Kidney transplant - Revision history

Chris.Rishel at 15:56, 11 November 2025

2025-11-11T15:56:04Z

← Older revision		Revision as of 08:56, 11 November 2025
Line 9:		Line 9:
	}}		}}

	~~Kidney transplantation~~ provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).		A '''kidney transplant''' provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

	== Preoperative management ==		== Preoperative management ==

CFitzgerald: clarified wording

2023-07-03T22:35:33Z

clarified wording

← Older revision		Revision as of 15:35, 3 July 2023
Line 84:		Line 84:

	* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics		* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
	**Choice of fluids: balanced electrolyte solution vs normal saline		**Choice of fluids: balanced electrolyte solution (Plasmalyte, Normosol, or Lactated Ringer) vs normal saline
	***Historically normal saline was the fluid of choice. ~~Some surgeons may prefer NS due to~~ lower rates of delayed graft function ~~in one RCT~~ (30 versus 40 percent; BEST-Fluids trial<ref>{{Cite journal\|last=Collins MG, Fahim MA, Pascoe EM, et al\|title=Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial\|url=https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00642-6.pdf\|journal=Lancet}}</ref>). ~~However~~, many institutions have changed to balanced electrolyte solutions ~~(Plasmalyte, Normosol, or Lactated Ringer)~~ due to high rates of hyperchloremic metabolic acidosis<ref>{{Cite journal\|last=Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E.\|date=Jan 2015\|title=An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial.\|url=https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/01000/An_Acetate_Buffered_Balanced_Crystalloid_Versus.19.aspx\|journal=Anesthesia & Analgesia\|via=doi: 10.1213/ANE.0000000000000419}}</ref> seen in large volume NS administration (NS also increased need for vasoactives intraop).		***Historically normal saline was the fluid of choice. Recent study showed are lower rates of delayed graft function (30 versus 40 percent in NS group; BEST-Fluids trial<ref>{{Cite journal\|last=Collins MG, Fahim MA, Pascoe EM, et al\|title=Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial\|url=https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00642-6.pdf\|journal=Lancet}}</ref>). Additionally, many institutions have changed to balanced electrolyte solutions due to high rates of hyperchloremic metabolic acidosis<ref>{{Cite journal\|last=Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E.\|date=Jan 2015\|title=An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial.\|url=https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/01000/An_Acetate_Buffered_Balanced_Crystalloid_Versus.19.aspx\|journal=Anesthesia & Analgesia\|via=doi: 10.1213/ANE.0000000000000419}}</ref> seen in large volume NS administration (leading to similar intracellular K+ rates). NS also increased need for vasoactives intraop in this study.
	*Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates		*Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates
	* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)		* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)

CFitzgerald: IV fluid choice discussion, fixed spelling typo, added section on maintenace of normothermia

2023-07-03T22:28:20Z

IV fluid choice discussion, fixed spelling typo, added section on maintenace of normothermia

← Older revision		Revision as of 15:28, 3 July 2023
Line 9:		Line 9:
	}}		}}

	Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).		Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).

	== Preoperative management ==		== Preoperative management ==
Line 35:		Line 35:
	\|-		\|-
	\|Renal		\|Renal
	\|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds		\|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds. Most recipients also suffer from long-standing, HTN and its systemic concequences.
	\|-		\|-
	\|Endocrine		\|Endocrine
	\|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes		\|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
	\|-		\|-
	\|~~Other~~		\|Vascular
	\|		\|Many patients have coronary arterial, cerebrovascular, and peripheral vascular disease in addition to their HTN.
	\|}		\|}

Line 84:		Line 84:

	* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics		* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
			**Choice of fluids: balanced electrolyte solution vs normal saline
			***Historically normal saline was the fluid of choice. Some surgeons may prefer NS due to lower rates of delayed graft function in one RCT (30 versus 40 percent; BEST-Fluids trial<ref>{{Cite journal\|last=Collins MG, Fahim MA, Pascoe EM, et al\|title=Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial\|url=https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00642-6.pdf\|journal=Lancet}}</ref>). However, many institutions have changed to balanced electrolyte solutions (Plasmalyte, Normosol, or Lactated Ringer) due to high rates of hyperchloremic metabolic acidosis<ref>{{Cite journal\|last=Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E.\|date=Jan 2015\|title=An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial.\|url=https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/01000/An_Acetate_Buffered_Balanced_Crystalloid_Versus.19.aspx\|journal=Anesthesia & Analgesia\|via=doi: 10.1213/ANE.0000000000000419}}</ref> seen in large volume NS administration (NS also increased need for vasoactives intraop).
			*Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates
	* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)		* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
	*Anticipate prolonged drug effects for renally metabolized/excreted medications		*Anticipate prolonged drug effects for renally metabolized/excreted medications
	** Avoid meperidine (which may accumulate as ~~nomeperidine~~ > CNS toxicity)		** Avoid meperidine (which may accumulate as normeperidine > CNS toxicity)
	* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics		* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
	*Will be instructed to clamp Foley by surgeons		*Will be instructed to clamp Foley by surgeons

CFitzgerald: added regional anesthesia consideration

2023-07-03T21:55:39Z

added regional anesthesia consideration

← Older revision		Revision as of 14:55, 3 July 2023
Line 62:		Line 62:

	* Epidural or CSE may be used for postop pain management		* Epidural or CSE may be used for postop pain management
			*Pre-emergence TAP catheter vs single-shot

	== Intraoperative management ==		== Intraoperative management ==
Line 106:		Line 107:
	* PCA		* PCA
	* Epidural		* Epidural
			*TAP block

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
Line 111:		Line 113:
	* Fistula thrombosis if improperly padded		* Fistula thrombosis if improperly padded
	* Hemorrhage		* Hemorrhage
	* Delayed urine output, dialysis may be ~~needed~~ until renal function returns		* Delayed urine output, dialysis may be necessary until renal function returns
	* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses		* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses

CFitzgerald: BP monitoring options

2023-07-03T21:52:02Z

BP monitoring options

← Older revision		Revision as of 14:52, 3 July 2023
Line 2:		Line 2:
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = ETT		\| airway = ETT
	\| lines_access = PIV x2 <br/> Arterial line <br/> +/- Central line		\| lines_access = PIV x2 <br/> +/- Arterial line <br/> +/- Central line
	\| monitors = Standard, 5-lead ECG		\| monitors = Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line
	\| considerations_preoperative = ESRD patients should have potassium checked preop		\| considerations_preoperative = ESRD patients should have potassium checked preop
	\| considerations_intraoperative = Mannitol, ~~lasix~~, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used		\| considerations_intraoperative = Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used
	\| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time		\| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time
	}}		}}

Tony.Wang at 02:39, 29 June 2022

2022-06-29T02:39:54Z

← Older revision		Revision as of 19:39, 28 June 2022
Line 86:		Line 86:
	*Anticipate prolonged drug effects for renally metabolized/excreted medications		*Anticipate prolonged drug effects for renally metabolized/excreted medications
	** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)		** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)
	* ~~May~~ be instructed to clamp Foley by surgeons		* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
			*Will be instructed to clamp Foley by surgeons
			*May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

Tony.Wang at 02:37, 29 June 2022

2022-06-29T02:37:32Z

← Older revision		Revision as of 19:37, 28 June 2022
Line 52:		Line 52:

	* Prepare arterial line setup		* Prepare arterial line setup
	* Have mannitol, furosemide, heparin in room		* Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room
			*May need steroid and/or anti-thymocyte globulin prepared

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
Line 67:		Line 68:

	* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.		* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
	* ± Arterial line for blood pressure monitoring and frequent lab draws~~, avoiding~~ the side of ~~the~~ AV fistula		* Arterial line for blood pressure monitoring and frequent lab draws
			*IVs and arterial lines should avoid the side of AV fistula if present

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
Line 80:		Line 82:
	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

	* ~~Standard maintenance~~		* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
	* Anticipate prolonged drug effects for renally metabolized/excreted medications		* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
			*Anticipate prolonged drug effects for renally metabolized/excreted medications
	** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)		** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)
	* Have large vial of mannitol ready to give (preferably warmed to prevent crystallization)
	* May be instructed to clamp Foley by surgeons		* May be instructed to clamp Foley by surgeons

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:43:49Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:43, 21 February 2022
Line 25:		Line 25:
	\|CHF is common in undialyzed patients		\|CHF is common in undialyzed patients
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.		\|Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia.
	\|-		\|-

Barrett.Larson at 01:01, 3 September 2021

2021-09-03T01:01:28Z

← Older revision		Revision as of 18:01, 2 September 2021
Line 2:		Line 2:
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = ETT		\| airway = ETT
	\| lines_access = PIV x2~~, arterial~~ line, +/- ~~central~~ line		\| lines_access = PIV x2 <br/> Arterial line <br/> +/- Central line
	\| monitors = Standard, 5-lead ECG		\| monitors = Standard, 5-lead ECG
	\| considerations_preoperative = ESRD patients should have potassium checked preop		\| considerations_preoperative = ESRD patients should have potassium checked preop

Tony.Wang: Added mannitol and foley clamp

2021-09-01T13:44:23Z

Added mannitol and foley clamp

← Older revision		Revision as of 06:44, 1 September 2021
Line 66:		Line 66:
	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

	* After induction of anesthesia, a 3-way ~~foley~~ catheter is placed into the bladder.		* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
	* ± A-line for blood pressure monitoring and frequent lab draws, avoiding the side of the AV fistula		* ± Arterial line for blood pressure monitoring and frequent lab draws, avoiding the side of the AV fistula

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
Line 83:		Line 83:
	* Anticipate prolonged drug effects for renally metabolized/excreted medications		* Anticipate prolonged drug effects for renally metabolized/excreted medications
	** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)		** Avoid meperidine (which may accumulate as nomeperidine > CNS toxicity)
			* Have large vial of mannitol ready to give (preferably warmed to prevent crystallization)
			* May be instructed to clamp Foley by surgeons

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===