Anesthesia for Renal Transplantation – Adult & Pediatric


I. Introduction

Renal transplantation is the definitive treatment for ESRD (end-stage renal disease). It involves placement of a healthy donor kidney (living/deceased) in the iliac fossa, connected to external iliac vessels and urinary bladder.


 II. Goals of Anesthetic Management

Goal

Description

Maintain perfusion to graft

Adequate MAP, low SVR, high flow

Avoid nephrotoxins

No NSAIDs, no HES

Optimize acid-base and electrolytes

Correct hyperkalemia, acidosis

Minimize cardiac and fluid risk

Common in ESRD patients

Prepare for delayed graft function

Esp. in deceased donors



III. Preoperative Assessment

🔹 1. Functional Systems Review

System

Points to Evaluate

Cardiac

LVH, CAD (ECG, ECHO, stress test), EF

Respiratory

Pulmonary edema, pleural effusion

Hematologic

Anemia (normocytic), platelet dysfunction

GI

Gastroparesis, uremic gastritis, reflux

Neurological

Encephalopathy, neuropathy



🔹 2. Laboratory Optimization

Test

Considerations

Electrolytes

K⁺ < 5.5 mEq/L, correct Ca²⁺, Mg²⁺, PO₄⁻

Acid-base

Correct metabolic acidosis

Hemoglobin

Aim: >10 g/dL

Coagulation

Prolonged bleeding time due to uremia

Crossmatch & typing

ABO, HLA, PRA, DSA, CDC



🔹 3. Dialysis

  • Last dialysis within 24 hours pre-op
  • Remove excess fluid, correct hyperkalemia
  • Ultrafiltration goals tailored to avoid hypotension


IV. Intraoperative Anesthesia Management

🔹 1. Monitoring

Monitor

Notes

ASA monitors

ECG, SpO₂, NIBP, Temp, Capnography

Arterial line

For labile BP or high-risk patients

CVP

Fluid management (optional, varies by center)

Foley catheter

Mandatory; for urine output from graft

BIS (optional)

For depth of anesthesia



🔹 2. Induction Agents

Drug

Notes

Propofol

Common; avoid in hypovolemia

Etomidate

For poor EF or unstable patients

Fentanyl

Preferred opioid (no active metabolite)

Succinylcholine

Used only if K⁺ < 5.5 mEq/L

Rocuronium/Vecuronium

Rocuronium safe; vecuronium accumulates in ESRD

Atracurium/Cisatracurium

Preferred (Hofmann elimination)



🔹 3. Maintenance

Agent

Comments

Volatile agents

Isoflurane/sevoflurane preferred

N₂O

Avoid (bowel distension, PONV)

Opioids

Fentanyl/remifentanil preferred

Muscle relaxants

Atracurium safe

TIVA

If unstable; adjust dose to renal metabolism



🔹 4. Fluids

Goal: Maintain high renal perfusion and promote graft function

Preferred Fluids:

  • Balanced crystalloids (e.g., Plasmalyte, Ringer’s lactate)
  • Avoid NS excess → hyperchloremic acidosis
  • Avoid colloids (e.g., HES)


🔹 5. Vasopressors

  • Norepinephrine preferred if hypotension (low dose)
  • Avoid high-dose pressors (↓ graft perfusion)


🔹 6. Diuretics (after reperfusion)

  • Furosemide: jumpstarts urine output
  • Mannitol: osmotic diuresis; some centers use pre-reperfusion


 V. Postoperative Management

🔹 1. ICU Monitoring

  • Hemodynamics, urine output, creatinine trends
  • Electrolytes and acid-base
  • Immunosuppression (cyclosporine, tacrolimus, MMF, steroids)

🔹 2. Graft Monitoring

  • Brisk urine output post-op (10–15 mL/kg/hr initially)
  • Delayed graft function = no UO in 24–48 hr


VI. Pediatric Renal Transplantation

🔹 Challenges Unique to Pediatrics:

Feature

Difference

Blood volume

Small → increased fluid sensitivity

Hypotension

Poorly tolerated; MAP > 60 mmHg

Graft size

Often adult graft → risk of hypoperfusion

Access

Central line, arterial line often essential

Temperature

Strict control (warming blanket, fluids)



🔹 Drug Considerations in Pediatrics:

  • Induction: Sevoflurane (inhalational) or IV propofol
  • Opioids: Fentanyl (short-acting, safe)
  • Neuromuscular blockers: Atracurium/cisatracurium
  • Maintenance: Sevoflurane-based


🔹 Fluids in Pediatrics:

  • Higher per kg requirement
  • Avoid overload
  • Replace third space and insensible losses


🔷 VII. Complications

Time

Complication

Intraop

Hypotension, bleeding, arrhythmia, anuria

Early post-op

Delayed graft function, rejection, infection

Late

Chronic rejection, drug toxicity, infection (CMV, BK virus)



🔷 VIII. Viva & MCQ Pearls

  • ❓Preferred muscle relaxant in ESRD?
    ➤ Atracurium or cisatracurium (Hofmann elimination)
  • ❓Why avoid NS in large volumes?
    ➤ Risk of hyperchloremic acidosis → vasoconstriction → ↓ renal perfusion
  • ❓Most important fluid target intraop?
    ➤ Maintain MAP > 80 mmHg and promote urine output
  • ❓Why avoid HES in renal transplant?
    ➤ Associated with AKI and graft dysfunction
  • ❓When is mannitol given?
    ➤ Pre-reperfusion, especially with deceased donor grafts
  • ❓MCQ: Which vasopressor is preferred?
    ➤ Low-dose norepinephrine (preserves renal perfusion)