**2. Pre-operative transplant management**

## **2.1 Initial clinical assessment pre-transplant**

Patients on the kidney transplant waiting list have usually undergone a thorough medical and surgical assessment prior to listing to identify significant comorbidities that would preclude transplantation. Optimisation of cardiovascular comorbidities, including diabetes mellitus (DM) and hypertension, is important not only for prevention of cardiovascular disease but also for avoidance of hypertensive and diabetic damage to the transplanted graft. Nevertheless, at the point that an intended recipient is admitted to hospital for transplantation, a thorough reassessment is important to identify any new medical issues, as well as to ensure that the recipient is sufficiently medically stable for a general anaesthetic and surgery.

On arrival at the transplanting hospital, bloods are collected with a request for the laboratory to process these urgently (**Table 1**). In addition, a chest radiograph and ECG are performed.

While these investigations are being processed, a medical history and examination should be undertaken with the patient with the aim of documenting:


The presence of potential new medical comorbidities should prompt review of suitability for, and safety of proceeding with transplantation. The development of ischaemic heart disease, vascular disease, malignancy or active infection would preclude proceeding with transplantation.

**13**

combination.

follows:

*Perioperative Care for Kidney Transplant Recipients DOI: http://dx.doi.org/10.5772/intechopen.84388*

**2.2 Management of pre-existing medication**

outside the perioperative period.

A key decision during the assessment is whether a patient requires dialysis prior to transplantation. Similarly, donor factors associated with a high probability of delayed graft function (e.g., donation after circulatory death [DCD] kidney, prolonged anticipated cold ischaemic time) require a lower threshold for dialysis. Significant hyperkalaemia (a typical threshold may be a serum potassium concentration > 5.5 mmol/L) or fluid overload should prompt urgent dialysis prior to transplantation. In general, it is better to control fluid and electrolyte abnormalities effectively with dialysis pre-operatively rather than to attempt dialysis in a less stable patient post-surgery. Due to tissue damage and intraoperative bleeding, hyperkalaemia may worsen post-operatively. If haemodialysis is required prior to transplantation, patients are usually slightly above their target weight with the aim of avoiding intraoperative hypotension. Minimal or no heparin should be adminis-

tered during dialysis to minimise the risk of perioperative haemorrhage.

Patients with advanced kidney disease are often on multiple medications, many of which can be safely discontinued at the time of transplantation, including most antihypertensive medication, phosphate binders, cinacalcet, and erythropoiesisstimulating agents. However, some medications should usually be continued as

• Active vitamin D compounds in patients post-parathyroidectomy are usually continued. Calcium levels post-transplant follow a biphasic pattern with early decline in the post-operative week without supplementation. The protective effect of raised PTH is absent in patients post-parathyroidectomy, thereby risking precipitating severe hypocalcaemia if such patients are not supplemented with active vitamin D compounds (calcitriol and alfacalcidol) [6].

• Beta blockers are usually not stopped abruptly in the perioperative period due to concerns that this may lead to rebound tachycardia and increase the risk of mortality [7]. However, it may be reasonable to reduce the dose and/or convert patients to a beta blocker with a shorter duration of action (e.g., metoprolol) to

• Statins, although generally safe, can predispose to rhabdomyolysis if used in conjunction with CYP450-3A4 inhibitors [8]. We suggest ceasing statins until

• Antiplatelet therapy with aspirin is usually continued perioperatively, and many transplant centres routinely prescribe aspirin to recipients who are not already receiving this agent to reduce the risk of transplant vessel thrombosis, although this has a poor evidence base [9]. Dual antiplatelet therapy with aspirin plus agents, such as platelet P2Y12 receptor inhibitors (e.g., clopidogrel and ticagrelor), would usually be considered a contraindication to transplantation, both because of the increased risk of bleeding and the frequent association of significant vascular disease in patients requiring this

• Erythropoiesis stimulating agents (ESA) may be continued on the basis of some studies identifying anaemia as an independent predictor of mortality in the intermediate post-transplant period [10]. There are, however, no studies showing benefits of continued ESA therapy or defining optimal haemoglobin

reduce the risk of hypotension in the post-operative period.

#### **Table 1.** *Usual investigations for a patient presenting for kidney transplant.*

*Perioperative Care for Kidney Transplant Recipients DOI: http://dx.doi.org/10.5772/intechopen.84388*

*Perioperative Care for Organ Transplant Recipient*

**2. Pre-operative transplant management**

**2.1 Initial clinical assessment pre-transplant**

and ECG are performed.

The increase in mortality associated with kidney transplantation highlights the need for optimal perioperative management to minimise the risks and maximise the benefits associated with transplantation. This chapter focuses on the principles and

Patients on the kidney transplant waiting list have usually undergone a thorough medical and surgical assessment prior to listing to identify significant comorbidities that would preclude transplantation. Optimisation of cardiovascular comorbidities, including diabetes mellitus (DM) and hypertension, is important not only for prevention of cardiovascular disease but also for avoidance of hypertensive and diabetic damage to the transplanted graft. Nevertheless, at the point that an intended recipient is admitted to hospital for transplantation, a thorough reassessment is important to identify any new medical issues, as well as to ensure that the recipient

On arrival at the transplanting hospital, bloods are collected with a request for the laboratory to process these urgently (**Table 1**). In addition, a chest radiograph

While these investigations are being processed, a medical history and examina-

development of vascular disease (angina, claudication, peripheral ulceration), malignancy (unexpected weight loss, new mass or lymphadenopathy) or active

• Signs or symptoms of fluid overload, with assessment of the patient's weight in relation to their recent clinic weights (or current target weight if on dialysis).

The presence of potential new medical comorbidities should prompt review of suitability for, and safety of proceeding with transplantation. The development of ischaemic heart disease, vascular disease, malignancy or active infection would

evidence of perioperative management of transplant patients.

is sufficiently medically stable for a general anaesthetic and surgery.

tion should be undertaken with the patient with the aim of documenting:

infection (fever, constitutional symptoms).

• The patient's usual daily urine volume.

preclude proceeding with transplantation.

Serum for tissue typing investigations

Pregnancy test as appropriate Urine culture unless anuric Chest radiograph Electrocardiogram

Renal and liver chemistry including phosphate, calcium, and LDH

Serology for CMV, EBV, VZV, toxoplasma hepatitis B, hepatitis C, HIV

*Usual investigations for a patient presenting for kidney transplant.*

• Any new medical comorbidities, in particular symptoms suggesting the

**12**

**Table 1.**

Blood tests:

Full blood count Coagulation profile Blood group + hold

A key decision during the assessment is whether a patient requires dialysis prior to transplantation. Similarly, donor factors associated with a high probability of delayed graft function (e.g., donation after circulatory death [DCD] kidney, prolonged anticipated cold ischaemic time) require a lower threshold for dialysis. Significant hyperkalaemia (a typical threshold may be a serum potassium concentration > 5.5 mmol/L) or fluid overload should prompt urgent dialysis prior to transplantation. In general, it is better to control fluid and electrolyte abnormalities effectively with dialysis pre-operatively rather than to attempt dialysis in a less stable patient post-surgery. Due to tissue damage and intraoperative bleeding, hyperkalaemia may worsen post-operatively. If haemodialysis is required prior to transplantation, patients are usually slightly above their target weight with the aim of avoiding intraoperative hypotension. Minimal or no heparin should be administered during dialysis to minimise the risk of perioperative haemorrhage.
