# Situation: A 45-year-old man is on day 5 after a living-donor kidney transplant. He takes tacrolimus at 8:00 AM and 8:00 PM, mycophenolate, and prednisone. He has an indwelling urinary catheter, and his urine output over the past day was 150–200 mL/h. Over the last 2 hours, his urine output has fallen to 20 mL/h. His blood pressure is 132/84 mmHg, and he has no pain. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 45-year-old man is on day 5 after a living-donor kidney transplant. He takes tacrolimus at 8:00 AM and 8:00 PM, mycophenolate, and prednisone. He has an indwelling urinary catheter, and his urine output over the past day was 150–200 mL/h.

Over the last 2 hours, his urine output has fallen to 20 mL/h. His blood pressure is 132/84 mmHg, and he has no pain. What should the nurse do FIRST?

## 보기

1. Notify the transplant surgeon about the drop in output
2. Increase the intravenous fluid rate to replace losses
3. Send blood for an urgent serum creatinine level
4. Check the catheter and tubing for clots or kinks **✔ 정답**

**정답: 4**

## 해설

A sudden drop in urine output after kidney transplant may come from graft thrombosis, obstruction, or rejection, but the quickest correctable cause is a blocked catheter. The nurse first checks the catheter and tubing for clots or kinks, then reports at once. Raising fluids without an order or waiting for laboratory results delays finding the cause.

## 심화 해설

Clinical context

A sudden drop in urine output during the early post-transplant period is a nursing priority because the new kidney is vulnerable to graft-threatening events such as vascular thrombosis, acute rejection, or mechanical obstruction [1][2][3][4]. On day 5 after living-donor transplantation, the patient had been making 150–200 mL/h, so a fall to 20 mL/h over 2 hours represents an abrupt and significant change.

Why the catheter is checked first

The most rapidly correctable cause of sudden oliguria in a transplant recipient with an indwelling urinary catheter is mechanical obstruction of the drainage system. A kinked tube, a dependent loop, sediment, or a clot can block outflow and mimic a dangerous drop in urine production. Because catheter obstruction can be identified and relieved at the bedside within seconds, it must be ruled out before more invasive or time-consuming steps are taken. The patient’s stable blood pressure of 132/84 mmHg and absence of pain make hypovolemia or acute surgical bleeding less likely as the immediate explanation, which further supports checking the tubing before escalating care.

Differential causes of early post-transplant oliguria

| Cause | Key feature | First nursing action |
| --- | --- | --- |
| Catheter obstruction | Sudden drop in output, bladder may be distended, no hemodynamic change | Inspect catheter and tubing for kinks, clots, or dependent loops; flush only with an order |
| Vascular thrombosis | Abrupt anuria, graft tenderness, rising creatinine; may occur in first month | Notify transplant team immediately after checking the catheter |
| Acute rejection | Gradual or sudden decline in output, fever, graft swelling, elevated creatinine | Report findings; prepare for labs and possible biopsy |
| Hypovolemia or hypotension | Low blood pressure, tachycardia, poor skin turgor, recent high output | Assess volume status; do not increase IV fluids without an order |

Why the other options are not first

Watch out! Notifying the transplant surgeon is essential, but it should occur after the nurse has gathered the immediate bedside information. A call that includes “the catheter is patent and there are no kinks” is far more useful than a call that skips this step. Key point! Increasing the intravenous fluid rate without a specific order is unsafe in a transplant recipient because fluid overload can worsen graft function and precipitate pulmonary edema, especially when the cause of oliguria is not yet known. Sending blood for an urgent serum creatinine is appropriate, but it takes time to result and does not address a mechanical obstruction that could be fixed immediately.

Pathophysiology link to graft vulnerability

Early allograft function depends on adequate renal perfusion and unobstructed urine drainage. Perioperative factors such as hemodynamic instability, vascular compromise, and surgical complications can all reduce urine output in the first days to weeks [1]. Renal vein thrombosis, although uncommon, is a feared early complication that can lead to rapid graft loss if not recognized promptly [2]. Renal artery thrombosis similarly threatens the graft and may be related to technical factors or hypercoagulable states [3][4]. A blocked catheter is the least dangerous of these possibilities and the easiest to correct, which is why it is assessed first in the nursing sequence.

Clinical reasoning summary

The nurse’s first action is to inspect the catheter and tubing for clots or kinks. If the system is patent and the oliguria persists, the nurse then notifies the transplant surgeon immediately, prepares to send urgent labs including serum creatinine, and continues close monitoring of vital signs, urine output, and graft site. This sequence prevents unnecessary delays in identifying a correctable mechanical problem while still ensuring rapid escalation for true graft-threatening events.References (research sources)

- [1]Perioperative Kidney Transplant Care: A Narrative Review of Preoperative Optimization, Intraoperative Management, and Early Postoperative Allograft Surveillance.Research articleAlrashidi FS, Alonazi R, Alazmi NN, Alrufayyiq N, Al-Humaidi K. (2026) · DOI: 10.7759/cureus.113062

- [2]Recurrent transplant renal vein thrombosis caused by May-Thurner syndrome: a case report and review of literature.Case reportKamali K, Saffari H, Zolfi E, Najafizadeh S, Abian N, Ahmadi F, Vahedisoraki V. (2026) · DOI: 10.1016/j.eucr.2026.103516

- [3]Transplant renal artery thrombosis caused by acute rejection : a case report.Case reportFang J, Li R, Xie Y, Liu S, Liu Y (2026) · DOI: 10.1186/s12882-026-05165-9

- [4]Acute graft thrombosis in a patient with factor V Leiden mutation: A case report and review of literature.Case reportLekehal B, Ait Youssef N, Lekehal M, Jdar A, El Hassani AEA, Belyazid I, Bakkali T, Bounssir A. (2026) · DOI: 10.5500/wjt.v16.i1.114162

## 임상 시나리오

Early Post-Transplant Oliguria: First ActionRule out catheter obstruction before escalating care
A sudden drop in urine output from 150–200 mL/h to 20 mL/h in a kidney transplant recipient is a graft-threatening sign. The most rapidly correctable cause is catheter obstruction from kinks, dependent loops, clots, or sediment. Inspect the catheter and tubing at the bedside first.

Stable blood pressure (132/84 mmHg) and absence of pain make hypovolemia or acute bleeding less likely. Do not increase IV fluids without an order. After checking for mechanical causes, report findings to the transplant surgeon immediately.

CautionDo not flush the catheter without a specific order. If obstruction is confirmed and not relieved by repositioning, notify the surgeon before any irrigation attempt.

## 핵심 개념

- **Oliguria** — Abnormally low urine output, often defined as less than 400 mL/day or less than 30 mL/h in adults
- **Catheter obstruction** — Blockage of urinary drainage by kinks, clots, sediment, or dependent loops, causing sudden drop in measured output
- **Graft thrombosis** — Vascular clot in the transplanted kidney causing abrupt anuria, graft tenderness, and rising creatinine
- **Acute rejection** — Immune-mediated injury to the transplanted kidney, often presenting with rising creatinine and decreased urine output
- **Living-donor kidney transplant** — Transplantation of a kidney from a living donor, typically with early graft function and high urine output

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