Renal transplantation- Recommendations for enhanced recovery after surgery

Enhanced Recovery After Surgery protocols are used widely in major surgery and improving postsurgical outcomes. However, due to challenges in evaluating their safety and efficacy, uptake of these programs has been slow in kidney transplantation. There has been no guidance and protocols specific to ERAS in kidney transplantation surgery to date. In the article, Jaimee H S Tan, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK, and colleagues aimed to summarise current evidence in the literature and develop ERAS protocol recommendations for recipients of kidney transplantation. 

The researchers searched the online databases up to August 2021, for studies relevant to ERAS protocols in kidney transplantation. For each recommendation, a secondary search was repeated to explore the availability of specific evidence for each section of the protocol. Randomized controlled trials, case-control, and cohort studies were included. 

The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework was used to evaluate the quality of evidence available and recommendations.

Preoperative counseling and education

Preoperative education and counseling on postoperative care regimens, potential complications is recommended, and how to reduce/manage them.

Preoperative optimization

Prehabilitation programs are recommended to improve frailty issues.

Carbohydrate loading

Carbohydrate loading before operation can be safely given to non-diabetic kidney transplant recipients. 

Fluid management

A goal-directed fluid therapy strategy is recommended over liberal fluid therapy with dynamic monitoring.

Local anaesthetic wound infiltration

Transversus abdominis plane (TAP) block is recommended to reduce reliance on opioid analgesics.

Catheter and drains

Catheter removal as early as possible is recommended to reduce the risk of urinary tract infection (UTI). Prophylactic drain insertion does not appear to confer any benefit.

Physiotherapy and early mobilization

Early mobilization is recommended to reduce complications, hospital, and overall recovery time.

Diet, laxatives, and bowel movement

Early resumption of the diet is recommended with active measures to manage emesis.

Ureteric stent management

Prophylactic ureteric stenting may reduce post-transplant urological complications but early removal is advised.

Postoperative counseling and education

Education and counseling on medication regimens, lifestyle advice, and smoking cessation programs are recommended (where indicated).

The researchers wrote in their conclusion, "the evidence base for ERAS in kidney transplantation is scarce compared to other surgical specialties, with further room for research and development." However, with the application of the currently available evidence, significant improvements to patient outcomes are already possible." 

"This has shown that ERAS in kidney transplantation surgery is safe and feasible, with improved postoperative outcomes." 

Reference:

Jaimee H S Tan, Kailash Bhatia, Videha Sharma, Mruthunjaya Swamy, David van Dellen, Raman Dhanda, Hussein Khambalia, Enhanced recovery after surgery recommendations for renal transplantation: guidelines, British Journal of Surgery, 2022;, znac325, https://doi.org/10.1093/bjs/znac325