title: Intraoperative management and early postoperative outcomes of pediatric renal transplants.
abstract: BACKGROUND
  Smaller children are presenting for renal transplantation as the treatment of choice for end-stage renal disease. Adult donor organs are more successful than pediatric deceased donor organs. An adult kidney may sequester ~75% of the circulating volume of a 5 year-old child and requires significantly increased cardiac output to maintain renal perfusion. Treatment includes volume, inotropic or vasopressor agents, or central neuroaxial blockade for sympatholysis. We describe the perioperative anesthestic management as a guide to clinical outcomes.
  
  
  METHODS
  A retrospective chart review of renal transplant patients between 2006 and 2014 was performed. We recorded patient demographics, surgical and anesthetic factors and postoperative outcome.
  
  
  RESULTS
  One hundred and fifty-six children underwent renal transplantation, of which 38% were from living donors. There were 99/156 (63.5%) males. Median age was 10 years (range 1-17 years) and the mean weight was 36.2 kg (sd 20.6 kg; range 7.6-109.6 kg). There were 36 children ≤5 years of age and 14 children ≤2 years of age. One hundred and nineteen (77%) were dialysis dependent. Pharmacological support to increase renal perfusion included mannitol in 95%, and dopamine in 83%. Furosemide was used in 82% of cases. Inotropic therapy continued into the postoperative period in 34%. Radiological pulmonary edema was diagnosed in 33% and clinical pulmonary edema in 7%. Intraoperative use of dopamine delayed the time to creatinine nadir in all grafts (9.5 days vs 6.5 days, P = 0.04) and in deceased donor grafts (12.9 vs 7.4 days, P = 0.007). Patients who received dopamine had no significant difference in central venous pressure (CVP) preclamp removal, 14 mmHg vs 11.5 mmHg (P = 0.12) but a higher CVP after clamp removal, 14.3 mmHg vs 11.8 mmHg (P = 0.003).
  
  
  CONCLUSIONS
  Dopamine use was common and was an independent risk factor for delayed time to creatinine nadir. Many different agents were used to enhance renal perfusion. The 'supra-physiological' hemodynamics resulted in pulmonary edema in 33% of patients.
authors.affiliation: Department of Anesthesia, Hospital for Sick Children, Toronto, Canada.|Department of Anesthesia, University of Toronto, Toronto, Canada.
authors.forename: Katherine
authors.initials: K
authors.lastname: Taylor
authors.affiliation: Department of Anesthesia, Hospital for Sick Children, Toronto, Canada.
authors.forename: Wooheon Thomas
authors.initials: WT
authors.lastname: Kim
authors.affiliation: Department of Anesthesia, Hospital for Sick Children, Toronto, Canada.
authors.forename: Malak
authors.initials: M
authors.lastname: Maharramova
authors.affiliation: Department of Urology, Hospital for Sick Children, Toronto, Canada.
authors.forename: Victor
authors.initials: V
authors.lastname: Figueroa
authors.affiliation: Department of Anesthesia, Hospital for Sick Children, Toronto, Canada.
authors.forename: Smruthi
authors.initials: S
authors.lastname: Ramesh
authors.affiliation: Department of Urology, Hospital for Sick Children, Toronto, Canada.|Department of Surgery, University of Toronto, Toronto, Canada.
authors.forename: Armando
authors.initials: A
authors.lastname: Lorenzo
mesh_terms: D000293:Adolescent; D000758:Anesthesia / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D004232:Diuretics / Q000627:therapeutic use; D004298:Dopamine / Q000627:therapeutic use; D015259:Dopamine Agents / Q000627:therapeutic use; D005260:Female; D005665:Furosemide / Q000627:therapeutic use; D006801:Humans; D007223:Infant; D007430:Intraoperative Care / Q000379:methods*; D007668:Kidney / Q000601:surgery; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000379:methods*; D008297:Male; D011183:Postoperative Complications / Q000188:drug therapy / Q000453:epidemiology*; D011654:Pulmonary Edema / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D004232:Diuretics; D015259:Dopamine Agents; D005665:Furosemide; D004298:Dopamine
keywords: clinical outcomes; dopamine; hemodynamic goals; kidney transplantation; pediatrics; retrospective study