Kidney transplantation: the recipient
Stem
A 54-year-old man, 86 kg, with end-stage renal disease from diabetes and hypertension, is having a deceased-donor kidney transplant. Cold ischemia time is 16 hours. He dialyzed yesterday through a left forearm fistula and is 1 kg above dry weight. Potassium is 5.3 mmol/L, bicarbonate 20, hemoglobin 10.2 g/dL. Echo shows concentric hypertrophy with an ejection fraction of 55%. He makes little urine.
Question
How will you manage him to give the graft its best start?
Ideal answer
HeadlineThe graft needs pressure and flow at reperfusion without drowning the patient, so I plan around perfusion, potassium and a balanced fluid.
- Balanced crystalloid, not saline: in BEST-Fluids Plasma-Lyte cut delayed graft function from 40% to 30%.1
- Pressure before reperfusion: MAP at least about 90 mmHg as the clamps come off, with an early vasopressor rather than reflex volume.2
- Fluid by response, not CVP: dynamic indices, echo and blood loss guide it; CVP is context only.2
- Potassium watched, acidosis avoided; a potassium-free saline load makes hyperkalemia worse through hyperchloremic acidosis.3
- Cisatracurium, or rocuronium reversed with neostigmine: Hofmann elimination spares the kidney;4 after neostigmine I confirm a quantitative TOF ratio of at least 0.9.5
Watch for: the graft pinking up and making urine at reperfusion, potassium, and hypotension from vasodilation.
Breaking down the answer
- Why reperfusion is the moment — the new kidney autoregulates poorly after ischemia; sustained hypotension cuts graft flow and injures tubules.2 Changes if: poor ventricle or pulmonary hypertension, I add an arterial line and echo, and an inotrope.
- Balanced fluids and potassium — ninety-eight percent of potassium is intracellular, so the acidosis shift matters more than 4–5 mmol/L in the bag;3 trials found similar or lower potassium with Ringer's than saline.3
- Sugammadex — not recommended below a creatinine clearance of 30 mL/min, because the complex is renally excreted.6 Changes if: the graft functions promptly; the decision belongs before induction.
- Communicate the transplant data — donor type, ischemia times, crossmatch, antibodies and the induction immunosuppression plan go into a joint briefing before incision.2
- Induction — diabetic gastroparesis and uremia slow gastric emptying, so I use a rapid sequence with rocuronium, succinylcholine only if potassium is below 5.5.4 Changes if: a recent gastric ultrasound shows an empty antrum.
- Protect the fistula — no cuff, line or tight positioning on that arm; it is his dialysis access if the graft fails.
- Delayed graft function — dialysis within the first week; long cold ischemia and donation after circulatory death raise it.2
Follow-up question
Ten minutes after reperfusion, the kidney looks mottled and makes no urine. MAP is 68 mmHg on low-dose norepinephrine, and a blood gas shows potassium 6.4 mmol/L with peaked T waves. What do you do?
Follow-up answer
HeadlineHyperkalemia after reperfusion with a poorly perfused graft; I tell the surgeon and treat both now.
Calcium chloride for the membrane, then insulin with dextrose and ventilation to correct acidosis; bicarbonate if the pH is low. I raise MAP with norepinephrine and judge volume on echo. Reperfusion is a diagnostic window: I ask the surgeon to check for arterial or venous thrombosis, kinking or malposition, with Doppler ultrasound.2 I repeat the gas in 15 minutes and keep dialysis available.
Pitfalls that cost points
- Running saline "because it has no potassium."
- Pushing litres to a CVP target in a hypertrophied ventricle, then extubating into pulmonary edema.
Rapid-fire
Q: How was delayed graft function defined in BEST-Fluids? A: Dialysis within 7 days of transplant; the trial randomized 808 deceased-donor recipients at 16 hospitals.1
Q: What other metabolic problems destabilize reperfusion? A: Acidosis, low calcium and magnesium, hypothermia, hyperglycemia and anemia.2
Q: Why does a new graft tolerate low pressure poorly? A: Ischemia-reperfusion injury, vasoplegia, calcineurin inhibitor exposure and the recipient's vascular disease all blunt its autoregulation.2
Q: Urine output falls on the ward that night. What first? A: Early Doppler ultrasound, to separate a vascular, urological or hemodynamic cause from delayed graft function.2
Q: What does urine output tell you? A: Less than you think: osmotic diuresis, diuretics and tubular injury all confound it.2
Numbers to know
| Item | Value |
|---|---|
| Delayed graft function | 30% balanced vs 40% saline1 |
| Reperfusion MAP | ≥ about 90 mmHg if tolerated2 |
| Sugammadex limit | CrCl <30 mL/min, not recommended6 |
| Intracellular potassium | 98% of total body3 |
| BEST-Fluids | 808 recipients, 16 hospitals; adjusted RR 0.741 |
| Delayed graft function definition | Dialysis within 7 days1 |
Links
- Chronic kidney disease and the dialysis patient, hyperkalemia, Fluid management: crystalloid, colloid, goal-directed, sugammadex, Brain death and the organ donor
- BEST-Fluids trial (Lancet 2023)
Sources
- 1.Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial · The Lancet (Collins et al.), Europe PMC abstract record, 2023 · ebi.ac.ukPMID 37343576. 808 recipients, 16 hospitals; DGF 30% vs 40%.
- 2.Perioperative Kidney Transplant Care: A Narrative Review of Preoperative Optimization, Intraoperative Management, and Early Postoperative Allograft Support · Cureus (Alrashidi et al.), 2026 · ebi.ac.uk
- 3.Fluid Selection in Renal Transplant Patients: Considerations for Hyperkalemia Management · Turkish Journal of Anaesthesiology and Reanimation (Tontu), 2025 · ebi.ac.uk
- 4.Perioperative considerations in kidney transplantation: An anaesthesiologist's perspective · World Journal of Transplantation (Goyal, Shekhrajka, Mittal), 2025 · europepmc.orgCisatracurium and atracurium undergo ester hydrolysis and Hofmann elimination to inactive metabolites; CKD brings gastroparesis and aspiration risk; succinylcholine for rapid sequence only if potassium is below 5.5 mEq/L, otherwise rocuronium.
- 5.Neuromuscular Blocking Agents in Anesthesia: A Narrative Review of Contemporary Challenges and Reversal Approaches · Journal of Clinical Medicine (Radkowski et al.), 2026 · europepmc.orgSummarizes ASA 2023 and ESAIC: quantitative monitoring after neostigmine until the TOF ratio exceeds 0.9; extubate only at TOFR >= 0.9.
- 6.BRIDION (sugammadex) injection, prescribing information · FDA / DailyMed · dailymed.nlm.nih.gov
Facts on this page were checked against these sources on Oct 22, 2026. Guidelines change; confirm doses against current institutional protocols.