Learning objectives

• Definition of a renal transplant
• Management of a living donor during a nephrectomy
• Management of a renal transplant recipient

Definition and mechanisms

• A renal transplant is the organ transplant of a kidney into a patient with end-stage kidney disease (ESRD)
• Classified as deceased-donor (formerly known as cadaveric) or living-donor nephrectomy (LDN)
• Improves both length and quality of life for patients with end-stage renal disease (ESRD)
• ESRD is defined as chronic kidney disease (CKD) with a glomerular filtration rate (GFR) <15 mL/min/1.73 m² or where renal replacement therapy is needed
• Diabetes is the most common cause of ESRD followed by glomerulonephritis, polycystic kidney disease, pyelonephritis, hypertension, and auto-immune disorders
• Two-year graft survival is > 80% for cadaveric and 90% for living-donor grafts and overall patient survival is > 95%

Signs and symptoms

See chronic kidney disease

Complications

• Bleeding
• Vascular thrombosis and stenosis
• Transplant rejection (hyperacute, acute, or chronic)
• Ureteral obstruction
• Urinary leakage
• Infections and sepsis due to immunosuppression
• Post-transplant lymphoproliferative disorder
• Electrolyte imbalance (particularly calcium and phosphate)
• Proteinuria
• Hypertension

Management of the living donor during nephrectomy 

Postoperative care of the living donor

• Provide postoperative analgesia via a fentanyl PCA
• Consider a paravertebral or TAP block to complement analgesia
• Avoid NSAIDs
• Apply early mobilization along with breathing exercises and incentive spirometry
• Consider postoperative complications:
  • Pulmonary embolism
  • Hepatitis
  • Myocardial infarction
  • Arrhythmias
  • Pneumonia
  • Atelectasis
  • Urinary tract infection
  • Wound infections
  • Splenic lacerations

Management of the recipient

Suggested reading

• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
• Mayhew D, Ridgway d, Hunter JM. 2016. Update on the intraoperative management of adult cadaveric renal transplantation. BJA education. 16;2:53-57.
• O’Brien, B., Koertzen, M., 2012. Anaesthesia for living donor renal transplant nephrectomy. Continuing Education in Anaesthesia Critical Care & Pain 12, 317–321.
• Rabey P. 2001. Anesthesia for renal transplantation. BJA CEPD Reviews. 1;1:24-17.

Clinical updates

Kim et al. (RAPM, 2024) report in a double-blinded randomized controlled trial of 88 living-donor renal transplant recipients that a unilateral anterior quadratus lumborum (QL) block did not reduce 24-hour postoperative opioid consumption or pain scores compared with a sham block when used within a multimodal analgesia regimen. Secondary outcomes were also similar between groups, suggesting routine use of the anterior QL block is not supported for analgesia after renal transplantation.

• Read more about this study HERE.

Hofer et al. (2025, A&A) report that preoperative intrathecal hydromorphone (median 100 µg) in kidney transplant recipients is associated with a 66% reduction in 72-hour postoperative opioid consumption and significantly lower pain scores at 24 and 72 hours, without increasing respiratory depression, naloxone use, or length of stay. The main trade-off was a higher incidence of postoperative nausea and vomiting, underscoring the need for proactive antiemetic prophylaxis. These findings support intrathecal opioids as a safe, opioid-sparing adjunct within evolving ERAS-style pathways for renal transplantation.

• Read more about this study HERE.