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Perioperative management of kidney transplants

An overview of the principles of managing pediatric transplant recipients in the immediate preoperative and postoperative periods

Preoperative 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
    catheter is in place, culture all lumens of the HD catheter
  • If on
    , 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:
    • 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
    • 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


Polymerase chain reaction (PCR) is a type of NAT

Dialysis plan

  • If on
    , will they require a dialysis treatment prior to going to the OR?
    • Ensure that up-to-date information is available regarding their dialysis prescription
  • Does this patient require intraoperative

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 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


  • 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


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

Transplant surgery

  • 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

Postoperative ICU management

Immediate postoperative care

  • Maintenance IV fluids (0.9% NaCl, normal saline) to cover insensible losses
  • Strict monitoring of intake/output
    • Urine output goal typically 50 mL/h
  • Urine replacement with 0.45% NaCl or 0.9% NaCl for 24 hours
    • Typically 1:1 replacement, assessed every hour, with max of 200-500 mL/h
  • Check serum electrolytes on arrival to the ICU, then every 6 hours
  • Monitor CVP for first 24 hours
    • Goal typically >8, but the transplant surgeon will note what CVP was associated with good intraoperative urine output and may adjust the postoperative CVP goal accordingly
    • If needing intravascular volume repletion, bolus 10 mL/kg with 0.9% NaCl (normal saline)
      • Consider 10 mL/kg of 5% albumin (colloid)
    • [OpenPediatrics: Interpreting CVP Waveforms]
  • Avoid hypotension: SBP goals typically ~120-140 mmHg
    • May adjust goal to 100-140 mmHg if younger and/or no history of hypotension, as long as perfusion continues to be good (i.e., urine output is stable)
    • Vasopressor of choice: dopamine
    • Oral options for BP augmentation are available: midodrine, fludrocortisone
  • If fluid overloaded:
    • Reduce urine output replacement, or stop replacement fluids and transition to maintenance fluids


Transplanted kidneys can be extremely sensitive to diuretics. If diuretics are required, start with 1/4 or 1/2 of the usual initial dose and titrate to effect.