Renal Transplant Surgery

• One needs to know the underlying aetiology of their CKD/need for renal transplant
• Elucidate the presence of coalescing diseases e.g. HTN, IHD, diabetes
• Enquire about dialysis:
• Method e.g. PD vs. HD
• Lines/fistulae
• Last dialysis date
• Fluid status and dry weight
• Drug history; often polypharmacy

• FBC
• Patients are frequently anaemic; iron replacement, erythropoietin or blood transfusion to [Hb] >70g/L if necessary
• Platelet number may be normal although function may be compromised
• A raised WCC should prompt investigation for infection ± consideration of cancelling surgery in view of mandatory post-operative immunosuppression
• Clotting studies and group & cross-match


• Post-dialysis U&E, including chloride, bicarbonate and acid-base status
• K+ levels >6mmol/L require pre-operative dialysis
• K+ levels 5 - 6mmol/L may be judged on an individual basis


• Routine observations inc. NIBP
• ECG; need one from booking and one more pre-operatively to ensure no changes following electrolyte imbalance
• CXR
• TTE ± further cardiovascular investigations if warranted


• Some measure of functional capacity e.g. CPET

• In short: prehabilitation
• Slightly longer:
• Patient education (see below)
• Correct anaemia
• Optimise cardiac comorbidities
• Smoking and alcohol cessation
• Nutritional assessment + optmisation + carbohydrate drinks pre-operatively


• Avoid routine pre-operative placement of central lines
• Avoid excessive fluid volume replacement

• Continue aspirin, statins, β-blockers and diuretics
• Patients are typically hypertensive
• Beware the patient on zero anti-hypertensive agents; it implies their cardiovascular physiology is too frail to tolerate an anti-hypertensive agent!
• Usual treatment is with ACE-I/ARA and, as HTN is often refractory, other drugs including CCB, ɑ-blockers and β-blockers
• These drugs impair autoregulation and ability to respond to hypovolaemia under anaesthesia
• Consider withholding ACE-I pre-operatively, unless there is LV dysfunction

• Pre-operative dialysis will reduce plasma potassium concentration, correct acidosis and potentially avoid need for post-operative dialysis
• Conversely, it will cause relative intravascular depletion and lead to transient anticoagulation
• 'If in doubt, dialyse'

• Introduction to principles of ERAS
• Managing expectations for the peri-operative period
• Identifying potential challenges and barriers to optimal recovery and discharge
• Education around the importance of maintaining cardiovascular health and keeping well on the transplant waiting list

• AAGBI as standard inc. neuromuscular monitoring
• Consider depth of anaesthesia monitoring in the elderly/frail patient
• Arterial line only if concerns about cardiac status
• Avoid forearm and antecubital veins for cannulae in case need future fistula
• Use RIJ for CVC (avoid subclavian as may compromise future fistula formation)
• ± haemodialysis catheter
• ± Oesophageal Doppler

• In general, consider the renal elimination of the drugs used
• RSI should be considered, especially in patients with autonomic dysfunction ± delayed gastric emptying


• Propofol and thiopentone are viable agents - reduce dose of thiopentone in uraemia to correct for changes in plasma protein binding
• IV opioid options include fentanyl and remifentanil
• mMrphine's active metabolites are renally excreted, so it should probably be avoided (although can be used in lower doses)
• Rocuronium is the NMBA of choice for RSI
• Use of atracurium for intra-operative paralysis may be preferential as rocuronium (30%) and the rocuronium-sugammadex complex are renally excreted
• Suxamethonium and its potassium-boosting ways are not welcome here

• Both sevoflurane and isoflurane are suitable maintenance agents, with neither associated with post-operative renal dysfunction
• For cases >4 MAC-hours, desflurane is associated with less fluoride ion production although this is not demonstrably clinically significant
• TIVA is a suitable alternative

• Generally supine + lateral roll as necessary
• Meticulous AVF care is required:
• Avoid cannulating it
• Wrap it with cotton wool (both literally and metaphorically)
• Careful position to avoid traction/compression injuries

• Paracetamol
• Incremental doses of fentanyl (up to 1μg/kg) [or morphine (up to 0.1mg/kg)]
• TAP blocks
• Consider a neuraxial technique, which may reduce perioperative opioid requirements, although issues include:
• Existing thrombocytopaenia/coagulopathy
• Need for immediate post-operative haemodialysis (with anticoagulation)
• Therefore higher risk of spinal/epidural haematoma
• More pronounced hypotensive sequelae in patients with cardiac disease/on anti-hypertensives

• A higher MAP target preserves residual native renal function, reduces delayed graft function and reduces the need for post-operative dialysis
• A CVP of 12 - 14cmH₂O at time of graft perfusion improves graft survival and function


• Fluid management must strike a balance:
• Adequate fluid therapy for optimised CO and renal perfusion, and reduced blood viscosity, may improved outcomes
• Over-administration of fluid risks post-operative pulmonary oedema; outcomes may be better if total fluid administration is <2.5L
• Balanced crystalloid or HAS are options; avoid 0.9% NaCl and HES


• Other treatments aimed at improving renal outcomes:
• Mannitol 20% 0.5g/kg at time of arterial clamp removal; no great evidence for improved graft survival
• Dopamine use is ever-decreasing as no evidence it improves patient or graft outcomes
• Blood transfusion; use allogenic CMV-negative blood judiciously as may cause hyperkalaemia or fluid overload

• Standard measures apply:
• Maintain normothermia
• Maintain normoglycaemia
• Appropriate VTE prophylaxis
• Multi-modal anti-emesis

• High-dose methylprednisolone administered at the time of venous anastomosis
• Administration of basiliximab 20mg slow IV (or rituximab)

• Routine admission to L2/3 care is not absolutely necessary, but should be considered for usual indications
• A dedicated post-transplant unit is essential as staff are trained in the care of these patients, and any complications


• Standard ERAS targets including early mobilisation, early removal of drains and catheters

• Paracetamol
• TAP blocks ± wound infusion catheters
• An opioid PCA
• Fentanyl
• Oxycodone
• If a morphine PCA must be used, reduce the bolus dose to 1mg

• Target appropriate MAP post-operatively; suboptimal MAP increases incidence of delayed graft failure
• Transplant of live donor kidneys usually results in immediate return of urine output
• Cadaveric transplants may not produce urine straight away


• Titrate fluid therapy to match urine output in the post-operative period (or 30ml/hr + UO)
• Encourage early return to oral intake to reduce risks associated with excessive IV fluid administration
• Daily clinical assessment of volume status including weight, and input / output, providing the patient with a daily oral intake target

• Modern regimens consist of two phases: induction (see above) and maintenance


• Ciclosporin was historically used but is less fancied now owing to effects such as:
  • Neurological: post-transplant seizures, tremor, encephalopathy
  • Reduced GFR
  • Hepatic impairment
  • Hypertension
  
  
• Biological agents are used instead to induce immunosuppression (e.g. basiliximab 20mg slow IV, alemtuzumab 30mg IV over 1hr)
• These agents reduces the incidence of early cellular rejection, but carry risks such as:
• Anaphylaxis or anaphylactoid reactions
• Perioperative cardiac events
• Infectious complications
• Cutaneous events