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Robot-Assisted Kidney Transplantation
Published on: July 19, 2021
Intraoperative management and early postoperative outcomes of pediatric renal transplants
Katherine Taylor1,2, Wooheon Thomas Kim1, Malak Maharramova1
1Department of Anesthesia, Hospital for Sick Children, Toronto, Canada.
Insights
Dopamine use in pediatric renal transplants is common but delays graft function and increases pulmonary edema risk. Alternative strategies are needed for better outcomes in these young patients.
Area of Science:
- Pediatric Nephrology
- Transplant Surgery
- Anesthesiology
Background:
- Pediatric end-stage renal disease (ESRD) increasingly requires renal transplantation.
- Adult donor kidneys pose unique challenges in pediatric recipients due to size and circulatory demands.
- Perioperative anesthetic management is critical for successful pediatric renal transplants.
Purpose of the Study:
- To describe the perioperative anesthetic management in pediatric renal transplant recipients.
- To evaluate the impact of anesthetic agents and perioperative factors on clinical outcomes.
- To identify risk factors for delayed graft function and adverse events.
Main Methods:
- Retrospective chart review of 156 pediatric renal transplant patients (2006-2014).
- Analysis of patient demographics, surgical factors, anesthetic management, and postoperative outcomes.
- Comparison of outcomes based on donor type, age, and pharmacological support.
Main Results:
- Dopamine was used in 83% of cases, often with mannitol (95%) and furosemide (82%).
- Intraoperative dopamine use was associated with delayed creatinine nadir (graft function) in all and deceased donor grafts.
- Pulmonary edema occurred in 33% of patients, linked to 'supra-physiological' hemodynamics.
Conclusions:
- Dopamine administration is an independent risk factor for delayed renal graft function in children.
- The use of various agents to enhance renal perfusion can lead to significant complications like pulmonary edema.
- Optimized anesthetic and hemodynamic management is essential for improving outcomes in pediatric renal transplantation.
Introduction:
Smaller children are presenting for renal transplantation as the treatment of choice for end-stage renal disease. Adult donor organs are more successful than pediatric deceased donor organs. An adult kidney may sequester ~75% of the circulating volume of a 5 year-old child and requires significantly increased cardiac output to maintain renal perfusion. Treatment includes volume, inotropic or vasopressor agents, or central neuroaxial blockade for sympatholysis. We describe the perioperative anesthestic management as a guide to clinical outcomes.
Methods:
A retrospective chart review of renal transplant patients between 2006 and 2014 was performed. We recorded patient demographics, surgical and anesthetic factors and postoperative outcome.
Results:
One hundred and fifty-six children underwent renal transplantation, of which 38% were from living donors. There were 99/156 (63.5%) males. Median age was 10 years (range 1-17 years) and the mean weight was 36.2 kg (sd 20.6 kg; range 7.6-109.6 kg). There were 36 children ≤5 years of age and 14 children ≤2 years of age. One hundred and nineteen (77%) were dialysis dependent. Pharmacological support to increase renal perfusion included mannitol in 95%, and dopamine in 83%. Furosemide was used in 82% of cases. Inotropic therapy continued into the postoperative period in 34%. Radiological pulmonary edema was diagnosed in 33% and clinical pulmonary edema in 7%. Intraoperative use of dopamine delayed the time to creatinine nadir in all grafts (9.5 days vs 6.5 days, P = 0.04) and in deceased donor grafts (12.9 vs 7.4 days, P = 0.007). Patients who received dopamine had no significant difference in central venous pressure (CVP) preclamp removal, 14 mmHg vs 11.5 mmHg (P = 0.12) but a higher CVP after clamp removal, 14.3 mmHg vs 11.8 mmHg (P = 0.003).
Conclusion:
Dopamine use was common and was an independent risk factor for delayed time to creatinine nadir. Many different agents were used to enhance renal perfusion. The 'supra-physiological' hemodynamics resulted in pulmonary edema in 33% of patients.
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