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Anaesthesia for renal transplant surgery Moderator - Prof Chandralekha Dr Jyotsna www.anaesthesia.co.in [email protected]

Moderator - Prof Chandralekha Dr Jyotsna [email protected]@gmail.com

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Anaesthesia for renal transplant surgery

Moderator - Prof Chandralekha Dr Jyotsna

www.anaesthesia.co.in [email protected]

DM Hypertension Glomerulonephritis Pyelonephritis Polycystic kidney Others

Causes of ESRD :

Hemodialysis Peritoneal dialysis Transplantation

Treatment options for ESRD :

Diffusion of solutes across a semipermeable membrane down conc gradient

Hemodialysis - shunt / fistula Peritoneal dialysis – IPD, CAPD,CCPD

Dialysis

Hyperkalemia unresponsive to conservative means

Refractory acidosis Volume overload Uremic pericarditis Uremic neuropathy

Indications :

Predominant technique Done three times a week Duration 2.5 - 5 hrs

Hemodialysis

Hemodialysis : Arteriovenous fistula - long term Arteriovenous shunt - short term Temporary venous catheters – short term

Access for dialysis

Needs 4 weeks to mature Complications : Thrombosis Infection Haemorrage StealPrecautions- Padding of fistula Avoid BP cuff No sampling Avoid hypotension

Care of fistula :

Peritoneum as endogenous dialysis membrane

CAPD /CCPD Access via silastic catheter

Peritonial dialysis :

advantages disadvantages

Hemodialysis – short time , better small solute removal

Need heparin ,vascular access , hypotension , poor BP control

Peritonial : steady state , higher hematocrit, better BP control , large solute removal , source of nutrition

Peritonitis , hernia back pain , obesity

Hemodialysis vs peritonial dialysis

Acute : Hypovolemia Electrolyte imbalance Disequilibrium syndromeChronic : Dialysis dementia Hypoproteinemia infections

Complications :

Better quality of life Better 5 yr survival rates 70% vs 30% Improves anaemia , peripheral neuropathy ,

autonomic neuropathy and cardiomyopathy Dialysis negatively affects success of

transplantation

Transplant Vs dialysis

Patients with ESRD with expected 5 yr survival

Criteria for transplant :

Absolute contraindications : Disseminated or untreated cancer Severe psychiatric disease Irresolvable psychosocial problems Persistent substance abuse Severe mental retardation Un-reconstructable coronary artery disease

or refractory congestive heart failure

Contraindications for renal transplant

Treated malignancy Chronic liver disease History of substance abuse Structural genitourinary tract anomaly Past psychosocial abnormality

Relative contraindications :

LIVE or CADAVERLive -> related or unrelated Ideal donor Age = 18 - 60yrs Compatible blood groupNo DM or HTNPsychologically motivatedViral markers ( - )

Donors for kidney transplant :

Fully informed of risk and benefits Aware of alternative methods Willing to donate Psychosocially capableUnrelated donors – Need permission from authorization

committee

Pre op consent

Hemogram ,KFT , LFT CT angiography and urography Psychiatry , dental ,opthalmologic and

cardiac evaluation CMV antibodies DTPA scan and global GFR Immunological testing

Investigations

Good physical health ASA 1or 2 Open / laparoscopic Flank position – risk of hypotension Maintain good hydration and diuresis Mannitol before cross clamping Avoid direct acting vasopressors Post op pain – iv opioids , no NSAIDS

Anaesthetic concerns for living donors

Brain dead donors or non heart beating :Brain dead donors : Need peri op hemodynamic stabilization Metabolic and electrolyte disturbances

Intra op goals ( rule of 100 ): Systolic BP >100 mm hg Pao2 > 100mm hg Urine output > 100ml /hr Hemoglobin > 10 gm/dl CVP between 5 -10 mm Hg

Anaesthetic concerns for cadaveric donors :

Muscle relaxation needed Analgesia not required Volatile and opioids needed for

hemodynamic stability

Non heart beating donors :Long warm ischemia time

CVS :◦ Control hypertension ◦ Accelerated CAD - dyslipidemia , hypertension ,

Calcium & phosphate metabolism◦ volume overload - dialysis

Pre – operative assessment and optimization

Chronic anemia Maintain hematocrit close to 25% Erythropoietin supplementationUremic coagulopathy : deficient factor VIII , VWf and abnormal

platelet function Dialysis ,conjugated estrogen,

desmopressin, cryoprecipitate , FFP

Hematological assessment :

Hyperkalemia – K >5.5 need treatment Dialysis or pharmacological intervention Calcium phosphate product > 60 -

calcification in vessel Hypermagnesemia - enhance muscle

relaxants

Fluid and electrolytes :

Hypoalbuminemia or volume overload– risk of pulmonary edema

Pleural effusion Dialysis , albumin supplementation

Pulmonary status :

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DM Stiff joint syndrome Autonomic neuropathy Silent MI Peripheral neuropathy Electrolyte imbalance Diffuse atherosclerosis Ensure blood sugar control

Risk of haemodynamic fluctuation Risk of gastric aspiration Reduced heart rate variability >15 / min is

normal

Autonomic neuropathy:

Site of AV fistula Previous cannulation Ascites

Examination :

ABO compatibility HLA matching Crossmatching negative PRA( panel reactive antibody) levels ideally

less than10%

Immunological assessment :

Hemoglobin , platelets ,KFT ,LFT, CXR ,ECG, echo ,MCU, viral markers ,immunological testing

Pre op dialysis - a day prior to surgery Patients native urine output Post dialysis inv : serum electrolytes ,urea,

ECG , CXR , pt weight (<2kg difference)

Preoperative investigation

Aspiration prophylaxis – delayed gastric emptying

Dose reduction of H2 antagonists Continue antihypertensives Anxiolysis - midazolam (water solubility )

Premedication :

Standard ASA monitoring -> 5 lead ECG Pulse oximeter eTCO2 Temp NIBP ( non fistula arm ) CVP ( PAC – sig LV dysfunction ) NMT

Monitoring :

Thiopentone - ↑free fraction needs reduced dosing, slow rate of administration

Etomidate – minimal cardiodepressant effect

Ketamine - hypertensive effect ; avoid Propofol - titrated doses

IV inducing agent :

Enflurane , methoxyflurane – flouride toxicity

Desflurane , sevoflurane – safe Halothane – reduces RBF , cardiac

depressant effect Isoflurane – preserves RBF , mild

cardiodepressive effect , low renal toxicity Anesthetic agent of choice

Inhalational agents :

Morphine , meperidine – metabolites renally excreted

Fentanyl Sufentanil Alfentanil Remifentanil Doses reduced by 30-50%

opioids

Atracurium and cisatracurium - organ independent elimination

Rapid sequence induction – Succinylcholine - K < 5.5 meq/L Rocuronium – 1.5mg/kg , hepatobiliary

elimination Vecuronium – metabolite accumulation

Muscle relaxants :

Maintain asepsis Supine position , fistula care Preoxygenation Rapid sequence intubation – diabetics IV agents - thiopentone most popular

Induction :

Adequate intravascular volume - improves graft function

Maintain CVP – 10 -15 mm hgMannitol - 0.5-1 g/kg Increases renal cortical blood flow and

intravascular volume , free radical scavenger , increases release of prostaglandins

Intraoperative management :

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Dopamine and Dopexamine Low dose Dopamine has been proved

neither a reduction in acute renal failure nor an improvement in renal function in patient with renal failure

It also did not demonstrate improved renal protection when used in cadaveric renal transplantation.

Dopexamine has been shown some renal protection during aortic surgery but its potential benefit during renal transplant has not been evaluated.

Furosemide - counteracts action of stress induced ADH release , inhibits Na –K ATPase to decrease O2 consumption , converts oliguric to non oliguric

Calcium channel blockers – verapamil injection in renal artery .Preserves RBF , reduces effects of cold ischemia

Avoid potassium containing fluids in stage 5 CKD

Medium / low molecular weight HES can be used

Albumin can be used

Fluids in renal transplant :

Adequate volume status Maintain blood pressure Avoid renal vasoconstriction Prevent tubular obstruction diuretics

Factors improving urine output

Extra caution : Intubation – avoid hypertension and

tachycardia Anastomosis - avoid hypotension,

hypovolemia and hyperkalemia Extubation - NMB fully reversed , awake

patient

Intraoperative complications :

Monitor urine output Post op analgesia – intermittent boluses of

fentanyl /morphine or PCA Potassium levels , urea and creatinine levels

measure daily Maintain adequate hydration

Postoperative period :

TIVA – propofol with fentanyl /alfentanyl/ remifentanil /atracurium

Neuraxial blocks – epidural / CSE Advantages – avoids intubation , opioids and

relaxants ,good post op analgesia Disadvantages : uremic

coagulopathy,peripheral neuropathy,hypotension ,duration of surgery

Anaesthetic techniques for renal transplant :

Local anaesthetics – Faster onset and offset Dose reduction by 25% to avoid CVS and

CNS effects

Warm ischemia time – from clamping of donor vessels to cold perfusion and placement to anastomosis in recipient

Duration affects acute tubular necrosis < 30 min Cold ischemia time : storage in preservation

solution to implantation in recipient Ideally < 24 hrs upto 72 hrs

Ischemia time

Mediators of ischemic injury : ATP depletion ->loss of Na K ATPase pump Movement of ions along conc gradient ->

edema and cell swelling Ischemia -> anaerobic metabolism causing

acidosis -> lysosomal disruption Free radical production

Kidney preservation :

Euro Collins solution University of Wisconsin solution Bretscheider HTK solution

Compositon : Rich in potassium ,low Na ,free radical

scavengers and other ions Static or perfused storage

Preservative solutions :

University of wisconsin soltion

Collins HTK custodial

Modified HESPotassium phosphateMagnesium sulphateAdenosineAllopurinolglutathione

Potassium phosphatePotassium chlorideSodium bicarbonateGlucoseMagnesium sulphate

HistidineTryptophanLow potassiumKetoglutrateCalciumMagnesiummannitol

Local anaesthetics – Faster onset and offset Dose reduction by 25% to avoid CVS and

CNS effects

agent effect toxicity

steroids ↓ interleukin production Hyperglycemia myopathy osteoporosis hypertension

azathioprine Inhibits DNA synthesis

Anaemia thrombocytopenia

cyclosporine Inhibits T cells Hyperkalemia hypertension nephrotoxicity hepatotocicity

Tacrolimus Inhibits IL 2 production

Nephrotoxicity hyperkalemia hypertension,seizures

OKT 3 Inactivates T cell Cytokine release syndromne

Immunosupressants

Induction therapy –iv tacrolimus ,MMF and methylprednisolone (2 days prior to surgery )

Maintainance therapy – same drugs on post op day 0

All three drugs continued through out life

Immunosupressents in renal transplant

1. Criteria compliance with HARRTCD4 count > 200undetectable viral loadno systemic manifestation of disease/infection

HIV positive recepient