Management of Acute Pulmonary Edema in Kidney Transplant Patients in the ICU

INTRODUCTION

Chronic Kidney Disease (CKD) is a prevalent medical condition that has a significant negative impact on the healthcare system. In 2019, the federal government signed an Executive Order titled “Advancing American Kidney Health,” which, among its objectives, aimed to facilitate and promote kidney transplantation as the optimal modality for kidney replacement therapy [1-3]. Kidney transplantation is considered the best treatment option for patients with end-stage kidney disease (ESKD), as it not only improves the quality of life compared to dialysis, but also extends patient survival. For kidney transplant recipients, the survival rate one year post-transplant can exceed 95% [3].

Pulmonary complications are common after kidney transplantation, and a variety of infectious and noninfectious complications are observed. Infectious complications significantly increase the morbidity and mortality in these patients. Several risk factors contribute to the development of pulmonary complications, including advanced age, smoking status, comorbidities, pre-transplant peritoneal dialysis, cadaveric kidney transplantation, heavy immunosuppression, and rejection treatment [1].

Intraoperative fluid management can significantly affect posttransplant outcomes. However, the amount and type of fluids administered as well as monitoring techniques vary considerably across institutions, with limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients [2].

Pulmonary complications may be exacerbated in patients with comorbidities, such as hypertension, diabetes mellitus, and those receiving immunosuppressive therapy (e.g., mycophenolate, azathioprine, or tacrolimus). Recognizing these risk factors allows the identification of high-risk patient groups, enabling close monitoring to prevent post-transplant pulmonary diseases. This proactive approach can lead to a reduction in overall morbidity and mortality in kidney transplant patients [4].

This case report presents the case of a kidney transplant patient who developed acute pulmonary edema due to fluid overload, requiring treatment in the General ICU at Hasan Sadikin Hospital, Bandung. The patient was admitted to the ICU for four days, and on the second day, experienced severe respiratory distress. Ultrasonography of the lungs revealed a B-profile in both lung fields, which was confirmed by chest radiography, indicating pulmonary edema. This was attributed to inadequate urine output. Continuous administration of furosemide proved effective, but required careful blood pressure management to maintain renal perfusion, particularly given the patient's pre-existing chronic hypertension.

CASE REPORT

A 42-year-old male with a history of CKD managed with regular hemodialysis (HD) for 5 months presented to the emergency department (ED) with complaints of severe shortness of breath. The patient was diagnosed with diabetes mellitus (DM) and chronic hypertension, which had been managed intermittently. He had a history of a maximum blood glucose level of 350 mg/dL and hypertension (200/120 mmHg). The patient was referred for kidney transplantation with his wife as the donor. Pre-transplant evaluation and counseling were completed, and both the recipient and donor consented to the procedure.

Table 1. Chronological Status of the Patient in ICU

Day	GCS	Blood Pressure (mmHg)	Heart Rate (bpm)	Respiratory Rate (bpm)	SpO2 (%)	Oxygen Therapy	Fluid Balance (mL)
1	E4V5M6	194/78 (no support)	99–101	16–18	100	3L/min nasal cannula	-510
2	E4V5M6	160/66 (nicardipine 0.5 mcg/kg/min)	105	25–30	95	3L/min nasal cannula	+164
3	E4V5M6	164/71 (nicardipine 0.25 mcg/kg/min)	107	19–23	100	3L/min nasal cannula	-2195
4	E4V5M6	170/84 (nicardipine 0.5 mcg/kg/min)	111	16–18	99	3L/min nasal cannula	+500

Upon presentation to the ED, the patient was alert and oriented with the following vital signs: blood pressure, 150/90 mmHg; heart rate, 98 beats per minute; respiratory rate, 27 breaths per minute; and oxygen saturation, 96% on room air. His body temperature was measured at 37.6°C. Physical examination did not reveal conjunctival pallor or scleral icterus. Chest auscultation revealed bilateral vesicular breath sounds with no additional sounds. Cardiovascular examination showed regular heart sounds with no additional murmurs, and abdominal examination was unremarkable with normal bowel sounds.

Laboratory tests showed: hemoglobin 8.9 g/dL, hematocrit 24.8%, leukocyte count 14,490/mm3, platelet count 304,000/mm3, urea 46.2 mg/dL, creatinine 2.81 mg/dL, sodium 135 mEq/L, potassium 3.4 mEq/L, chloride 99 mEq/L, and blood glucose 158 mg/dL. Arterial blood gases (ABG) showed a pH of 7.453, pCO2 of 27.3 mmHg, pO2 of 107.1 mmHg, and HCO3 of 19.3 mEq/L. Chest radiography revealed cardiomegaly and aortic atherosclerosis. aorta. Electrocardiography (ECG) showed sinus rhythm at 100 beats per minute, and echocardiography revealed a dilated left ventricle (LV) with concentric LV hypertrophy (LVH), borderline left ventricular systolic function (LVEF 53%), and mild mitral regurgitation (MR). No evidence of pulmonary hypertension (PH) or right ventricular dysfunction was found.

Figure 1. Chest X-ray of the patient before surgery

The patient underwent kidney transplantation, with his wife as the donor. The surgery, lasting 5.5 hours, was performed under general anesthesia with appropriate monitoring. Preoperative anesthesia assessment classified the patient as ASA III owing to comorbidities such as CKD, hypertension, and diabetes. Intraoperative monitoring included non-invasive blood pressure (NIBP), ECG, SpO2, temperature, central venous pressure (CVP), end-tidal CO2 (EtCO2), arterial line, and bispectral index (BIS). Anesthesia was induced using fentanyl, propofol, and rocuronium, and endotracheal intubation was performed. A central venous catheter (CVC) and arterial line were placed, and a quadratus lumborum (QL) block was used for regional analgesia.

Intraoperative fluid management included 1,000 mL of crystalloid resuscitation, and 400 mL of blood loss was replaced. The patient's urine output was minimal during the surgery, and renal Doppler ultrasound revealed inadequate renal perfusion. Subsequently, norepinephrine and dobutamine were administered as vasopressors to elevate the systolic blood pressure above 150 mmHg, which resulted in improved renal perfusion and urine output. The patient was extubated postoperatively and was transferred to the ICU for close monitoring.

The patient was admitted to the ICU post-transplantation on November 3, 2024, with stable hemodynamics but requiring vasopressor support (dobutamine 5 µg/kg/min and norepinephrine 0.1 mcg/kg/min) to maintain a mean arterial pressure (MAP) of 110 mmHg. His heart rate was 101 beats per minute, respiratory rate was 22–24 breaths per minute on a simple mask at 6 L/min, and oxygen saturation was 96–98%. On the second postoperative day, the patient developed respiratory distress, and lung ultrasound revealed a B-profile in both lung fields. Chest radiography confirmed a diagnosis of pulmonary edema, and the patient was treated with continuous furosemide infusion.

As part of the management strategy, the patient’s fluid balance was closely monitored. Diuresis was targeted at 1 mL/kg/h, and further fluid resuscitation was guided by urine output and hemodynamics. A significant improvement in the respiratory status was noted, and the patient’s blood pressure was managed with nicardipine to maintain a target systolic pressure of 160 mmHg.

Pulmonary complications such as pulmonary edema are common in kidney transplant recipients and can be exacerbated by fluid overload, pre-existing comorbidities such as hypertension and diabetes, and intraoperative management. In this case, early identification and management of fluid overload through furosemide administration and careful hemodynamic monitoring were crucial for stabilizing the patient. The importance of maintaining optimal fluid balance, especially in high-risk patients, cannot be overstated.

Upon admission to the ICU, patient management followed the FAST HUG BID protocol, which included feeding, analgesia, sedation, thromboprophylaxis, head-up position, ulcer prophylaxis, and glucose control. Initially, the patient underwent gastric lavage, followed by test feeding. For pain management, tramadol was administered via a syringe pump with additional doses of paracetamol and continuous bupivacaine for nerve block. To manage his blood glucose, insulin was infused at a rate of 6 U/h with hourly glucose monitoring, aiming for a target range of 140-180 mg/dL. His fluid balance and diuresis were carefully monitored, with a urine output of 1 cc/kg/hour.

The patient was also prescribed cefazolin for infection prophylaxis and continuous hemodynamic support with dobutamine and norepinephrine was provided. Fluid therapy was adjusted to maintain negative fluid balance, and regular assessments, including echocardiography and kidney ultrasonography, were performed to monitor any potential complications.

Table 2. Laboratory Results and Antibiotics Administered

Day	Hemoglobin (g/dL)	Leukocytes (mm3)	Urea (mg/dL)	Creatinine (mg/dL)	Glucose (mg/dL)	Troponin I (ng/mL)	BNP (pg/mL)	Meropenem (g)
H0	8.9	14,490	46.2	2.81	158	0.56	8171	1
H1	7.3	18,730	107.3	4.3	142	0.98	-	1
H2	7.6	20,410	101.5	3.57	115	-	-	1
H3	7.1	17,000	123.9	2.73	174	-	-	1
H4	7.3	13,830	137	2.28	189	-	-	1

Progress and Complications

On the first night in the ICU, the patient's blood pressure increased despite discontinuation of vasopressors. Nicardipine was introduced to achieve a target mean arterial pressure of 150-160 mmHg. On the second day, chest radiography revealed cardiomegaly and pulmonary edema, prompting further investigation. Lung ultrasonography revealed bilateral B profile changes, indicating the presence of pulmonary edema. In response, furosemide was administered, and diuresis improved. The patient's fluid balance improved, and adjustments were made to the patient’s medication regimen.

By day two, the patient's blood pressure had been managed with nicardipine, and urine output had improved to approximately 100 mL/h. The insulin infusion rate was adjusted to maintain blood glucose levels between 140-180 mg/dL. Despite improvements, the patient's pulmonary condition remained a concern, and a repeat chest radiograph confirmed the presence of pulmonary edema. Echohemodynamic studies revealed a cardiac output (CO) of 4.7 L/min and a cardiac index (CI) of 3.06 L/min/m², suggesting that his hemodynamic status was still suboptimal.

Day 3 and 4 Management

By day three, the patient's blood pressure was further stabilized with nicardipine infusion, and his diuresis was more effectively managed with furosemide. His fluid balance remained positive but slowly approached the target of neutral balance. His renal function continued to improve, with urine output reaching approximately 180 mL/h. Echocardiography on the third day revealed further improvements, with CO increasing to 6.7 L/min and CI to 4.33 L/min/m². The patient's condition continued to improve, and with blood pressure was maintained at the target systolic pressure of 160 mmHg.

By day four, the patient showed further progress, with blood pressure stabilizing at 160/78 mmHg and a continued reduction in the need for vasopressor support. Urine output remained within the target range of 1-1.3 mL/kg/hour. The patient’s renal and cardiac functions continued to stabilize, and he was transitioned from a clear liquid diet to a soft diet. The plan for the day included further monitoring of blood glucose levels, with insulin adjusted accordingly, and continued management of the patient’s fluid balance and renal function.

This case highlights the complex nature of managing post-kidney transplant patients with multiple comorbidities including diabetes mellitus, hypertension, and ESRD. Postoperative complications, particularly pulmonary edema, require careful monitoring and intervention, including the use of diuretics and vasopressors, to stabilize hemodynamics. This case underscores the importance of a multidisciplinary approach, with continuous monitoring and adjustments to the therapeutic plan, including fluid management, glucose control, and renal function monitoring. Although the patient experienced significant challenges during the postoperative period, timely intervention and careful management resulted in stabilization and recovery. This case emphasizes the importance of personalized care in the ICU to ensure that patients receive appropriate interventions to optimize outcomes following kidney transplantation.

Table 3. Summary of Key Parameters

Day	Blood Pressure (mmHg)	Heart Rate (bpm)	Urine Output (mL/hour)	Fluid Balance (mL)	Medication Adjustments	Key Interventions
1	140/81	101	5	0	Dobutamine, Norepinephrine, Insulin infusion	Gastric lavage, test feeding, ultrasound
2	161/68	101	100-50-100	+164	Nicardipine, Furosemide	Chest X-ray, Lung Ultrasound, Fluid adjustment
3	164/71	101	170-180-180	-2195	Furosemide, Meropenem	Echohemodynamics, Fluid titration
4	160/78	101	135-90-120	-908	Furosemide, Prograf, Myfortic	Transition to soft diet, Echo assessment

DISCUSSION

Kidney transplantation remains the most common solid organ transplantation, providing a viable solution for patients with end-stage renal disease (ESRD). This procedure significantly enhances patients' quality of life and life expectancy, but the postoperative period is often complicated by multiple factors, such as hypertension, fluid balance, and pulmonary complications. In this case, a patient with pre-existing hypertension and diabetes mellitus type 2, undergoing kidney transplantation demonstrated various complications typical of high-risk transplant recipients.

Intraoperative fluid management plays a critical role in kidney transplant outcome. Maintaining optimal mean arterial pressure (MAP) is essential for ensuring adequate renal graft perfusion. MAP should be maintained between 80-110 mmHg during the perioperative period to avoid delayed graft function (DGF) [1-2]. In the present case, the patient experienced a significant drop in blood pressure during surgery, which was managed with the administration of crystalloids and vasopressors. Following this intervention, blood pressure stabilized, and graft perfusion improved, as confirmed by postoperative ultrasound. This intervention highlights the importance of hemodynamic optimization in preventing early graft dysfunction and improving transplant outcomes.

Hypertension is a common and significant complication of kidney transplantation that affects long-term graft survival and increases the risk of cardiovascular morbidity. The pathophysiology of post-transplant hypertension is multifactorial, including factors such as pre-existing hypertension, medication side effects, and changes in kidney function post-transplant [2-5]. The patient in this case was classified as having persistent hypertension, as he had a history of poorly controlled blood pressure before transplantation. Nicardipine, a calcium channel blocker, was chosen for its positive effects on graft function and compatibility with immunosuppressive therapies. Managing blood pressure post-transplant is crucial for preserving graft function and preventing cardiovascular complications, and strict control of blood pressure, particularly in patients with a history of hypertension, is essential for optimal outcomes [6-8].

Pulmonary complications such as acute respiratory failure (ARF) and pulmonary edema are common after kidney transplantation and are often exacerbated by factors such as immunosuppressive therapy and pre-existing comorbidities. The patient developed acute respiratory failure on day two post-surgery, marked by an increase in respiratory rate and decreased oxygen saturation. Chest radiography and ultrasound revealed signs of pulmonary edema, which was managed with continuous diuretics (furosemide) to improve urine output and reduce fluid overload. Pulmonary complications, particularly in high-risk patients like this one, necessitate careful monitoring and early intervention to prevent long-term morbidity [9-10].

Acute kidney injury (AKI) remains a major concern in kidney transplant recipients and often manifests as delayed graft function (DGF) or early graft failure. In the present case, the patient experienced a temporary reduction in urine output that was attributed to poor renal perfusion following a drop in blood pressure during surgery. Timely intervention, including fluid resuscitation and vasopressor administration, restored adequate perfusion and urine output to acceptable levels. This case underscores the importance of vigilant monitoring of graft function and early recognition of AKI to prevent long-term graft failure and improve post-transplant survival [11-13].

Patients undergoing kidney transplantation are at a high risk of infection, owing to the need for immunosuppressive therapy to prevent graft rejection. In this case, the patient developed an increase in white blood cell count, which prompted the initiation of broad-spectrum antibiotics. Effective management of infections is crucial in preventing complications, especially since transplant recipients are highly susceptible to bacterial, viral, and fungal infections. Appropriate antibiotic stewardship, guided by clinical signs and laboratory findings, is essential for improving outcomes in the post-transplant period [14-15].

CONCLUSION

Kidney transplantation is the most prevalent solid organ transplantation, offering significant improvements in the quality of life of patients with end-stage renal disease (ESRD). However, careful management of comorbidities such as hypertension and diabetes mellitus is essential to prevent post-transplant complications. In this case, the patient experienced acute kidney injury (AKI) due to impaired graft perfusion, which was likely triggered by a drop in blood pressure during surgery. This resulted in reduced urine output and suboptimal graft function, as highlighted by the postoperative ultrasound findings. Additionally, fluid overload leads to pulmonary edema and heart failure, necessitating continuous diuretic therapy and antihypertensive management to restore baseline blood pressure and support graft function. Postoperative immunosuppressive therapy also requires careful monitoring for infection, leading to the initiation of broad-spectrum antibiotics owing to significant leukocytosis. This case underscores the importance of optimal perioperative management, including hemodynamic stability, infection prevention, and graft function monitoring, to ensure successful long-term outcomes in kidney transplant recipients.

DECLARATIONS

None

CONSENT FOR PUBLICATION

The Authors agree to be published in Journal of Society Medicine.

FUNDING

None

COMPETING INTERESTS

The authors declare no conflict of interest in this case report.

AUTHORS’ CONTRIBUTIONS

All authors contributed to the work, including data analysis, drafting, and review of the article. They approved the final version and were accountable for all the aspects.

ACKNOWLEDGMENTS

None

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