Pulse Index Continuous Cardiac Output-Guided Hemodynamic Therapy in Living Donor Kidney Transplantation: A Prospective Cohort Study.

Background: Central venous pressure (CVP)-guided fluid therapy remains common during kidney transplantation, although CVP is a static marker with limited ability to predict fluid responsiveness. This prospective observational cohort study evaluated whether pulse index continuous cardiac output-guided goal-directed hemodynamic therapy (GDHT), using dynamic and volumetric hemodynamic variables, was associated with improved early graft function compared with conventional CVP-guided management in living donor kidney transplantation. Methods: Eighty living donor kidney transplant recipients at Cho Ray Hospital, Vietnam, were enrolled between May 2024 and December 2025. Patients were managed according to the institutional anesthetic monitoring protocol in use at the time of surgery: CVP-guided fluid therapy (group C, n = 40) or PiCCO-guided GDHT (group P, n = 40). The PiCCO protocol incorporated stroke volume variation, pulse pressure variation, cardiac index, global end-diastolic volume index, systemic vascular resistance index, and extravascular lung water index. Outcomes included intraoperative fluid volume, vasopressor use, postoperative urine output, serum creatinine through postoperative day 7, delayed graft function, and postoperative complications. Results: Baseline recipient, donor, and operative characteristics were comparable between groups, with the exception of cold ischemia time, which was longer in group P. Total intraoperative fluid volume was lower in group P than in group C (2,656 ± 480 mL vs. 3,097 ± 555 mL; P = 0.001), and vasopressor use was numerically lower but not statistically significant (12.5% vs. 27.5%; Fisher's exact P = 0.161). First-hour postoperative urine output was higher in group P (1,235 ± 162 mL vs. 1,010 ± 315 mL; P < 0.001). Serum creatinine was similar on postoperative day 1 but was significantly lower in group P on day 3 (1.3 (0.8-1.8) mg/dL vs. 1.6 (1.4-1.9) mg/dL; P = 0.036); the difference on day 7 was not statistically significant (1.1 (0.7-1.4) mg/dL vs. 1.3 (1.1-2.1) mg/dL; P = 0.16). No patient in either group developed delayed graft function within 7 days. Extravascular lung water index remained within the reference range during surgery, and no patient developed clinical pulmonary edema. Conclusions: In this prospective cohort, PiCCO-guided GDHT was associated with lower intraoperative fluid administration, numerically lower vasopressor use, and faster early recovery of graft function after living donor kidney transplantation. These findings support further evaluation of multiparameter hemodynamic monitoring as an individualized perioperative strategy in kidney transplantation.