I agree with you totally that either method probably doesn't affect renal allograft function, but let's be clear, you are offering your opinion and I am offering mine. I think reasonably dosed opioids can be part of a balanced renal transplant induction based on my experience; you don't. If you're posting with the sole intent of just having everyone pat you on the back every time you offer one of your pearls, I don't know what to tell you. Could I have phrased my incredulity better? Sure. So, if my "LOL" offended your sensibilities, I truly apologize for the slight of laughing out loud.
You posted one UCSF guideline and pointed to two posters and are shocked that I could have any skepticism about it? I love guidelines and use them frequently but I don't consider one guideline in isolation to be the end-all-be-all of anesthesia, echocardiography, or critical care. That being said, I don't know you and you don't know me; for instance, I traveled halfway across the country to do fellowship in a different place with different attendings using different methodologies because there's always a different (and likely equally acceptable) way to skin a cat. I've been here for over 10 years and have learned a ton from the greats, even some things which have significantly changed my practice. At the end of the day, your judgement of whether I am humble enough or not based on a cursory search of my post history is relatively meaningless to me.
And since you brought up some guidelines, here's a section from the UTD article on anesthesia for renal transplant, written by a Stanford anesthesia professor and edited by the transplant nephrology director at Hopkins. Maybe it'll help you understand where my original post came from vis a vis the acceptability of opioids in transplant and my emphasis on volume status and other causes of hypotension such as ace-i (which have been known since the early 2000s to confer a mortality benefit in ESRD, hence my saying 100% of ESRD pts are on one at the time of transplant is barely an exaggeration):
"
We typically induce general anesthesia with IV
propofol 1 to 2.5 mg/kg because the pharmacokinetic and pharmacodynamic responses to this agent are not markedly altered by ESRD [
18,19].
We reduce and titrate the propofol dose in patients who may be hypovolemic since a standard induction dose administered as a bolus may result in profound hypotension due to venous and arterial dilation. Induction doses of propofol are also reduced in patients with known coexisting heart failure or older age [
20-22]. (See
"Anesthesia for dialysis patients", section on 'Induction' and
"General anesthesia: Intravenous induction agents", section on 'Propofol'.)
During induction in most patients, we also administer adjuvant medications to blunt tachycardia due to the sympathetic response to laryngoscopy and endotracheal intubation
(eg, fentanyl 1 to 2 mcg/kg and/or
lidocaine 1 mg/kg), as well as a neuromuscular blocking agent (NMBA). Some ESRD patients require rapid sequence induction and intubation (RSII) due to gastroparesis with risk of aspiration of gastric contents.
Succinylcholine (SCh) can be safely used as the NMBA to facilitate laryngoscopy if potassium concentration is <5.5 mEq/L and there are no electrocardiographic (ECG) changes [
23]. If potassium is ≥5.5 mEq/L in a patient who requires RSII, we use a relatively large dose of
rocuronium (1 mg/kg) rather than SCh. A
remifentanil intubation technique is an alternative that facilitates laryngoscopy while avoiding any NMBA. (See
"Anesthesia for dialysis patients", section on 'Induction' and
"Rapid sequence induction and intubation (RSII) for anesthesia".)
Hydration status is assessed immediately before induction, including whether dialysis was recent and whether there is any deviation from the target dry weight (see 'Volume overload' above). For patients with likely hypovolemia, we suggest volume expansion before administration of anesthetic induction agents, with rapid IV administration of 1 to 2 L of isotonic crystalloid solution (eg, normal [0.9 percent] saline or an acetate-buffered, chloride-reduced solution such as Normosol-R, Ringer's lactate [also termed Hartmann's solution], or Plasmalyte). (See
'Fluid management' below.)"
..
"We supplement an inhalation-based anesthetic technique with
intermittent bolus doses of an opioid (eg, fentanyl or sufentanil) titrated to treat hemodynamic parameters indicating sympathetic responses to pain (eg, tachycardia and/or hypertension). (See
"Anesthesia for dialysis patients", section on 'Opioids' and
"Perioperative uses of intravenous opioids in adults".)"
