Renal transplant

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Summary

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Anaesthesia for Renal Transplants

Preoperative Assessment

  • Aim to limit cold ischaemic time.
  • Important considerations:
    • Associated comorbidities.
    • Cardiovascular risk.
    • Fluid status.
  • IV access history (including AV fistulas, dialysis lines, previously stenosed or thrombosed vessels).

Anaesthesia

  • Induction: Propofol with alfentanil or fentanyl.
    • RSI may be indicated if delayed gastric emptying is a concern.
  • Maintenance: Volatile or TIVA.
  • Muscle relaxant:
    • Atracurium.
    • Suxamethonium provided K+ < 5 mmol/L or high dose rocuronium as part of RSI.
    • Sugammadex (not licensed in severe renal impairment but appears safe and to provide complete reversal of blockade).

Targets

  • Warm and well perfused.
  • Adequate MAP (ideally within 20% of baseline).
  • Euvolaemia.
  • CVP 10-15 mmHg.

Monitoring and Access

  • Monitoring as per AAGBI/ SASA guidelines.
  • Arterial line not essential unless indicated by comorbidities.
  • NIBP on opposite side to AV fistula.
  • 20G IV access is sufficient.
  • Central venous access (dialysis line if no previous fistula).
  • Oesophageal temperature probe and urinary catheter.

Analgesia

  • IV paracetamol.
  • Fentanyl boluses titrated to effect (usually 200-300 mcg).
  • TAP blocks or local infiltration by surgeons.
  • Fentanyl PCA postoperatively.

Fluid Management

  • Important factor in post-transplant renal function.
  • Typically require ~40 ml/kg crystalloid
  • Colloid and blood rarely required.
  • Caution regarding overzealous filling which can strain the myocardium.
  • Transfusion trigger of 7 → may cause autoimmune activation and early graft rejection

Suitability of Drugs Commonly Used During Transplantation Surgery

Use Avoid
Volatile anaesthetics: Iso/Sevo/Desflurane Enflurane
Neuromuscular blocking drugs: Cis/atracurium Pancuronium, Sugammadex
Rapid sequence induction: Rocuronium (1.2mg/kg), Succinylcholine (if K+ < 5mmol/l) or Cisatracurium (1.5mg/kg) –
Analgesics: All fentanyl analogues NSAIDS Morphine
Diuretics: Mannitol, Furosemide

Immunosuppressive Medications in Renal Transplantation

  • Calcineurin Inhibitors:
    • Tacrolimus
    • Cyclosporine
  • Antiproliferative Agents:
    • Mycophenolate Mofetil
    • Mycophenolate Sodium
    • Azathioprine
  • mTOR Inhibitor:
    • Sirolimus
  • Steroids:
    • Prednisone
  • Sequence of drugs before reperfusion:
    • Promethazine, Hydrocortisone (or methylprednisolone)
    • Natalizumab or Grafalon (Monoclonal antibodies T-Cell). Given over 30 min via CVP

Anaesthetic Considerations in Recipients of Renal Transplants Presenting for Non-transplant Surgery

Summary

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Ongoing Management of Comorbidities

  • Diabetes Mellitus (DM)
  • Hypertension (HPT)
  • Ischemic Heart Disease (IHD)
  • Dyslipidemia
  • Vasculitis

Effects of Steroids and Immunosuppressants

  • Consider potential side effects and interactions (source required for specific details).

Drug Considerations (Depending on Renal Function)

  • Morphine: Risk of accumulation of metabolites.
  • Non-depolarizing Muscle Relaxants (NDMR): Effects can be unpredictable.
  • NSAIDs: Contraindicated regardless of renal function.

Avoid Hypovolemia and Hypotension

  • Important to prevent exacerbation of renal injury.

Multisystem Disease and Renal Dysfunction

  • Renal dysfunction is likely due to multisystem disease.
  • Important to inquire about the primary disease (e.g., DM) and associated comorbidities (e.g., HPT, hyperlipidemia, coronary artery disease (CAD).
  • Renal Function: May have reduced GFR; check post-transplant baseline.

Anaesthesia for Living Donor Renal Transplant Nephrectomy

Classification of Renal Transplants by Donor Organ Source

  1. Deceased Donor
    • Brainstem dead, heart-beating.
    • Non-heart-beating.
  2. Living Donor
    • Related: The donor is genetically related to the recipient (parent, child, sibling, half-sibling, aunt, uncle, niece, nephew, first cousin).
    • Unrelated
      • Emotional connection.
      • No emotional connection.
      • Altruistic.
      • Paired.
      • Pooled: Occasionally, more than two donors and two recipients will be involved in a swap. Each recipient gains from a transplant that they would not otherwise have had. The donors might not have given their kidney to the person they know, but that person will have received a kidney from one of the other pooled donors.

Surgical Techniques Used for Living Donor Nephrectomy (LDN)

  1. Open.
  2. Laparoscopic LDN.
  3. Hand-assisted laparoscopic LDN.
  4. Robot-assisted laparoscopic LDN.

Perioperative Anaesthetic Care Key Messages

  • No routine prophylactic antibiotic (clean procedure).
  • Comprehensive thromboembolism prophylaxis:
    • LMWH, graduated stockings, pneumatic compression devices.
  • Consultant Surgeon and Consultant Anaesthetist present.
  • Careful positioning to prevent pressure damage.
  • Combination of local and regional anaesthesia with GA:
    • Epidural.
    • Paravertebral block.
    • Transverse Abdominal Plain Block.
    • LA catheter in wound.
    • Local infiltration by surgeon.
  • Avoid Non-steroidal Anti inflammatory drugs.
  • Wide bore IV access.
  • Non-invasive monitoring, unless patient-specific indication.
  • Fluid preloading (e.g. 1 litre of Normal Saline post-induction).
  • Positive fluid balance throughout procedure.
  • Avoid vasoconstrictors.
  • Keep renal perfusion pressures / MAP at preoperative values.
  • Heparin (e.g. 5000 IU) before the application of arterial clamp.
  • Protamine (e.g. 50 mg) after kidney isolation.
  • High normal urine output (>100 ml /h)–Mannitol 0.5 g/kg can be used.
  • Fentanyl PCA.
  • Avoid hypothermia.

Frequency of Complications for Donors

  • Pneumonia: 9.3%.
  • Pulmonary atelectasis: 7.4%.
  • Urinary tract infection: 5.3%.
  • Wound infection: 4.3%.
  • Pneumothorax: 3.1%.
  • Urinary retention: 1.0%.
  • Ileus: 1.0%.
  • Pleural effusion: 0.9%.
  • Intra-abdominal haematoma: 0.5%.
  • Pulmonary embolus: 0.4%.
  • Wound herniation: 0.3%.
  • Splenectomy: 0.2%.
  • Deep venous thrombosis: 0.2%.
  • Intra-abdominal abscess: 0.2%.
  • Other unspecified: 5.3%.

Links

References:

  1. O’Brien, B. and Koertzen, M. (2012). Anaesthesia for living donor renal transplant nephrectomy. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 12(6), 317-321. https://doi.org/10.1093/bjaceaccp/mks040
  2. Rabey, P. (2001). Anaesthesia for renal transplantation. BJA CEPD Reviews, 1(1), 24-27. https://doi.org/10.1093/bjacepd/1.1.24
  3. Mayhew, D., Ridgway, D. M., & Hunter, J. (2016). Update on the intraoperative management of adult cadaveric renal transplantation. BJA Education, 16(2), 53-57. https://doi.org/10.1093/bjaceaccp/mkv013
  4. Meredith, S., Basavaraju, A., & Logan, N. (2021). Anaesthesia for renal transplantation. Anaesthesia &Amp; Intensive Care Medicine, 22(8), 500-504. https://doi.org/10.1016/j.mpaic.2021.06.012

Summaries:

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