Kidney Transplant (deceased or living donor)
Patient phenotype
ESRD on dialysis, age 40-70, multiple comorbidities (DM, HTN, secondary cardiac, anemia, electrolyte issues). Dialyzed within 24h before surgery (depending on K). Living-donor recipients usually less ill.
Procedure
Lower-quadrant retroperitoneal incision, anastomose donor kidney to iliac vessels (artery + vein) + ureter to bladder. ~3-4 hours. Goal: graft urine production within minutes of unclamping.
Anesthetic plan
GETA. CVC for fluid + drug delivery + CVP monitoring. Liberal fluid early (priming the graft with volume) — different from most surgeries! Avoid vasoconstrictors that compromise graft. Mannitol + furosemide pre-anastomosis.
Setup
- ·Standard ASA + temp
- ·A-line (especially if cardiac comorbidity)
- ·CVC (often new — many ESRD patients have HD catheters in awkward locations)
- ·Two large PIVs
- ·Type & cross 2 units (ESRD patients anemic baseline)
- ·Dialysis access protected from BP cuffs
- ·Mannitol 12.5g + furosemide drawn
Biggest concerns by phase
Pre-op dialysis status + electrolytes + dry weight
Verify last dialysis (within 24h ideal), K (< 5.5 ideal), volume status (often dialyzed dry). HD patients on EPO + iron, often Hb 8-10. AV fistula must be protected — no BP, no IV in that arm.
Drug PK altered in ESRD — avoid renally-cleared drugs
Avoid: morphine (M6G accumulation), midazolam (active metabolites), sux (K rise on top of baseline elevated). Use: fentanyl, remifentanil (no renal clearance), cisatracurium (Hofmann elimination), propofol. Reduced doses for hepatic-cleared drugs in renal failure (altered protein binding).
Volume optimization for graft — liberal fluids EARLY
Graft needs preload to perfuse. Goal: CVP 10-15 mmHg before unclamping. Aggressive crystalloid (1-2 L of NS or balanced solution) early. Different from most surgeries where we restrict — here we want the graft loaded with volume.
Avoid LR (potassium) + albumin (cost-no benefit)
LR has 4 mEq/L K — additive in already-hyperkalemic patient. Use NS or Plasma-Lyte. Albumin doesn't improve graft outcomes per current data — saves cost.
Pre-anastomosis: mannitol + furosemide for graft
Pre-clamp release: mannitol 12.5-25 g (osmotic diuretic, free-radical scavenger) + furosemide 40-60 mg (forced diuresis to prove graft function). Some surgeons request methylprednisolone or basiliximab — confirm protocol.
Postop: graft function (UOP), immunosuppression, infection risk
UOP > 100 mL/hr first 24h = good graft function. Watch for delayed graft function (oliguria — may need dialysis post-op). Immunosuppression starts immediately (tacrolimus + MMF + steroids). Watch for infection (immunosuppressed) and rejection (creatinine trend).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your kidney transplant patient: ESRD on HD, last dialysis 24h ago, K is 5.7 today (dialysis went poorly). Surgeon wants to start. What do you do?
What an examiner probes for
- ▹Recognize K 5.7 manageable but borderline — ECG assessment
- ▹Risk-benefit: surgical urgency vs. K correction
- ▹If proceeding: avoid sux, avoid LR, monitor K trend, calcium ready
- ▹Plan: insulin/dextrose if K rises, dialysis access available post-op if needed
Sources
- Miller's Ch 73
- ASTS Anesthesia for Renal Transplantation
Anatomy reference
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