CHAPTER 88: Surgical Aspects of Pediatric Kidney Transplantation

INTRODUCTION

• 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

SURGICAL APPROACH

• 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

INTRAOPERATIVE MANAGEMENT

• 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

EARLY COMPLICATIONS

• 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 ...