ANAESTHESIA FOR RENAL
TRANSPLANTATION
Dr.M.Kannan MD DA
Professor and HOD of Anaesthesiology
Tirunelveli 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 & revascularisation
• Irreversible LV dysfunction with very
low cardiac output
contraindication
Associated co-morbid conditions
Congestive cardiac failure
• CCF is present before dialysis
Independent prognostic
Motality
• CCF Associated with CRF
IHD
Hypoalbuminemia
Old age Uremic cardiomyopathy
Diabetes
Anaemia AV-fistula
Associated co-morbid conditions
Systemic Hypertension
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70% of ESRD patients
Discontinued before surgery
ACE-inhibitors
serum.K+ level monitored
Calcium channel blockers
Beta-blockers
Continued peri-operatively
Diuretics
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 revascularization)
• 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
•
Erythropoietin
platelet
function
Uremic Coagulopathy Abnormal
Normocytic
normochromic
Hyperkalemia
Factor
8
anaemia
Acidosis
Uremic Cardiomyopathy Pre-operative
dialysis
Hypertension,
Treatment-Dialysis
Toxins Delays
l- guanidinosuccinate,phen
CVA, -Anaesthesia
recovery
Se.K+& acid-base status Phenolic
Thrombosis ofacid
fistulas
•
•
• Delayed gastric emptying
Sensitization of the recipient
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
• Reduced clearance
• Accumulation of
active metabolites
• Fentanyl, sufentanil, • Safer
alfentanil,
• Metabolites are
remifentanyl
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
• Less desirable in uremia.
• Vecuronium
• Slight in duration
Elimination half lives of
• Atracurium anti-cholinesterases
• Hoffmann elimination
are
prolonged
• Rocuronium
• Clearance is unaffected in
renal failure.
Monitors
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5-lead ECG.
Arterial BP
SpO2
EtCo2
Temperature .
Urine output
Special Monitors
• CVP monitoring
• Direct arterial
pressure monitoring
Sonicated albumin:
• Pulmonary artery
Hypotension
>20/15
Systolic
BP viability &
Predict
renal
occlusion pressure 1.Poorlyvariation
Hypovolemia
controlled hypertension
or LV dysfunction
2. CAD
with
• TEE
Guide pharmacological
correlates
well
with .
Myocardial
contractility
3 .Valvular
heart disease
interventions.
• Contrast-EnhancedLV end-diastolic
4.COPD whenvolume
severe.
Perfusion USG
Factors affecting kidney
viability
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•
•
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
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.
Relative contra-indications
• Age above 70 years
• Diabetes mellitus
• High serum creatinine before organ
harvesting
• Excessive pre-terminal use of vasopressors.
Guidelines for intra-op
management of the brain dead
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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 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
Anaesthetic considerations in
the recipient
• Positioning – Care of the AV Fistula