultrasound of the Supra-hepatic Vein by Transesophageal Echocardiography in a Kidney Transplant Patient: Clinical case

INTRODUCTION: The hepatic vein decongestion is a crucial aspect in the management of various liver and cardiac conditions, where excessive blond accumulation in the liver can lead to serious complications such as portal hypertension and liver failure. The hepatic vein, responsible for blood draining from the liver to the general circulation, can be affected by a pathologies variety that alter its functionality and consequently, the venous return.

CASE REPORT Scenario: A 32-year-old female patient (56 kg, 1.55 m) with a chronic kidney disease history in pre-dialysis without renal function replacement treatment underwent an anticipated related living donor kidney transplant. The procedure is performed under balanced general anesthesia according to the standards of the Hospital Juarez de México with type III monitoring with transesophageal echocardiography with Mindray TE7 Ultrasound, Edwards Hemosphere and GE Vital Signs Monitor.

During kidney transplantation, type I monitoring (GE monitor) is performed: Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR); Type II monitoring (Hemosphere/Edwards): Central venous pressure (CVP), mean systemic filling pressure (MSFP), systemic vascular resistance (SVR), stroke volume (SV), cardiac output (CO), stroke volume variability (SVV); Type III monitoring with transesophageal echocardiography (TEE/MindrayTE7): End-systolic volume (ESV), end-diastolic volume (EDV) and ejection fraction (LVEF) and supra-hepatic vein doppler velocity from baseline on “S” and “D” wave. Measurements were made during all different kidney transplantation stages.

Before Reperfusion in Kidney Transplantation: SBP 133mmHg, DBP 76mmHg, TAM 95mmHg, HR 69bpm, CVP15mmHg, MSFP20.04mmHg, SV89ml/min, CO6.14lt/min, SVR 1041dynas/cm3, SVV11%, CP1.29J/min, EH0.25, EDV149ml/min, ESV60l/min, LVEF59.7%, AE1.34, VE2.0, AoV0.67. When measuring the values by Doppler ultrasound of the “S” and “D” waves, they were 37.22cm/s and 41.44cm/s, so the S/D Index is 0.9

Reperfusion (1st minute): SBP124mmHg, TAD75mmHg, MAP91mmHg, HR67bpm, CVP13mmHg, MSFP17.76mmHg, SV81ml/min, CO5.43lt/min, SVR1154dynas/cm3), SVV12%, CP1.1J/min, EH0.27, EDV136ml. /min, ESV55ml/min, LVEF59.6%, AE1.38, VE2.03, AoV0.68. When measuring the values by Doppler ultrasound of the “S” and “D” waves were 39.94cm/s and 32.14cm/s, so the S/D index is 1.24.

DISCUSSION: When the patient presents dynamic fluid overload (before reperfusion), the “S” wave decreases its amplitude/velocity and thus the right ventricle capacity to manage hepatic venous flow during systole. In this case “D” wave, shows a low velocity flow during diastole, so in congestion due to the increase in portal pressure the retrograde velocity increases and therefore the S<D pattern, and S/D index is less than 1.

CONCLUSION: Hepatic vein doppler is a valuable tool in the management of fluid de-escalation in kidney transplant patients.