Perioperative considerations in kidney transplantation: An anaesthesiologist’s perspective

Table 1 Preoperative considerations for kidney transplantation

Area of management	Anaesthesia considerations
Preoperative evaluation	Detailed history of kidney disease, dialysis, urine output, blood transfusion, previous transplant or surgery, pregnancy, comorbidities, multisystem involvement, medications, and drug abuse
	Detailed donor evaluation
	Physical assessment of the recipient for fitness of surgery
	Routine investigations for surgery
	Special testing to decide transplant candidacy
	Secondary evaluation by other specialists, if needed
	Correction of anemia
Preoperative optimization	Weight reduction, exercise, and nutritional build-up
	Smoking and alcohol cessation at least 4-6 weeks before surgery
	Incentive spirometry
	Preoperative haemodialysis
	Repeat electrolytes and coagulation profile on the day of surgery
Preoperative advice	Continue antihypertensive, antianginals, beta-blockers
	Discontinue oral hypoglycemics, anticoagulants, and antiplatelets
	Fasting: As per standard fasting guidelines, prolonged in patients with gastroparesis, diabetes, and ascites
	Anti-anxiety: Short-acting benzodiazepine
	Oral antacid: H2 receptor blockers or proton pump inhibitors

Table 2 Intraoperative considerations for kidney transplantation

Area of management	Anaesthesia considerations
Anaesthesia technique	General anaesthesia with intubation: Preferred
	Neuraxial blocks: Risk of spinal or epidural hematoma
	Dose of LA should be reduced
Anaesthesia monitoring	Monitoring: Standard ASA monitors (NIBP, SPO2, ECG, ETCO2, temperature)
	Arterial line: For beat-to-beat blood pressure monitoring and arterial blood gas analysis, avoided in fistula arm
	Central venous catheter: For infusion of induction therapy and vasopressors/inotropes
Fluid management	Fluid responsiveness by dynamic indices (SVV or PPV): Target 10%-15%
	Crystalloids: Low chloride solutions – preferred to avoid normal saline large doses, risk of hyperkalemia and lactic acidosis with ringer lactate
	Colloids: Avoid starches: Risk of coagulopathy, renal injury, routine use of albumin is not recommended
Transfusion management	Red cell transfusions: Transfusion trigger is haemoglobin < 70-80 g/L, Leukoreduced red cell preferred
	Fresh frozen plasma/ cryoprecipitate/ platelet: Avoided routinely, if required point of care coagulation monitoring guide suggested
Pain management	Multimodal analgesia and individualized approach: IV paracetamol, fascial plane block, intrathecal morphine, epidural analgesia, skin infiltration with local anaesthetic Avoid NSAIDS
Immunosuppression	Induction therapy: Antithymocyte globulin, 1-1.5 mg/kg or basiliximab, 20 mg
	IV methylprednisolone (10 mg/kg): 10-15 min before reperfusion of graft
Other interventions	Blood glucose: Target blood sugar 6-10 mmol/L
	Temperature: > 35.5 °C, forced air warming device or blankets, fluid warmers
	Antibiotic prophylaxis: Cefazolin 2 g IV, 30-60 min before surgical incision
	PONV prophylaxis: IV palanosetron 0.075 mg

LA: Local anaesthetic agents; ASA: American Society of Anaesthesiologists; NIBP: Noninvasive MAP; SPO2: Oxygen saturation; ECG: Electrocardiogram; ETCO2: End-tidal carbon dioxide; SVV: Stroke volume variation; PPV: Pulse pressure variation; IV: Intravenous; NSAIDS: Nonsteroidal anti-inflammatory drugs; PONV: Postoperative nausea and vomiting.