Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Abstract

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Considerations regarding anesthesia for renal transplantation

“…Preoperative assessment and optimization of identified risks can be applied to mitigate perioperative risks, such as cardiovascular, pulmonary, or other medical complications. Jaszczuk et al [ 7 ] proposed the following recommendations: (1) Patients presenting with unstable coronary syndromes, decompensated heart failure, significant valvular disease, or arrhythmias should undergo reevaluation of their cardiac status. (2) Echocardiography should be performed in individuals with impaired ventricular function, valvular abnormalities, or a risk of developing pulmonary hypertension.…”

“…Avoiding transfusions is recommended for potential kidney transplant recipients [ 10 ]. The consideration of erythropoiesis-stimulating agent treatment is recommended for renal transplantation recipients with hemoglobin levels < 9-10 g/dl [ 7 ].…”

“…During renal transplantation, delayed graft function can occur if the mean arterial pressure (MAP) falls below 70 mmHg. Several studies have recommended maintaining an MAP range of 80-110 mmHg [ 7 , 15 ].…”

“…Ketamine should be avoided in patients with ischemic heart disease (IHD) due to its potential for sympathetic stimulation. In contrast, etomidate may be a suitable choice for patients with IHD or impaired ventricular function owing to its high cardiovascular stability [ 7 ]. Fentanyl, alfentanil, sulfentanil, and remifentanil can be safely used, whereas morphine should be avoided because of the potential for its metabolite morphino-6-glucuronide to cause end-stage renal failure [ 7 ].…”

“…However, research conducted in humans has not provided evidence of any harmful effects on renal function [ 21 , 22 ]. Desflurane, isoflurane, and propofol can be used for anesthesia [ 7 ].…”