Anaesthesia for renal transplant

Surgical approach

• Usually extraperitoneal approach to iliac fossa (often right)
  • Incision: Rutherford-Morrison / lower abdominal oblique incision; develop extraperitoneal space
• Vascular anastomoses
  • Renal vein → external iliac vein (end-to-side)
  • Renal artery → external iliac artery (end-to-side) or internal iliac artery (end-to-end, less common)
• Reperfusion phase
  • Clamp release → haemodynamic changes; graft may produce urine immediately (more common living donor)
• Ureteric implantation
  • Ureteroneocystostomy into bladder; often ureteric stent placed
• Native kidneys usually left in situ
  • Nephrectomy only for specific indications (e.g. recurrent infection, malignancy, space, polycystic kidneys, reflux nephropathy complications)
• Cold ischaemia time important (especially deceased donor)
  • Aim to minimise; prolonged time associated with delayed graft function

Anaesthetic management

• Type of anaesthesia: GA (standard). Regional techniques mainly for analgesia (e.g. TAP block) rather than sole anaesthetic
  • Neuraxial anaesthesia alone uncommon due to anticoagulation, haemodynamic goals, and need for controlled ventilation/CO2
• Airway: ETT usually preferred
  • Allows controlled ventilation, reliable access for longer cases, and management of fluid shifts/reperfusion
• Duration: typically 2–4 hours (variable: living donor often shorter; complex vascular anatomy longer)
• Pain: moderate (lower abdominal incision); consider multimodal + regional fascial plane block
  • Avoid NSAIDs early post-op (nephrotoxicity/bleeding risk depending on centre policy)
• Key physiological goals: adequate preload, avoid hypotension, maintain oxygen delivery; avoid nephrotoxins; manage electrolytes (esp. K+)

Indications and recipient population

• End-stage kidney disease: diabetes, glomerulonephritis, hypertensive nephrosclerosis, polycystic kidney disease, reflux nephropathy, etc.
• Recipient physiology: uraemia + dialysis-related issues + high cardiovascular risk
  • Accelerated atherosclerosis; LVH; diastolic dysfunction; pulmonary hypertension; autonomic neuropathy (esp. diabetes)

Pre-operative assessment

• History and functional status
  • Exercise tolerance; angina/dyspnoea; orthopnoea; OSA; previous anaesthetic issues
  • Dialysis modality: haemodialysis vs peritoneal; last dialysis session; complications (hypotension, arrhythmias)
• Cardiovascular evaluation (major determinant of outcome)
  • ECG + echocardiography (LV function, LVH, valvular disease, pulmonary pressures)
  • Ischaemia assessment as per local transplant pathway (e.g. stress imaging/CTCA/invasive angiography in high-risk)
  • Optimise BP; note antihypertensives (ACEi/ARB often withheld on day to reduce refractory hypotension—centre dependent)
• Volume status
  • Aim euvolaemia pre-op; assess dry weight, oedema, JVP, lung creps; dialysis timing affects intra-op fluid needs
• Electrolytes and acid–base
  • Check K+, bicarbonate, Ca2+/phosphate, Mg2+; treat hyperkalaemia pre-op
  • Consider ECG changes with hyperkalaemia; avoid suxamethonium if K+ high/unknown
• Haematology
  • Anaemia common; check Hb; consider EPO/iron history; crossmatch blood (bleeding usually modest but vascular anastomoses can bleed)
  • Platelet dysfunction in uraemia; review antiplatelets/anticoagulants; plan neuraxial accordingly
• Diabetes and gastroparesis
  • High aspiration risk; autonomic neuropathy; brittle control; plan insulin infusion and frequent glucose checks
• Infection and immunology
  • Screen for active infection; lines/fistula infections; MRSA status; ensure prophylactic antibiotics as per protocol
  • Immunosuppression: induction agents may be given intra-op (e.g. basiliximab, ATG) with potential for anaphylaxis/cytokine reactions
• Medication review
  • Continue beta-blockers; manage antihypertensives individually; stop/adjust diuretics if anuric; phosphate binders etc.
  • Avoid nephrotoxins (NSAIDs, aminoglycosides where possible); check contrast exposure history
• Access planning
  • Protect AV fistula/graft: no BP cuff/venepuncture on access arm
  • Consider difficult IV access; plan ultrasound-guided cannulation

Monitoring and vascular access

• Standard monitoring + temperature + urine output (after reperfusion) + neuromuscular monitoring
• Arterial line: commonly used (beat-to-beat BP, blood gases, K+, Hb)
• Central venous access: selective
  • Consider if poor peripheral access, significant cardiac disease, anticipated vasoactive infusions, or need for reliable large-bore access
  • CVP is an imperfect guide; focus on dynamic assessment and perfusion endpoints
• Cardiac output monitoring: consider in high-risk recipients (significant LV dysfunction, pulmonary HTN, severe IHD)

Induction and maintenance

• Aspiration risk: consider RSI in diabetics/uraemia/delayed gastric emptying; ensure adequate pre-oxygenation
• Induction agents: propofol (depending on haemodynamics); opioid (fentanyl/alfentanil/remifentanil)
• Neuromuscular blockade
  • Rocuronium commonly used; prolonged effect possible in renal failure (less than vecuronium); monitor with TOF
  • Atracurium/cisatracurium suitable (organ-independent metabolism); useful if concern about prolonged blockade
  • Suxamethonium: avoid if hyperkalaemic or high risk; may be acceptable if K+ normal and urgent RSI needed (local practice varies)
  • Reversal: sugammadex is renally excreted, can be used but prolonged complex retention; many centres prefer neostigmine/glycopyrrolate if appropriate
• Maintenance: volatile (sevoflurane/isoflurane) or TIVA; avoid prolonged hypotension; maintain normocapnia and normoxia
• Temperature management: active warming; hypothermia worsens coagulopathy and vasoconstriction (may impair graft perfusion)

Fluids, haemodynamics, and graft perfusion

• Haemodynamic goals: maintain adequate perfusion pressure and intravascular volume, especially at reperfusion
  • Common targets: MAP ≥ 70–80 mmHg (individualise: higher if chronic hypertension/vascular disease)
• Fluid strategy: balanced approach, avoid both hypovolaemia (graft hypoperfusion) and overload (pulmonary oedema)
  • Use clinical endpoints + dynamic indices (SVV/PPV if ventilated) + echo where available
• Choice of crystalloid
  • 0.9% saline avoids potassium but large volumes → hyperchloraemic metabolic acidosis and renal vasoconstriction
  • Balanced crystalloids (e.g. Plasma-Lyte/Hartmann’s) contain small K+; often safe with monitoring; may reduce hyperchloraemia—follow local protocol
• Colloids: avoid starches (AKI risk); albumin may be used selectively
• Vasoactive drugs
  • If hypotensive despite volume: use vasopressors (e.g. noradrenaline) to maintain MAP; avoid prolonged low perfusion pressure
  • Dopamine for renal protection is not recommended (no outcome benefit; arrhythmias)
• Diuretics at reperfusion (centre dependent)
  • Furosemide may be given to promote diuresis if concern about delayed graft function; ensure adequate volume first
  • Mannitol sometimes used before clamp release as osmotic diuretic/free radical scavenger; evidence mixed; avoid if volume overloaded

Electrolyte and acid–base management

• Potassium: monitor closely (ABG/VBG); treat hyperkalaemia promptly
  • Treat: calcium salts (membrane stabilisation), insulin + dextrose, nebulised salbutamol, sodium bicarbonate if acidotic; consider dialysis if refractory (rare intra-op)
• Acidosis: common with saline loads and uraemia; severe acidaemia reduces catecholamine responsiveness and may worsen hyperkalaemia
• Calcium: citrate load from transfusion + low albumin can reduce ionised Ca2+; correct if hypotension/arrhythmias

Analgesia and regional techniques

• Multimodal analgesia: paracetamol + opioids (titrate carefully; increased sensitivity in uraemia)
• Avoid/limit NSAIDs early post-op due to nephrotoxicity and bleeding risk (local transplant protocol)
• Opioid choice
  • Fentanyl/alfentanil/remifentanil preferred intra-op (no active renally excreted metabolites)
  • Morphine: active metabolites accumulate in renal failure; if used, reduce dose and monitor for respiratory depression
• Regional analgesia options
  • TAP block / ilioinguinal-iliohypogastric block / wound infiltration: useful opioid-sparing
  • Epidural: can provide excellent analgesia but consider coagulation/antiplatelets, haemodynamic goals, and post-op immunosuppression/infection risk

Immunosuppression and intra-op reactions

• Induction therapy may be administered peri-operatively (centre dependent):
  • Basiliximab 20mg (IL-2 receptor antagonist) or anti-thymocyte globulin (ATG)
  • Steroids (Methylprednisolone 1g over 15 mins)
• Potential issues
  • Anaphylaxis/infusion reactions (ATG more likely): hypotension, bronchospasm, fever; treat per anaphylaxis guidelines; stop infusion; inform surgical team
  • Steroids often given (hyperglycaemia; infection risk)

Post-operative care

• Destination: HDU/ICU if significant comorbidity, haemodynamic instability, major blood loss, or poor graft function
• Fluid balance: strict input/output; urine output may be high (post-transplant diuresis) → replace losses per protocol and monitor electrolytes
• Delayed graft function: oliguria/anuria, rising creatinine; may require dialysis; exclude surgical causes (vascular thrombosis/obstruction) urgently
• Analgesia: opioid-sparing; avoid oversedation; consider regional catheter/blocks if used
• Complications to watch
  • Bleeding/haematoma; vascular thrombosis; urine leak/ureteric obstruction; infection; pulmonary oedema; MI/arrhythmias