Adult kidney transplant recipient pathway

It is best that the principles of enhanced recovery are embedded at the earliest opportunity and be revisited at contact points such as clinic visits and annual review on the waiting list.

Core elements include:

• Introduction to principles of ERAS
• Managing expectations for the peri-operative period
• Identifying potential challenges and barriers to optimal recovery and discharge
• Standardised information, relevant to individual transplant units, reflected in all pre-transplant interactions to ensure consistent messaging

Desirable elements include:

• Introduction to an interactive patient journal to optimise patient engagement throughout their hospital stay
• Provision of other ERAS-specific educational documents and audiovisual resources. Consider accessibility options and translated versions to overcome disability and language barriers.
• Development of group education sessions for patients on the waiting list to include prehabilitation/wellness on the waiting list and enhanced recovery counselling
• Development of a patient local peer-support network

For living donor recipients, ERAS counselling can be given in a structured manner in the immediate weeks prior to transplantation.

For recipients of a deceased donor transplant there is a need to revisit enhanced recovery counselling on admission for transplant.

Formal prehabilitation can be resource intensive. However, there are elements of patient optimisation that are relatively easy to adopt.

Core elements include:

• Physical activity, dietary support and weight management advice
• Smoking cessation and substance misuse support
• Education around the importance of maintaining cardiovascular health and keeping well on the transplant waiting list

Desirable elements include:

• Development of a formal prehabilitation programme to include optimisation of physical fitness and function and ongoing monitoring of physical activity on the waiting list
• Psychosocial support to include behaviour change and patient empowerment

These could be delivered by a mixture of face to face and virtual support.

Renal transplant recipients have historically received relatively high volumes of perioperative intravenous fluids, but it is now appreciated that this is not necessary for kidney transplant function and may impede recovery.

Goal directed fluid therapy provides a judicious means of fluid replacement and is standard in many other surgical ERAS protocols.

Core elements include:

• Preoperative dry weight assessment and estimation
• Avoidance of routine insertion of central venous catheter
• Avoidance of excessive intravenous fluid administration above replacement requirements

Desirable elements include:

• Consider having a mean arterial pressure (MAP) cutoff. There is evidence to support the importance of maintaining adequate blood pressure perioperatively.
• Use of appropriate intraoperative fluid monitoring (e.g. Arterial wave form monitoring)
• Judicious use of vasopressor or inotropic agents dependent on cardiovascular status

A multimodal stepwise approach to perioperative analgesia is important in enhanced recovery protocols as it improves patient mobility, reducing the risk of respiratory and thromboembolic complications.

Core elements include:

• Deploying different routes and classes of analgesic agents (e.g. IV paracetamol, local wound infiltration etc)
• Minimising the routine use of opioid analgesia
• Availability of pain team input when required

Desirable elements include:

• The use of regional anaesthetic blocks (e.g. transversus abdominus plane (TAP ) catheters)

Routine drain insertion has historically been considered essential in kidney transplantation but increasing evidence shows this not to be the case.

Core elements include:

• Selective drain insertion on a case-by-case basis
• If required, aim to limit to one non-vacuum surgical drain (dependent on state of surgical field)

Recipients of kidney transplants have traditionally had intravenous fluids administered for prolonged periods of time. Recent evidence shows that this is not required and may even be harmful.

Early oral fluids and diet should be encouraged.

Core elements include:

• Eating and drinking as able from the immediate post-operative period
• IV fluid replacement equal to urine output, aiming to discontinue IV fluids by 6-12 hours after transplant*
• Daily clinical assessment of volume status including weight, and input / output, providing the patient with a daily oral intake target.

*Exceptions:

• IV fluids as part of fasting diabetic protocol – to discontinue once first meal tolerated
• Specific individual cases where unable to tolerate oral intake or if concern regarding intravascular volume status.

Desirable elements include:

• Specialist dietetic input

There is sufficient evidence to support the benefit of early mobilisation after surgery and this can be extrapolated to kidney transplantation.

Core elements include:

• Setting achievable daily mobility targets for recipients adaptable to individuals' capabilities (e.g. day 1 sitting out in the morning, walking a target distance in the afternoon)

Additional elements include:

• Dedicated physiotherapy staff with a focus on patient engagement and patient driven pathway.
• Individualised patient records for target achievement

The evidence behind prolonged catheter stay to protect the ureteric anastomosis is weak.

Early removal of drains and catheters can facilitate patient mobilisation and reduce the risk of falls and hospital acquired infections.

Desirable elements include:

• Catheter removal on day 1 or 2 and encourage frequent voiding*
• If drain present, goal is removal on day 1 or 2 unless high volume output or concerns about drain content

*Catheter removal may be delayed if there are concerns about:

• Intraoperative findings/complications
• Bladder function (e.g. prolonged anuria prior to transplant)
• Prostatic hypertrophy in older male patients

There is good evidence that minimisation of opioid analgesia post-operatively is beneficial for patient recovery. Optimal multimodal analgesia will encourage effective breathing, improve mobility and minimise postoperative complications.

Core elements include:

• Minimisation of opioid-based analgesia postoperatively*
• First 24 hours, local anaesthetic wound infiltration
• First 24 to 48 hours, IV paracetamol

*Exceptions:

• Simultaneous nephrectomy
• Laparotomy for intra-peritoneal placement
• Additional surgical/anaesthetic complexity

Desirable elements include:

• No routine post-operative use of opioid-based analgesia
• Pain team support for individualised care
• Bespoke analgesic guidelines for kidney transplant recipients

If the above elements of enhanced recovery are applied, then early discharge can be safely achieved.

Planning for this should start at an early stage, ideally at the time of listing.

Core elements include:

• Standardised post-operative education programme with targeted day for delivery to include self- medication training, and symptoms/signs of complications
• Early consideration of any barriers to discharge including transport needs
• Timely consideration of required procedures such as tunnelled line removal
• Timely completion and ordering of medications for discharge
• Clear identification of out-patient review arrangements
• A clear pathway for readmission when required

Desirable elements include:

• A bespoke pathway for follow up and contact after early discharge
• Specialist pharmacist input for education and prescription support

Optimisation of patient recovery does not end at the time of discharge and should ideally continue in the early post discharge period.

Consideration should be made to develop the following areas as part of an enhanced recovery service to avoid prolonged hospitalisation and optimise patient recovery.

Core elements include:

• Ongoing rehabilitation and avoidance of excessive weight gain post-transplant
• Provision of an ongoing mobility plan and guidance regarding suggested activity levels following discharge from hospital
• Advice on healthy eating, smoking cessation and wellbeing post-transplant, including signposting to local available services and support
• Signposting to virtual platforms where appropriate, offering nutritional support, physical activity promotion, behaviour change techniques and self-monitoring of weight and physical activity levels
• Earlier routine stent removal (around 2-3 weeks for uncomplicated cases)

Desirable elements include:

• Formal multidisciplinary rehabilitation programme
• Management of delayed graft function in the outpatient setting
• Management of rejection in the outpatient setting
• Remote monitoring of relevant post operative blood results