Review Article

Renal Transplantation


Sevda Özkardeşler, Şafak Emre Erbabacan and Uğur Koca*

1Dokuz Eylül Unıvercıty School of Medicine Anestehesiology and Reanimation Department, Turkey

2Cerrahpaşa Unıvercıty School of Medicine Anestehesiology and Reanimation Department, Turkey

3Dokuz Eylül Unıvercıty School of Medicine Anestehesiology and Reanimation Department, Intensive Care Unıt, Turkey

Received Date: 07/07/2020; Published Date: 29/07/2020

*Corresponding author: Uğur Koca, Dokuz Eylül Unıvercıty School of Medicine Anestehesiology and Reanimation Department, Intensive Care Unıt, Turkey

DOI: 10.46718/JBGSR.2020.03.000079

Cite this article: Uğur Koca, Renal Transplantation. Op Acc J Bio Sci & Res 3(4)-2020.


The standard motorization proposed by the American Society of Anesthesia will be sufficient for both the donor and the recipient. ECG (ideally with ST segment analysis), pulse oximeter, capnography, urine volume, non-invasive blood pressure, neuromuscular monitoring are required. Appropriate anesthesia technique should be selected taking into account the existing diseases of the patient, the duration of surgery and the possibilities of renal protection. Since preservation of graft function is directly related to graft perfusion, it is the primary issue of renal perfusion during donor nephrectomy. Renal transplant recipients without severe cardiac or respiratory problems are extubated after surgery. Very rarely, the patient needs mechanical ventilation in intensive care conditions.

Intraoperative Period

        Anesthesia Monitoring

The standard monitorization proposed by the American Society of Anesthesia will be sufficient for both the donor and the recipient [1]. ECG (ideally with ST segment analysis), pulse oximeter, capnography, urine volume, non-invasive blood pressure, neuromuscular monitoring are required. While renal transplant candidates are cardiac patients, central vein catheterization is used as a standard in some centers, while some centers are not preferred because they are not a good indicator of fluid need or response [2]. Wide IV routes should be opened, but IV route interventions may not always be easy in these patients. Difficulty becomes even more pronounced, especially in patients with arteriovenous (AV) fistulas or who have had frequent central venous dialysis catheters. Central vein catheterization under ultrasound provides a great advantage in this respect. Central vein catheterization should be done from the side without AV fistula if possible. Invasive blood pressure monitoring is not indicated in every patient. Because donors are generally healthy patients, they rarely need invasive follow-up. In the recipients, depending on the AV fistulas present, the process may be inconvenient and also pose a risk for future fistulas. Therefore, intraoperative invasive blood pressure follow-up is recommended only in renal transplant candidates with advanced cardiac disease. Instead, non-invasive blood pressure monitoring is sufficient. Care should be taken to use the leg in the contralateral side of the side to which the allograft will be attached if the cuff is placed on the arm without AV fistula, if it cannot be used in both arms for some reason and the measurement will be made from the lower extremity [3]. Transesophageal echocardiography can be used in patients with ventricular insufficiency, pulmonary hypertension, or advanced coronary artery disease. New invasive monitoring techniques analysis is not preferred because it requires artery monitoring, but it is a good alternative to central vein pressure monitoring [4]. Inhibition of hypothermia is of great importance for direct graft function. Therefore, monitoring the body temperature is very important in the intraoperative period.

Anesthesia maintenance

Appropriate anesthesia technique should be selected taking into account the existing diseases of the patient, the duration of surgery and the possibilities of renal protection [5]. Regardless of the method of anesthesia, varicose stockings and blankets in which active heating can be provided should be used to prevent the destructive effect of hypothermia on the graft in terms of mechanical thrombophylaxis [3]. The use of central regional methods is rare and controversial in patients with chronic renal failure [6-8]. However, in the literature, successful use of regional anesthesia in both donors and recipients has been reported many times during renal transplant. (4.6 to 8). Epidural anesthesia can be used both alone and in combination with general anesthesia and has a positive effect on graft by suppressing surgical stress in the intraoperative and postoperative period [4]. General anesthesia is the most preferred anesthesia method [1]. Induction and intubation may cause exaggerated hemodynamic changes in patients with cardiac pathologies and diabetes [1]. Especially in patients with diabetes, rapid serial intubation may be necessary due to gastroparesis due to autonomic disfunction.

End-stage renal failure affects the pharmacokinetics and pharmacodynamics of drugs. In addition, changes in body fluid distribution also affect drug distribution, causing changes in the metabolism of drugs used in the perioperative period [9]. It is important that these changes are known to the anesthetist. Midazolam can be used safely for premedication as its distribution and excretion do not change [10]. Propofol and thiopental are hypnotic agents that can be used safely during anesthesia induction [9]. Both agents are metabolized in the liver. In the intraoperative period, analgesia can be achieved with synthetic opioids independent of renal function such as fentanyl, sulfentanil, alfentanil or remifentanil. Unlike these agents that do not have an active metabolite, morphine and meperidine should not be used because they have active metabolites that can accumulate due to reduced kidney function. Due to the accumulation of morphine-6-glucoronide, these patients may experience prolonged respiratory failure in the postoperative period. Succinylcholine is a depolarizing neuromuscular blocker, the use of which should be avoided as it can cause hyperkalemia. Atracurium and cisatracurium, which are non depolarizing neuromuscular agents, are the first-choice muscle relaxants. They can be used safely in patients with kidney failure, since their metabolism is independent of any organ and is broken down by Hoffman elimination and ester hydrolysis. Since vecuronium and rocuronium clearance are dependent on both kidney and hepatic metabolism, their duration of action is observed. For this reason, it has been shown that rocuronium can be used safely in renal transplant patients, and that neuromuscular effect can be successfully reversed with sugammadex if they should be used with caution [11].

Maintenance of anesthesia can be done with both inhalation anesthetics and propofol induction. In a study in which propofol and sevoflurane were compared, it was reported that although there was no difference in terms of graft functions, lower 2-year rejection rates with sevoflurane were observed [12]. Although it is stated in the literature that sevoflurane may have a nephrotoxic effect due to compound A formation and floride, no significant nephrotoxic effect has been observed with clinical studies [13,14]. This effect can be prevented by keeping the fresh gas flow above 4 l / min [5]. Isoflurane, desflurane are inhalation agents that can be used safely.


Except for very rare cases, the receiver and the transmitter are given different positions. The preferred position in the donor is the lateral position. As the left kidney is preferred because of the longer vein of the left kidney, the left lateral position is usually used. Although open nephrectomy is preferred in many centers, laparoscopic or robotic nephrectomy is also used safely in some centers [15]. In buyers, the position is supine position. Renal allograft is frequently placed in the right or rarely left extraperitoneal fossa.


1. Ricaurte L, Vargas J, Lozano E, Díaz L (2013) Organ Transplant Group. Anesthesia and kidney transplantation. Transplant Proc 45(4):1386-1391.

2. Bacchi G, Buscaroli A, Fusari M, Neri L, Cappuccilli ML, et al. (2010) The influence of intraoperative central venous pressure on delayed graft function in renal transplantation: a single-center experience. Transplant Proc 42(9): 3387-3391.

3. Bennett K, Pace N (2015) Anaesthesia for renal transplantation: an update. Anesth Int Care Med 16(7): 334–338.

4. Hadimioglu N, Ulugol H, Akbas H, Coskunfirat N, Ertug Z, et al. (2012) Combination of epidural anesthesia and general anesthesia attenuates stress response to renaltransplantation surgery. Transplant Proc 44(10): 2949-2454.

5. Bajwaa S (2012) Kulshresthab Anaesthesia considerations and challenges during renal transplantation: Current perspectives Apollo Medicine 9(2): 126-132.

6. Akpek EA, Kayhan Z, Dönmez A, Moray G, Arslan G (2002) Early postoperative renal function following renal transplantation surgery: effect of anesthetic technique. J Anesth 16(2): 114-118.

7. Akpek E, Kayhan Z, Kaya H, Candan S, Haberal M (1999) Epidural anesthesia for renal transplantation: a preliminary report. Transplant Proc 31(8): 3149-3150.

8. Sener M, Torgay A, Akpek E, Aktas A, Colak T, et al. (2005) The effect of anesthetic technique on early postoperative renal function after donor nephrectomy: a preliminary report. Transplant Proc 37(5): 2023-2027.

9. Martinez B, Casanova I, Adesanya A (2013) Anesthesia for Kidney Transplantation. A ReviewJ Anesth Clin Res 4:1.

10. Vinik HR, Reves JG, Greenblatt DJ, Abernethy DR, Smith LR (1983) The pharmacokinetics of midazolam in chronic renal failure patients. Anesthesiology 59(5): 390-394.

11. de Souza CM, Tardelli MA, Tedesco H, Garcia NN, Caparros MP, et al. (2015) Efficacy and safety of sugammadex in the reversal of deep neuromuscular blockade induced by rocuronium in patients with end-stage renal disease: A comparative prospective clinical trial. Eur J Anaesthesiol 32(10): 681-686.

12. Nieuwenhuijs-Moeke GJ, Nieuwenhuijs VB, Seelen MAJ, Berger SP (2017) Propofol-based anaesthesia versus sevoflurane-based anaesthesia for living donor kidney transplantation: results of the VAPOR-1 randomized controlled trial. Br J Anaesth 118(5): 720-732.

13. Karadeniz MS, Ciftci HS, Tefik T, Mammadov O, Yazıcı H, et al. (2017) Comparison of Two Different Inhalation Anesthetics on Grafted Kidney Function in Patients Undergoing Renal Transplantation Surgery: Desflurane or Sevoflurane? Transplant Proc 49(3):448-453.

14. Yildirim M, Kucuk HF, Demir T, Yakupoglu S, Yavuz A, et al. (2015) Early Allograft Function in Renal Transplant Recipients: Is it Affected by Volatile Anesthetics? Transplant Proc 47(5):1352-1355.

15. Tuğcu V, Şener NC, Şahin S, Yavuzsan AH, Akbay FG, et al. (2017) Robotic Kidney Transplantation: Comparison of the First 40 Cases of Open vs Robotic Transplantations by a Single Surgeon BJU Int.

16. De Gasperi A, Narcisi S, Mazza E, Bettinelli L, Pavani M, et al. (2006) Perioperative fluid management in kidney transplantation: is volume overload still mandatory for graft function? Transplant Proc 38(3): 807-819.

17. Gabriëls G, August C, Grisk O, Steinmetz M, Kosch M, et al. (2003) Impact of renal transplantation on small vessel reactivity. Transplantation 75(5): 689-697.

18. Jae Moon Choi, Jun-Young Jo, Jae-Won Baik, Sooyoung Kim, Chan Sik Kim, et al. (2017) Risk factors and outcomes associated with a higher use of inotropes in kidney transplant recipients. Medicine (Baltimore) 96(1): e5820.

19. Ciapetti M, di Valvasone S, di Filippo A, Cecchi A, Bonizzoli M, et al. (2009) Low-dose dopamine in kidney transplantation. Transplant Proc 41(10): 4165-4168.

20. Pfortmueller C, Funk GC, Potura E, Reiterer C, Luf F, et al. (2017) Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in patients undergoing renal transplantation: Prospective, randomized, controlled trial. Wien Klin Wochenschr. 2017 Mar 2.

21. Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, et al. (2015) An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial. Anesth Analg 120(1): 123-129.

22. Hadimioglu N, Saadawy I, Saglam T, Ertug Z, Dinckan A (2008) The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation. Anesth Analg 107(1):264-269.

23. Lemmens H (2015) Kidney transplantation : recent developments and recommendations for anesthetic mamagement. Anesthesoiol Clin North America 22: 651-662.

24. Bordin JO, Heddle NM, Blajchman MA (1994) Biologic effects of leukocytes present in transfused cellular blood products. Blood 84: 1703-1721.

25. Lee PC, Hung CJ (2000) Suspected acute posttransplant neuropsychosis due to interaction of morphine and cyclosporine after a renal transplant. Anaesthesia 55: 827-828.

26. Stahl RAK (1998) non-steroidal anti- inflammatory agents in patients with a renal transplant. Nephrol Dial Transpl 13: 1119-1120.

27. Serlo W, Haapanemi L (1985) Regional Anaesthesia in Paediatric Surgery. Acta Anaesthesiol Scand 29: 283-286.

28. Care I, Lumpur HK (2015) Guidelines on anaesthetıc management for renal transplant. p. 1-25.

29. Shoeibi G, Babakhani B, Mohammadi SS (2009) The efficacy of ilioinguinal-iliohypogastric and intercostal nerve co-blockade for postoperative pain relief in kidney recipients. Anesth Analg 108: 330-333.

30. Mukhtar KKI (2010) Transversus abdominis plane block for renal transplant recepients. Br J Anaesth 104: 663-664.


31. Zorica B. Jankovic, Stephen G. Pollard MMN (2009) Continuous Transversus Abdominis Plane Block for Renal Transplant Recipients. Anesth Analg 109: 1709-1710.