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Chapter 80. Renal Transplant

Brooke Albright, MD

  • 5 stages of renal failure
    • Most common causes of ESRD: DM, glomerulonephritis, polycystic kidney disease, and systemic HTN
  • Renal blood flow: 3–5 mL/min/gm in normal tissue
    • If RBF <0.5 mL/min/gm, renal cells become ischemic and drug elimination is slowed
  • Survival rate of patients after renal transplantation depends on the source of the donor kidney
    • Kidneys from a living donor seem to do better at 1 and 5 years post-transplantation compared to kidneys from a cadaver
  • Common causes of morbidity and mortality in renal transplant recipients include hypertension (75%), coronary artery disease (15–30%), sepsis (27%), diabetes (16–19%), neoplasm (13%), and stroke (8%)
    • During the first year post-transplantation, most deaths are due to infectious causes

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StageDescriptionGFR (mL/min/1.73 m2)
1Kidney damage with normal or increased GFR≥90
2Kidney damage with mild decrease in GFR60–89
3Moderate decrease in GFR30–59
4Severe decrease in GFR15–29
5Kidney failure<15 (or HD)

  • Living related donor (LRD):
    • Need good bilateral renal function without h/o of diabetes, neoplasia, nor severe HTN
    • Similar HLA and ABO blood group antigens to kidney recipient
    • Start maintenance IV fluids (IVF) evening before surgery and double the rate 3–5 hours before surgery for adequate hydration
  • Recipient:
    • Blood pressure control – most ESRD patients have HTN – if they present hypotensive, suspect profound extracellular volume depletion. Ideally, after HD, patients should be 2–4 kg above their dry weight
      • Antihypertensive meds: alpha blockers, such as clonidine and prazosin, can prove very useful, as well as nitroprusside and IV labetalol for acute HTN
    • Electrolyte disturbances: hyperkalemia, hypermagnesium, etc
    • GI disturbances: delayed gastric emptying, gastroparesis, N/V, GI bleeding, hiccups
    • Hematologic disturbances: anemia, platelet dysfunction, and thrombocytopenia
    • Cardiac disturbances: LVH, CHF, LV dysfunction, CAD, cardiac conduction abnormalities, and pericarditis associated with uremia
      • Uremic pericarditis responds to dialysis and rarely leads to tamponade. Dialysis pericarditis is associated with pain, fever, and leukocytosis, and tamponade is more likely
    • Assess airway
      • Difficult intubation more common in long term type 2 DM due to diabetic stiff joint syndrome, which is characterized by a short stature, joint rigidity, and tight waxy skin. This can be seen clinically by asking the patient to approximate their palms – if they cannot bend their fingers backwards (“prayer sign”) then they may be at risk for difficult intubation
    • Be aware of immunosuppressive treatment; some immunosuppressive drugs interact with anesthesia drugs (e.g., cyclosporine)
      • Calcium channel blockers and certain antibiotics (e.g., erythromycin, doxycline, ketoconazole) increase levels of cyclosporine and can lead to nephrotoxicity. Other drugs, including certain antibiotics (nafcillin, isoniazid) and anticonvulsants (e.g., phenytoin, phenobarbital), decrease levels of cyclosporine and predispose the patient to infection

  • In addition to standard ASA monitors, invasive monitors are patient dependant
    • +/− CVP monitoring for guiding rate and volume of IVF intraoperative; prefer IJ, avoid side of AVF
    • A-line, if needed, best inserted in femoral position
  • Arm with AVF protected; no IV, no BP ...

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