Anaesthetic Management for Renal Transplant

Dr. Shafiul Alam DA, FCPS

Registrar

Department of Anaesthesiology & Surgical ICU

BIRDEM General Hospital

Introduction

Renal transplantation is the treatment of choice for end stage renal disease

Quality of life, Reduced long term mortality rate & Cost effective

Cadaver, Living related & Living unrelated ( emotional )

Organ transplant in 104 countries

African region: 10 countries

Region the Americas: 21 countries

Southeast Asian Region: 9 countries

Region of Europe: 40 countries

Eastern Mediterranean Region:12 countries

Western Pacific Region: 12 countries

Every year around 1,00,800 solid

organ transplant

Kidney transplant 69,400 (46% from living donor)

Liver transplants 20,200 (14.6% from living donors)

Heart transplants 5400

Lung transplants 3400

Pancreas transplants 2400

Ref: WHO report data analysed from 2008

In Bangladesh

Chronic Renal Failure : 20-25 thousand patients per year

Acute Renal Failure : 10-15 thousand patients per year

Every hour > 4 patient died due to kidney failure

Ref: Global Health Statistics (7.6/100,000/year),

WHO May-2014 ( 24/ 100,000/year)

Demand for kidney transplant is 5000 per year

Renal Transplant done: 50-60 per year

Ref: The Open Urology & Nephrology Journal

ISSN: 1874-303X – Volume 10,2017

World’s first kidney transplant – Boston, 1954, Identical twins

Surgeon - Dr Joseph Murray

First kidney transplant Bangladesh - October 1981 Only one center upto 2004, but now 8 centers

Three major centers in Bangladesh

BSMMU

BIRDEM

NIKDU

Stages of CKD

Normal • 100 – 120 ml/min/1.73 sqm

Stage 1 • Kidney damage with normal ↓GFR > 90

Stage 2 • Kidney damage with mild ↓GFR 60 – 90

Stage 3 • Kidney damage with moderate ↓ GFR 30 - 59

Stage 4 • Kidney damage with severe ↓GFR < 15 - 29

Stage 5 • Kidney Failure with GFR < 15

Ref: Kasper DL, Braunwald E, Fauci AS, et al. Harrison’s principles of internal medicine, 16th ed. New York: McGraw-Hill, 2005:1654

ESRD Hemodialysis

Hemofiltration

Peritoneal dialysis

Renal transplantation

GFR

< 10 ml/min

Why ESRD

Diabetes mellitus (40%)

Hypertension (27%)

Chronic glumerulonephritis

(13%)

Polycystic kidney disease

(4%)

Interstitial nephritis (4%)

Others (12%)

Ref: Kasper DL, Braunwald E, Fauci AS, et al. Harrison’s principles of internal medicine, 16th ed. New York: McGraw-Hill, 2005:1654

Changes in the body in ESRD

Anaemia, Platelet dysfunction, Bleeding diathesis, B- and T-cell

dysfunction

Systemic HTN, LVH, CHF, Pulmonary edema,

Cardiomyopathy, Hyperdynamic circulation

Nausea, Vomiting, Gastroperesis, GI bleeding,

Uremic gastroenteritis

Volume expansion, Hyponatremia, Hypocalcemia, Hyperkalemia, Hyperurecemia,

Metabolic acidosis

Hyperparathyroidism, Hypertriglyceridemia,

Carbohydrate intolerance

Ref: Kasper DL, Braunwald E, Fauci AS, et al. Harrison’s principles of internal medicine, 16th ed. New York: McGraw-Hill, 2005:1654

Anaesthetic Challenges

Anaemia

Uremic Coagulopathy

Electrolyte abnormality

Uremic Cardiomyopathy

Delayed gastric

emptying

Low Serum protein & albumin

level

Preoperative dialysis

Optimize fluid and

electrolyte balance

Correct hemostatic

abnormalities

Reduced perioperative mortality rate from 16% to almost 0%

Ref: Anaesthesia for renal transplant: recent

developments and recommendations

Zorica jankovic, chunda sri‐chandana current anaesthesia & critical care (2008) 19, 247–253

AV fistula

long term vascular

access for HD

Veins of the arm low

blood flow difficult to

HD

large diameter

and higher blood flow

Peripheral arteries high blood flow , too small for

repeated catheterization

Preoperative evaluation

ECG

Chest X-ray

CBC

Electrolyte Serum glucose

BUN

Creatinine

Coagulation profile

Liver function test

Urinalysis

H/O Dialysis

H/O AV fistula

Ref: Sprung J, Kapural L, Bourke DL, et al. Anesthesia for kidney transplant. Anesthesiol Clin North America 2000; 18 (4): 919 - 951

Preoperative optimization

Dialysis

Anaemia correction

Blood pressure control

Control of blood sugar

Correction of serum K level

Correction of Coagulopathy

Preparation & premedication

Continue antihypertensive drugs

Oral hypoglycemic drugs should be converted to short acting insulin

Antibiotic prophylaxis – first generation Cephalosporin

( Cefazolin 1gm 30 min before surgery, if Penicillin allergic, Vancomycin 1 gm)

H2 blocker: Aspiration Prophylaxis

Metoclopramide: 10 mg for accelerating gastric emptying, prevent vomiting, ↓risk of aspiration

Immunosupression: Methylprednisolone ( Solumedrol 500 mg) & Mycophenolate mofentil ( Cell Cept 500 to 1000mg)

Ref: The New York Hospital- Cornell Medical Center Kidney Transplantation Protocol 2005, New York.

What type of Anaesthesia

General Anaesthesia – Preferred technique

Epidural alone Combined GA & Epidural

Ref: Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s principles of surgery, 8th ed. New York: McGraw-Hill, 2005:307.

Hadimioglu N, Ertug Z, Bigat M, et al. A randomized study comparing combined spinal or general anesthesia for renal transplant surgery. Transplant Proc 2005; 37: 2020 – 2022

Anaesthetic consideration during donor nephrectomy

Preoperative hydration 100ml/kg/hr ( 4/2/1) starting from midnight before surgery

Maintain Adequate hydration

V/Q mismatching due to positioning

Target Urine output at least 100ml/hr

Start Mannitol after induction upto nephrectomy (0.5gm/kg) 200 -250 ml

Intraoperative infusion 20ml/kg/hr

Ref: Guidelines on aneasthetic management for renal transplant, Department of Anaesthesia & Intensive care Hospital, Kualalumpur, April-2013

Anaesthetic Consideration Recipient

Inhalational agent

Volatile agents are nearly ideal for patients with renal dysfunction

Safer agents are, Halothane, Isoflurane & Desflurane

Intravenous agents

Propofol : The pharmacokinetics of this drug is not significantly altered

Barbiturates: Increase sensitivity due to an increased free circulating barbiturate as a result of

decreased protein binding

Opioids: The accumulation of morphine and meperidine metabolites has been reported to prolong respiratory

depression

Fentanyl, Remifentanyl pharmacokinetics are not affected by renal failure

Muscle relaxants

Succinyl choline: It can be safely used in patient with renal failure, provided serum potassium concentration

should be < 5 meq/L

Cisatracurium & Atracurium do not depend on renal excretion. So, its our choice.

Kidney preservation

(Cold Ischemic time)

Hypothermia

Temperature

37ºC - 4ºC

Ideal cold ischemic time

20 – 30 min

36 to 40 hours

Pharmacological by slow down

metabolic process

1. Collins solution

2. Citrate solutions

(Marshall/Ross)

3. University of Wisconsin Solution (UW)

Ref: Howden B, Jablonski P, Rigol G, Barrell C, Rae D, Marshall VC, Tange J. Studies in renal preservation using a rat kidney transplant model:II. The

effect of reflushing with citrate. Transplantation. 1984; 37: 52 - 54

Clamping time

Reduced ischemic time

Inj. Furosemide 100mg (1 – 2mg/kg)

Inj. Sodium bicarbonate 50 mEq/l (1mEq/kg)

Fluid therapy

Good graft

Maintaining appropriate Renal perfusion pressure

Hemodynamic Auto-regulation mildly decreases resulting in

repeated ischemia to the transplanted kidney

Restoration and maintenance of intravascular volume – perioperative period

Goal of fluid therapy

CVP > 12 mmHg

IV fluids at least 30-50 ml/kg/hr

Mean Arterial BP

> 80 mmHg

Systolic BP > 130mmHg

Type of fluid

0.9% Normal saline causes hyperchloremic acidosis and Hartmann solution causes hyperkalemia

Mixture of 0.9% Normal saline and Hartmann solution –Choice of fluid

Ref: Guidelines on anaesthetic management for renal transplant department of anaesthesiology and intensive care, Hospital Kuala lumpur , April 2015 , P-

11,12

Intraoperative

Monitoring

Heart rate

Continuous ECG

Non-invasive blood

pressure

Central venous

pressure

Oxygen saturation

End-tidal CO2

Temperature

Postoperative care

O2 inhalation

Control of blood

pressure

Collection of drain

Urine output

PCA Morphine

1mg/bolus for Donor

Fentanyl 10mcg/bolus for Recipient

Epidurals Transversus

Abdominis

Plane Block

Fascia

Transversalis

Block

Post operative pain

Started : 6th November 2004

Total (Upto December 2016): 124

Annual

0

5

10

15

20

25

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

4

8

11

6

1112

17

20

9 9

5

8

4

ASA

Class II • 18 cases

Class III • 102 cases

Class IV • 04 cases

ASA II- Pt with mild systemic disease,

ASA III- Pt with severe systemic disease & ASA IV- Severe systemic disease that constant threat to life

Analysis - 124 Cases

Hb • 7 – 9 gm% with an average of 8.2 (±2.0SD) gm%

S.K

• 5 – 6.2 meq/l with an average of 4.5 (±0.64SD) mEq/l

S.Urea

• 15 – 140mg/dl with an average of 20 (±2.15SD) mg/dl

S. Cr • 3.4–16 mg/dl with an average of 7.4 (±2.45SD) mg/dl

HD

• Hemodialysis was done in 98 cases, before surgery within 24 hours

Anaesthesia

Combined

(GA+Epidural) : 04

Cases

GA : 120 Cases

Induction

Propofol: 108 cases

Thiopentone: 12 cases

Etomidate: 04 cases

Neuromuscular blockade was maintained with Atracurium 0.5mg/kg

Average duration of surgery was 4.5(±1.20SD) hrs

Average duration of Anaesthesia was 4.8(±1.28SD) hrs

All patients extubated smoothly

Postoperative Complications

0

2

4

6

8

10

12

14

Dialysis Pneumonia Acute tubular

necrosis

Pulmonary

edema

Acute graft

rejection

Re-

exploration

4(3.23%)

8(6.45%)

12(9.68%)

5(4.03%)

8(6.45%)

3(2.42%)

Transplant team

References

1. Anaesthesia for renal transplant surgery: an update. Sebastian Schmid and Bettina Jungwirth. Eur J Anaesthesiol 2012; 29:552–558

2. Comparison of three perioperative fluid regimes for laparoscopic donor nephrectomy. A prospective randomized dose finding study. Mertens zur Borg I.R.A, Di

Biase M, Verbrugge S, IJzermans J.N.M, Gommers D. Surg Endosc (2008) 22: 146-150

3. Understanding the Complexities of Kidney Transplantation: Perioperative Hydration Policy. Mahmoud M. Othman

4. Perioperative fluid management in renal transplantation: a narrative review of the literature. Schnuelle P, Johannes van der Woude F. Transpl Int. 2006 Dec; 19(12):947-

59.

5. Perioperative Fluid Management in Kidney Transplantation: Is Volume Overload Still Mandatory for Graft Function? De Gasperi A, Narcisi S, Mazza E, Bettinelli L,

Pavani M, Perrone L, Grugni C, Corti A. Transplant Proc. 2006 Apr;38(3):807-9

6. Early hemodynamic changes after renal transplantation: determinants of low CVP in the recipients and correlation with acute renal dysfunction. Ferris RL, Kittur DS,

Wilasrusmee C. Med Sci Monit. 2003;9:61–66.

7. The Impact of Timing of Maximal Crystalloid Hydration on Early Graft Function during Kidney Transplantation. Othman MM, Ismael AZ, GE Hammouda. Anesth Analg

2010: 110; 1440-6 25 | P a g e

8. An Acetate-Buffered Balanced Crystalloid Versus 0.9% Saline in Patients with End-Stage Renal Disease Undergoing Cadaveric Renal Transplantation: A Prospective

Randomized Control Trial. Potura E., Lindner G, Biesenbach B, Funk G.C, Reiterer C,

Kabon B, Schwarz C, Druml W, Fleischmann E. Anesth Analg 2015; 120: 123-9

9. Hydration and mannitol reduce the need for dialysis in cadaveric

kidney transplant recipients treated with CyA. Lauzurica R, Teixido J, Serra A, et al Transplant Proc 1992; 24: 46.

10. A multivariate analysis of the risk factors for post-transplant renal

failure: beneficial effect of a flush solution with mannitol. Porras I,

Gonzalez- Posada JM, Losada M, et al. Transplant Proc 1992; 24: 52.

11. Mannitol reduces ATN in cadaveric allografts. Richards KF, Belnap

LP, Stevens LE. Transplant Proc 1989; 21(1 Pt2): 1228.

12. Prevention of acute tubular necrosis in cadaveric kidney

transplantation by the combined use of mannitol and moderate

hydration. Tiggeler, et al Ann Surg. 1985 February; 201(2): 246–251.

13. Mannitol as an indispensable constituent of an intraoperative hydration protocol for the prevention of acute renal failure after cadaveric transplantation van Valenberg PL, Hoitsma AJ, Tiggeler RG, Berden JH, van Lier HJ, Koene RA. Transplantation. 1987; 44:784-788

14. Anaesthesia for Renal Transplant Surgery. Sarin Kapoor H, Kaur R, Kaur H. Acta Anaesthesiol Scand 2007; 51: 1354–1367

T H A N K Y O

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