Kidney transplant
Anesthesia type

General

Airway

ETT

Lines and access

PIV x2
Arterial line
+/- Central line

Monitors

Standard, 5-lead ECG

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

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Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis. 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
Endocrine If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
Other

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

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
  • 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 nomeperidine > 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

Potential complications

  • Fistula thrombosis if improperly padded
  • Hemorrhage
  • Delayed urine output, dialysis may be needed 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

References