Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice

Abstract

BackgroundThere is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. MethodsA 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. ResultsA 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. ConclusionsThis questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

Enhanced Recovery after Surgery: History, Key Advancements and Developments in Transplant Surgery

“…The uptake of ERAS into the field of renal transplantation has been equally slow. In 2019, Morkane et al concluded that there was a high degree of heterogeneity between perioperative practises across 23 renal transplantation (RT) centres [69]. They found that 27.3% of centres utilised cardiac output measures to guide fluid administration, 40.9% aimed for specific intra-operative targets of central venous pressure, and 54.5% use fentanylbased patient-controlled anaesthesia alongside transversus abdominis plane block [69].…”

“…In 2019, Morkane et al concluded that there was a high degree of heterogeneity between perioperative practises across 23 renal transplantation (RT) centres [69]. They found that 27.3% of centres utilised cardiac output measures to guide fluid administration, 40.9% aimed for specific intra-operative targets of central venous pressure, and 54.5% use fentanylbased patient-controlled anaesthesia alongside transversus abdominis plane block [69]. This highlights the poor standardisation of perioperative care with regards to RT, despite evidence that enhanced recovery reduces length of hospital stay and confers better pain control than standard practices [70].…”

Abdominal Organ Transplantation: Noteworthy Literature in 2019

“…They identified a broad range of practice among 23 transplant centers in the United Kingdom with regard to intraoperative fluid management, blood pressure targets, vasopressor administration, central venous pressure monitoring, and pain management strategies. 15 Of note, 54.5% of centers performed TAP blocks, and 90.9% of centers provided patient-controlled analgesia (PCA) with fentanyl, morphine, or oxycodone (IV). Only a single center reported a renal transplant-specific ERAS program for cadaveric organ recipients.…”

“…Only a single center reported a renal transplant-specific ERAS program for cadaveric organ recipients. 15 In our 2018 review, 16 we cited an initial implementation of an ERAS protocol for renal transplant recipients, which included 286 recipients in the ERAS group and 151 in the traditional recovery group, and showed significantly better pain control, decreased length of stay, and cost savings. 17 In 2019, Dias et al published the results of their standardized ERAS protocol with prospective data from July 2017 to December 2018 (N ¼ 100) and compared it with data from prior to ERAS implementation (N ¼ 100).…”

A retrospective study of the relationship between postoperative urine output and one year transplanted kidney function

“…In early stages of KT, urine production is considered to be a sign of successful reperfusion after anastomosis [8, 9]. The use of perioperative diuretics to increase urine volume differs among centers with respect to type and dose [10, 11]. Some reports have shown that long-term prognosis can be predicted by urine volume after KT [12, 13].…”