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Stanford Guide to Kidney Transplants

Setup for Deceased Donor Kidney Transplant

Room Setup/Equipment:

  1. Usual MSMAIDS
  2. Optional: 18 Fr OGT, Sedline
  3. 16G TLC (ideally 16cm long for RIJ, not 20cm) unless with Dr. Melcher (no CVC)
  4. ≥ 2 IVs, at least 1 large
  5. Techs to provide:

    1. 1-2x blood pumps
    2. Ultrasound
    3. Arterial line setup
    4. 0.2micron filter (for thymoglobulin)

  1. Circulator will provide a clamp for the Foley catheter

Supplies for central lines:
  1. Sterile gloves
  2. US probe covers
  3. biopatches
  4. blue caps / MaxPlus
  5. sterile flushes

 

Drugs to grab from pharmacy:
  1. Mannitol 25g (ensure not crystallized)
  2. Methylprednisolone 125 mg
  3. Acetaminophen 1g IV
  4. Cefazolin vs Pip/Tazo (2 doses)
  5. Phenylephrine bag
  6. Dopamine bag (discuss)
  7. Cisatracurium (discuss)

Drugs / Tasks Intraop (confirm timing with surgeon):

  1. Before Incision: Cefazolin vs. Pip/tazo (if using pip/tazo and patient is ESRD, no redose until kidney is reperfused, then q2hr after that; can check with pharmacy)
  2. Near incision: Methylprednisolone 125mg and diphenhydramine 50mg (ask surgeon)
  3. Kidney out of ice: start mannitol (25g over 25-30min) (ask surgeon)
  4. Before reperfusion:
    1. IV fluid goals by this time are usually 2-4 L crystalloid - can minimize for patient factors, but discuss with surgeon
    2. Surgeons may request specific blood pressure goals before reperfusion - maintain a buffer for kidney reperfusion: expect mild hypotension / bradycardia
  5. After vascular reperfusion and before ureteral anastomosis: clamp Foley
    1. Fills bladder and allows for anastomosis, and carries some antibiotics in
  6. After completion of ureteral anastomosis: furosemide 80mg (ask surgeon)
    1. Surgeons may ask you to “zero the Foley,” not count irrigation fluid, and start counting postreperfusion urine output
  7. Thymoglobulin (ordered by surgeon) bolus over 6-8 hours (usually easier to program as basic infusion), using 0.2micron filters (from our techs)
  8. Reverse with sugammadex vs. neostigmine (discuss)

 

Overview

  1. Recipients will undergo evaluation from transplant nephrology/surgery, social worker, and a variety of other specialists
  2. Cases are usually booked after a donor OR time is confirmed, and occasionally they are canceled for a variety of donor organ reasons
  3. Organs are allocated based on a variety of factors including time on dialysis and likelihood of benefitting from a transplant for a longer time
  4. Stanford performs ~155 kidney transplants/yr, of which ~30 will be living donors; CA does ~2,700/600; nationally ~24,000/6,000
  5. Helpful links: Anesthesia for kidney transplantation and living donor kidney transplantation

Pre-op:

  1. Write a preop note including cardiac workup and existing lines / dialysis access
  2. Apply kidney transplant macro to intraop record
  3. Verify a type and screen is at least in process before rollback and consider having 2U pRBCs on hold, especially if the antibody screen is positive
  4. Check preoperative potassium level and when pt last had dialysis

 

Lines:

  1. Central line (if placed) is principally for thymoglobulin infusion, but also allows for timely collection of lab results (immunosuppression levels)
  2. 2 PIVs - postoperatively, some surgeons will need a dedicated IV to run ½ NS w/bicarb to balance electrolytes and pH
  3. Arterial line is standard at Stanford and is usually removed in PACU

Intraop:

  1. Rocuronium / Sugammadex is common, though succinylcholine and cisatracurium / neostigmine are also good options; consider quantitative twitch monitoring, as residual blockade, hypoventilation, and acidosis will worsen hyperkalemia postoperatively
  2. Thymoglobulin (rabbit antithymocyte globulin) depletes lymphocytes as it is infused over several hours through a 0.22 micron filter; side effects include a SIRS-like response from T-cell activation including hypotension, headache, fever, arthralgias, and rigors
  3. Fluids and diuretics are administered to encourage kidney function; discuss with surgeon on limiting fluids (in patients with heart failure, for example)
  4. Dopamine is traditionally preferred, though far less predictable than the usual alternatives. Low dose vasopressors with a reasonable dose of anesthetic titrated to an appropriate blood pressure is good for end organ perfusion; high dose vasopressors should prompt further investigation (ABG, sedline, POCUS, etc.)

 

Postop:

  1. Avoid deep narcosis and worsening hyperkalemia at extubation
  2. Rejection and Delayed Graft Function - this can result in brisk diuresis and severe electrolyte derangements
  3. Graft congestion, bleeding, and other issues may prompt an urgent return to OR

Living Kidney Donation

These patients are typically healthy ASA 1 or 2 and will donate the left kidney (longer vein). The recipient operation is usually in the same OR with the same team, while the kidney is on ice. Turnover time should be minimized if possible, though ideally a separate team should take the recipient into the OR to minimize ischemia time.

Surgically, the donor operation is performed laparoscopically with a hand assist port via a Pfannensteil or low abdominal laparotomy incision. They will mobilize the kidney, ureter, and surrounding vasculature; ensure a backtable, ice, and preservative fluid is available; extract the kidney, flush with preservative, and place it on ice; and finally ensure hemostasis in the abdomen. Before closure, some surgeons will place a nerve block catheter in the surgical field and patients will go to PACU with an ON-Q pump running local anesthetic.

Similarly to kidney recipients, surgeons may also ask for:

  1. Fluids and diuretics (sometimes)
  2. Heparin 3-5k IV before arterial clamp
  3. Protamine 30-50mg after kidney is extracted (give a 10mg test dose to check for anaphylactic and anaphylactoid reactions)

Things to consider:

  1. LTA for sore throat
  2. ERAS interventions for pain (ketamine or lidocaine infusions)

Living Donor Kidney Transplant

These patients are typically healthier, sometimes on peritoneal dialysis or not at all. Ischemia time for the graft organ should be minimized as much as possible, so rapid turnover and line placement is desirable. Setup and plan is the same as above for deceased donors.

The donor organ typically produces urine immediately after anastomosis and recipients usually experience lower rates of delayed graft function (requiring postoperative dialysis, etc.), improved graft survival, and improved survival.

 

Additional Reading

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