ANAESTHESIA FOR RENAL TRANSPLANTATION

Dr.M.Kannan MD DAProfessor and HOD of

AnaesthesiologyTirunelveli Medical College

Demand-supply imbalance

3000

300 per million

1800 per year in Tamilnadu

Associated co-morbid conditions

•Coronary artery disease

•Congestive cardiac failure

•Systemic Hypertension

•Diabetes Mellitus

Associated co-morbid conditions

Coronary artery disease

• Incidence 17%-34% • Coronary angiography & re-

vascularisation • Irreversible LV dysfunction with

very low cardiac output

contraindication

Associated co-morbid conditions

Congestive cardiac failure• CCF is present before dialysis

• CCF Associated with CRF IHD HypoalbuminemiaOld age Uremic cardiomyopathy DiabetesAnaemia AV-fistula

Independent prognosticMotality

Associated co-morbid conditions

Systemic Hypertension

• 70% of ESRD patients • ACE-inhibitors • Calcium channel blockers• Beta-blockers• Diuretics

Discontinued before surgeryserum.K+ level monitored

Continued peri-operatively

Laryngoscopy&Intubation

• Exaggerated stress response

• Opioids • beta-blockers• IV Lignocaine

Associated co-morbid conditions

Diabetes Mellitus Cardiac complications gets doubled Revised cardiac risk index • 1.High-risk surgical procedure.• 2.h/o IHD(excluding previous coronary re-

vascularization)• 3.Heart failure• 4.h/o stroke or transient ischemic attacks• 5.Pre-operative insulin therapy• 6.Pre-operative creatinine levels higher

than 2 mg/dl.

Patho-physiological consequences of ESRD

• Anaemia -Transfusion• Uremic Coagulopathy

• Uremic Cardiomyopathy • Se.K+& acid-base status

• Delayed gastric emptying

Erythropoietin Normocytic normochromic

anaemia Hypertension,

CVA,Thrombosis of fistulas

Sensitization of the recipient

Abnormal platelet function Factor 8

Pre-operative dialysis Toxins l- guanidinosuccinate,phenol

Phenolic acid

HyperkalemiaAcidosis

Treatment-DialysisDelays recovery -Anaesthesia

Pre-operative dialysis

• Optimize fluid and electrolyte balance• Correct hemostatic abnormalities• Post dialysis weight loss of >2 kg -Indicate intra-vascular volume

depletion -Thromboplastin time is checked for

residual heparin -Hepatitis can be endemic

Pre-operative optimazisation

• Adequate BP control

• Adequate control of blood glucose

• Correction of se.K+ levels.

• Correction of anaemia

• Correction of coagulopathy

Anaesthetic Agents

• Thiopental• Propofol• Isoflurane -peripheral vaso-dilatation -minimal cardio-depressive

effects -preservation of RBF

-low renal toxicity Desflurane

Sevoflurane

• Fluoride • CompoundA

• Fresh gas flow rates >4 L/min

Opioids

• Morphine • Pethedine

• Fentanyl, sufentanil, alfentanil, remifentanyl

• Reduced clearance

• Accumulation of active metabolites

• Safer • Metabolites are

not potent,

Muscle Relaxant

-Succinyl choline ? -not contra-indicated in

pts. with ESRD

0.6 m eq/l can be tolerated

without significant cardiac risk

Muscle Relaxant

• Pancuronium

• Vecuronium

• Atracurium

• Rocuronium

• Less desirable in uremia.

• Slight in duration

• Hoffmann elimination

• Clearance is unaffected in renal failure.

Elimination half lives of anti-cholinesterases are

prolonged

Monitors

• 5-lead ECG.• Arterial BP• SpO2• EtCo2• Temperature .• Urine output

Special Monitors

• CVP monitoring • Direct arterial

pressure monitoring

• Pulmonary artery occlusion pressure

• TEE • Contrast-

Enhanced Perfusion USG

Systolic BP variation

correlates well with LV end-diastolic volume

>20/15 1.Poorly controlled hypertension

2. CAD with LV dysfunction 3 .Valvular heart disease

4.COPD when severe.

Hypotension Hypovolemia

or Myocardial contractility.

Sonicated albumin:

Predict renal viability &

Guide pharmacological interventions.

Factors affecting kidney viability

• Management of the kidney donor(living or cadaveric).

• How well the harvested organ is preserved.

• Peri-operative management of the kidney recipient.

Anaesthetic considerations during donor nephrectomy

• Venous return due to the kidney -adequate hydration

• V/Q mismatching due to positioning

• Mannitol and IV heparin (3000-5000) units before cross-clamping the renal vessels.

• Administration of protamine to normalize coagulation

Management of the Brain dead Kidney donor

• Selection -Stable hemodynamics Adequate respiratory

parametersAbsolute contra-indicationsAbsolute contra-indications Prolonged hypotension Hypothermia Collagen vascular diseases Congenital or acquired metabolic disorders Malignancies, Generalized viral or

bacterial infections DIC’ Hep B, HIV.

Relative contra-indications

• Age above 70 years• Diabetes mellitus• High serum creatinine before

organ harvesting• Excessive pre-terminal use of

vaso-pressors.

Guidelines for intra-op management of the brain

dead• A systolic BP >100 mm Hg• PaO2 >100 mm Hg• Urine output >100 ml/hr• Hemoglobin concentration >100

g/l• Central venous pressure

between 5 and 10 mm Hg

Guidelines for intra-op management of the brain

dead• Vasodilators -Phentolamine• Hypotension- Fluid

administration Pharmacological support

• Bradycardia - Iso-prenaline (a direct acting chronotrope) and not

atropine.

Anaesthetic management of kidney recipients

General Anaesthesia with controlled ventilation

-Good hemodynamic stability -Better patient comfort.

Regional AnaesthesiaDis-advantages: Systemic blood pressure -viability of the kidney

donated. Large volumes of IVF precipitate acute LVF. Advantages It is cost-effective Complete abolition of stress response Less exposure to anaesthetic drugs

Anaesthetic considerations in the recipient

• Positioning – Care of the AV Fistula