Chapter 89: Renal Transplantation

INTRODUCTION

There are more than 10,000 deceased donor and 6000 live donor kidney transplants performed annually in the United States. According to the National Kidney Foundation, there are currently 123,175 people waiting for organ transplants in the United States, 82% of which are awaiting kidney transplants. That list continues to grow as nearly 3000 new patients are added to the kidney waiting list each month, and unfortunately, approximately 12 people die each day of end-stage renal disease.

Kidney donors can be classified as living and deceased, with living donors having a higher success rate long term than those from deceased donors. Since the rise in the use of laparoscopic surgery, the number of live donors has increased as well, mostly due to a decrease in pain and scarring, as well as a swifter recovery. About 98% of people who receive a living-donor kidney transplant live for at least 1 year after their transplant, and about 90% live for at least 5 years, whereas 94% of people who receive a deceased-donor kidney transplant live for at least 1 year after their transplant, and about 82% live for at least 5 years.

PREOPERATIVE EVALUATION

The average wait time for kidney recipients is 3 years, which makes it difficult to maintain up-to-date assessments on these patients. However, these patients require accurate preoperative optimization of multiple organ systems.

Volume Status

Hemodialysis patients will usually know their “dry weight,” which can be used preoperatively to estimate volume status. It is important to remember that patients may be hypovolemic following dialysis. Postdialysis goals include the following:

• K⁺ 4–5.5 mEq/L

• BUN < 60 mg%

• Creatinine < 10mg%

Laboratory Status

• Metabolic acidosis, hypocalcemia, and hyperkalemia may require preoperative correction with dialysis.

• Coagulation status requires assessment of PTT, INR, PT, fibrinogen, and platelet count due to the concern for potential uremic platelet dysfunction.

• Evaluation of hemoglobin levels is necessary because most patients will be anemic prior to their transplant. Because the failing kidneys do not synthesize sufficient erythropoietin, the bone marrow produces fewer red blood cells. Other contributors to anemia in ESRD include blood loss from dialysis and low levels of iron, vitamin B₁₂, and folic acid.

Cardiovascular Status

Preoperative evaluation of cardiac function by electrocardiography and echocardiography is the minimal required workup for every patient preparing to undergo kidney transplant. Follow-up studies should be repeated on an annual basis. The optimization of cardiac comorbidities such as hypertension, coronary artery disease (CAD), uremic cardiomyopathy, dysrhythmias, and pericardial effusion is of crucial importance. Each of these cardiovascular implications are quite common in the undialyzed patient. Dobutamine stress echocardiography (DSE) should replace a regular echocardiogram and be repeated every year for all of the following:

• Diabetic mellitus (DM)

• Any ...