In 1954, Guild et al.1 performed the first successful renal transplantation on identical twins. In recent years the organ survival rate has increased significantly, mainly due to improvements in immunosuppressant therapy. Many studies have shown a significant reduction of mortality in patients following renal transplantation compared with patients remaining on the waiting list.2,3 Therefore, the kidney donor pool, as well as the number of recipients, has been expanded, including donors as well as recipients older than 60 years, and the use of marginal organs for transplantation.3–6
Despite this substantial progress in renal transplant surgery, the risk of perioperative complications remains. About 25% of all kidney recipients suffer from postoperative delayed graft function, needing renal replacement therapy, resulting in an increase in mortality of 40%.7–9 Cardiovascular complications have been described in 10% of renal transplant recipients, particularly in patients older than 50 years.10 Perioperative caregivers, including anaesthesiologists, need to optimise the treatment of these high-risk patients in order to reduce postoperative complications. In particular, anaesthesiologists require a consolidated knowledge of the characteristics of renal transplant patients and of the impact of their co-morbidities on outcome. Optimised haemodynamic management and the identification and avoidance of potentially nephrotoxic drugs are essential. This review provides an update on recommended preoperative assessment, care for the living donor, the use of potential nephrotoxic drugs and haemodynamic and postoperative management in renal transplant surgery patients.
Patients undergoing renal transplant surgery present with several risk factors which have an impact on postoperative outcome (Table 1). These factors should be identified during an extensive preoperative ‘work-up’, not just for risk stratification but also for the development of a tailored perioperative treatment regime including advanced haemodynamic monitoring. Cardiovascular disease remains the most important limiting factor affecting postoperative morbidity and mortality.11 The incidence of coronary artery disease in patients with chronic kidney disease is 25%.12,13 According to the ACC/AHA perioperative guidelines, patients who need emergency surgery, such as those undergoing renal transplant surgery, ‘should proceed to the operating room and the attending anaesthetist has to continue perioperative surveillance and postoperative risk stratification and risk factor management’.14 As patients are on the waiting list for some years before a suitable donor organ is available, repeated cardiac assessment is recommended, particularly in patients with active cardiac conditions such as unstable coronary syndromes, decompensated heart failure, significant arrhythmias and severe valvular disease.14
Other co-morbidities often associated with chronic kidney disease include hypertension and diabetes mellitus. The prevalence of hypertension is up to 90% in patients with a glomerular filtration rate below 30 ml min.15 Hypertension is both a cause and a consequence of chronic kidney disease. The latter is mediated via different mechanisms including activation of the renin–angiotensin–aldosterone system and fluid overload.16 Diabetes mellitus is seen in up to 30% of patients who need renal replacement therapy and can aggravate hypertension and cardiovascular disease, resulting in a greater risk of stroke or myocardial infarction.17,18 According to the recent ESA guidelines on perioperative cardiac evaluation, renal transplantation is an intermediate-risk surgical procedure.19 Because end-stage renal disease is a risk factor for cardiac complications, a 12-lead ECG is recommended and low-dose β-blocker therapy is recommended. As the medication should be started at least 1 week before surgery, initiation of therapy has to be considered when adding the patient to the transplant list.19
The immediate preoperative assessment includes identification of disturbances in acid–base balance and electrolytes, as well as an estimation of fluid status, which can range from severe hypovolaemia to pronounced hypervolaemia in patients undergoing renal transplant surgery. The patient's volume status can be estimated by the frequency of dialysis and when it was last performed. Several studies have investigated the benefit of dialysis immediately prior to surgery. Although one study showed no benefit in relation to delayed graft failure or 1-year survival, another larger retrospective study (more than 22 000 patients) demonstrated a greater risk of delayed graft failure in patients on haemodialysis compared with patients on peritoneal dialysis, who usually present with a better volume status.20,21 Although further studies are needed, the routine use of haemodialysis immediately prior to surgery cannot be recommended, but should be considered in patients with high serum potassium levels which may be accentuated during graft reperfusion when a significant amount of potassium is released. Most patients have a dialysis shunt in place which requires special care during positioning for surgery. Its cannulation is reserved for absolute emergencies such as resuscitation without other vascular access. Metabolic acidosis is a common problem in patients with end-stage renal disease. Careful correction of acidosis during surgery is recommended for two reasons. First, adjustment of acid–base balance with bicarbonate helps to reduce the commonly elevated levels of serum potassium. Second, the function of the transplanted kidney is supported, particularly in terms of maintaining a balanced acid–base state.22 Blood glucose concentration should be managed; a level more than 8.9 mmol l during reperfusion is associated with delayed graft function after surgery.23
Living donor transplantation
Living donor transplantation has become more common due to the shortage of organs. The European organisation responsible for the allocation of organs (Eurotransplant) has reported a 30% increase in the number of living donor transplants in the last 5 years.24 Patients receiving organs from a living donor are usually in a better clinical condition. In some patients, pre-emptive kidney transplantation is performed before they require renal replacement therapy and develop complications associated with dialysis.25 This leads to a better postoperative outcome, with an increased 5-year graft survival (80 vs. 69%) compared with deceased donor transplantation.26 Survival, as well as the incidence of end-stage renal disease, in patients who donate a kidney is similar to the normal population, and donors have no long-term disadvantage.27 Nephrectomy can be performed as an open or laparoscopic operation with no difference in postoperative kidney function, but with more severe pain after open surgery.28,29 A combination of general and epidural anaesthesia should be considered, as the avoidance of pain is of paramount importance. The optimal volume management (type and amount of fluid) is still under debate. Starting hydration on the evening before surgery can increase postoperative urine output of the transplanted patient, without any effect on organ function after 3 days.30
Avoidance of potentially nephrotoxic agents
Potential nephrotoxic agents should be avoided in any patient, but particularly in patients undergoing renal transplant surgery and in potential kidney donors. The nephrotoxic properties of drugs commonly used during anaesthesia warrant special consideration in this review and are summarised in Table 2.
There have been some safety concerns about the use of sevoflurane for renal transplant surgery. Compound A is generated as a result of a chemical reaction between sevoflurane and the carbon dioxide absorbent. There is evidence that Compound A harms renal function in rats31,32; however, this effect has never been shown in humans. In contrast, many studies have shown no negative effect on renal function,33–35 and sevoflurane can be used safely for renal transplant surgery, as can isoflurane and desflurane.36 Due to fluoride ions from the metabolism of enflurane, some cases of kidney failure have been reported associated with the use of this volatile anaesthetic,37 and it should not be the first choice in patients undergoing renal transplant surgery.38
Neuromuscular blocking drugs
The bowel motility in patients with end-stage renal disease may be reduced due to uraemic neuropathy. Although this could not be confirmed in large studies, some investigations have shown prolonged gastric emptying in patients with end-stage renal disease and diabetes.39,40 Therefore, a rapid sequence induction can be performed in order to reduce the risk of aspiration in diabetic patients, but it is not recommended for every patient undergoing transplantation. Succinylcholine can be used for rapid sequence induction bearing in mind that an increase in serum potassium concentration, particularly in patients with uraemic or diabetic neuropathy, may affect cardiac function.41 This has to be considered in patients with elevated serum potassium levels prior to induction or other co-morbidities that could cause a significant release of potassium due to up-regulated acetylcholine receptors, for example denervation.42 Rocuronium is an equally effective, non-depolarising, alternative when used at a dose of 1.2 mg kg.43 However, prolonged neuromuscular blockade in patients with end-stage renal disease has been reported, especially when repetitive doses are used.44,45 Recently, sugammadex has been introduced for reversal of rocuronium-induced neuromuscular blockade. Due to the 100% renal excretion pathway of the sugammadex and rocuronium complex, its use is not recommended in patients with end-stage renal disease.45 The first clinical studies in patients on dialysis showed the efficacy of sugammadex was not impaired and there were no signs of reappearance of neuromuscular block.46 However, further studies are needed before sugammadex can be recommended in these patients.
If a rapid sequence induction is not necessary, non-depolarising muscle relaxants can be used. Atracurium and cis-atracurium are recommended as they are inactivated by Hofmann elimination and hydrolysis by esterases independent of renal function. Although the degradation products are eliminated renally, studies have shown muscle relaxation was not prolonged.47–49 Hofmann elimination is influenced, however, by blood pH. Acidosis is a common finding in end-stage kidney disease and may prolong the effects of atracurium and cis-atracurium. Laudanosine is a potentially toxic metabolite and undergoes renal elimination. At high concentrations it can cause convulsions. Although concentrations at toxic levels have never been seen in humans, cis-atracurium may be a safer choice, as it is about four times as potent as atracurium resulting in lower laudanosine levels.50,51 Mivacurium can also be used in renal transplant surgery. However, muscle relaxation may be prolonged due to decreased plasma cholinesterase concentration in patients with end-stage renal disease.52 Due to its long duration of action and potential to accumulate, pancuronium cannot be recommended. Neuromuscular monitoring is recommended in all patients undergoing renal transplant surgery.
Propofol and thiopental are safe for induction of anaesthesia in renal transplant surgery, as they are inactivated in the liver. The use of etomidate cannot be recommended as it induces adrenal insufficiency and increases mortality in critically ill patients.53
Morphine-6-glucuronide is an active degradation product of morphine and concentrations may be increased in patients with renal insufficiency. Therefore, morphine should be avoided for pain therapy in renal transplant surgery. In contrast, all the fentanyl analogues (including alfentanil, sufentanil and remifentanil) can be used safely.54
The use of furosemide for the treatment of acute renal failure is controversial. Two large randomised controlled trials did not show any benefit of furosemide on the recovery from renal failure in patients with oliguria.55,56 The effect of diuretics on renal function after transplantation requires further study. The administration of 200 to 250 ml of mannitol 20% immediately before reperfusion has been shown to improve renal perfusion pressure. Three randomised controlled trials showed a significant, albeit transient, reduction in acute renal failure immediately after transplantation using mannitol,57–59 and it is administered to nearly all patients undergoing renal transplant surgery.
Advanced monitoring may optimise haemodynamic management and improve cardiac and renal outcome. However, the choice of monitoring device is still under discussion (Table 3).
Central venous pressure
Although some centres routinely use central venous pressure (CVP) to guide volume therapy, others use a central venous catheter in only 30% of renal transplant patients.60 This reflects the on-going debate on the use of CVP as suitable monitoring for optimising haemodynamic management. It has been shown that CVP does not correlate well with fluid status in general.61 This was also demonstrated in renal transplant patients.62 In contrast, other studies have shown a benefit of CVP-guided fluid therapy in these patients.63,64 The ideal range for the CVP has not been clearly identified. Some studies suggest slight over-hydration, others have shown no increase in the incidence of delayed graft function with a more restrictive hydration regime (CVP 7 to 9 mmHg).10 In summary, it is not possible to provider a clear recommendation for, or against, the use of CVP in renal transplantation.
Advanced haemodynamic monitoring
Whether thermodilution or pulse contour-based devices such as the PiCCO (PULSION Medical Systems SE, Feldkirchen, Germany) or LidCO (LiDCO Ltd, Cambridge, UK) can improve outcome after renal transplant surgery has not been studied. However, one limitation to the use of these devices is the need for an arterial line. Many of these patients have vascular disease and non-invasive devices, such as a recently introduced technique which computes beat-to-beat cardiac output from radial artery pressure and capillary pulse, could be an alternative.65 The use of transoesophageal or transthoracic echocardiography to assess fluid status during renal transplant surgery has not yet been studied. However, in some patients with significant cardiac complications or valvular disorders, echocardiography may be useful.
The management of fluid therapy depends on several factors. First, in the future advanced hemodynamic monitoring may help to optimise the amount of fluid administered. Second, if the patient has some residual urine production, urine loss has to be replaced during surgery. A urinary catheter is needed and the urine output should be monitored. The exact timing of fluid therapy is controversial, but it seems sensible to administer the fluids evenly throughout surgery, rather than administering a bolus directly before reperfusion.63 The debate about the type of fluid to be used in renal transplant patients is on-going.
In a survey performed in 2002, isotonic saline was used in more than 90% of renal transplant surgery procedures in order to avoid hyperkalaemia.66 However, recent studies have shown that its use leads to a significant increase of serum potassium when compared with Ringer's solution.67,68 This effect is most likely due to an extracellular shift of potassium, caused by acute changes in blood hydrogen ion concentration which occurs in association with hyperchloraemic metabolic acidosis.69 Another study reported no difference in the change of serum potassium, although use of 0.9% saline leads to a significant decrease in pH and a significant increase in serum chloride.70 Modern balanced crystalloid solutions are inexpensive and seem to be a suitable hydration solution in renal transplant surgery.67,68 As larger volumes may be required and patients should be kept normothermic, fluids are warmed before administration. Although the risk of a significant increase in serum potassium is small, continuous monitoring of serum electrolytes is essential during the operation, especially just before and after reperfusion of the transplanted organ.
Although there is little evidence from clinical studies for the use of albumin, many authors suggest an improvement in short-term and long-term outcome in renal transplant surgery patients after volume expansion with human albumin.71–73 These results were not confirmed in other investigations.74 Due to side-effects such as anaphylactic reactions and potential contamination with infectious diseases, the routine use of albumin is not recommended in renal transplant surgery. Artificial colloids such as gelatine, dextrans and hydroxyethyl starch (HES) have been developed within the last few years. Adverse effects have been reported with all of them. One problem is anaphylactic reactions which are more common with dextrans and gelatine than for HES.75 Other side-effects include bleeding complications, reticulo-endothelial system dysfunction and impaired renal function.76 An ideal HES solution combines the lowest in-vivo molecular weight above the threshold for renal elimination, with a low degree of hydroxyethyl substitution.77 The data on the use of HES 6% 200/0.625 are inconsistent. Although the administration to non-living kidney donors resulted in a negative effect of HES on renal function, the data were not confirmed in other studies.78,79 In recent studies, medium molecular weight HES with a low molar substitution (HES 130/0.4) was shown not to affect the incidence of delayed graft function.80 In contrast to gelatine 4%, medium molecular weight HES shows a slight advantage regarding the recovery of renal function immediately after transplantation.81 However, concerns about the use of HES were highlighted by the VISEP trial which reported a higher incidence of renal failure in septic patients when high molecular HES was used in doses greater than the recommended daily maximum dose.82 Even though these findings cannot be easily translated to the setting of renal transplant surgery, the HES should be used with caution and reserved for special indications, such as the need for large volumes of fluid or for an increase in colloid osmotic pressure, until more data about the effect of medium molecular weight HES on graft function is available.
Further prospective randomised trials are required to identify the ideal fluid for renal transplant surgery and to assess whether the incidence of delayed graft function can be reduced by an optimised volume therapy regime.
Although the immunomodulatory effects of blood transfusion were used in the 1970s to reduce organ rejection, later investigations showed a higher incidence of acute graft rejection. As many patients undergoing renal transplant surgery are treated with erythropoietin, haemoglobin values are increased and blood transfusion is not required before the operation.83 As most patients have become accustomed to anaemia for some years and significant blood loss during the operation is rare, transfusion should be performed reluctantly; the transfusion trigger for these patients is not known, but is probably lower than in patients without renal failure.
Next to the coronary and cerebral circulation, the transplanted organ benefits from optimised perfusion pressure, even though the ideal perfusion pressure during reperfusion is not known yet. However, improved oxygenation of the graft immediately after reperfusion results in decreased incidence of delayed graft function.84
Dopamine has been used for many years for treatment of renal failure. However, two large meta-analyses have shown a detrimental effect of dopamine on renal function in acute renal failure.85,86 In addition, another study showed a higher mortality and prolonged length of ICU stay in patients receiving dopamine after renal transplant surgery.87 Therefore, the use of dopamine in renal transplant surgery cannot be recommended.
In contrast, dobutamine can be used as a positive inotrope for patients with a low cardiac output. However, in these patients advanced haemodynamic monitoring may help to optimise volume and drug therapy.
Optimised volume therapy is essential. However, when volume loading is not tolerated, such as in patients with pulmonary oedema, vasopressors should be considered despite the risk of renal vasoconstriction. The use of noradrenaline in donors does not have a negative effect on graft function in recipients.88 This is most because the harmful effect of a low blood pressure outweighs the potential renal vasoconstriction caused by vasopressors.89 On the basis of the current data, a clear recommendation for the use of vasopressors cannot be made; however, it seems sensible to avoid hypotensive episodes, especially after reperfusion.
There are many aspects regarding the postoperative management of renal transplant patients. First, nephrotoxic agents should be avoided. Second, optimised volume therapy is essential, for example treatment based on the urine output. However, no recommendations or algorithms have yet been published or evaluated. Third, immunosuppressant medication has to be continued. Most patients receive triple immunosuppression consisting of calcineurin inhibitors, anti-proliferative agents and corticosteroids. Some patients, such as those receiving a living donor organ, may profit from an immunosuppression induction therapy with anti-thymocyte globulin administered after induction of anaesthesia.90 As anti-thymocyte globulin can induce an anaphylactic reaction, it should be given carefully over a period of 60 min. Because of the use of immunosuppressive therapy, sterile conditions for the placement of a central venous catheter are essential. Fourth, there are no recommendations as to whether all renal transplant patients should be admitted to the ICU, as their risk hospital-acquired infection is increased. When they are treated in the ICU, for example if they require mechanical lung ventilation, their outcome is worse compared with other patients.91
Delayed graft failure and adverse cardiovascular events remain common complications after renal transplant surgery. An extensive preoperative ‘work-up’ is required to identify risk factors, to improve cardiac conditions, to treat hyperkalaemia and acid–base disturbances and to develop individualised and tailored perioperative therapy regime. This, in combination with optimal care for the living donor, the avoidance of potential nephrotoxic drugs, the implementation of goal-directed haemodynamic management and optimised postoperative care, may improve outcome after renal transplant surgery.
Assistance with the study: none declared.
Financial support and sponsorship: none declared.
Conflicts of interest: none declared.
1. Guild WR, Harrison JH, Merrill JP, Murray J. Successful homotransplantation of the kidney
in an identical twin. Trans Am Clin Climatol Assoc
2. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation
, and recipients of a first cadaveric transplant. N Engl J Med
3. Gill J, Bunnapradist S, Danovitch GM, et al. Outcomes of kidney transplantation
from older living donors to older recipients. Am J Kidney Dis
4. Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol
5. Saxena R, Yu X, Giraldo M, et al. Renal transplantation
in the elderly. Int Urol Nephrol
6. Chavalitdhamrong D, Gill J, Takemoto S, et al. Patient and graft outcomes from deceased kidney
donors age 70 years and older: an analysis of the Organ Procurement Transplant Network/United Network of Organ Sharing database. Transplantation
7. Boom H, Mallat MJ, de Fijter JW, et al. Delayed graft function influences renal function, but not survival. Kidney Int
8. Frei U, Noeldeke J, Machold-Fabrizii V, et al. Prospective age-matching in elderly kidney
transplant recipients: a 5-year analysis of the Eurotransplant Senior Program. Am J Transplant
9. Bronzatto EJ, da Silva Quadros KR, Santos RL, et al. Delayed graft function in renal transplant recipients: risk factors and impact on 1-year graft function – a single center analysis. Transplant Proc
10. De Gasperi A, Narcisi S, Mazza E, et al. Perioperative fluid management in kidney transplantation
: is volume overload still mandatory for graft function? Transplant Proc
11. Kasiske BL, Maclean JR, Snyder JJ. Acute myocardial infarction and kidney transplantation
. J Am Soc Nephrol
12. de Lusignan S, Chan T, Stevens P, et al. Identifying patients with chronic kidney
disease from general practice computer records. Fam Pract
13. McClellan WM, Chertow GM. Beyond Framingham: cardiovascular risk profiling in ESRD. J Am Soc Nephrol
14. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac surgery) – developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation
15. Lindholm B, Wang T, Heimburger O, Bergstrom J. Influence of different treatments and schedules on the factors conditioning the nutritional status in dialysis patients. Nephrol Dial Transplant
1998; 13 (Suppl 6):66–73.
16. Fliser D, Franek E, Joest M, et al. Renal function in the elderly: impact of hypertension and cardiac function. Kidney Int
17. Ansell D. UK Renal Registry 11th annual report (December 2008). Chapter 1: Summary of findings in the 2008 UK Renal Registry report. Nephron Clin Pract
2009; 111 (Suppl 1):1–2.
18. Gaston RS, Danovitch GM, Adams PL, et al. The report of a national conference on the wait list for kidney transplantation
. Am J Transplant
19. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for preoperative cardiac risk assessment and perioperative cardiac management in noncardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Noncardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol
20. Kikic Z, Lorenz M, Sunder-Plassmann G, et al. Effect of hemodialysis before transplant surgery on renal allograft function: a pair of randomized controlled trials. Transplantation
21. Snyder JJ, Kasiske BL, Gilbertson DT, Collins AJ. A comparison of transplant outcomes in peritoneal and hemodialysis patients. Kidney Int
22. Tejchman K, Domanski L, Sienko J, et al. Influence of perioperational acid-base balance disorders on early graft function in kidney transplantation
. Transplant Proc
23. Parekh J, Niemann CU, Dang K, Hirose R. Intraoperative hyperglycemia augments ischemia reperfusion injury in renal transplantation
: a prospective study. J Transplant 2011; (ePub).
25. Witczak BJ, Leivestad T, Line PD, et al. Experience from an active preemptive kidney transplantation
program: 809 cases revisited. Transplantation
26. Cecka JM. The OPTN/UNOS Renal Transplant registry. Clinical Transplants
UCLA Tissue Typing Laboratory: Los Angeles, 2005: 1–16.
27. Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney
donation. N Engl J Med
28. Genc V, Ozgencil E, Orozakunov E, et al. Pure laparoscopic versus open live donor nephrectomy: evaluation of health survey and graft functions. Transplant Proc
29. Ungbhakorn P, Kongchareonsombat W, Leenanupan C, et al. Comparative outcomes of open nephrectomy, hand-assisted laparoscopic nephrectomy, and full laparoscopic nephrectomy for living donors. Transplant Proc
30. Mertens zur Borg IR, Di Biase M, Verbrugge S, et al. Comparison of three perioperative fluid regimes for laparoscopic donor nephrectomy: a prospective randomized dose-finding study. Surg Endosc
31. Gonsowski CT, Laster MJ, Eger EI, et al. Toxicity of compound A in rats. Effect of a 3-h administration. Anesthesiology
32. Keller KA, Callan C, Prokocimer P, et al. Inhalation toxicity study of a haloalkene degradant of sevoflurane, Compound A (PIFE), in Sprague-Dawley rats. Anesthesiology
33. Bito H, Ikeuchi Y, Ikeda K. Effects of low-flow sevoflurane anesthesia on renal function: comparison with high-flow sevoflurane anesthesia and low-flow isoflurane anesthesia. Anesthesiology
34. Conzen PF, Kharasch ED, Czerner SF, et al. Low-flow sevoflurane compared with low-flow isoflurane anesthesia in patients with stable renal insufficiency. Anesthesiology
35. Teixeira S, Costa G, Costa F, et al. Sevoflurane versus isoflurane: does it matter in renal transplantation
? Transplant Proc
36. Litz RJ, Hubler M, Lorenz W, et al. Renal responses to desflurane and isoflurane in patients with renal insufficiency. Anesthesiology
37. Eichhorn JH, Hedley-Whyte J, Steinman TI, et al. Renal failure following enflurane anesthesia. Anesthesiology
38. Conzen PF, Nuscheler M, Melotte A, et al. Renal function and serum fluoride concentrations in patients with stable renal insufficiency after anesthesia with sevoflurane or enflurane. Anesth Analg
39. Folwaczny C, Hundegger K, Volger C, et al. Measurement of transit disorders in different gastrointestinal segments of patients with diabetes mellitus in relation to duration and severity of the disease by use of the metal-detector test. Z Gastroenterol
40. Gaber AO, Oxley D, Karas J, et al. Changes in gastric emptying in recipients of successful combined pancreas-kidney
transplants. Dig Dis
41. Walton JD, Farman JV. Suxamethonium hyperkalaemia in uraemic neuropathy. Anaesthesia
42. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology
43. Perry JJ, Lee JS, Sillberg VA, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev
44. Cooper RA, Maddineni VR, Mirakhur RK, et al. Time course of neuromuscular effects and pharmacokinetics of rocuronium bromide (Org 9426) during isoflurane anaesthesia
in patients with and without renal failure. Br J Anaesth
45. Staals LM, Snoeck MM, Driessen JJ, et al. Reduced clearance of rocuronium and sugammadex in patients with severe to end-stage renal failure: a pharmacokinetic study. Br J Anaesth
46. Staals LM, Snoeck MM, Driessen JJ, et al. Multicentre, parallel-group, comparative trial evaluating the efficacy and safety of sugammadex in patients with end-stage renal failure or normal renal function. Br J Anaesth
47. Fahey MR, Rupp SM, Fisher DM, et al. The pharmacokinetics and pharmacodynamics of atracurium in patients with and without renal failure. Anesthesiology
48. Jirasiritham S, Tantivitayatan K. A comparison of the efficacy of cisatracurium and atracurium in kidney transplantation
operation. J Med Assoc Thai
49. Modesti C, Sacco T, Morelli G, et al. Balanced anestesia versus total intravenous anestesia for kidney transplantation
. Minerva Anestesiol
50. Parker CJ, Jones JE, Hunter JM. Disposition of infusions of atracurium and its metabolite, laudanosine, in patients in renal and respiratory failure in an ITU. Br J Anaesth
51. Eastwood NB, Boyd AH, Parker CJ, Hunter JM. Pharmacokinetics of 1R-cis 1’R-cis atracurium besylate (51W89) and plasma laudanosine concentrations in health and chronic renal failure. Br J Anaesth
52. Head-Rapson AG, Devlin JC, Parker CJ, Hunter JM. Pharmacokinetics and pharmacodynamics of the three isomers of mivacurium in health, in end-stage renal failure and in patients with impaired renal function. Br J Anaesth
53. Albert SG, Ariyan S, Rather A. The effect of etomidate on adrenal function in critical illness: a systematic review. Intensive Care Med
54. Murphy EJ. Acute pain management pharmacology for the patient with concurrent renal or hepatic disease. Anaesth Intensive Care
55. Cantarovich F, Rangoonwala B, Lorenz H, et al. High-dose furosemide for established ARF: a prospective, randomized, double-blind, placebo-controlled, multicenter trial. Am J Kidney Dis
56. Shilliday IR, Quinn KJ, Allison ME. Loop diuretics in the management of acute renal failure: a prospective, double-blind, placebo-controlled, randomized study. Nephrol Dial Transplant
57. Tiggeler RG, Berden JH, Hoitsma AJ, Koene RA. Prevention of acute tubular necrosis in cadaveric kidney transplantation
by the combined use of mannitol and moderate hydration. Ann Surg
58. van Valenberg PL, Hoitsma AJ, Tiggeler RG, et al. Mannitol as an indispensable constituent of an intraoperative hydration protocol for the prevention of acute renal failure after renal cadaveric transplantation
59. Weimar W, Geerlings W, Bijnen AB, et al. A controlled study on the effect of mannitol on immediate renal function after cadaver donor kidney transplantation
60. Niemann CU, Eilers H. Abdominal organ transplantation
. Minerva Anestesiol
61. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest
62. Ferris RL, Kittur DS, Wilasrusmee C, et al. Early hemodynamic changes after renal transplantation
: determinants of low central venous pressure in the recipients and correlation with acute renal dysfunction. Med Sci Monit
63. Othman MM, Ismael AZ, Hammouda GE. The impact of timing of maximal crystalloid hydration on early graft function during kidney transplantation
. Anesth Analg
64. Bacchi G, Buscaroli A, Fusari M, et al. The influence of intraoperative central venous pressure on delayed graft function in renal transplantation
: a single-center experience. Transplant Proc
65. de Wilde RB, Schreuder JJ, van den Berg PC, Jansen JR. An evaluation of cardiac output by five arterial pulse contour techniques during cardiac surgery. Anaesthesia
66. O’Malley CM, Frumento RJ, Bennett-Guerrero E. Intravenous fluid therapy in renal transplant recipients: results of a US survey. Transplant Proc
67. Khajavi MR, Etezadi F, Moharari RS, et al. Effects of normal saline vs. lactated ringer's during renal transplantation
. Ren Fail
68. O’Malley CM, Frumento RJ, Hardy MA, et al. A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation
. Anesth Analg
69. Halperin ML, Kamel KS. Potassium. Lancet
70. Hadimioglu N, Saadawy I, Saglam T, et al. The effect of different crystalloid solutions on acid-base balance and early kidney
function after kidney transplantation
. Anesth Analg
71. Dawidson I, Peters P, Sagalowsky A, et al. The effect of intraoperative fluid management on the incidence of acute tubular necrosis. Transplant Proc
72. Dawidson IJ, Sandor ZF, Coorpender L, et al. Intraoperative albumin administration affects the outcome of cadaver renal transplantation
73. Willms CD, Dawidson IJ, Dickerman R, et al. Intraoperative blood volume expansion induces primary function after renal transplantation
: a study of 96 paired cadaver kidneys. Transplant Proc
74. Bunn F, Alderson P, Hawkins V. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev
75. Laxenaire MC, Charpentier C, Feldman L. Anaphylactoid reactions to colloid plasma substitutes: incidence, risk factors, mechanisms. A French multicenter prospective study [in French]. Ann Fr Anesth Reanim
76. Davidson IJ. Renal impact of fluid management with colloids: a comparative review. Eur J Anaesthesiol
77. Treib J, Baron JF, Grauer MT, Strauss RG. An international view of hydroxyethyl starches. Intensive Care Med
78. Cittanova ML, Leblanc I, Legendre C, et al. Effect of hydroxyethylstarch in brain-dead kidney
donors on renal function in kidney
-transplant recipients. Lancet
79. Deman A, Peeters P, Sennesael J. Hydroxyethyl starch does not impair immediate renal function in kidney
transplant recipients: a retrospective, multicentre analysis. Nephrol Dial Transplant
80. Hokema F, Ziganshyna S, Bartels M, et al. Is perioperative low molecular weight hydroxyethyl starch infusion a risk factor for delayed graft function in renal transplant recipients? Nephrol Dial Transplant
81. Wu Y, Wu AS, Wang J, et al. Effects of the novel 6% hydroxyethyl starch 130/0.4 on renal function of recipients in living-related kidney transplantation
. Chin Med J (Engl)
82. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med
83. Carpenter CB. Blood transfusion effects in kidney transplantation
. Yale J Biol Med
84. Scheeren TW, Martin K, Maruschke M, Hakenberg OW. Prognostic value of intraoperative renal tissue oxygenation measurement on early renal transplant function. Transpl Int
85. Kellum JA, Decker JM. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med
86. Marik PE. Low-dose dopamine: a systematic review. Intensive Care Med
87. Ciapetti M, di Valvasone S, di Filippo A, et al. Low-dose dopamine in kidney transplantation
. Transplant Proc
88. Kim JM, Kim SJ, Joh JW, et al. Is it safe to use a kidney
from an expanded criteria donor? Transplant Proc
89. Bellomo R, Wan L, May C. Vasoactive drugs and acute kidney
injury. Crit Care Med
90. Schenker P, Ozturk A, Vonend O, et al. Single-dose thymoglobulin induction in living-donor renal transplantation
. Ann Transplant
91. Klouche K, Amigues L, Massanet P, et al. Outcome of renal transplant recipients admitted to an intensive care unit: a 10-year cohort study. Transplantation