DISCHARGE DIAGNOSES: End stage renal disease secondary to rapidly progressive glomerulonephritis.

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1 DISCHARGE SUMMARY DISCHARGE DIAGNOSES: End stage renal disease secondary to rapidly progressive glomerulonephritis. OPERATIONS/PROCEDURES: Living related renal transplantation. HISTORY: For full details of the patientâ s history and physical, please see Dr. [NAME] note dictated on [DATE]. HOSPITAL COURSE: The patient was taken to the operating room and on [DATE] the patient underwent a living related donor renal transplant. The patient tolerated the procedure well and was ready to transfer to the medical/surgical intensive care unit in stable condition. On postoperative day number one, the patient was noted to be doing very well. He had excellent urine output, approximately cc per hour. His creatinine decreased to 3.3 with a hematocrit of His wound was dry without signs of a palpable hematoma. His urine, however, was somewhat bloody. On postoperative day number one his ultrasound demonstrated minimal hydronephrosis. He had no perinephric fluid noted. His radiology and nuclear medicine study was also unremarkable. On postoperative day number two we had him on a select diet. He was tolerating this quite well. He had approximately 2.5 liters of urine output this time. However, he did continue to have the pink urine, thus we did continue his bladder irrigation. He continued to put out approximately cc, and his creatinine was essentially as by postoperative day number three. The remainder of his postoperative course was only eventful for continued clots noted in his urine. This continued to approximately postoperative day number six. We did remove his Foley at that time, and he did spontaneously void without difficulty. At this time, he was tolerating a regular diet. His creatinine was to 1.4. He did have excellent bowel movements with stool softeners. His CyA level was also therapeutic as well. Thus he is ready for discharge now on postoperative day number eight. His wound is well approximated. He is ambulating without difficulty. DISPOSITION: The patient is to followup with Dr. [NAME] in seven to ten days. The patient is to undergo no heavy lifting or strenuous activity for four to six weeks. DISCHARGE MEDICATIONS: Percocet one to two tablets p.o. q. 4 hours p.r.n. pain, Septra DS one tablet p.o. q. day, Prednisone 50 mg p.o. t.i.d., Colace 100 mg p.o. b.i.d., Acyclovir 200 mg p.o. q.i.d., Imuran 75 mg p.o. q. day, CyA 300 mg p.o. b.i.d., Procardia XL 60 mg p.o. q. day.

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3 OPERATION REPORT PREOPERATIVE DIAGNOSIS: Chronic renal failure. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Living related donor right renal transplant. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: 450 cc. TUBES, PACKS, DRAINS: None. POSTOPERATIVE CONDITION: Stable. PROCEDURE: The patient was placed on the table in the supine position and general anesthesia was induced. The skin of his abdomen was prepped with Betadine gel and sterile drapes were then applied. A diagonal incision was made from a point above the symphysis pubis and then carried just lateral to the anterior/superior iliac spine. The incision was deepened through all layers of the abdominal wall using cautery. The rectus sheath was entered inadvertently and this was closed with running 2-0 Vicryl. We went lateral to the rectus sheath then and divided the external oblique, internal oblique and transversalis muscles. After incising these layers, we dissected bluntly medially until we had exposed the iliac artery and vein. We also encountered the inferior epigastric artery and vein and these were divided between clamps and then ligated with 2-0 silk ties. We then placed our retraction and began dissection of the artery and vein. The lymphatics of both the artery and vein were surrounded with 4-0 silk ties and then divided. We continued this process until we cleared off approximately 6 cm of each vessel. We then surrounded each with Rumel clamps, both proximal and distally to our proposed anastomosis site; we did not at that point tie them down. As the donor kidney was prepared, we tightened down the renal vein with Rumels and then made a venotomy with a No. 11 blade. We then placed our proximal and distal anastomosis sutures as well as our triangulation sutures into the recipient vein. After the kidney was up on the table, we sewed the corner stitches in place as well as the triangulation stitches and then completed the anastomosis with running 5-0 Prolene. At the completion of this anastomosis, we tightened down the Rumel clamps around the artery; we then made an arteriotomy with a No. 11 blade and completed it with Potts scissors. We then started out anastomosis with a running 5-0 Prolene. At the completion of this anastomosis, we released the venous Rumels and then released the arterial Rumels. There was immediate pulsation in the kidney and also a pulse distal to the kidney in the iliac artery. The kidney began to make urine on the table. After completing these anastomoses, there was some bleeding at the arterial site and this was controlled with gentle pressure from a Ray-Tec sponge. We then pulled the bladder up into the wound and divided the tissues overlying the bladder with cautery. A single perivesical vessel was surrounded with 4-0 ties and ligated and divided. We then made a cystotomy with cautery and exposed the urinary trigone as well as the Foley catheter. With the tonsil clamp we made a tunnel in the submucosal tissues of the bladder for approximately 2 cm. A hole was then made in the mucosa of the bladder and the tonsil clamp was passed

4 through. The catheter was passed and pulled back through the tunnel. It was sewn to the ureter with 3-0 silk. The ureter was then pulled through and a stay suture of 4-0 PDS was placed. It should be noted that at this, when we transected the ureter at this point, it was impossible to pass even a 5 French feeding tube very far up the ureter. The ureter had a very small lumen but did have a very thick muscularis and vascular bed. We then made a longitudinal incision through the ureter to create a nipple. With the 5 French infant feeding tube in placed, we then sewed the anastomosis between the bladder and the ureter. This was done with interrupted stitches of 4-0 PDS. It was necessary to do this several times because on a couple of occasions when we would sew the anastomosis, it was impossible to see urine pouring out and the ureter appeared to be dilating; however, when we did the anastomosis with the 5 French feeding tube in place, upon its withdrawal there was free flow of urine into the bladder. Approximately eight interrupted sutures were used for the anastomosis. The bladder was then closed in two layers with an inner layer of running 3-0 chromic. There were then three outer layers of 4-0 PDS. At the completion of this, we irrigated the wound extensively and obtained hemostasis with cautery. The fascia was then closed in two layers with running No. 1 PDS-2. The skin was then closed with staples. The wound was dressed.

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