Perioperative anesthesia care for the pediatric patient undergoing a kidney transplantation: An educational review

Abstract

End-stage renal disease (ESRD) in children is rare with an incidence of 5-15 per million depending on geographic location. The best treatment option is kidney transplantation, which delays end-organ damage, enhances physical growth and improves quality of life. Advances in immunosuppressive therapy, surgical techniques and donor selection have improved both graft and patient survival over the last decades. Best outcomes are achieved with a pre-emptive transplantation (before the initiation of dialysis) from a living donor and at a young recipient age (<5 years). The resulting one-and five-year graft survival rates are then 99.5 and 94.9 percent, respectively. 1 Because of the low incidence of kidney transplantation in children and the complexities related to patient and surgery, care tends to be centralized in designated centers. Moreover, only 20% of pediatric kidney transplantations occur in recipients under the age of five, making it a rare procedure for the pediatric anesthesiologist to encounter. Notwithstanding, there is a clear lack of evidence-based guidelines resulting in diverse perioperative approaches. 2,3 The purpose of this review of recent literature is to describe the pathophysiological changes occurring in children with ESRD. In addition, we aim to provide recommendations and potential guidelines for anesthesia care in children undergoing either kidney transplantation or other surgical procedures in the presence of a donor kidney. | EPIDEMI OLOGYChildren account for less than 2% of all ESRD patients and about 5% of all kidney transplantations in Europe and North America. Kidney

Intraoperative management of pediatric renal transplant recipients: An opportunity for improvement

“…Most were single-center experiences reporting small numbers, [3][4][5][6][7][8] and only two journal publications provided evidence-based direction of intraoperative anesthetic management. 3,9 There did not appear to be agreement between the various publications in terms of standard intraoperative monitoring, specific blood pressure or central venous pressure (CVP) goals, and fluid management. There was clear agreement that intraoperative anesthetic goals should focus on maximizing perfusion pressure to the transplanted kidney, but there was limited information to guide evidence-based practice in pediatric patients.…”

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

“…Many patients with ESKD have impaired long function because of fluid overload and leakage of alveolar membranes. Therefore, lung protective mechanical ventilation might be beneficial in pediatric kidney transplantation (130,131).…”

“…Norepinephrine is recommended in patients that do not respond to fluid administration. It prevents post reperfusion hypotension which is commonly seen in small pediatric patients that receive a kidney form an adult donor (76,131).…”

“…During surgery, multiple monitoring tools are used including end tidal CO 2 and oximetry. In children < 20 kg we use Pulse Contour Cardiac Output (PiCCO) technique for advanced hemodynamic monitoring (131).…”

Novel Histopathologic and Ultrastructural Findings in Renal Allografts From Patients With Size and Age Mismatches: A Case Series

“…The spectrum of nonrejection histopathologic changes in kidney allografts is a testament to the improvements in human leukocyte antigen (HLA) identification techniques and immunosuppressive therapies available to patients [1]. Additionally, advancements in surgical techniques have led to more creative and complex donor-recipient situations [2][3][4][5]. These situations are most pronounced among pediatric populations, both as donors and recipients.…”