All patients should be fasted from four hours prior to the anticipated theatre time unless otherwise stated by surgeons or anaesthetist.
- A critical appraisal of the patient’s fluid status must be performed, as described in examination section above. Patients may well be relatively fluid deplete, especially those undergoing haemodialysis.
- Once the final results are known and it is accepted that the patient is going ahead to transplant, then any obvious fluid depletion should be corrected, by intravenous therapy (after discussion with renal registrar or consultant).
- More commonly, if dialysis is planned prior to theatre, patients should not have fluid removed unless they are grossly fluid overloaded.
- Patients will often not require their full dialysis time, and theatre should not be delayed because of dialysis unless absolutely necessary.
(i) Patients on peritoneal dialysis
- Continue peritoneal dialysis until immediately pre-op (abdomen should be emptied 30 – 45 minutes pre-operatively.
(ii) Patients on haemodialysis
- Patient may require haemodialysis because:
- dialysis is due irrespective of transplant.
- based on the results of admission U&Es.
In practice, unscheduled haemodialysis is unlikely to be required except for hyperkalaemia. (If ECD or DCD and delayed graft function likely, consider dialysis if time permits). No anticoagulation must be used if patient is being dialysed.
Pre-operative management of serum potassium
Once serum potassium is obtained discuss with the SpR/Cons on call.
- If K+ >5.5: dialysis.
- If 5-5.5: dialysis if there is time/risk factors for delayed graft function.
(a) Patient’s “routine” medication
- Anti-hypertensives are withheld except for beta-blockers and centrally acting agents. This decision should be discussed with SpR and/or anaesthetist.
- ACE inhibitors and angiotensin II antagonists are omitted.
- Omit NSAIDS, Diuretics.
- Review aspirin. If any doubt as to whether or not to continue, discuss with surgeon.
- Warfarin: patients on the waiting list on warfarin should have a plan for reversal and timing of reintroduction of anticoagulation, discussed with haematology prior to listing.
(b) Antibiotic prophylaxis – given at induction of anaesthesia
- Piperacillin/tazobactam 4.5g IV, unless patient is allergic to penicillin.
- If patient is allergic to penicillin give Vancomycin 1 Gram IV in Normal Saline over 2 hours and Ciprofloxacin 400 mgs infused over 60 mins. If Piperacillin/tazobactam not available (supply issue in 2017), we will use Metronidazole 400mg, Temocillin 1g and Amoxicillin 1g.
(c) Immunosuppression – as per protocol (page 24)
(d) Anti-viral prophylaxis – as per protocol (page 33)
(e) Pneumocystis jirovecii prophylaxis – as per protocol (page 32)
(f) DVT prophylaxis
- Herapin 5000U/SC at anaesthetic induction and 5000U/SC/bd thereafter until mobile post operatively (adhering to hospital protocol).
(g) Gastric protection
- Ranitindine 150mg bd unless already on PPI in which case use or switch to lansoprazole 30mg.
(h) Bone prophylaxis for 1 year and then review if needed
- Calcichew 2 tablets nocte.
- Alfacalcidol 250 nanograms once daily.
The above initial management should be changed before discharge to Calcichew D3 Forte 2 tablets per day, if eGFR>30mls/min/1.73m2. This provides cholecalciferol (25-vitamin D) instead of activated vitamin D.
If already on high dose alfacalcidol consider whether this dose needs to be continued.
If serum calcium is high, omit Calcichew. Vitamin D can be prescribed as Fultium D3 800 iu daily.
NB Patients with tertiary hyperparathyroidism may require altered bone prophylaxis and should be considered in an individual basis.
Note: The antibiotics, methylprednisolone + heparin should all be prescribed in the drug kardex pre-operatively (no immunosuppression should be administered until known if patient is eligible for randomisation to any ongoing trials & confirmed that operation is to proceed i.e. cross match negative and organs suitable).