Version June 2024
INTRODUCTION — Living kidney donors are in good health, with normal kidney function, and without chronic illness or clinically significant hypertension. This topic will review anesthetic management of the living donor during nephrectomy, with emphasis on the primary considerations of safety and comfort.
The medical evaluation of a prospective living kidney donor, the risks of donor nephrectomy, and the techniques of living-donor nephrectomy are reviewed separately:
●(See "Kidney transplantation in adults: Evaluation of the living kidney donor candidate".)
●(See "Kidney transplantation in adults: Risk of living kidney donation".)
●(See "Deceased- and living-donor kidney allograft recovery".)
OVERVIEW OF LIVING DONOR KIDNEY TRANSPLANTATION — Kidneys from living donors have better graft and patient survival rates for the recipient than kidneys from deceased donors. This is because living donors are physiologically and hemodynamically normal; hence, the graft is not exposed to ischemic alterations associated with brain death or cardiac death in deceased donors. Also, transplantation can be scheduled electively, with both donor and recipient surgeries coordinated at the same facility. This minimizes cold ischemia time for the donated kidney.
In ideal circumstances, kidney transplantation from a living donor is preemptive, so that the recipient with end-stage kidney disease (ESKD) avoids the complications of dialysis altogether. Details are discussed separately:
PREANESTHESIA CONSULTATION — Potential donors are extensively evaluated prior to being accepted as donors. As a result, thorough medical and surgical evaluations are always available at the time of the preanesthesia consultation. (See "Kidney transplantation in adults: Evaluation of the living kidney donor candidate", section on 'Donor evaluation'.)
Healthy donors are exposed to some, albeit limited, medical and surgical risks, as well as some degree of postoperative pain. (See "Kidney transplantation in adults: Risk of living kidney donation" and 'Pain management' below.)
SURGICAL DETAILS — Donor nephrectomy from a living donor may be performed using an open or laparoscopic-assisted technique. The open technique utilizes retroperitoneal exposure of the kidney, whereas the laparoscopic technique employs an intraperitoneal approach.
●Laparoscopic nephrectomy – A majority of live kidney donations in the United States are performed via laparoscopy rather than via open nephrectomy with a large incision. Advantages include significantly less pain and a shorter recovery period and hospital stay without increased complication rates [1,2]. (See "Deceased- and living-donor kidney allograft recovery", section on 'Laparoscopic-assisted technique'.)
●Open nephrectomy – A large subcostal (flank) incision is made, typically from the lateral border of the left rectus at the level of the umbilicus to a point underneath the 12th rib. Open nephrectomy is more painful and is associated with a longer recovery period and hospital stay compared with laparoscopic nephrectomy [1,2]. (See "Deceased- and living-donor kidney allograft recovery", section on 'Open technique'.)
●Minimally invasive nephrectomy – A variation of the open nephrectomy technique is the minimally invasive nephrectomy, with a smaller, more anterior subcostal incision that leaves the 12th rib intact. This approach has also been associated with less postoperative pain and shorter hospital stay than the traditional open procedure [3] but more pain and longer hospital stay than the laparoscopic technique [2,4]. There have been several reports of robot-assisted laparoscopic donor nephrectomy, although it is not clear whether there are any additional advantages for this technique (eg, less blood loss) compared with conventional laparoscopic nephrectomy. (See "Kidney transplantation in adults: Benefits and complications of minimally invasive live-donor nephrectomy".)
Intraoperative surgical considerations for both open and laparoscopic-assisted donor nephrectomy include the following:
●Antibiotic prophylaxis – Antibiotic prophylaxis is administered within the 60 minutes prior to surgical incision [5]. This is discussed in more detail elsewhere. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antibiotic administration'.)
●Positioning – Positioning is similar with either laparoscopic or open techniques. The left kidney is usually harvested due to its longer renal vein. Thus, with either a laparoscopy-assisted technique or planned open approach, the patient is placed left-side up in lateral decubitus position, with elevation of the kidney bar of the operating table. Some surgeons also flex the table. A chest roll is usually placed caudal to the axilla to prevent compression injuries of axillary structures. (See "Patient positioning for surgery and anesthesia in adults", section on 'Nerve injuries associated with the lateral decubitus position'.)
●Anticoagulation and reversal of anticoagulation – Most surgeons request administration of intravenous heparin 3000 to 5000 units to achieve anticoagulation immediately before clamping the renal vessels [6,7]. Then the renal artery and vein are separately clamped and divided, and the kidney is removed. Subsequent reversal of anticoagulation with protamine may be requested by the surgeon to achieve hemostasis. (See "Deceased- and living-donor kidney allograft recovery", section on 'Open technique'.)
ANESTHETIC MANAGEMENT
General considerations
Vascular access — We insert two large-bore intravascular catheters because significant bleeding is a possibility, although rare [8]. Invasive monitoring (eg, insertion of a central venous catheter or arterial catheter) is not indicated.
Induction and maintenance of general anesthesia — General anesthesia is employed for either laparoscopic or open nephrectomy.
●Induction – For most kidney donors, we suggest intravenous (IV) propofol for induction of general anesthesia because of its antiemetic properties (see "General anesthesia: Intravenous induction agents", section on 'Propofol'). We administer a neuromuscular blocking agent (NMBA) to achieve tracheal intubation. We typically add a short-acting opioid (eg, fentanyl or sufentanil) to attenuate the stress response to laryngoscopy and endotracheal intubation. Details regarding these induction techniques are discussed separately. (See "Induction of general anesthesia: Overview".)
●Maintenance – Maintenance of general anesthesia may be achieved with either a potent volatile inhalation agent, total intravenous anesthesia (TIVA), or a combination of these techniques. (See "Maintenance of general anesthesia: Overview".)
An NMBA is administered to avoid high intra-abdominal pressure, which is especially important during abdominal distention with carbon dioxide (CO2) during laparoscopic nephrectomy. (See 'Considerations for laparoscopic nephrectomy' below.)
Sevoflurane has theoretical kidney toxicity due to an inorganic fluoride ion metabolite and formation of a substance known as compound A. However, sevoflurane has not been associated with clinically significant kidney injury, and has been used safely in patients with stable chronic kidney disease and in patients on dialysis. We use fresh gas flows >2 L/minute to avoid formation of compound A when sevoflurane is administered. (See "Inhalation anesthetic agents: Clinical effects and uses", section on 'Sevoflurane'.)
We avoid nitrous oxide (N2O) because it may cause bowel distention that interferes with the surgical view and procedural tasks [9]. Also, N2O is associated with a modestly higher incidence of postoperative nausea and vomiting (PONV) compared with other inhalation anesthetic agents. (See "Maintenance of general anesthesia: Overview", section on 'Nitrous oxide gas' and "Inhalation anesthetic agents: Clinical effects and uses", section on 'Disadvantages and adverse effects'.)
It is not necessary to avoid IV anesthetic agents excreted by the kidney since kidney function is generally good (ie, estimated glomerular filtration rate [GFR] >60 mL/minute per 1.73 m2), even after nephrectomy. However, we avoid all nephrotoxic agents to preserve function in the remaining kidney.
Mechanical ventilation — We employ standard lung protective settings for mechanical ventilation (eg, pressure-controlled ventilation with 6 to 8 mL/kg, based on ideal body weight, positive end-expiratory pressure [PEEP] of 5 to 10 cmH2O), as well as recruitment maneuvers [10]. These issues are discussed in greater detail separately. (See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)
Modifications in ventilator settings become necessary during portions of a laparoscopic nephrectomy procedure. (See 'Modifications of mechanical ventilation' below.)
Maintenance of kidney perfusion — The major risk to the kidney that is being transplanted is ischemia, which can be associated with delayed graft function in the recipient (see "Kidney transplantation in adults: Risk factors for graft failure", section on 'Tissue injury'). Thus, it is important to maintain kidney perfusion with a goal for urine output >1 mL/kg per hour. Specific measures include the following:
●Maintaining intravascular volume – Intravascular volume is expanded with IV fluid (typically balanced crystalloid solutions) throughout the procedure to maintain optimal kidney perfusion and continuous urine output. (See "Intraoperative fluid management", section on 'Crystalloid solutions'.)
Volume requirements may be greater in patients undergoing laparoscopic nephrectomy compared with open nephrectomy to counteract the effect of the intraperitoneal gas on renal blood flow. (See 'Strategies to maintain hemodynamic stability' below.)
●Maintaining adequate mean arterial pressure (MAP) – Maintenance of MAP is extremely important. This is primarily accomplished by maintaining optimal intravascular volume, which maintains cardiac filling and output.
Vasopressors, particularly pure alpha agonists, are avoided if possible as these drugs may interfere with kidney perfusion. If necessary, an inotrope/vasopressor agent such as bolus doses of ephedrine 5 to 25 mg is administered to treat episodes of hypotension by increasing cardiac output and blood pressure. Very rarely, a continuous infusion of norepinephrine (at 1 to 30 mcg/min; 0.01 to 0.3 mcg/kg/min) may be necessary to treat significant hypotension refractory to volume administration and boluses of less potent agents. Norepinephrine acts on both alpha1 and beta1 adrenergic receptors to produce potent vasoconstriction and a modest increase in cardiac output [11,12].
●Avoiding high intraabdominal pressure – This is accomplished by administering an NMBA to provide muscle relaxation in both open or laparoscopic nephrectomy procedures. Also, use of low CO2 insufflation pressures is ensured during laparoscopy.
●Maintaining urine output – Most centers prophylactically administer 12.5 to 25 g of mannitol IV during the dissection phase as well as furosemide 20 mg IV 15 to 20 minutes before the anticipated cross clamping of the renal artery to maintain urine output. (See "Deceased- and living-donor kidney allograft recovery", section on 'Living-donor kidneys' and "Deceased- and living-donor kidney allograft recovery", section on 'Open technique'.)
Considerations for laparoscopic nephrectomy — General anesthesia with endotracheal intubation is necessary for laparoscopic nephrectomy due to (see "Anesthesia for laparoscopic and abdominal robotic surgery in adults"):
●The need to avoid patient discomfort associated with pneumoperitoneum.
●The need for controlled ventilation to reduce the increase in partial pressure of carbon dioxide (PaCO2) caused by CO2 insufflation and to avoid ventilatory compromise from the pneumoperitoneum itself.
●The need for muscle relaxation to reduce the intra-abdominal pressure needed for the desired degree of abdominal distention.
Modifications of mechanical ventilation — During laparoscopic nephrectomy, changes in pulmonary function (eg, reduction in lung volume, increase in peak inspiratory pressure, and decrease in pulmonary compliance) usually require modifications in mechanical ventilation settings [13]. High intrathoracic pressures are avoided (see 'Maintenance of kidney perfusion' above). Furthermore, insufflation of CO2 may result in hypercapnia. Thus, we increase minute ventilation as necessary by increasing the respiratory rate while maintaining a constant tidal volume. (See "Anesthesia for laparoscopic and abdominal robotic surgery in adults".)
However, we tolerate mild hypercapnia (ie, an end-tidal CO2 [ETCO2] of 45 mmHg) that typically develops during laparoscopy with CO2 insufflation. Mild hypercapnia may improve tissue oxygenation and perfusion due to vasodilation and increased cardiac output, and also may increase oxygen offloading due to a rightward shift of the oxyhemoglobin dissociation curve [13-15].
Strategies to maintain hemodynamic stability — Strategies to maintain hemodynamic stability include:
●Expand intravascular volume – Hypovolemia due to bleeding is treated with intravascular volume expansion (see 'Maintenance of kidney perfusion' above). Volume requirements during laparoscopic nephrectomy total 2 to 4 L of a balanced crystalloid solution. More aggressive fluid resuscitation is not associated with improved outcomes in the donor or recipient but may prolong hospital stay of the donor [16].
This is typically necessary to counteract adverse effects of the intraperitoneal gas on blood flow to the kidney due to increased intraperitoneal pressure during CO2 gas insufflation. (See "Deceased- and living-donor kidney allograft recovery", section on 'Laparoscopic-assisted technique'.)
●Ensure low insufflation pressures – The pneumoperitoneum pressure created with insufflation of CO2 is kept <15 mmHg to avoid decreased perfusion to the kidney. Limiting the pneumoperitoneum pressure to <15 mmHg during insufflation of CO2 minimizes alterations in cardiovascular function. (See "Deceased- and living-donor kidney allograft recovery", section on 'Laparoscopic-assisted technique'.)
●Treat increased systemic vascular resistance (SVR) – Increased SVR (and consequently increased MAP) may occur due to CO2 absorption with resultant increased sympathetic output, as well as the neuroendocrine response to compression of the arterial vasculature caused by increased intra-abdominal pressure during CO2 insufflation [13,17-19]. When depth of anesthesia is adequate, a MAP >95 mmHg can be treated with short-acting antihypertensive agents such as labetalol.
Considerations for open and minimally invasive nephrectomy — These procedures are more painful than a laparoscopic procedure. General anesthesia is often combined with an epidural or other regional techniques for postoperative analgesia. (See 'After open nephrectomy or minimally invasive nephrectomy' below and "Approach to the management of acute pain in adults", section on 'Regional anesthesia techniques'.)
POSTOPERATIVE CONSIDERATIONS
Pain management
After laparoscopic nephrectomy — Mild or moderate pain after laparoscopic nephrectomy may result from the port insertion site, the abdominal incision, pelvic organ manipulation, diaphragmatic irritation, and/or ureteral colic [20]. This pain is managed with supplemental intravenous (IV) opioids using patient-controlled analgesia (PCA) for one or two days, and subsequently with oral opioids and acetaminophen. Although one to two doses of ketorolac can be administered for pain control in young donors, we generally avoid this nonsteroid anti-inflammatory drug (NSAID) in older donors [21-23]. Subfascial infiltration of bupivacaine (0.5%) may also be employed to minimize opioid dosing [24]. (See "Use of opioids for postoperative pain control", section on 'Patient controlled analgesia'.)
Other interventions to further improve pain control are under investigation. An enhanced recovery protocol after laparoscopic nephrectomy has been studied, emphasizing preoperative carbohydrate loading and a multimodal pain management regimen that included a transversus abdominis plane (TAP) regional block [25] (see "Transversus abdominis plane (TAP) blocks procedure guide"). One study reported decreased length of stay in the hospital (from two days to one day) and decreased overall opioid use compared with a historical control group. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Gabapentinoids'.)
After open nephrectomy or minimally invasive nephrectomy — Pain may be moderate to severe after open or minimally invasive nephrectomy. The pain associated with a subcostal lateral incision may last for several days. This can result in pulmonary complications (eg, atelectasis and pneumonia) [26]. In most patients, adequate control of postoperative pain is achieved with epidural analgesia or PCA with opioids. Alternatively, multimodal opioid-sparing techniques such as continuous thoracic paravertebral block (PVB), erector spinae block, or intercostal blocks may be employed.
Details regarding these strategies are available in other topics:
●(See "Continuous epidural analgesia for postoperative pain: Technique and management".)
●(See "Use of opioids for postoperative pain control", section on 'Patient controlled analgesia'.)
●(See "Thoracic paravertebral block procedure guide".)
●(See "Thoracic nerve block techniques", section on 'Intercostal nerve block'.)
●(See "Erector spinae plane block procedure guide".)
Complications
●Gastrointestinal complications – Gastrointestinal complications such as postoperative nausea, vomiting, constipation, and ileus are more common after open nephrectomy compared with laparoscopic nephrectomy. Multimodal measures (eg, dexamethasone 4 to 8 mg administered after induction of anesthesia and ondansetron 4 mg administered at the end of surgery) are employed to prevent and treat these side effects of anesthesia and open or laparoscopic surgery. (See "Postoperative nausea and vomiting" and "Measures to prevent prolonged postoperative ileus".)
●Pulmonary complications
•Laparoscopic nephrectomy – For patients undergoing laparoscopic nephrectomy, the intraoperative reductions in lung volume that occur during insufflation of carbon dioxide (CO2) are temporary and typically resolve quickly after desufflation.
•Open nephrectomy – After open nephrectomy, pulmonary complications in the early postoperative period may occur due to moderate to severe pain, particularly with a subcostal lateral incision. Pain limits the patient’s efforts to breathe, cough, and move, potentially resulting in atelectasis and pneumonia [26]. (See 'After open nephrectomy or minimally invasive nephrectomy' above.)
Although other cardiopulmonary complications after open nephrectomy are rare, pulmonary embolism has been reported in large series [8,27]. (See "Complications of laparoscopic surgery".)
●Bleeding – Significant bleeding is rare after either surgical technique, occurring in 0.1 to 0.45 percent of donors [8].
●Venous thromboembolism – Venous thromboembolism (VTE) is not a common complication following laparoscopic nephrectomy. Prevention of VTE after donor nephrectomy is similar to that for other adult patients undergoing nonorthopedic surgery, as discussed elsewhere. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
SUMMARY AND RECOMMENDATIONS
●Overview – Living kidney donors are physiologically and hemodynamically intact; hence, the graft is not exposed to ischemic alterations associated with brain or cardiac death. Transplantation is scheduled electively, with both donor and recipient surgeries coordinated at the same facility, thus minimizing cold ischemia time for the donated kidney. (See 'Overview of living donor kidney transplantation' above.)
●Preanesthesia consultation – Potential donors are extensively evaluated prior to being accepted as donors. Thorough medical and surgical evaluations are available for the preanesthesia consultation. (See "Kidney transplantation in adults: Evaluation of the living kidney donor candidate", section on 'Donor evaluation'.)
●Surgical details – Living donor nephrectomy may be performed using an open, laparoscopic-assisted, or minimally invasive technique; open nephrectomy is more painful and associated with longer hospital stays. The left kidney is usually harvested; the patient is in lateral decubitus position with elevation of the operating table kidney bar. Anticoagulation is generally avoided; however, some surgeons administer heparin to achieve anticoagulation before clamping the renal vessels. (See 'Surgical details' above.)
●Anesthetic management
•Vascular access – We insert two large-bore intravascular catheters. (See 'Vascular access' above.)
•General anesthesia
-Induction – For most kidney donors, we suggest intravenous (IV) propofol for induction of general anesthesia (Grade 2C), because of its antiemetic properties. (See "General anesthesia: Intravenous induction agents", section on 'Propofol'.)
-Maintenance – Either a potent volatile inhalation agent (eg, isoflurane or desflurane), total intravenous anesthesia (TIVA), or a combination of these techniques may be used, and a neuromuscular blocking agent (NMBA) is administered. (See "Maintenance of general anesthesia: Overview".)
If sevoflurane is administered, we use fresh gas flows >2 L/minute. We avoid nitrous oxide (N2O) as it may cause bowel distention. (See "Maintenance of general anesthesia: Overview", section on 'Nitrous oxide gas' and "Inhalation anesthetic agents: Clinical effects and uses", section on 'Disadvantages and adverse effects'.)
•Mechanical ventilation – We employ standard lung protective settings, as discussed separately. (See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)
•Maintenance of kidney perfusion – It is important to maintain kidney perfusion and urine output. Specific measures include maintaining intravascular volume with IV fluid to maintain continuous urine output, maintaining adequate mean arterial pressure, and avoiding high intrabdominal pressure. (See 'Maintenance of kidney perfusion' above.)
●Considerations for laparoscopic nephrectomy – General anesthesia is necessary to minimize patient discomfort, control ventilation, and induce muscle relaxation to reduce intra-abdominal pressure during carbon dioxide (CO2) insufflation. Modifications to mechanical ventilation settings are usually necessary to address changes in pulmonary function during laparoscopic nephrectomy. Strategies to maintain hemodynamic stability include ensuring low CO2 insufflation pressure (<15 mmHg), expanding intravascular volume, and treating increased systemic vascular resistance. (See 'Considerations for laparoscopic nephrectomy' above.)
●Considerations for open and minimally invasive nephrectomy – General anesthesia is often combined with an epidural (to provide postoperative analgesia). (See "Deceased- and living-donor kidney allograft recovery", section on 'Open technique'.)
●Postoperative pain control
•Open and minimal invasive nephrectomy – Potentially severe pain is managed with epidural analgesia and/or patient-controlled analgesia (PCA) with opioids. (See 'After open nephrectomy or minimally invasive nephrectomy' above.)
•Laparoscopic nephrectomy – Mild or moderate pain is managed with PCA in the early postoperative period and subsequently with oral opioids and acetaminophen. (See 'After laparoscopic nephrectomy' above.)
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