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  • Kidney transplantation is the therapy of choice for end-stage renal disease (ESRD)

  • Every child with ESRD should be considered a candidate for transplantation until proven otherwise.

  • Compared to dialysis, transplantation provides for:

    • Increased survival

    • Enhanced quality of life

    • Improved physical, cognitive, and psychosocial development


  • Recipients <10 kg

    • Midline incision

    • Intraperitoneal location

    • Mobilization of the right colon and distal ileum

    • Implantation of the kidney onto the aorta and inferior vena cava (IVC)—as cephalad as possible

    • Bilateral native nephrectomies can be done prior to doing the transplant

    • Edge of peritoneum adjacent to right colon tacked to lateral side wall over the allograft (to prevent torsion)

  • Recipients 10–30 kg

    • Surgical approach and vessels for implantation determined on an individual basis

  • Recipients >30 kg

    • Lower quadrant incision

    • Retroperitoneal location

    • Implantation of the kidney onto the external iliac vessels

  • Although we do not routinely place ureteral stents or retroperitoneal drains, in some instances they may expedite postoperative management by facilitating the exclusion of ureter–bladder anastomotic strictures/edema in instances of low urine output as well as addressing fluid/blood collections in the retroperitoneum


  • Optimal hydration should be maintained, especially in small recipients, to ensure adequate renal perfusion

  • An adult kidney may lead to the sudden uptake of approximately 250 mL of blood at the time of reperfusion. Blood transfusions are often needed in small recipients

  • Lack of adequate volume infusion (which sometimes may represent as much as 50% of the total blood volume) can lead to severe hypotension, potential thrombosis of the newly implanted allograft, or delayed graft function

  • Central venous pressure of 20 cm H2O should be maintained during clamping and 12–15 cm H2O before removal of clamps

  • On release of the aortic and IVC clamps, the ischemic lower extremities and new kidney are reperfused, which may cause hypothermia, hyperkalemia, and acidosis

  • Replacing urine volume with intravenous (IV) fluids

  • Frequently monitoring serum electrolytes and correcting any abnormalities

  • Prior to reperfusion, IV furosemide (1 mg/kg) and 20% mannitol (0.5–1 g/kg) are administered

  • Dopamine can be added to achieve adequate blood pressure (MAP 65–70 mm Hg)

  • Acidosis should be monitored and treated

  • Special anesthesia considerations

    • Operating room temperature set at 32°C (89.6°F)

    • All prep solutions and fluids are warmed

    • Hypothermia aggressively corrected with warm saline abdominal lavage, transplanted kidney is externally warmed after reperfusion

    • Central venous pressure, arterial pressure, cardiac activity, oxygen saturation, arterial blood gases, electrolytes, and hemoglobin are monitored

  • Avoidance of nitrous oxide anesthesia to prevent intestinal distention

  • The infant’s abdomen must accommodate a new, large organ, which in addition to receiving a large percentage of the cardiac output, may impede respiration and decrease venous return


  • Vascular complications are inversely proportional to recipient size

  • Vascular thromboses represent a technical cause of allograft loss

  • Torsion of allograft pedicle and graft infarction can occur

  • Other ...

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