RENAL TRANSPLANT
Surgical Procedure Sequence:
1. Venous anastomosis
a. Side clamp IVC for venotomy
b. Allograft renal vein to recipient vena cava
c. Clamp renal vein distal to anastomosis
d. Unclamp IVC
2. Arterial anastomosis
a. Cross clamp aorta above and below aortotomy site
b. Allograft renal artery to recipient aorta
3. Reperfusion
a. Unclamp renal vein and aorta
4. Ureteral implantation over stent
Anesthetic Goals:
NOTE: Clarify CVP and SBP goal with surgeon prior to start of transplant
1. For reperfusion and thereafter: CVP 15-20, SBP > 120
2. After reperfusion: UOP 5-10 ml/kg/h
Lines:
1. Arterial line
2. Central venous line – multi-lumen
a. May use existing hemodialysis catheter
i. If so remember to remove 5 ml heparinized blood from catheter prior to use
b. One lumen for monitoring CVP, other lumen for drips
3. Large peripheral IV access
Infusions:
1. Dopamine – start 3-5 mcg/kg/min prior to reperfusion
Timing of Drug Dosing:
A. Immunosuppression (Please verity plan with transplant nephrologist)
a. Thymoglobulin (need 0.2 micron filter from PICU, infuse over 6-8 hours via dedicated
central line port because caustic to peripheral veins, premedicate to avoid adverse reaction)
i. If no central line prior to surgery give premed at induction
1. Solumedrol IV 2 mg/kg
2. Tylenol IV 15 mg/kg
3. Benadryl IV 1 mg/kg
b. Tacrolimus – usually not dosed by anesthesiologist, given preoperatively if needed
c. Cellcept – should be given preoperatively if needed, may finish infusion intraoperatively
i. 20 mg/kg over 2 hours
d. Solumedrol 10 mg/kg just prior to unclamping (maximum 500 mg, check with surgeon)
B. Prophylaxis for Ischemia/Reperfusion Injury – give just prior to unclamping of hepatic artery
a. Mannitol 0.5 gram/kg (check with surgeon for max dose)
b. Lasix 1 mg/kg
c. Start Dopamine infusion
C. Surgeon may request Heparin 10 units/kg during arterial anastomosis
D. Ureteral implantation
a. Clamp foley upon surgeon’s request for infusion of methylene blue solution retrograde into
bladder via foley catheter.