UCSF Anesthesia Resident Pearls: Renal Transplant

03/2023

UCSF Anesthesia Resident Pearls: Renal Transplant

How a patient gets on the UCSF Transplant list
1) Evaluation- Transplant nephrologists, Transplant surgeon, social worker, financial counselor begin the evaluation
2) Testing- Given high prevalence of diabetes and hypertension in the ESRD population, most patients will have an ECG, echo, and possibly a stress test in the system. Additional consultants (Hematology, Pulmonary, Infectious Disease, Rheumatology, Immunologic, Dental, etc.) as needed for comorbidities.

3) Immunologic evaluation- ABO blood group determination, human leukocyte antigen (HLA) typing, screening for antibodies to HLA phenotypes, and cross-matching.
4) Additional Health Maintenance: Per established guidelines; for example, age-appropriate colon cancer screening in patients older than 50.
5) Allocation- The allocation system for kidneys was revised at the end of 2014. Elements that determine a patient’s likelihood of receiving an offer include:

• Time on dialysis (now receive credit for any time spent on dialysis prior to being listed)
• Likelihood of long-term need for a kidney. The allocation system now tries to match kidneys
• with a high chance of lasting a longer time (as determined by donor factors) with recipients who
• have a high chance of surviving with a transplanted kidney for a longer time.
• Additional rules for pediatrics, blood type B, and patients who are immunologically hard to match
• (antibodies).

6) Recipients from living donors: often are earlier in their disease process; may be on peritoneal dialysis or never have been dialyzed (preemptive transplantation).

Epidemiology, in brief

Nation

• 101,000 patients on the waiting list as of January 2015
• 16,895 kidney transplants in 2013 (5,732 living donor and 11,163 deceased)

UCSF

• Busiest kidney transplant center in California
• 2013- 345 kidney transplants (211 deceased donor allografts and 134 live donor allografts)
• ~5,400 people on the kidney transplant waiting list at UCSF
• Wait list times are higher than national averages

Most common causes of ESRD requiring kidney transplant:

• Diabetes
• Hypertension
• Glomerular disease (FSGS, IgA nephropathy, SLE, etc)
• Congenital defects (children)

Day of Surgery Pre-op Assessment

1) Living Donor Recipients- Typically pre-screened by Dr Claus Niemann for phone consult vs. walk- in appointment with Prepare clinic.
2) State of Dialysis- Should be reviewed: last dialysis, type of dialysis, serum potassium, bicarbonate, and dry weight prior to OR.
3) Associated co-morbidities- Should already have an extensive work-up as above. System is set up so that candidates have a review and reevaluation approximately 1 year before anticipated transplant. Sometimes the information is hard to find. Sometimes important data can be found in “Care Everywhere” or “Letters.”

• Cardiovascular Risk- Coronary artery disease: Stress test, Echo with global EF, PA systolic pressure, Coronary Angiogram? Pacemaker? When depressed EF is secondary to uremia, cardiac function usually recovers after transplantation.
• Hypertension- Common in the ESRD population. Know the patient’s anti-hypertensive regimen, what medications they took on DOS, and where their BP usually runs. Intra-operative goal is to keep patient at or slightly above baseline, but this goal may need modification if the patient’s baseline borders on hypertensive urgency, or on the low end of normotension.
• ACEIs & ARBs- Check to see if your patient has taken one of these. The Prepare clinic generally tells other surgical patients to not take these drugs due to concern for refractory hypotension on induction. Because the timing of a deceased donor kidney is unpredictable, these patients are more likely to have already taken these meds. Discuss with your attending the utility of vasopressin to treat hypotension if your patient is on an ACEI/ARB.
• Diabetes- Check serum glucose, start insulin infusion once glucose greater than 150-180 mg/dl. Practice patterns vary. Common to bolus 4 units and infuse 4 units/hr, but modify based on patient’s preoperative insulin regimen. Recheck frequently.
• Electrolytes- Depending on dialysis history and recent lab values, you may wish to check K+ and HCO3- before surgery. Turnaround time is quickest with a STAT venous blood gas—make sure that the panel you order includes electrolytes!
• Hematologic- CBC, Coags. Anemia currently better treated with erythropoietin. If warranted, a preop CBC may be done to document the platelet count. Uremia can cause coagulopathy even with low normal counts.

 

Confirmation Match of patient and donor kidney blood/HLA to be done as additional safety check prior to transfer to OR. Yes, it’s done by others, but you should do it too!

Immunosupression

1) Oral Agents- Current practice is to start these post-operatively, but you should verify that any medications ordered by the surgical team for administration prior to the surgery have been given.

• Tacrolimus (Prograf, FK506)- Calcineurin inhibitor, keystone of immunosuppressive maintenance.
• Mycophenolate mofetil (Cellcept)- Adjunctive oral maintenance, inosine monophosphate dehydrogenase inhibitor.

2) Intravenous agents- Usually two agents given by anesthesia after induction is complete.

• Methylprednisolone- Standard dose is 500mg IV infused over 15-30 minutes after induction of anesthesia. Although rare, instances of anaphylactic reaction have been observed. Use an infusion pump.

One of the following is given as well after the methylpred infusion is complete:

• Basiliximab (Simulect)- Antibody to T-cell IL-2 receptor (affects T-cell function, but notnumber), used for patients with lower risk of rejection. Package insert says that it can be given as IV push, but some recommend giving as an infusion over 20-30 minutes. There are reports of acute hypersensitivity reactions.
• Thymoglobulin (Rabbit Anti-thymocyte globulin) – Provides lymphocyte depletion, used for patients with higher risk of rejection. Comes in a bag from pharmacy, should be infused with a 0.22micron filter in line. Should not be run in line with other medications. Goal is IV administration over 6 hours. Thymoglobulin can result in a SIRS-like response from activation of T-cells. In awake patients, side effects include headache, fever, arthralgias, rigors, and hypotension. Sometimes the infusion can be slowed to run over 8 hours if problems with hypotension in the OR.
  • Obtain an Alaris pump and IV tubing from the PACU. Use “basic infusion” to run the thymo at the appropriate rate. Take the Alaris pump with you to PACU at the end of the case.

Anesthetic/Intra-operative Management

1) Intravenous Access- Often challenging. One reliable, 20-22g PIV adequate for most inductions. 2nd larger PIV placed asleep. Sometimes must resort to central line (2- or 3-lumen). Reasonable to discuss with surgeon if you plan on a central line. Exception: we typically place a double- or triple-lumen line for kidney/pancreas transplants for secure multi-lumen access and frequent lab draws. Dialysis Catheters- Could potentially be used for induction in poor IV access patients. Typically locked with 3ml heparinized saline. Protocol for hep-lock is generally 1000 units/ml of heparin in each port after saline flush. (Volume of heparinized saline is typically printed on access ports) You MUST withdraw the heparinized saline until you get blood back before accessing. Discuss with your attending.

2) Monitoring-

• Arterial Line- Very rarely used for hemodynamic monitoring. May be indicated due to individual patient comorbidities. Note that patient will be positioned with both arms out, so a- line could be placed later if needed.
• CVP- CVP monitoring not shown to affect graft function. Could be used if central line placed due to poor access. CVP goal 10-15 mmHg
• AV Fistula Checks- Document checks Q15-30 minutes. Avoid compression of the fistula when securing the patient’s arms to the arm board. It is important to monitor for a thrill and to avoid prolonged hypotension. If the AV fistula loses its thrill or pulsation, you must discuss this with the surgeon. Dialysis may be needed post-op.

3) Induction-

• Hypnotic- Propofol is by far the standard induction agent at UCSF. Consider dose adjustment (e.g., hypovolemia due to recent dialysis).
• Muscle Relaxant- Cisatracurium (Nimbex) is the mainstay. Use a twitch monitor and document! It can be a long wait for intubating conditions with cisatracurium. If there is need for an RSI or modified RSI, rocuronium or succinylcholine can be used.

Rocuronium: The UCSF QI database suggests that the risk of residual neuromuscular blockade may be higher in patients who receive both rocuronium and cisatracurium during a case.

Succinylcholine: Remember that the increase in plasma K+ is not greater in ESRD than it is in patients with normal kidney function. If you know the patient’s K+, then sux can be a fine choice.

• Antibiotics- Discuss with surgeon. Typically cefazolin is given. If anaphylaxis to any drug is suspected, please remember to obtain a serum tryptase level.
• Esmolol- Consider esmolol for induction as a substitute for opioid. Repeated and somewhat high esmolol doses may be required for a smooth induction.
• Opioid- Mainstay is fentanyl. Recommend opioid loading at the end of the case, and no (or little) opioid with induction (see Esmolol). Once fascia is divided, there is very little surgical stimulus. Opioid up front may contribute to relative hypotension. Average amount of fentanyl 200- 250mcg/case.
• Special consideration needed for use of morphine or meperidine due to active morphine metabolite and normeperidine seizure potential.

4) Maintenance

• Anesthetic Maintenance- Inhalation agent is common but intravenous (TIVA) can be used. Theoretic risk of Compound A with Sevoflurane, but renal toxicity has not been shown in human studies.
• Hemodynamic Goals- Keep between baseline and +20% in most cases. Discuss with surgeon or attending if patient has a relatively “low” BP or is significantly hypertensive at baseline.
• Phenylephrine/Ephedrine- Theoretical concern for vasoconstriction in allograft potentially worsening function. Retrospective study at UCSF did not show relation to delayed-graft function. Discuss with attending and surgeon if needed for hemodynamic support once the graft is in place.
• Dopamine- Surgeons’ first choice for treating low BP in these cases. Tachycardia often a problem. We do not routinely run “renal dose” dopamine.

Fluid Management/ Transfusion Requirements- Fluid goals usually discussed during timeout, with usual range being 2-3L of crystalloid over the course of the operation.

• Colloids rarely given.
• Discuss Plasmalyte/LR versus NS with the anesthesia faculty (reference O’Malley study in A&A)
• Blood transfusion in less than 2 %

5) Transplanting- Use a Quicknote to document time the kidney is out of slush and time of reperfusion—this is the warm ischemia time. Average warm ischemia time is about 25 minutes.

• Hemodynamics- The period from just before reperfusion to the first appearance of urine is when the surgeon will pay the most attention to the blood pressure.
• Have these drugs ready for every case:
• Furosemide- Slow IV infusion of 100mg over 30 minutes +/- continuing infusion. 100mg given in the vast majority of cases. Check with anesthesia attending or surgeon regarding when to start it.
• Mannitol- 30 minute IV infusion of 12.5 grams or more depending on surgeon. Check vials for crystal precipitation, use a filter. Infuse through reliable IV d/t concern for extravasation.
• Mannitol and furosemide are started once, or just before, kidney is out of slush.

6) Post-reperfusion to Closing

• Urine Output- Circulating nurse will typically monitor UOP q15 minutes after ureter anastomosis to bladder.
  • No Urine? -Delayed Graft Function (DGF) is a common event, especially in Deceased Donor kidneys. Your anesthetic is most often not a major contributing factor to this. See below.
• Muscle Relaxants- You walk a fine line between relaxation during closure and full muscle strength for extubation. Patient needs to be well-relaxed during closure of the fascia. However, as alluded to above, UCSF Anesthesia’s QI database suggests that kidney transplant patients are at particular risk for residual neuromuscular blockade requiring reintubation in the OR or in PACU. Use your monitors, and document.

7) Emergence

• Pain management- We do not do epidurals for these patients. The mainstay of pain management is IV fentanyl.
• Please administer at least three antiemetic agents. Typically this is ondansetron and propofol infusion in addition to the methylprednisolone. Other antiemetics are acceptable as well.

Post-operative

1) Transfer

• PACU- Barring serious complications or failure to extubate, patients generally go to the PACU. Typical PACU report to the nurse.

Complications and Considerations

1) Rejection

• Hyperacute- This happens quickly in the OR after clamps are released or the following hours. Complement-mediated with recipient pre-existing antibodies. The graft is usually removed to prevent severe SIRS. Rare now with better matching techniques.
• Accelerated Acute- Subset of acute rejection that can be seen within the first week post-op. Cellular and/or antibody-mediated. Incidence of any rejection in first 30 days approaches 2%.

2) Delayed Graft Function (DGF)

• Usually defined as dialysis within first week of transplant
• Incidence now down to <3% with living donors
• ~20% incidence with standard criteria donors (SCD), ~30% with expanded criteria (ECD), and ~40% with donation after cardiac death (DCD)
• Donor Factors (ECD donor)
  • HTN, CrCl<80, Weight, Atraumatic Death, Increased age

Recipient Factors

• Pre-sensitization, ethnicity, Pre-OR pro-inflam cytokines, MAP<100

Surgical Factors

• Cold ischemia time, Warm ischemia time, Preservation solution

3) Survival

• UCSF Data (Adult)
  • Graft Survival
    • Deceased Donor: 1yr 93.6%, 3yr 89.5% 
    • Living Donor: 1yr 95.5%, 3yr 96.8% 
  • Patient Survival 
    • Deceased Donor:1yr 97.2%, 3yr 93.3% 
    • Living Donor: 1yr 99.2%, 3yr 97.7% 
• National Data 
  • Deceased Donor
    • Return to Dialysis: 5yr 15.2%, 10yr 29%
    • Death with Function: 5yr 12.7%, 10yr 25% 
  • Living Donor
    • Return to Dialysis: 5yr 9%, 10yr 21%
    • Death with Function: 5yr 7%, 10yr 18% 

4) Other Data

• Interested? Curious? A trove of data and information await at the United Network for Organ Sharing and the Scientific Registry of Transplant Recipients. 

 

Revised by: Stephen Weston, M.D., January 2015. 1 Edition: Jake Pletcher, MD Anesthesia Faculty Advisor: Bill Shapiro, M.D. Contributions by: Ryutaro (Ryo) Hirose, M.D., Transplant Surgeon Claus Niemann, M.D., Transplant Anesthesiologist