Version June 2024
INTRODUCTION — After progression to end-stage kidney disease (ESKD), kidney transplantation is the treatment of choice and is the most commonly performed organ transplantation. Compared with maintenance dialysis, successful transplantation improves quality of life and reduces mortality risk for most patients.
This topic reviews the preanesthesia consultation and anesthetic management of patients undergoing kidney transplantation. Medical evaluation of a kidney transplant recipient, issues related to dialysis before and after surgery, and complications following transplantation (eg, graft failure and mortality) are discussed separately:
●(See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient".)
●(See "Kidney transplantation in adults: Timing of transplantation and issues related to dialysis".)
●(See "Kidney transplantation in adults: Risk factors for graft failure".)
●(See "Kidney transplantation in adults: Patient survival after kidney transplantation".)
PREANESTHETIC CONSIDERATIONS
Living-donor versus deceased-donor kidney — Considerations affecting preoperative decisions for a kidney transplant recipient include whether the donated kidney is from a living or deceased donor. Transplantation of a living-donor kidney is an elective surgical procedure. Potential recipients are evaluated at a preoperative outpatient clinic prior to hospital admission so that the outpatient nephrologist can ensure optimal patient condition before surgery.
In contrast with living-donor kidney transplantation, transplantation of a deceased-donor kidney is a relatively urgent procedure (because of the time-limited viability of the donated kidney) performed in an elective population. Although patients on deceased-donor waiting lists are maintained medically cleared for transplant at all times, preoperative re-evaluation is performed in the hospital shortly before transplantation.
Further information regarding preoperative considerations in transplant recipients is available in other topics:
Assessing need for preoperative dialysis — Decisions regarding possible need for preoperative dialysis depend in part on whether the patient has been chronically dependent on maintenance dialysis, as well as whether hyperkalemia or volume overload is present. If possible, dialysis should be avoided for 24 hours prior to kidney transplantation. (See "Kidney transplantation in adults: Timing of transplantation and issues related to dialysis", section on 'Routine dialysis immediately prior to transplantation'.)
If hemodialysis is necessary on the day of surgery, we use heparin-free dialysis to avoid intraoperative coagulopathy. If heparin has been used for any reason, we wait three to four hours for the coagulation profile to return to normal, if possible, since the half-life of heparin is 90 minutes. We check that the partial thromboplastin time (PTT) has normalized (<45 seconds) at the time of surgery. (See "Medical management of the dialysis patient undergoing surgery", section on 'Use of heparin'.)
●Nondialysis patients – Patients with end-stage kidney disease (ESKD) who are awaiting a living-donor kidney transplantation are often not on maintenance dialysis even though they have significant kidney dysfunction. Such patients are closely followed by a nephrologist (eg, monthly, if not more frequently) to detect any indication to start dialysis. However, dialysis is avoided if possible since preemptive transplantation performed in patients who have not had prior dialysis is associated with better outcomes than transplantation performed in patients receiving chronic dialysis. (See "Kidney transplantation in adults: Timing of transplantation and issues related to dialysis", section on 'Preemptive transplantation'.)
In rare cases, a nondialysis patient will have an indication for preoperative dialysis shortly before transplantation (typically hyperkalemia and/or volume overload).
●Dialysis patients – Patients awaiting deceased-donor kidney transplantation are typically receiving chronic maintenance dialysis to treat their ESKD, and may have been on the transplant wait list for a prolonged period. Such patients have usually received dialysis within 48 to 72 hours of hospital admission for transplantation.
Hyperkalemia — Mild hyperkalemia at baseline is common among patients with ESKD [1]. If serum potassium is ≥5.5 mEq/L, we employ dialysis if possible. In a chronically dialyzed patient, a usable dialysis access site is typically available. If there is no functioning dialysis access, we place a temporary catheter to provide dialysis prior to surgery. (See "Medical management of the dialysis patient undergoing surgery", section on 'Indications for urgent preoperative dialysis'.)
However, there is variability among transplant centers regarding this decision. For example, if urgent surgery is necessary in a patient with chronic hyperkalemia and the preoperative serum potassium level is ≤6.0 mEq/L, medical therapy may be initiated in some centers, rather than delaying surgery for dialysis. This includes intravenous (IV) administration of 10 units of regular insulin together with 50 mL of 50 percent glucose (ie, 25 g of glucose). A subsequent infusion of 10 percent dextrose is administered at 50 to 75 mL/hour to avoid hypoglycemia. Serum glucose should be measured one hour after administration of insulin. A beta2 agonist (eg, albuterol or salbutamol) can be added to insulin-plus-glucose therapy in order to maximize reduction in serum potassium. (See "Treatment and prevention of hyperkalemia in adults", section on 'Insulin with glucose' and "Anesthesia for dialysis patients", section on 'Management of hyperkalemia'.)
A usable chronic dialysis access site or temporary catheter should be in place to provide dialysis in the immediate postoperative period due to the possibility of delayed renal graft function.
Volume overload — Volume overload is another potential indication for dialysis before transplantation.
Our approach depends upon whether the patient is on maintenance dialysis.
●Nondialysis patients – If significant volume overload is present in a nondialysis patient, our initial treatment is IV loop diuretics (see "Causes and treatment of refractory edema in adults"). If diuretic therapy is not effective, dialysis may be employed to remove fluid. In patients with no other indications for dialysis (eg, hyperkalemia), isolated ultrafiltration may be used to remove excess fluid rather than dialysis with ultrafiltration, but isolated ultrafiltration removes only 1 to 2 L [2,3].
Since patients awaiting living-donor transplantation are closely followed by an outpatient nephrologist, intravascular volume status is monitored and responsiveness to diuretic therapy is generally preserved. If there is little response to diuretic administration, possible changes in clinical status (eg, worsening cardiac function) should be sought prior to transplantation.
●Dialysis patients – If significant volume overload is present in a chronically dialyzed patient, we initiate dialysis before transplantation when feasible, rather than attempting a trial of diuretic therapy. Chronic dialysis patients are frequently anuric and therefore are not likely to respond to treatment with diuretics. Isolated ultrafiltration may be used to remove an appropriate amount of fluid [2,3]. Excessive peripheral edema in a chronically-dialyzed patient may be an indication of the subacute onset of heart failure, and should prompt evaluation for its presence (typically echocardiography) and possible causes. (See "Heart failure: Clinical manifestations and diagnosis in adults" and "Overview of screening and diagnosis of heart disease in patients on dialysis", section on 'Diagnosis of heart failure'.)
We avoid excessive ultrafiltration if hemodialysis is necessary for fluid removal on the day of surgery, since this may result in excessive intravascular volume depletion and consequent risk of intraoperative hypotension. We target a post-dialysis weight that is 1 to 2 L above the patient's usual target "dry weight," which is established by the outpatient nephrologist and documented on the outpatient dialysis chart.
Assessing comorbidities — Patients with ESKD, particularly those who require chronic dialysis, typically have multisystem comorbidities mediated by the primary disease process causing renal failure (eg, diabetes, hypertension) and/or by the adverse effects of chronic kidney disease and dialysis. These include cardiovascular disease (eg, coronary arterial, cerebrovascular, and peripheral vascular disease; heart failure; valvular heart disease; pulmonary hypertension; atrial fibrillation), anemia, coagulation abnormalities, gastrointestinal disorders, or osteodystrophy. In particular, preoperative frailty is associated with increased mortality risk [4]. Conversely, patients scheduled to receive a living-donor transplant are typically not on dialysis and may be relatively healthy without uremic symptoms and with few comorbidities. (See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient".)
Assessment for any signs or symptoms of active infection is particularly important in any transplant recipient. (See "Evaluation for infection before solid organ transplantation".)
Further details regarding recipient assessment are available in other topics. (See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient".)
Laboratory testing and blood availability — Results of a thorough pretransplant evaluation will be available. Available laboratory tests typically include a complete blood count, PTT and international normalized ratio (INR), blood urea nitrogen (BUN), creatinine, electrolytes, calcium, phosphorus, albumin, liver function tests, fasting lipid panel, uric acid, parathyroid hormone (PTH) level, urinalysis, and pregnancy test for potentially fertile women. Patients with multiple risk factors for cardiovascular disease often have one or more pretransplant echocardiography studies in their record. (See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient", section on 'Cardiovascular disease'.)
In addition, blood type compatibility and human leukocyte antigen (HLA) typing are performed. We routinely order crossmatching of 2 units of packed red blood cells (RBCs) since significant blood loss is a possibility in any surgical procedure involving ligation and reanastomosis of major blood vessels. However, blood loss is usually only 150 mL. Thus, these RBC units remain in the blood bank, rather than being immediately available in the operating room.
Other specialized tests are ordered in selected patients, as discussed in detail elsewhere. (See "Kidney transplantation in adults: HLA-incompatible transplantation" and "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient", section on 'Initial evaluation'.)
Planning for intraoperative immunosuppression — The intraoperative immunosuppression regimen to be used before and after reperfusion of the renal graft should be discussed with the surgeon in the immediate preoperative period. (See "Kidney transplantation in adults: Induction immunosuppressive therapy", section on 'Indications for induction therapy'.)
Medication management — Preoperative management of cardiovascular and other chronically administered medications is addressed elsewhere. (See "Perioperative medication management".)
It is reasonable to administer a small dose of IV midazolam (eg, 0.5 to 2 mg) to an anxious patient in the immediate preoperative period (ie, shortly before or after transport into the operating room), although not all clinicians and centers routinely do this.
Many ESKD patients have heartburn or other symptoms of gastroparesis [5,6]. In such patients, we administer an oral nonparticulate antacid (eg, sodium citrate 500 mg in 15 mL) and an IV histamine-2 receptor antagonist (eg, cimetidine, famotidine) to reduce gastric pH. We do not routinely administer metoclopramide. However, in ESKD patients with a history of poorly controlled diabetes, some clinicians do administer metoclopramide 10 to 20 mg IV at least 20 minutes prior to anesthetic induction in an attempt to reduce gastric volumes [7]. (See "Unique aspects of gastrointestinal disease in patients on dialysis", section on 'Gastroparesis'.)
Considerations during the COVID-19 pandemic — Solid organ transplantation should proceed with caution during the coronavirus disease 2019 (COVID-19) pandemic, taking into account the potential risks of virus transmission, the high mortality should COVID-19 develop in the recipient, and the loss of an opportunity for transplant should an available organ not be used [8]. However, it is recognized that the number of transplants may be reduced in institutions that are temporarily overwhelmed with regional COVID-19 cases. Similar to recommendations for patients with end-stage heart or lung disease who contract COVID-19 while waitlisted [9], a reasonable approach for patients with ESKD is to become inactive on the waitlist until at least 14 days after initial diagnosis if apparent recovery and two successive negative polymerase chain reaction (PCR)-based tests are documented at least 48 hours apart, since viral shedding has been demonstrated to occur after resolution of clinical symptoms. This timeframe is based on the higher acuity of waitlisted patients and lesser opportunities for solid organ availability. Considerations for anesthetic and airway management of patients who might still be shedding viral particles are discussed in a separate topic. (See "COVID-19: Perioperative risk assessment, preoperative screening and testing, and timing of surgery after infection" and "COVID-19: Issues related to solid organ transplantation" and "Overview of infection control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg, COVID-19)'.)
INTRAOPERATIVE ANESTHETIC MANAGEMENT
Surgical considerations
Technical aspects — With the patient in supine position, a curvilinear incision is made in the right or left lower abdominal quadrant. The extraperitoneal iliac fossa is developed and the external iliac artery and vein are identified and mobilized. Heparin may be administered before clamping of venous or arterial vessels.
The allograft is positioned, and its renal vein is anastomosed to the external iliac vein. After its renal artery is anastomosed to the external iliac artery, the allograft is reperfused. The bladder is filled with an antibiotic irrigation solution, and a ureter-to-bladder anastomosis is performed. Finally, the wound is closed, with the native kidneys left in place. Procedure duration is usually between 1.5 and 3 hours.
Some surgeons prefer to stent the ureteroneocystostomy to minimize the risk of leak or stenosis. When a stent is used, it is generally left in place for four to six weeks and is removed via cystoscopy. Other surgeons tie a suture to the stent and Foley catheter, with subsequent removal of both just before discharge from the hospital.
Further details can be found in other topics. (See "Kidney transplantation in adults: Overview of the surgery of deceased donor kidney transplantation".)
Antibiotic prophylaxis — A first-generation cephalosporin such as intravenous (IV) cefazolin is administered (ie, 2 g for a patient <120 kg and 3 g for a patient ≥120 kg, with redosing after four hours), beginning 30 to 60 minutes before the anticipated time of surgical incision to ensure that tissue levels of antibiotic are adequate during incision [10-13]. Generally, 24 hours or less of a broad-spectrum antibiotic provides adequate protection for kidney transplantation in the absence of specific microbiologic data that would require broader coverage. (See "Evaluation for infection before solid organ transplantation", section on 'Perioperative prophylaxis' and "Prophylaxis of infections in solid organ transplantation", section on 'Peri-transplantation prophylaxis'.)
If possible, regimens that include vancomycin or clindamycin should be avoided in order to decrease the risk of colonization with vancomycin-resistant organisms or postoperative diarrhea due to Clostridioides (formerly Clostridium) difficile (which is more likely after administration of clindamycin compared with other antimicrobial agents) [14]. However, patients who are allergic to penicillin or cephalosporins do receive vancomycin 1 g beginning 60 to 120 minutes before surgical incision, with this prolonged infusion time to avoid flushing, erythema, and hypotension (ie, "red man" syndrome). (See "Vancomycin hypersensitivity", section on 'Vancomycin infusion reaction'.)
Use of other perioperative antibiotics may be necessary when specific data are available regarding colonization or infection due to resistant organisms; this information is presented separately. (See "Evaluation for infection before solid organ transplantation" and "Prophylaxis of infections in solid organ transplantation".)
Patient positioning — During patient positioning, any arteriovenous fistula is carefully protected to avoid pressure that may lead to thrombosis.
Monitoring — The major goals of monitoring are maintenance of renal blood flow to the renal graft and maintenance of optimal intravascular volume status. (See 'Fluid management' below and 'Hemodynamic management' below.)
All centers use standard intraoperative monitors (table 1) (see "Basic patient monitoring during anesthesia", section on 'Standards for monitoring during anesthesia'). In addition, we routinely employ invasive hemodynamic monitors to optimally maintain hemodynamic stability and guide fluid administration. These include:
●An intra-arterial catheter to provide continuous monitoring of arterial blood pressure (BP) and evaluation of respirophasic variations in the pressure waveform (figure 1), and facilitate intermittent blood sampling for point-of care laboratory testing (eg, for potassium, glucose, and hemoglobin concentrations). (See "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness'.)
●A central venous catheter (CVC) is often inserted if it is difficult to establish adequate peripheral venous access (eg, a 14 or 16 gauge IV catheter) since rapid intraoperative blood loss is possible during kidney transplantation. Also, if infusion of vasoactive drugs is anticipated during the perioperative period, administration of vasoconstrictor agents via a CVC or peripherally inserted central catheter (PICC) is preferred. Although measurement of central venous pressure (CVP) via a CVC or PICC catheter provides supplemental data regarding intravascular volume status, CVP values poorly predict fluid responsiveness [15,16]. (See "Central venous access in adults: General principles", section on 'Indications' and "Intraoperative fluid management", section on 'Monitoring intravascular volume status'.)
●A bladder catheter is inserted to monitor urine output (UO) after the renal graft has been implanted. Although oliguria (UO <0.5 mL/kg/hour) is commonly used as an indicator of hypovolemia in patients with normal kidney function, most patients undergoing kidney transplantation are anuric until after the final vascular and ureteral anastomoses have been completed. Some may remain oliguric due to technical problems (eg, ureteral obstruction or vascular thrombosis) or decreased perfusion of the allograft. Thus, fluid administration solely for the purpose of increasing UO is not indicated and may lead to fluid overload. (See "Kidney transplantation in adults: Evaluation and diagnosis of acute kidney allograft dysfunction".)
Some patients may benefit from transesophageal echocardiography (TEE):
●Elective use of TEE to assess intravascular volume status and rapidly recognize acute hypovolemia (movie 1). (See "Intraoperative transesophageal echocardiography for noncardiac surgery", section on 'Assessment of left ventricular volume'.).
●Emergency use of perioperative TEE is indicated if unexplained persistent or life-threatening hemodynamic instability ("rescue echo") occurs, if equipment and expertise are available [17]. (See "Intraoperative rescue transesophageal echocardiography (TEE)".)
Anesthetic management
Choice of anesthetic technique — General anesthesia is employed for kidney transplantation surgery. Concerns regarding coagulopathy due to uremic platelet dysfunction and/or residual heparin from dialysis limit the use of neuraxial and other regional anesthetic techniques, although use of epidural anesthesia without a general anesthetic has been reported [18,19].
Metabolism and elimination of most anesthetic drugs may be delayed in end-stage kidney disease (ESKD), due to impairment of glomerular filtration and renal tubular function, leading to accumulation of drugs and their metabolites. Also, volume of distribution and degree of plasma protein binding of anesthetic drugs may be altered, resulting in higher-than-expected plasma concentrations. These changes gradually normalize after successful kidney transplantation.
Specific considerations for commonly used anesthetic agents in patients with ESKD are reviewed separately. (See "Anesthesia for dialysis patients", section on 'General anesthesia'.)
Induction — We typically induce general anesthesia with IV propofol 1 to 2.5 mg/kg because the pharmacokinetic and pharmacodynamic responses to this agent are not markedly altered by ESKD [20,21]. We reduce and titrate the propofol dose in patients who may be hypovolemic since a standard induction dose administered as a bolus may result in profound hypotension due to venous and arterial dilation. Induction doses of propofol are also reduced in patients with known coexisting heart failure or older age [22-24]. (See "Anesthesia for dialysis patients", section on 'Induction' and "General anesthesia: Intravenous induction agents", section on 'Propofol'.)
During induction in most patients, we also administer adjuvant medications to blunt tachycardia due to the sympathetic response to laryngoscopy and endotracheal intubation (eg, fentanyl 1 to 2 mcg/kg and/or lidocaine 1 mg/kg), as well as a neuromuscular blocking agent (NMBA). Some ESKD patients require rapid sequence induction and intubation (RSII) due to gastroparesis with risk of aspiration of gastric contents. Succinylcholine (SCh) can be safely used as the NMBA to facilitate laryngoscopy if potassium concentration is <5.5 mEq/L and there are no electrocardiographic (ECG) changes [25]. If potassium is ≥5.5 mEq/L in a patient who requires RSII, we use a relatively large dose of rocuronium (1 mg/kg) rather than SCh [26]. A remifentanil intubation technique is an alternative that facilitates laryngoscopy while avoiding any NMBA. (See "Anesthesia for dialysis patients", section on 'Induction' and "Rapid sequence induction and intubation (RSII) for anesthesia".)
Hydration status is assessed immediately before induction, including whether dialysis was recent and whether there is any deviation from the target dry weight (see 'Volume overload' above). For patients with likely hypovolemia, we suggest volume expansion before administration of anesthetic induction agents, with rapid IV administration of 1 to 2 L of isotonic crystalloid solution (eg, normal [0.9 percent] saline or an acetate-buffered, chloride-reduced solution such as Normosol-R, Lactated Ringer [also termed Hartmann's solution], or Plasmalyte). (See 'Fluid management' below.)
Maintenance
●Anesthetic agents and adjuvants – We typically employ inhalation agents to maintain anesthesia (eg, isoflurane in an air/oxygen mixture or in combination with 70 percent nitrous oxide [N2O]), since elimination occurs predominantly via exhalation, independent of renal function. N2O gas has low potency but may be used to decrease the dose of the selected volatile anesthetic agent. Its advantages include quick and reliable recovery, analgesic properties, and less myocardial depression than any of the potent volatile agents. (See "Inhalation anesthetic agents: Clinical effects and uses".)
Any of the potent volatile inhalation anesthetics (eg, isoflurane, desflurane, sevoflurane) may be used. There are theoretical concerns regarding renal toxicity during sevoflurane administration due to its inorganic fluoride ion metabolite or formation of compound A, but it has been used safely in patients with chronic stable renal insufficiency and in dialysis patients. The US Food and Drug Administration (FDA) recommends using fresh gas flows >1 to 2 L/minute to administer sevoflurane. (See "Inhalation anesthetic agents: Clinical effects and uses", section on 'Sevoflurane'.)
We supplement an inhalation-based anesthetic technique with intermittent bolus doses of an opioid (eg, fentanyl or sufentanil) titrated to treat hemodynamic parameters indicating sympathetic responses to pain (eg, tachycardia and/or hypertension).
●Neuromuscular blocking agents – We administer a nondepolarizing NMBA by intermittent bolus technique, titrated according to the degree of neuromuscular blockade with a peripheral nerve stimulator, in order to avoid intraoperative patient movement (eg, bucking and coughing). Movement can result in disruption of venous and arterial anastomoses, and revision of the anastomoses increases the warm ischemia time and may result in ischemic damage to the graft. Thus, we ensure maintenance of adequate muscle relaxation until the abdominal wall muscle fascia has been closed.
We typically select cisatracurium or atracurium because these NMBAs are metabolized through nonspecific plasma esterase-mediated hydrolysis and a nonenzymatic, pH- and temperature-dependent degradation called Hofmann elimination. Thus, their duration of action is not affected by ESKD (table 2). However, rocuronium or vecuronium is a reasonable alternative. (See "Anesthesia for dialysis patients", section on 'Maintenance'.)
Fluid management — The overall goal of fluid management is intraoperative volume expansion in order to increase renal blood flow and improve allograft function immediately after reperfusion [27-32].
Monitoring intravascular volume status — We monitor variations during respiration in systolic blood pressure (SPV), pulse pressure (PPV), or stroke volume (SV) on the waveform of the intra-arterial catheter (figure 1 and table 3). Hypotension and PPV >15 percent will likely improve with fluid resuscitation. Although these hemodynamic indices of respiratory variation can be computed (manually or automatically), visual estimation may be adequate to guide fluid therapy [33]. (See "Intraoperative fluid management", section on 'Respiratory variations in arterial pressure waveform'.)
If a CVC is present, we also monitor and maintain CVP in the range of 8 to 12 mmHg. (See "Intraoperative fluid management", section on 'Traditional static parameters'.)
Choosing fluids
●Crystalloid solutions – For maintenance fluid requirements, we administer isotonic crystalloid solutions at 1 to 3 mL/kg per hour. Also, we administer 250 mL increments to optimize intravascular volume if indicated by dynamic hemodynamic parameters, with reassessment of volume status after each 250-mL increment of fluid. (See "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness'.)
We select a balanced electrolyte solution (eg, Plasmalyte, Normosol, or Lactated Ringer [also termed Hartmann's solution]), although centers vary in their selection of solutions. Some administer normal saline and a balanced electrolyte solution in a 50-50 combination. We avoid administering >2 to 3 L of normal saline, as this may result in hyperchloremia, hyperchloremic metabolic acidosis, renal vasoconstriction, decreased glomerular filtration rate, and kidney injury [34-46].
In one randomized trial in 807 recipients of a deceased donor kidney transplant, the incidence of delayed graft function (defined as receiving dialysis in the first seven days after transplantation) was lower among recipients receiving a balanced crystalloid solution compared with those receiving normal saline (30 versus 40 percent, respectively) [47]. In another randomized trial in 150 transplant recipients, those receiving normal saline had significantly more hyperchloremia and metabolic acidosis than those receiving an acetate-buffered, chloride-reduced solution, although hyperkalemia was more common in patients receiving the chloride-reduced solution [46]. (See "Intraoperative fluid management", section on 'Crystalloid solutions'.)
●Colloid solutions – In addition to isotonic crystalloid solutions, some centers administer 5 percent albumin to replace blood loss on a 1:1 volume basis until a transfusion threshold is met. We limit administration of albumin and rarely exceed 500 mL. (See "Intraoperative fluid management", section on 'Colloid solutions' and "Intraoperative transfusion and administration of clotting factors", section on 'Red blood cells'.)
We avoid hydroxyethyl starch (HES) solutions because of increased risk of renal failure in critically ill patients [48-51]. (See "Treatment of severe hypovolemia or hypovolemic shock in adults", section on 'Fluids to avoid: hyperoncotic starch (colloid)'.)
Randomized trials and meta-analyses have failed to demonstrate benefits of albumin compared with crystalloid solutions [52,53]. In one large, retrospective cohort study using population-based data from 1,051,441 patients undergoing elective joint arthroplasty, perioperative fluid resuscitation with colloid (either 6 percent HES or 5 percent albumin) was compared with crystalloid [54]. Both HES (odds ratio [OR] 1.23, 95% CI 1.13-1.34; 43,732 patients) and albumin (OR 1.56, 95% CI 1.36-1.78; 8022 patients) were associated with a significantly increased risk of acute kidney injury compared with crystalloids. (See "Intraoperative fluid management", section on 'Colloid solutions' and "Treatment of severe hypovolemia or hypovolemic shock in adults", section on 'Second-line: Colloid solutions'.)
●Blood transfusions – Perioperative blood transfusion is avoided, if possible. However, transfusion may be necessary in patients with hemoglobin <7 g/dL (or <8 g/dL in patients with significant cardiovascular disease), particularly if surgical bleeding is ongoing [55]. For all transfusions, we use only salvaged, autologous, washed red blood cells (RBCs), if available, or leukocyte-reduced allogeneic RBCs from the blood bank. (See "Surgical blood conservation: Intraoperative blood salvage".)
Hemodynamic management — We maintain mean arterial pressure (MAP) at 70 to 90 mmHg in most patients by maintaining adequate intravascular volume and careful titration of anesthetic agents. We typically employ direct intra-arterial measurement of BP for early detection and treatment of hypotension or hypertension.
●Hypotension – Hypotension is avoided primarily by maintaining adequate intravascular volume, as well as careful titration of anesthetic agents. Administration of vasopressors is minimized since alpha agonists may interfere with renal perfusion to adversely affect graft function. If a vasopressor is needed for treatment of hypotension that does not respond to volume administration, we administer ephedrine 5 to 10 mg, with repeated doses as needed.
Dopamine is not typically used since it is not beneficial for renal allograft function and has potentially harmful effects [56]. In rare patients with refractory hypotension, we administer a dopamine infusion (eg, 3 to 5 mcg/kg/minute).
●Hypertension and/or tachycardia – Hypertension and/or tachycardia is treated with an IV beta blocker (eg, esmolol, metoprolol, labetalol) (table 4). Vasodilator therapy may be necessary for treatment of severe hypertension or ischemia (eg, nicardipine or nitroglycerin).
Management of hyperkalemia — Signs of hyperkalemia on the electrocardiogram (eg, peaked T waves, widened P waves, or prolonged PR interval) are managed with the following therapies [26]:
●IV calcium (eg, calcium chloride 500 to 1000 mg) to directly antagonize the membrane actions of hyperkalemia. Since hypocalcemia exacerbates potassium-induced cardiotoxicity, ionized calcium concentrations are monitored, and hypocalcemia is treated. (See "Treatment and prevention of hyperkalemia in adults", section on 'Calcium'.)
●IV insulin (typically administered with an IV glucose infusion) to drive extracellular potassium into cells. (See "Treatment and prevention of hyperkalemia in adults", section on 'Insulin with glucose'.)
●Hyperventilation to decrease PaCO2 to 30 to 35 mmHg combined with bicarbonate therapy if severe acute metabolic acidosis is present (ie, pH <7.1) may raise pH and drive extracellular potassium into cells (figure 2). The bicarbonate dose may be repeated if pH remains <7.1 after 30 minutes. Further details are available elsewhere. (See "Potassium balance in acid-base disorders", section on 'Metabolic acidosis'.)
●Treatment of reversible causes of hyperkalemia, such as correcting hypovolemia (table 5 and table 6). (See "Causes and evaluation of hyperkalemia in adults" and "Treatment and prevention of hyperkalemia in adults", section on 'Drug-induced hyperkalemia'.)
Management of hyperglycemia — We maintain an intraoperative blood glucose target of 140 to 180 mg/dL (7.7 to 10 mmol/L) in both diabetic and nondiabetic patients. If glucose is >180 mg/dL (10 mmol/L) in a diabetic patient, we administer an IV bolus of 5 units of regular insulin, followed by an insulin infusion titrated according to subsequently measured glucose concentration [57]. Dextrose is also administered at approximately 5 to 10 g of glucose/hour. We monitor intraoperative serum glucose approximately every 30 minutes during insulin infusion. If glucose is >180 mg/dL (10 mmol/L) in a nondiabetic patient, we administer an IV bolus of 2 units of regular insulin and then monitor serum glucose at least hourly during the intraoperative period. (See "Perioperative management of blood glucose in adults with diabetes mellitus", section on 'Glucose management'.)
Diabetic patients are susceptible to either hyperglycemia or hypoglycemia during kidney transplantation. Targeting a blood glucose concentration of 140 to 180 mg/dL (7.7 to 10 mmol/L) avoids marked hyperglycemia. However, it is particularly important to avoid hypoglycemic episodes. Thus, we do not use a more stringent target in an attempt to achieve lower perioperative blood glucose concentrations. Furthermore, the incidence of delayed allograft function is not decreased with strict perioperative glycemic control in diabetic patients undergoing kidney transplantation [58].
Avoidance of hypothermia — Warming devices are employed to maintain normothermia (temperature ≥35.5°C) [59-62]. These include upper- and lower-body forced-air warming devices and blankets, insulation water mattresses, and devices for warming all IV fluids. In some cases, it may be necessary to adjust the operating room temperature to maintain body temperature. Maintenance of normothermia is important for optimal allograft perfusion. Adverse effects of systemic hypothermia include increased release of catecholamines that may decrease graft perfusion, bleeding, prolonged response to NMBAs, adverse cardiac events, and postoperative infection [62]. (See "Perioperative temperature management".)
During robotic kidney transplantation, a "regional hypothermia" technique is used [63]. The pelvic bed is lined with ice slush to achieve pelvic-bed cooling. This regional hypothermia results in a decrease in the core temperature of 0.7 to 1.2°C. Subsequent rewarming can cause vasodilation, fluid redistribution, hypotension, decreased central venous pressure, and decreased graft perfusion. If the anastomosis time is kept in a 30 to 40 minute range, intraoperative cooling of the graft may not be necessary [64].
Renal reperfusion — After vascular anastomoses are completed, we carefully maintain adequate BP (typically MAP 70 to 90 mmHg) and avoid hypotension during renal reperfusion. If baseline MAP was high in a patient with chronic hypertension (eg, >90 to 100 mmHg), we maintain MAP >90 mmHg after reperfusion of the allograft. (See 'Hemodynamic management' above and "Anesthesia for patients with hypertension", section on 'Determination of target blood pressure values'.)
Also, we ensure maintenance of adequate intravascular volume by administering fluid in 250 mL increments if respiratory variations in intra-arterial pressure waveform parameters are >15 percent indicating fluid responsiveness, and by maintaining CVP at 8 to 12 mmHg. More aggressive volume resuscitation may be necessary if significant surgical bleeding occurs (eg, from a vascular anastomosis when vascular clamps are released). (See 'Monitoring intravascular volume status' above.)
In addition to maintaining adequate BP and expanding intravascular volume, the osmotic agent mannitol or other agents (eg, furosemide) may be requested by the surgeon to promote diuresis immediately after reperfusion. However, there is scant evidence that any agent decreases the incidence of acute tubular necrosis (ATN) after kidney transplantation.
Immunosuppression — The immunosuppression regimen to be used before and after reperfusion is selected before surgery (see 'Planning for intraoperative immunosuppression' above). This includes a glucocorticoid administered as a bolus before reperfusion. In addition, antilymphocyte preparations are typically administered shortly before or after reperfusion, via slow infusion to avoid hypotension. (See "Kidney transplantation in adults: Induction immunosuppressive therapy", section on 'Indications for induction therapy'.)
EARLY POSTOPERATIVE MANAGEMENT
Pain
●Intravenous pain medications – Adequate pain control is typically achieved with intravenous (IV) fentanyl or hydromorphone administered via a patient-controlled analgesia (PCA) regimen without a basal rate. We avoid meperidine because its renally excreted active metabolite, normeperidine, may accumulate and cause respiratory depression and neuro-excitatory effects (eg, seizures). Also, we avoid morphine because of potential accumulation of its renally excreted active metabolite, morphine-6-glucuronide, which may cause respiratory depression since it is ten times more potent than morphine. (See "Anesthesia for dialysis patients", section on 'Postoperative analgesia' and "Use of opioids for postoperative pain control", section on 'Patient controlled analgesia'.)
Nonsteroidal antiinflammatory drugs (NSAIDs) are avoided due to nephrotoxicity. Acetaminophen and/or hydrocodone are used for late postoperative pain management when the PCA is discontinued.
●Regional anesthesia – Continuous wound infiltration (eg, with an OnQ pump system) is used by some surgeons as part of a multimodal approach to controlling pain [65]. Ilioinguinal, iliohypogastric, and transversus abdominis plane (TAP) blocks have been used to reduce postoperative opioid requirements, with inconsistent results [66,67].
Concerns regarding coagulopathy in kidney transplant recipients, including uremic platelet dysfunction and/or residual heparin from preoperative dialysis, have limited the use of neuraxial anesthesia for postoperative pain control. In one small study, epidural analgesia was effective for control of postoperative pain, and no complications were observed [19].
Renal dysfunction — Urine output (UO) is closely monitored in the initial postoperative period and replaced on a milliliter-by-milliliter basis with IV fluids. Any acute decrease in UO is immediately investigated. If a prerenal cause is suspected, the treatment is volume expansion. Postrenal causes requiring early surgical reexploration include ureteral obstruction, vascular thrombosis, and bleeding. (See "Kidney transplantation in adults: Evaluation and diagnosis of acute kidney allograft dysfunction".)
After evaluation and treatment of all possible causes of delayed renal graft function, postoperative dialysis may be prescribed. Indications for acute dialysis in the immediate postoperative period are the same as those for nontransplant patients who develop acute kidney injury. (See "Kidney transplantation in adults: Timing of transplantation and issues related to dialysis", section on 'Dialysis immediately after transplantation'.)
Respiratory insufficiency — Although infrequent, some circumstances necessitate postoperative mechanical ventilation (eg, pulmonary edema due to high pressure pulmonary edema, inadequate reversal of neuromuscular blockade). In a large retrospective study of over 88,000 kidney transplant recipients, immediate postoperative mechanical ventilation was necessary in 2.1 percent [68].
SUMMARY AND RECOMMENDATIONS
●Preoperative phase
•Transplantation of a living-donor kidney is elective surgery, while deceased-donor transplantation is an urgent procedure because of time-limited viability of the donated kidney. (See 'Living-donor versus deceased-donor kidney' above.)
•Decisions regarding preoperative dialysis depend in part on whether the patient has been chronically dependent on maintenance dialysis, as well as whether hyperkalemia or volume overload is present. If possible, dialysis should be avoided for 24 hours prior to kidney transplantation. (See 'Assessing need for preoperative dialysis' above.)
•Patients with end-stage kidney disease (ESKD) commonly have comorbidities that caused renal failure (eg, diabetes, hypertension) or resulted from adverse effects of chronic kidney disease and dialysis. These include cardiovascular disease (eg, coronary arterial, cerebrovascular, or peripheral vascular disease; valvular heart disease; heart failure; pulmonary hypertension; atrial fibrillation), anemia, coagulation abnormalities, gastrointestinal disorders, or osteodystrophy. Conversely, patients scheduled to receive a living-donor transplant are typically not on dialysis and may be relatively healthy without uremic symptoms and with few comorbidities. (See 'Assessing comorbidities' above.)
•It is reasonable to administer a small dose of intravenous (IV) midazolam (eg, 0.5 to 2 mg) in the immediate preoperative period. In patients with heartburn or other symptoms of gastroparesis, we administer an oral nonparticulate antacid (eg, sodium citrate 500 mg in 15 mL) and a histamine-2 receptor antagonist (eg, cimetidine, famotidine) to reduce gastric pH. (See 'Medication management' above.)
Intraoperative phase
•General anesthesia is employed for kidney transplantation surgery. Concerns regarding coagulopathy (eg, uremic platelet dysfunction, residual heparin from dialysis) limit the use of neuraxial and other regional anesthetic techniques. (See 'Choice of anesthetic technique' above.)
•We typically induce general anesthesia with IV propofol 1 to 2.5 mg/kg since the pharmacokinetic and pharmacodynamic responses to this agent are not markedly altered by ESKD. We reduce and titrate the propofol dose in patients who may be hypovolemic since a standard induction dose administered as a bolus may result in profound hypotension due to venous and arterial dilation. In most patients, we also administer adjuvant medications to blunt tachycardia due to the sympathetic response to laryngoscopy and endotracheal intubation (eg, fentanyl 1 to 2 mcg/kg and/or lidocaine 1 mg/kg), as well as a neuromuscular blocking agent (NMBA). If rapid sequence induction and intubation (RSII) is necessary, succinylcholine (SCh) can be safely used as the NMBA to facilitate laryngoscopy if potassium concentration is <5.5 mEq/L. If potassium ≥5.5 mEq/L, we use a relatively large dose of rocuronium (1 mg/kg) or a remifentanil intubation technique rather than SCh. (See 'Induction' above.)
•We typically employ inhalation agents to maintain anesthesia (eg, isoflurane, desflurane, or sevoflurane in an air/oxygen mixture or in combination with 70 percent nitrous oxide [N2O]), since elimination occurs predominantly via exhalation, independent of renal function. We supplement this inhalation technique with intermittent bolus doses of an opioid (eg, fentanyl or sufentanil), and we use a nondepolarizing NMBA (eg, cisatracurium) to avoid movement. (See 'Maintenance' above.)
•The major goals of monitoring are maintenance of renal blood flow and maintenance of optimal intravascular volume status. An intra-arterial catheter is usually inserted to provide continuous monitoring of arterial blood pressure (BP) and evaluation of respirophasic variations in the pressure waveform (figure 1). If a central venous catheter (CVC) is inserted, we also monitor and maintain central venous pressure (CVP) in the range of 8 to 12 mmHg. (See 'Monitoring' above and 'Monitoring intravascular volume status' above.)
•For maintenance fluid requirements, we administer isotonic crystalloid solutions at 1 to 3 mL/kg per hour (typically normal [0.9 percent] saline). Also, we administer 250 mL increments to optimize intravascular volume if indicated by dynamic hemodynamic parameters, with reassessment of volume status after each 250 mL increment of fluid. We avoid administering >2 to 3 L of normal saline by also using an acetate-buffered, chloride-reduced solution. Five percent albumin may be administered to replace blood loss on a 1:1 volume basis until a transfusion threshold is met, although we limit total albumin to ≤500 mL. (See 'Choosing fluids' above.)
•We maintain mean arterial pressure (MAP) at 70 to 90 mmHg in most patients. After reperfusion of the allograft, we maintain a higher MAP (eg, >90 mmHg) in patients who had higher preoperative MAP values. Hypotension is avoided primarily by maintaining adequate intravascular volume and careful titration of anesthetic agents. Administration of vasopressors is minimized since alpha agonists may interfere with renal perfusion and affect graft function. (See 'Hemodynamic management' above.)
•We avoid hypothermia by using a warming device for administration of all IV fluids and a forced-air warmer on body surface areas that are not in the surgical field. (See 'Avoidance of hypothermia' above.)
•The immunosuppression regimen to be used before and after reperfusion of the renal graft should be discussed with the surgeon in the immediate preoperative period (typically, a glucocorticoid administered as a bolus before reperfusion and antilymphocyte preparations administered as a slow infusion shortly before or after reperfusion). (See 'Planning for intraoperative immunosuppression' above and 'Immunosuppression' above.)
●Postoperative phase
•Adequate pain control is typically achieved with fentanyl or hydromorphone administered via a patient-controlled analgesia (PCA) regimen without a basal rate. We avoid meperidine or morphine because of respiratory depression, and we avoid nonsteroidal antiinflammatory drugs (NSAIDs) because of nephrotoxicity. Continuous wound infiltration (eg, with an OnQ pump system) is used by some surgeons. (See 'Pain' above.)
•Urine output (UO) is closely monitored and replaced on a milliliter-by-milliliter basis with IV fluids. Acute decreases in UO are immediately investigated. If a prerenal cause is suspected, the treatment is volume expansion. Postrenal causes requiring early surgical reexploration include ureteral obstruction, vascular thrombosis, and bleeding. (See 'Renal dysfunction' above.)
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