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

Anesthesia and intensive care unit care in pediatric kidney transplantation: An international survey

BACKGROUND

Despite the high perioperative risk profile, international guidelines for anesthesia and intensive care unit (ICU) care in pediatric kidney transplantation do not exist. Optimizing hemodynamics can be challenging in these patients, while scientific data to guide decisions in hemodynamic monitoring, hemodynamic targets, and perioperative fluid management are lacking. The limited annual number of pediatric kidney transplantations, even in reference centers, necessitates the urge for international collaboration to share knowledge and develop research and guidelines. The aim of this study was to collect data on current perioperative anesthesia and ICU care practices in pediatric kidney transplantation.

METHODS

An international survey with an anonymized link was sent from a validated electronic data capture system (Castor). Inclusion criteria were: medical doctor in anesthesia, (ICU), or pediatric nephrology working in a pediatric kidney transplantation specialized center; and signed informed consent. Data were analyzed using descriptive statistics.

RESULTS

Thirty-three records were analyzed. Responders were anesthesiologists (58%), pediatric nephrologists (30%), and pediatric intensivists (12%), representing 13 countries worldwide. About half of the centers (48%) performed more than 10 pediatric kidney transplantations a year. Perioperative hemodynamic support was guided by intra-arterial blood pressure (88%), central venous pressure (CVP; 88%), and cardiac output (CO; 39%). The most variation was seen in the hemodynamic targets CVP and CO, fluid administration, and inotrope/vasopressor use. The protocolized use of furosemide (46%) and mannitol (61%) also varied between centers. Postoperative care for the youngest recipients occurred in the pediatric intensive care unit at all centers.

CONCLUSION

The results of this survey reveal a large variation in anesthesia and ICU care in pediatric kidney transplantation centers worldwide, particularly in CVP and CO targets, hemodynamic therapy, and the use of furosemide and mannitol. These data identify areas for further research and can be a starting point for international research collaboration and guideline development.

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

BACKGROUND

Optimal organ perfusion at the time of pediatric renal transplantation is a commonly agreed upon goal. Intraoperative conditions such as fluid balance and arterial pressure determine the success of this goal. Sparse literature guides the anesthesiologist in accomplishing this. We, therefore, hypothesized that significant variability exists in the methods used to optimize renal perfusion during transplantation.

METHODS

A literature search was performed to assess what guidelines currently exist to optimize intraoperative renal perfusion. The intraoperative practice pathways of six large children's hospitals in North America were obtained to compare suggested guidelines. A retrospective chart review of anesthesia records was performed of all pediatric renal transplants over 7 years at the University of North Carolina.

RESULTS

There did not appear to be agreement between the various publications in terms of standard intraoperative monitoring, specific blood pressure or central venous pressure goals, and fluid management. The practice pathways of six children's hospitals showed significant variation and lack of a consensus-driven approach. The chart review demonstrated significant variation between anesthesiologists in terms of invasive monitoring, fluid management, hemodynamic goals, vasopressor use, and analgesic choices. However, children <30 kg were significantly more likely to have arterial lines and epidural catheters placed prior to surgery.

CONCLUSION

Significant variation exists across centers of expertise and even within centers of expertise with regard to the intraoperative management of pediatric kidney transplant recipients. In the era of enhanced recovery after surgery, this presents an opportunity to develop consensus on an evidence-based approach to optimize initial organ perfusion during surgery.

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

While reports on the long-term pathology in mismatched allografts have been focused on the donor and recipient body surface area, evidence is emerging to support donor-recipient age difference as an additional prognostic factor. Most reports are based on pediatric recipients receiving older/bigger allografts. Here, we describe three cases with age mismatch including two cases of adult patients receiving pediatric allografts and a third case of a younger patient receiving an allograft from an older donor exhibiting findings not described in extant literature. Each of these cases exhibits unique changes seen in mismatched donor-recipient size/age post-transplant pathology. These non-rejection changes should be suspected in cases of donor-recipient size/age mismatch. In cases of allograft function decline, a full biopsy workup, including electron microscopy, should be considered.

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.