Transplant: Perioperative Management

Necessary labs

• Rapid-turnaround preoperative COVID screening should be performed immediately upon arrival

• Human leukocyte antigen (HLA) at time of transplant

• Comprehensive metabolic panel (CMP)

• Complete blood count (CBC) with differential

• Coagulation factors: prothrombin time (PT), partial thromboplastin time (PTT)/international normalized ratio (INR)

• If a hemodialysis (HD) catheter is in place, culture all lumens of the HD catheter

• If on peritoneal dialysis (PD), collect dialysate fluid cell count, gram stain and culture

  • After sample is collected, connect PD catheter to drain bag and allow to drain to gravity

• Urinalysis (UA) and urine culture if able to collect a urine sample (e.g., not anuric/severely oliguric)

• Girls ≥12 years of age:

  • Urine hCG if able to collect a urine sample (e.g., not anuric/severely oliguric), otherwise blood hCG

• Unless precluded by state laws, OPTN policies dictate that for patients ≥12 years of age the following labs must be sent after admission but before anastomosis of the graft:

  • HIV using a CDC recommended laboratory HIV testing algorithm

  • Hepatitis B virus (HBV): [PDF: CDC interpretation guide]

    • HBcAb: hepatitis B core antibody (total, IgG + IgM),

    • HBsAb: hepatitis B surface antibody (quantitative), and

    • HBsAg: hepatitis B surface antigen

  • Hepatitis C virus (HCV):

    • Anti-HCV antibody (IgG)

    • HCV ribonucleic acid (RNA) by nucleic acid test (NAT), quantitative

      • Note: polymerase chain reaction (PCR) is a type of NAT

  • Patients who are <12 years of age will have these labs drawn as part of their transplant evaluation process or while they are on the waiting list

Dialysis plan

• If on hemodialysis (HD) or peritoneal dialysis (PD), will they require a HD and PD treatment prior to going to the OR?

  • Ensure that up-to-date information is available regarding their dialysis prescription

• Does this patient require intraoperative CKRT?

Immunosuppression plan

• Induction immunosuppression?

  • Typically anti-thymocyte globulin, mycophenolate mofetil, and methylprednisolone

  • For patients who will be going promptly to the OR, mycophenolate mofetil (Cellcept) is generally given intravenously immediately after IV access is established

  • Is plasmapheresis required?

  • Do they require a dose of eculizumab?

• Maintenance immunosuppression: steroid free or steroid based?

Consent

• Consent should be obtained by the transplant surgery team

  • If a donor is classified as high/increased risk, then a "high risk consent" must be obtained from the patient/family by the transplant surgery team

Diet

• Patients should be made NPO on arrival (and are often instructed to be NPO prior to arrival to the hospital)

Fluid management

• Strict I&Os: all intakes and outputs should be closely measured

  • Careful ongoing assessment of fluid balance is essential to ensure appropriate hydration status before going to the OR

  • For some patients, this data can be used to determine whether a patient is actively polyuric

• Continuous intravenous fluids

  • If they are dehydrated and require resuscitation, consider a fluid bolus (10-20 mL/kg, up to 1 L) with 0.9% normal saline

  • D5-NS is often an appropriate choice

    • If a patient is polyuric, monitor closely to keep their fluid balance net positive

      • If they have a urinary concentrating defect, D5-0.45% ("half normal") or D5-0.225% ("quarter normal") saline may be a more appropriate fluid choice

    • If a patient is oliguric/anuric, target a fluid balance that slightly exceeds insensible losses to maintain a gentle positive fluid balance

      • Estimate insensible losses at 400 mL/m²/day, and divide over 24 hours to get the hourly fluid rate

Medication management

• Discontinue ACE inhibitors

• Target blood pressures on the high end of normal (around 90th percentile)

• Consider discontinuing other antihypertensives

Nephrectomy

• Patients may need to have one or both of their native kidneys removed at time of transplant:

  • Uncontrolled kidney-related hypertension

  • Difficult to control kidney-related hypertension (i.e., requiring ≥3 agents)

  • Polycystic kidney disease, especially in patients with a history of infected cysts or very large kidneys

  • Polyuria to a degree that the recipient would have difficulty keeping up enough fluid intake to balance the urine lost from the transplanted kidney and native kidneys

  • Severe vesicoureteral reflux and megaureter that is not amenable to repair

  • Recent history of recurrent UTIs

  • Need for space

• The kidney allograft is placed extraperitoneally in the right or left iliac fossa (typically on the right)

• The donor renal vessels are usually anastomosed to the external iliac vessels of the recipient, though this may vary

• Urinary reconstruction is almost always via uretero-neocystostomy (donor ureter is connected to recipient bladder), although at times other types of reconstruction can be chosen

• After anastomosis, the surgery team will be able to note the blood pressure at which the kidney appears well perfused and has robust urine output; this information will be useful in the postoperative period

• Initial function of the allograft is enhanced by:

  • Short cold ischemia time

  • Short rewarming (anastomosis) time

  • Intravascular volume repletion

POST-OP INPATIENT MANAGEMENT

• Don’t forget basic general surgery: eval for flatulence/bowel sounds/movement

• Will have to adjust timing and medications of everything in the order set

• Total max goals of IVF POD0 can be up to 500 cc/hr when doing the 1:1 urine replacement

• Urine output goals POD0 typically minimum 50 cc/hour

• When the urine output starts to drop to less than the 50 cc/hr, the 1:1 replacement of fluids doesn’t provide enough IVF, and should change over to 2.5 L/m2/day of total fluids (most often by POD1)

• If needing volume/boluses:

  • NS @ 10 cc/kg

  • Consider 5% albumin (Colloid) @ 10 cc/kg

• Initial vasopressor of choice: Dopamine

  • PO options for BP augmentation: 1) Midodrine 2) Fludrocortisone

• Diuretics:

  • Think twice before giving Lasix -- transplanted kidneys are extremely sensitive to diuretics, and require a very low dose

• Interpreting CVP waveforms: https://learn.openpediatrics.org/learn/course/internal/view/elearning/3115/interpreting-central-venous-pressure-waveforms

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