Liver/Kidney/Pancreas Transplantation

Amy E. Gallo MD (Kidney, pancreas transplantation)¹

Marc L. Melcher MD, PhD (Kidney, pancreas transplantation)¹

Dev M. Desai MD, PhD, FACS (Liver transplantation)¹

Carlos O. Esquivel MD, PhD (Liver transplantation)¹

Timothy Angelotti MD, PhD (Kidney, pancreas transplantation, multiorgan procurement)²

Hendrikus J. M. Lemmens MD, PhD (Liver transplantation)²

¹SURGEONS

²ANESTHESIOLOGISTS

KIDNEY TRANSPLANTATION—CADAVERIC AND LIVE-DONOR

SURGICAL CONSIDERATIONS

Description: Kidney transplantation offers patients with end-stage renal disease (ESRD) freedom from dialysis. The source of the renal graft may be a cadaveric donor, a relative (e.g., parent, sibling) or a genetically unrelated donor such as a spouse, friend, or person through paired donor exchange.

After induction of anesthesia, a 3-way Foley catheter is placed into the bladder. The kidney allograft is placed in the extraperitoneal iliac fossa. A curvilinear incision is made in the right or left lower quadrant. The retroperitoneal space is developed by retracting the peritoneum medially and cephalad exposing the iliac vessels. A self-retaining retractor is usually placed to maintain exposure. The external iliac artery and vein are identified and surrounding lymphatics are ligated and divided. Several centimeters of the vessels are mobilized. The external iliac vein is clamped first and the renal-vein-to-iliac-vein anastomosis is performed. Then the external iliac artery is clamped and an artery-to renal-artery anastomosis is performed. The clamps are then released starting with the renal vein. (Fig. 7.12-1). The patient should be euvolemic at this point; mannitol and/or furosemide can be given. The bladder is filled with an antibiotic irrigation solution to facilitate the implantation of the ureter. The spatulated ureter is anastomosed to the mucosa of the bladder. The detrusor muscle is then reapproximated over 3-4 cm of ureter to create an antireflux valve. The wound is closed, normally leaving native kidneys intact.

Variant procedure or approaches: Cadaveric or live-donor transplantation

Usual preop diagnosis: ESRD

Figure 7.12-1. Sketch of a kidney transplant labeled 1, 2, 3 in the order of the surgical anastomoses. 1-renal vein to external iliac vein; 2-renal artery to external iliac artery, and 3-ureter to bladder. The inset shows the lower quadrant curvilinear incision. (Paul Gallo, DDS).

▪ SUMMARY OF PROCEDURES

	Cadaveric Kidney	Live-Donor Kidney
Position	Supine	⇚
Incision	Lower quadrant curvilinear (Fig. 7.12-1 inset)	⇚
Special instrumentation	Self-retaining retractor; vascular instruments; CVP; Foley catheter (3-way)	⇚
Unique considerations	CVP 10-12 mm Hg; mannitol 12.5-25 g; intraop immunosuppression before reperfusion (steroids, antilymphocyte preparation); potassium-free iv fluid; protection of shunt or fistula important.	⇚
Antibiotics	Pipercillin/tazobactam 3.375 g iv, within 1 h preop	Cefazolin 1-2 g iv, 1 h preop
Surgical time	1.5-3 h	2-3 h
EBL	100-200 mL	⇚
Postop care	Replace UO mL/mL with i.v. fluids; may have delayed graft function 2° prolonged cold storage; ICU selectively	Fluid replacement; delayed graft function unlikely; ICU selectively
Mortality	1-2%	⇚
Morbidity	Lymph or serous leak/stenosis: 3-5%	⇚
	Postop bleeding: 3-5%	1-2%
	MI: 2-3%	⇚
	Ureteral leak/stenosis: 2-3%	⇚
	Wound infection: 2-3%	⇚
	Arterial thrombosis: 1-2%	⇚
	Venous thrombosis: 1-2%	⇚
	Wound hematoma: 1-2%	⇚
	Other infectious complications: 15-40%	⇚
Pain score	5	5

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Cadaveric Kidney/Pancreas Transplantation, p. 698.

Suggested Readings

1. Kahan BD, Ponticelli C: Principles and Practice of Renal Transplantation. Martin Dunitz, Ltd., London: 2000.

2. Morris PJ: Kidney Transplantation. WB Saunders, Philadelphia: 2001.

3. Odorico JS, Sollinger HW: Technical and immunosuppressive advances in transplantation for insulin-dependent diabetes mellitus. World J Surg 2002; 26:194-211.

CADAVERIC KIDNEY/PANCREAS TRANSPLANTATION

SURGICAL CONSIDERATIONS

Description: Pancreas transplantation: Combined kidney and pancreas transplantation not only provides renal replacement for the Type I diabetes patient with end-stage renal disease (ESRD), but also controls diabetes. Over 80% or more of pancreas transplants are performed in combination with kidney transplantation from the same donor (simultaneous kidney/pancreas transplant [SPK]). Pancreas transplantation also can be performed for patients who have already received a kidney transplant (pancreas after kidney [PAK]). Less commonly, pancreas transplantation is done for patients with brittle diabetes or with impending complications while they still enjoy normal or near-normal kidney function. Immunosuppression regimen for pancreas transplantation is generally more aggressive than that used for kidney transplantation, and induction therapy with antilymphocyte preparation (ATG, IL-2 blockers) is commonly used.

The pancreas transplant is placed in the right iliac fossa, and the kidney transplant is placed in the left iliac fossa. This can be done through a transperitoneal lower midline incision or through two separate extraperitoneal lower-quadrant incisions in the same manner as kidney transplantation. The graft is first prepared on the back table. For arterial in-flow, a Y-graft is fashioned using the donor iliac artery bifurcation. The portal vein coming off the pancreatic graft is anastomosed to the external iliac vein. The Y extension vascular graft is then anastomosed to the recipient external or common iliac artery. The donor duodenum is anastomosed to a loop of small bowel or to the urinary bladder to drain the exocrine secretions (Fig. 7.12-2A). With pancreas transplantation, there may be significant blood loss if the graft mesenteric vessels are not occluded properly. After the pancreas is implanted, the kidney transplant is placed into the opposite iliac fossa (as described in Kidney Transplantation, p. 694).

Variant procedure or approaches: The pancreas may be placed in the upper abdomen with the portal vein anastomosed to the superior mesenteric vein. The exocrine secretions are bowel-drained. This more physiologic approach, however, is associated with a higher technical failure rate and requires a long upper midline incision (Fig. 7.12-10). Pancreatic islet cells may be infused via a radiological portal vein approach, a procedure that is usually performed in the radiology/angio suite.

Usual preop diagnosis: ESRD 2° diabetes mellitus (DM)

▪ SUMMARY OF PROCEDURE

Position	Supine; cushion heels
Incision	Midline or bilateral lower quadrant
Special instrumentation	Thompson retractor; vascular instruments; Foley catheter; NG tube; CVP; arterial line
Unique considerations	Do not correct hyperglycemia < 300 mg/dL. Maintain adequate hydration, CVP 10-12 mm Hg; mannitol 0.25-0.5 g/kg on unclamping; intraop immunosuppression before reperfusion (125-250 mg methylprednisolone, monoclonal or polyclonal preparation [e.g., ATG, Zenepax, OKT3, Simulect]).
Antibiotics	Pipercillin/tazobactam 3.375 g iv q 6 h × 5 d; fluconazole 200-400 mg (nl creatine clearance)
Surgical time	4-6 h
EBL	250-500 mL
Postop care	ICU × 1-2 d, hourly monitoring of glucose; serum glucose should decline by 50 mg/dL each hour and remain < 200 mg/dL.
Mortality	2%
Morbidity	Thrombosis of graft: 5-10% Postop bleeding: 5-10% Wound infection: 2-6% Pancreatitis: 2-4% Anastomotic leak: 1%
Pain score	7

Figure 7.12-2. A: SPK transplantation, with drainage of pancreatic exocrine secretions into the bladder. Note that portal vein drains into iliac vein (systemic venous [SV] drainage). In normal individuals, 50% of secreted insulin is extracted from the circulation in the first pass through the liver. Transplant recipients with SV have peripheral insulin levels 2-2½ × higher than normal. B: SPK transplantation with drainage of pancreatic exocrine secretions into the proximal jejunum (enteric drainage [ED]). This technique has been adopted for SPK by most transplant centers in the United States for solitary pancreas transplantation, most centers still utilize ED to allow monitoring of the urinary amylase. Note that donor portal vein drains into the recipient superior mesenteric vein (portal venous [PV] drainage) preventing peripheral hyperinsulinemia. Most centers continue to place the pancreas in the pelvis, combining ED and SV, which requires enteric anastomosis to a more distal segment of jejunum or ilium. (Reproduced with permission from Greenfield LJ, et al, eds: Surgery: Scientific Principles and Practice, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001.)

ANESTHETIC CONSIDERATIONS FOR KIDNEY AND KIDNEY/PANCREAS TRANSPLANTATION

PREOPERATIVE

Typically, patients presenting for renal transplantation fall into two patient populations: (1) the young and relatively healthy (following dialysis), or (2) an older, more chronically ill group. Rarely, patients will present for transplant surgery without adequate preparation (e.g., ↑ K⁺, ↓ pH, hypervolemia). Patients presenting for pancreas transplantation are usually severe diabetics with many of the associated problems, such as CAD, autonomic neuropathy, gastroparesis, and stiff-joint syndrome (difficult intubation).

Respiratory	Pleuritis and pleural effusions may occur in this patient population. Increased susceptibility to infection is common in the patient with chronic uremia.
Cardiovascular	Pericarditis (acute or constrictive), HTN, CHF, dysrhythmias, pericardial effusion are common, especially in the undialyzed patient. Diabetes, a common cause of ESRD, is often associated with PVD, CAD, and autonomic neuropathy. Tests: ECG (rhythm, CAD, electrolyte abnormalities, pericarditis, LVH). Other tests (ECHO, stress, etc.) as indicated from H&P.
Gastrointestinal	Gastroparesis may occur, especially in diabetic patients with autonomic neuropathy. Consider full stomach precautions. Ranitidine (50 mg iv) and metoclopramide (10 mg iv) should be given 60 min preop to aid gastric emptying and ↓ acidity.
Renal	Patients are usually on dialysis. Postdialysis goals include: K⁺ = 4-5 mEq/L, BUN < 60 mg%, creatinine < 10 mg%. Metabolic acidosis, hypocalcemia, and hypermagnesemia often present and may require preop correction. Patients may be hypovolemic following dialysis; [check mark] pre- and postdialysis weight (> 2 kg loss is significant). Rapid correction of severe hyperkalemia can be achieved by giving 50 mL of 50% glucose iv, together with 10 U regular insulin and 50 mEq NaHCO. Further correction can be obtained by coadministration of an inhaled β-agonist (e.g., albuterol; 5-10 puffs). Tests: Cr; BUN; creatinine clearance; electrolytes
Hematologic	These patients are frequently anemic. Preop correction usually not needed. A coagulation disorder may be present with abnormal Plt function (improved by dialysis) as well as thrombocytopenia, resulting in a prolonged bleeding time. There is a high incidence of posttransfusion hepatitis in this patient population. Tests: Hct; PT; PTT; Plt count; hepatic screen, consider platelet function assay.
Endocrine	Assess glycemic control preop. Individualize diabetic Rx for day of surgery. In general, hold oral agents 12-24 h, and ↓ or hold usual insulins, and consider sliding scale insulin day of surgery. Favor hyperglycemia (≥ 120-200 mg/dL) over tight glucose control. Preop/intraop corticosteroid immunosuppressive Rx will likely → hyperglycemia. Postop glycemic management complex and dynamic. Tests: Serial glucose levels
Neurologic	Peripheral neuropathy may occur, and specific deficits should be documented. Autonomic neuropathy can → cardiac problems (e.g., orthostatic hypotension, ↑ HR, or ↓ HR), silent MI, and GI problems.
Premedication	Consider midazolam 1-2 mg iv.

INTRAOPERATIVE

Anesthetic technique: GETA favored. Spinal, epidural, or combined spinal-epidural anesthesia may be considered for renal transplantation, if coagulation and platelet function acceptable. Ilioinguinal-iliohypogastric and intercostal nerve blockade can be utilized as an alternative method for postop pain control. Avoidance of hypotension after organ(s) transplantation is an important consideration that may limit effectiveness of RA techniques.

Induction	Rapid-sequence induction (see p. B-5). ET intubation is aided by succinylcholine (1 mg/kg), if K⁺ < 5.5 mEq/L; otherwise, use cisatracurium (0.2-0.5 mg/kg) or rocuronium (1.2 mg/kg). Fentanyl (2-5 mcg/kg) may be used to suppress the cardiovascular response to intubation.
Maintenance	Standard maintenance (see p. B-3). Maintain muscle relaxation with cisatracurium or rocuronium, titrated to effect using a nerve stimulator. Avoid meperidine (accumulation of normeperidine → CNS toxicity). Anticipate prolonged drug effects, and avoid agents that are primarily excreted by the kidney.
Emergence	Usually extubated in the OR after protective laryngeal reflexes have returned. Ensure adequate reversal of NMB’s drugs. Pancreatic transplant patients (e.g., brittle diabetics, hemodynamically unstable) are sent to the ICU for close glycemic management.
Blood and fluid requirements	IV: 14-16 ga × 1 NS/colloid to keep CVP = 10-15 mm Hg Warm fluids	Preop fluid status is highly variable (hypo→hypervolemia). Give fluids to maintain CVP 10-15 mm Hg. Important to maintain adequate vascular volume and BP. Mannitol (0.25-1 g/kg), furosemide (5-20 mg), and low-dose dopamine are often given with reperfusion of the kidney.
Monitoring	Standard monitors (see p. B-1). Arterial line CVP/PA line Hct, K+, and glucose Neuromuscular	Arterial pressure is often monitored. Avoid the side of AV fistulae. Axillary artery is a useful alternative. CVP is essential, and a PA line is needed occasionally (severe cardiac disease). CVP is kept at 10-15 mm Hg, especially after the new kidney is reperfused, to ensure adequate renal blood flow. In pancreatic transplant patients, glucose should be checked q 30 min and then q 10 min for the first h following reperfusion. Keep glucose < 300 mg/dL prior to reperfusion, but do not fully correct to < 150 mg/dL. Monitor neuromuscular block to avoid excessive use of neuromuscular relaxants; anticipate prolonged effects.
Positioning	[check mark] and pad pressure points [check mark] eyes Protect/pad AV fistulas	Pressure on AV fistula may lead to thrombosis. Document bruit q15 minutes.
Complications	Disruption of renal anastomoses Hemorrhage Low UO Reperfusion injury (pancreas transplant)	Bucking or coughing during emergence, due to inadequate neuromuscular blockade, may → forceful tugging on transplanted kidney. This “popping” of kidney may → disruption of venous and arterial anastomoses and possible ischemic damage requiring urgent surgical revision.

POSTOPERATIVE

Complications

Fluid overload and CHF

Femoral neuropathy

Hemorrhage

Electrolyte abnormalities

Hypo/hyperglycemia

PONV

VTE

Monitor UO. Dialysis may be needed until renal function returns. Sudden cardiac arrest can complicate pancreatic transplantation (due to autonomic neuropathy).

Especially dynamic in pancreas tx

See p. B-6.

See p. B-8.

Pain management

PCA (see p. C-3).

Epidural

Anticipate prolonged effect of some opiates. Strive to avoid hypotension.

Tests

Hct

Electrolytes

Cr, BUN

Amylase

Glucose

A rise in amylase and blood glucose may indicate failure of the pancreatic transplant.

Suggested Readings

1. Hadimioglu N, Ertug Z, Bigat Z, et al: A randomized study comparing combined spinal epidural or general anesthesia for renal transplant surgery. Transplant Proc 2005; 37(5):2020-2.

2. Halpern H, Miyoshi E, Kataoka LM, et al: Anesthesia for pancreas transplantation alone or simultaneous with kidney. Transplant Proc 2004; 36(10):3105-6.

3. Lemmens HJM: Kidney transplantation: recent developments and recommendations for anesthetic management. Anesthesiol Clin North Am 2004; 22(4):651-62.

4. SarinKapoor H, Kaur R, Kaur H: Anaesthesia for renal transplant surgery. Acta Anaesthesio Scand 2007; 51:1354-67.

5. Shoeibi G, Babakhani B, Mohammadi SS: The efficacy of ilioinguinal-iliohypogstric and intercostal nerve co-blockade for postoperative pain relief in kidney repair recipients. Anesth Analg 2009; 108(1):330-33.

LIVE-DONOR NEPHRECTOMY—LAPAROSCOPIC AND OPEN

SURGICAL CONSIDERATIONS

Description: Use of a kidney donated by a healthy genetically or emotionally related donor greatly increases the number and quality of kidneys available for transplantation. Kidney transplantation from living donors is associated with a better patient and graft survival rate. A laparoscopic (LSC) approach for kidney donation was introduced in 1995 as an alternative that would reduce postop pain, wound morbidity, and recovery time associated with open nephrectomy. Now the LSC approach is the procedure of choice for more than 75% of the live kidney donations in the United States. Initial concerns regarding ureteral complications and longer warm ischemic time have mostly subsided with the improvement of the surgical technique and greater experience. The left kidney is preferred for the LSC approach, as the renal vein is longer. Some centers use the LSC approach for the right kidney with comparable results.

The patient is positioned in lateral decubitus over a cushioned beanbag, the kidney rest is slightly elevated, and pillows and an axillary roll are used to prevent compression injuries. Three or four ports are used for the pure laparoscopic approach. The hand-assisted approach, however, has gained popularity over the years and is currently the preferred technique of the majority of Transplant Centers in the United States. In this approach two or three ports are used with a 6-8 cm incision made at the level of the umbilicus or infra-umbilical. The pneumoperitoneum is kept < 15 mm Hg to avoid decreased perfusion to the kidney. Aggressive hydration and intermittent use of iv mannitol help improve kidney perfusion. On the left side, the descending colon and spleen are mobilized medially; the renal vessels are exposed; the adrenal, lumbar, and gonadal veins are clipped and divided; the ureter is mobilized en bloc, along with the gonadal vein, down to the pelvic inlet. The artery is freed from surrounding lymphatic and neural tissue as it comes off the aorta (Fig. 7.12-3). Gerota’s fascia is mobilized to completely free the kidney. The ureter is transected distally. If the procedure is done purely laparoscopically, a 6-cm suprapubic incision is then made, the peritoneum is exposed in the midline, and an 18-mm port is used to insert a 15-mm Endocatch retrieval bag. The kidney is placed in the bag as it continues to be perfused, avoiding warm ischemia. With the hand-assisted approach the incision is already made for retrieval with the surgeon’s hand. The patient is fully heparinized. An endo TA vascular stapler is used to staple and transect the artery close to the aorta and the vein close to the vena cava. An endo GIA
vascular stapler can also be used. The kidney is brought to the suprapubic incision and gently extracted. The kidney is immediately immersed in cold slush. The kidney is perfused with preservation solution in the usual manner. The heparin is reversed with protamine, the suprapubic incision is closed, and homeostasis is verified before extracting the ports. For a right nephrectomy, the right colon and duodenum are mobilized medially and the liver is retracted upward. The remainder of the operation is as described for the left kidney.

Figure 7.12-3. Anatomy for laparoscopic live-donor nephrectomy. (Reproduced with permission from Cho ES, Flowers JL: Laparoscopic live-donor nephrectomy. In: Zuker KA, ed. Surgical Laparoscopy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2001.)

In open nephrectomy, the donor/patient is placed in a lateral decubitus position on a flexible OR table with a kidney rest. A beanbag or sandbags are also helpful for positioning. An incision is made from the rectus muscle, angling slightly cephalic to cross into the flank just below the tip of the 12th rib. The retroperitoneum is exposed using a Thompson retractor. The kidney is then mobilized, and the ureter is transected. A clamp is placed across the renal artery at the aorta and the renal vein at the IVC. Just before clamping the renal artery, furosemide and/or mannitol may be given to stimulate diuresis. It is important to keep the vascular volume expanded in these patients before kidney removal. The kidney is removed and taken to the back table, where it is flushed with a cold preservation solution. It is then transported into the recipient room for reimplantation. Some surgeons use a full dose of heparin (75 U/kg) before clamping and use protamine afterward. Smaller incisions and muscle-sparing incisions are now used to improve postop recovery.

Usual preop diagnosis: Donor nephrectomy

▪ SUMMARY OF PROCEDURES

	Laparoscopic Nephrectomy	Open Nephrectomy
Position	Lateral decubitus	⇚
Incision	3-4 ports; retrieval incision, Pfannenstiel’s or vertical suprapubic	Flank; may require 12th rib resection
Special instrumentation	Foley catheter; flexible OR table with kidney rest; beanbag; SCDs for DVT prophylaxis; harmonic scalpel	Foley catheter; Thompson retractor; flexible OR table with kidney rest; beanbag or sandbags; SCDs for DVT prophylaxis
Unique considerations	Avoid ETT dislodgement when turning patient from supine to flank position; vigorous hydration.	Possible pneumothorax; avoid ETT dislodgement when turning patient from supine to flank position. Vigorous hydration to encourage urine production.
Antibiotics	Cefazolin 1-2 g iv	Cefazolin 1-2 g, iv
Surgical time	2.5-4.5 h	2-2.5 h
Closing considerations	–	Delfex table to facilitate closure
EBL	Minimal	100 mL
Postop care	PACU → ward; PCA for pain management	PACU → ward; PCA for pain management
Mortality	< 0.1%	⇚
Morbidity	Ileus: 2-5% Urinary retention: 2-5% Wound infection: 1-2% Bleeding: 0.1-0.5%	5-10% 5-10% 1-3% Pneumothorax: 1%
Pain score	3-5	7

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Kidney Transplant Nephrectomy, p. 704.

KIDNEY TRANSPLANT NEPHRECTOMY

SURGICAL CONSIDERATIONS

Description: With improvements in graft survival and immunosuppressive therapy, the necessity of removing a kidney transplant graft for uncontrolled rejection has decreased significantly. This operation is divided into categories: early nephrectomy, performed during the first month posttransplant, and late nephrectomy, thereafter. Early transplant nephrectomy may be required for primary nonfunction, vascular thrombosis, and, rarely, refractory rejection. In these cases, an extracapsular approach, through the original transplant incision, is used.
The kidney is freed from the surrounding adhesion to obtain vascular control of the renal artery and renal vein. These structures are clamped and oversewn individually. The ureter is ligated as close as possible to the bladder and excised completely, with primary repair of the bladder. A suction drain is used if minimal oozing or lymph drainage is present. Late transplant nephrectomy is performed most commonly for acute, irreversible rejection with failure of the renal allograft. Most of these patients have returned to dialysis, and the immunosuppressive medications are stopped. Chronic infection and HTN associated with nonfunctional grafts are also an indication for surgical removal of the kidney allograft. It may be a difficult operation, as intense inflammatory adhesions are present between the renal capsule and the surrounding tissue. In the setting of acute late rejection, the graft is usually swollen and enlarged. Hematuria may be present, and the graft is friable. Spontaneous rupture and hemorrhage have been reported. The surgical approach is through the same incision as the implantation. In contrast to early transplant nephrectomy, extracapsular dissection may not be possible with late nephrectomy. To avoid injury to extrarenal structures, such as the iliac vessels, an intracapsular approach may be preferred. The kidney is mobilized gently from within the capsule toward the hilum. The capsule is reopened on the medial side to have access to the renal vessel high in the hilum. When the hilum is sufficiently mobilized, a strong vascular clamp is applied high in the hilum of the kidney away from the iliac vessels. After clamping the hilum en bloc, confirmation of distal pulses is obtained; then the kidney is excised over the vascular clamp. A running suture is used over the clamp, which is then released, and hemostasis is obtained. The ureter is identified and excised as close as possible to the bladder. The intracapsular dissection of the kidney may be associated with significant bleeding, as the kidney may fracture. This step should be done expeditiously to avoid excessive bleeding. The patient must have good vascular access for fluid resuscitation. Blood must be available for transfusion. After hemostasis is obtained, a low-pressure suction drain may be placed before closing.

Usual preop diagnosis: Transplant rejection

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Previous incision used for kidney transplant
Instrumentation	Self-retaining retractor; vascular instruments
Unique considerations	Large-bore vascular access; PRBCs available; stress dose of steroids, if chronic usage; protection of shunt or fistula
Antibiotics	Cefazolin 1-2 g iv
Surgical time	1-2.5 h
EBL	200-1000 mL
Postop care	PCA for pain management → PACU → ward
Mortality	1-3%
Morbidity	Overall: 3-5% Wound infection: 3-5% Abscess formation: 1-2% Exsanguinating hemorrhage: < 1%
Pain score	5

ANESTHETIC CONSIDERATIONS FOR LIVE-DONOR AND POSTTRANSPLANTATION NEPHRECTOMY

PREOPERATIVE

In order to be a live donor, one must be in good health with bilaterally functional kidneys. Diabetes, HIV infection, liver disease, and malignancy are all contraindications to kidney donations.

Only gold members can continue reading. Log In or Register to continue