ANAESTHESIA FOR RENAL TRANSPLANTATION

1. ANAESTHESIA FOR RENAL TRANSPLANTATION Dr.M.Kannan MD DA Professor and HOD of Anaesthesiology Tirunelveli Medical College

2. Demand-supply imbalance 3000 300 per million 1800 per year in Tamilnadu

3. Associated co-morbid conditions • Coronary artery disease • Congestive cardiac failure • Systemic Hypertension • Diabetes Mellitus

4. Associated co-morbid conditions Coronary artery disease • Incidence 17%-34% • Coronary angiography & re-vascularisation • Irreversible LV dysfunction with very low cardiac output contraindication

5. Associated co-morbid conditions Congestive cardiac failure • CCF is present before dialysis • CCF Associated with CRF IHD Hypoalbuminemia Old age Uremic cardiomyopathy Diabetes Anaemia AV-fistula Independent prognostic Motality

6. Associated co-morbid conditions Systemic Hypertension • 70% of ESRD patients • ACE-inhibitors • Calcium channel blockers • Beta-blockers • Diuretics Discontinued before surgery serum.K+ level monitored Continued peri-operatively

7. Exaggerated stress response Opioids beta-blockers IV Lignocaine Laryngoscopy&Intubation

8. 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.

9. 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 Hyperkalemia Acidosis Treatment-Dialysis Delays recovery -Anaesthesia

10. 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

11. Pre-operative optimazisation • Adequate BP control • Adequate control of blood glucose • Correction of se.K+ levels. • Correction of anaemia • Correction of coagulopathy

12. Anaesthetic Agents • Thiopental • Propofol • Isoflurane -peripheral vaso-dilatation -minimal cardio-depressive effects -preservation of RBF -low renal toxicity Desflurane

13. Sevoflurane • Fluoride • CompoundA • Fresh gas flow rates >4 L/min

14. Morphine Pethedine Fentanyl, sufentanil, alfentanil, remifentanyl Reduced clearance Accumulation of active metabolites Safer Metabolites are not potent, Opioids

15. Muscle Relaxant -Succinyl choline ? -not contra-indicated in pts. with ESRD 0.6 m eq/l can be tolerated without significant cardiac risk

16. Pancuronium Vecuronium Atracurium Rocuronium Less desirable in uremia. Slight in duration Hoffmann elimination Clearance is unaffected in renal failure. Muscle Relaxant Elimination half lives of anti-cholinesterases are prolonged

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

18. CVP monitoring Direct arterial pressure monitoring Pulmonary artery occlusion pressure TEE Contrast-Enhanced Perfusion USG Special Monitors Hypotension Hypovolemia or Myocardial contractility. Sonicated albumin: Predict renal viability & Guide pharmacological interventions. • >20/15 • Poorly controlled hypertension • 2. CAD with LV dysfunction • 3 .Valvular heart disease • 4.COPD when severe. Systolic BP variation correlates well with LV end-diastolic volume

19. 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.

20. 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

21. Management of the Brain dead Kidney donor • Selection-Stable hemodynamics Adequate respiratory parameters Absolute contra-indications Prolonged hypotension Hypothermia Collagen vascular diseases Congenital or acquired metabolic disorders Malignancies, Generalized viral or bacterial infections DIC’ Hep B, HIV.

22. Relative contra-indications • Age above 70 years • Diabetes mellitus • High serum creatinine before organ harvesting • Excessive pre-terminal use of vaso-pressors.

23. 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 The rule of 100 is followed

24. 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.

25. Anaesthetic management of kidney recipients General Anaesthesia with controlled ventilation -Good hemodynamic stability -Better patient comfort. Regional Anaesthesia Dis-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

26. Anaesthetic considerations in the recipient • Positioning – Care of theAV Fistula