Kidney transplant

Kidney transplant

Anesthesia type	General
Airway	ETT
Lines and access	PIV x2 +/- Arterial line +/- Central line
Monitors	Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line
Primary anesthetic considerations
Preoperative	ESRD patients should have potassium checked preop
Intraoperative	Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used
Postoperative	Replace UOP with IVF, may have delayed graft function if increased cold storage time
Article quality
Editor rating	Comprehensive
User likes	2

Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

Preoperative management

Patient evaluation

System	Considerations
Neurologic	Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy
Cardiovascular	CHF is common in undialyzed patients
Pulmonary	Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.
Gastrointestinal	Gastroparesis may occur in diabetic patients with autonomic neuropathy
Hematologic	Many patients will have chronic anemia as a result of low EPO
Renal	Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds. Most recipients also suffer from long-standing, HTN and its systemic concequences.
Endocrine	If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
Vascular	Many patients have coronary arterial, cerebrovascular, and peripheral vascular disease in addition to their HTN.

Labs and studies

• CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production)
• BMP (pay attention to K which may be elevated in ESRD)

Operating room setup

• Prepare arterial line setup
• Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room
• May need steroid and/or anti-thymocyte globulin prepared

Patient preparation and premedication

• Midazolam, Tylenol

Regional and neuraxial techniques

• Epidural or CSE may be used for postop pain management
• Pre-emergence TAP catheter vs single-shot

Intraoperative management

Monitoring and access

• After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
• Arterial line for blood pressure monitoring and frequent lab draws
• IVs and arterial lines should avoid the side of AV fistula if present

Induction and airway management

• If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used

Positioning

• Supine
• Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded.

Maintenance and surgical considerations

• Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
  • Choice of fluids: balanced electrolyte solution (Plasmalyte, Normosol, or Lactated Ringer) vs normal saline
    • Historically normal saline was the fluid of choice. Recent study showed are lower rates of delayed graft function (30 versus 40 percent in NS group; BEST-Fluids trial). Additionally, many institutions have changed to balanced electrolyte solutions due to high rates of hyperchloremic metabolic acidosis seen in large volume NS administration (leading to similar intracellular K+ rates). NS also increased need for vasoactives intraop in this study.
• Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates
• After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
• Anticipate prolonged drug effects for renally metabolized/excreted medications
  • Avoid meperidine (which may accumulate as normeperidine > CNS toxicity)
• Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
• Will be instructed to clamp Foley by surgeons
• May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection

Emergence

• Patients are usually extubated in the OR
• Ensure adequate NMB reversal

Postoperative management

Disposition

• Usually to PACU
• Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU

Pain management

• PCA
• Epidural
• TAP block

Potential complications

• Fistula thrombosis if improperly padded
• Hemorrhage
• Delayed urine output, dialysis may be necessary until renal function returns
• Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications