Do you hold renin-angiotensin system blockade at the time of kidney transplant and restart it only once graft function is established, or do you continue it through the perioperative period?

Yes, it is our usual practice to hold RAAS blockade at the time of transplant until renal function has stabilized due to risks of hyperkalemia and delaying renal recovery. For blood pressure control in the early post-transplant period, our first-line agents are usually the calcium channel antagonists and beta-blockers.

We do hold ACEs and ARBs at the time of transplant. After three months, we are typically pretty comfortable restarting an ACE or ARB if needed. If proteinuria develops early post-transplant, we might consider earlier institution of an ACE or ARB after renal ultrasound and biopsy. One exception is with pediatric en-bloc kidneys, where we are a little more hesitant due to the small caliber of the vessels. The other consideration is whether there are accessory arteries that are small and might be s...