Anesthesia for Renal transplantation.

1. Anesthesia for Living Donor Renal
Transplantation
DR:IBRAHIM HASSAAN,MBCHB,MSC,EDAIC
07/07/2023

4. A-Preoperative Assessment specific to Chronic Kidney
Disease
History
• Assess underlying condition—DM,HTN etc (controlled,
medication,complications)
• Symptoms of ESRD: asymptomatic, fatigue, weakness, confusion, nausea,
vomiting, paresthesias, dyspnea, pruritus, nocturia, reduced urine output
• Comorbid disease
• Previous abdominal surgery (scarring/adhesions can make dissection difficult
and increase blood loss)

5. 1-Current renal replacement therapy
How intraperitoneal/ hemodialysis /When done?
2-Volume status, current weight, dry weight?
3- Electrolytes?
4-Vascular access sites, current and past, fistula ?
5-Planned post operative dialysis

6.  Medication history:
- high-dose ACE inhibitors should be withheld perioperatively unless there is left
ventricular dysfunction.
- beta-blockers, statins and aspirin should not be stopped perioperatively.
- continue diuretics in the perioperative period.

7. Physical Exam
 ESRD: altered mental status, neuropathies, hyperreflexia, seizures, weight loss, HTN,
dependent edema, orthostatic hypotension
• Sites for IV access, central access
 -Gastrointestinal
 -peripheral neuropathy, autonomic neuropathy
 -Haematological – anaemia, thrombocytopenia, coagulopaty
 -Endocrine/ metabolic – Hyperparathyroidism, Mg,Na,Cl
 acidosis, impaired thermoregulation, hypervolaemia (compare to patient’s dry weight)
 -Immunological – decreased immune function, intercurrent infection, Hepatitis C
infection from dialysis,
 -Vascular access – fistula sites and functionality, current and previous central venous
access

8. Lab Tests/Imaging
• CBC, urea/creatinine, electrolytes, glucose, CXR
• ECG, echocardiogram

9. B-Anesthetic care
Preop-
- AV fistula wrapped and padded. Patency checked at regular
intervals.
-monitors
 Arterial line, blood pressure cuff placed on the opposite side
 Monitoring central venous access, ECG with ST segment
monitoring, neuromuscular and temperature.

10.  Induction
GA/ETT with RSI as required
- Aim normothermic, normotensive, normal intravascular volume.
- Target CVP >10-12 mmHg, If PAC insitu target pulmonary artery diatolic
pressure >15mmHg
- Typical volume required 60-100 ml/kg
- Type of fluids less important
- Prompt replacement of blood if sudden massive haemorrhage to preserve
kidney perfusion

11. How can the function of the transplanted
kidney be optimized intraoperatively?
 General measures
- General anaesthesia with paralysis and ventilation allows better haemodynamic
control and muscle relaxation than that of regional anaesthesia.
This also avoids the risk of coughing and anastomotic breakdown.
- Maintain normothermia, normoxia, normocapnia, normoglycaemia

12.  Specific to renal transplant
- MAP of 90mmHg ;aim is to maintain adequate hydration and renal perfusion (adjusted
higher for Maintain normotension at the time of graft arterial clamp removal to
optimise graft perfusion.
- Maintain a CVP of 12-14cm H2O at the time of graft perfusion.
- Cardiac output monitoring to guide fluid management.
-Liberal fluid administration at the beginning of surgery but keeping
total infusion volumes less than 2.5L.
- Blood transfusion with a transfusion target of 70g/L will improve
oxygen delivery to the transplanted kidney.

13. Drugs to improve graft function
- Dopamine as an infusion to improve renal blood flow
- Furosemide (40-250mg IV) as a bolus prior to reperfusion to promote diuresis,
renal blood flow and avoid oliguria.
- Mannitol (0.5g/kg IV) as a bolus prior to reperfusion to increase intravascular
volume and improve renal blood flow

14. C-Postoperative
 PACU or ICU as required
• Monitor for bleeding, metabolic dysfunction
•Treat hypotension hypovolemia, monitor arterial and central venous pressure
Isotonic 0.9% saline at 30ml/hr plus previous hour urine output
Pain Management
 PCA morphine used with care, epidural can be used, avoid hypotension.
 TAP block with multimodal analgesia can be adequate.

15. Common Postoperative Analgesic drugs
should be Avoided
Non-steroidal anti-inflammatory drugs are contraindicated
as they inhibit prostaglandin synthesis and therefore reduce renal blood
flow and glomerular filtration autoregulation.
Cyclo-oxygenase 2 inhibitors should also be avoided due a similar
mechanism.