ANAESTHESIA FOR RENAL

TRANSPLANT RECEPIENT
CHRONIC RENAL FAILURE
■ Chronic renal failure and end stage renal disease are functional
diagnoses characterise by progressive decrease in glomerular
filtration rate.
■ Classification of chronic kidney disease
STAGE GFR(ml/min/1.73 m2) KIDNEY FUNCTION

STAGE 1 >90 NORMAL

STAGE 2 60 – 89 MILD

STAGE 3 30 -59 MODERATE

STAGE 4 15 – 29 SEVERE

STAGE 5 <15 END STAGE RENAL

DISEASE
Pathological consequences of chronic renal
failure
■ Cardiovascular system
-IHD is leading cause of morbidity and mortality.
-Systemic hypertension is most common feature due to sodium water retention,
significantly improved by dialysis
-Ischemic heart disease due to accelerated atherosclerosis secondary to impaired TG
clearance and lipoprotein lipase activity to impaired lipolysis
-Metastatic Calcific valvular heart disease due to hypocalcaemia and
hyperphosphatemia
-sudden death from acute cardiac arrhythmias due to IHD and electrolyte abnormality
- Haemorrhagic pericarditis may progress to cardiac tamponade
■ ELECTROLYTE AND FLUID ABNORMALITY
-May be sodium retention ,sodium wasting and normal sodium balance.

-Hyperkalaemia due to potassium secretion in distal tubule affected , certain drugs like
beta blocker, potassium sparing diuretic, ACE inhibitor, angiotensin antagonist, NSAIDS
,extracellular acidosis

-Hypomagnesemia(muscle weakness ,potentiate NDMR)

-Hypocalcaemia due to decrease in production of D3 and hyperphosphatemia

-hyperphosphatemia as excretion impaired

-chronic metabolic acidosis is common feature of ESRD.

 Haematological abnormalities
 Normochromic normocytic anaemia

- decreased renal erythropoietin

-reduced red cell life span due to uraemia

-dietary deficiency of iron and folate

-chronic upper GI losses

 Coagulopathy

-Qualitative function of platelet impaired due to decreased adhesiveness and

agrgregation.probably due to impaired release of von willebrand factor/ factor VIII
complex which bind to activate platelet.
 Pulmonary abnormality
-Atelectasis and infection due to fluid overload , malnutrition, anaemia, impaired humoral and
cellular immune function, decreased surfactant production.

 Immune function
-Inhibition of cell mediated immunity and humoral defence mechanism results fistula and

catheter site infection and poor wound healing

 Gastrointestinal abnormalities
-Gastrointestinal bleeding due to uremia which is mucosal irritant
-Delayed gastric emptying leading anorexia , nausea ,vomiting

 Endocrine disturbances
-Hyperparathyroidism secondary to hypocalcaemia and hyperphosphatemia which
increases osteoclast and osteoblast activity causing osteitis fibrosa cystica
-Reduced production of erythropoietin leads to anaemia.
-Requirement of insulin decreases probably due to reduced metabolism of insulin
-Temperature regulation is altered with reduced basal metabolic rate predisposing to
hypothermia
 Neurological abnormalities
-Both central and peripheral nervous system may be affected.
-CNS changes ranges from mild alterations in personality to asterixis, myoclonus,
convulsion and encephalopathy
-dialysis improve the neuropathy
- Presence of peripheral neuropathy implies autonomic neuropathy and this should
alert regarding delayed gastric emptying, postural hypotension, silent MI
-Two types of neurological disturbances are unique to patients on dialysis
1. Dialysis dementia
 Subacute, progressive and potentially fatal.
 Occurs due to aluminium toxicity resulting aluminium phosphate salt or aluminium in
dialysate
 Now incidence is low as aluminium removed from dialysate.
 Multisystem disease includes encephalopathy ,osteomalaia, proximal myopathy and
anaemia.
 Symptoms-Dysarthria, apraxia, personality changes, myoclonus to convulsion and finally
dementia
 Progressing to death within 6 month
2. Dialysis disequilibrium syndrome

 Self limiting condition caused due to reverse urea effect

 Urea cleared at slower rate than blood creates osmotic gradients from blood to brain
causes cerebral oedema

 Symptoms-headache , nausea , vomiting, blurred vision,disorientation,delirium,

hypertension ,tremors, and convulsion.
RENAL REPLACEMENT THERAPY
■ Dialysis
 Haemodialysis

 Peritoneal dialysis

■ Transplantation
INDICATIONS

■ End stage renal disease (GFR: 5-10%) – due to

 Diabetes
 Hypertension
 IgA nephropathy
 Glomerulonephritis
 Chronic pyelonephritis
 Chronic obstructive nephropathy
 Congenital anomalies: Alport syndrome, Polycystic kidney disease etc.
CONTRAINDICATIONS
■ ABSOLUTE
 Uncontrolled malignancy

 Active HIV infection

 Life expectancy less than 2 years due to other illness

■ RELATIVE
 Age more than 70 years
 Active infection
 Liver cirrhosis, chronic disease or active hepatitis
 Active tuberculosis
 Active substance abuser
 Severe diffuse atherosclerotic or CAD not amenable to surgical repair
 LVEF less than 20%
 Any psychological or behavioural abnormality.
 Those who are morbidly obese
RECEIPIENT EVALUATION
■ History
I. Causes of CKD, uremic symptoms, other systemic involvement, signs of fluid
overload duration, frequency of dialysis, last dialysis , site and patency of AV fistula
II. H/o dialysis :duration ,frequency ,assess, complication
III. . Comorbidities and their treatment
IV. h/o headache and aneurysms in polycystic kidney disease.

■ Examination
I. General examination
II. Examination of vascular access- AV fistula- site and patency, CV access
III. Systemic examination
IV. Airway and spine examination
■ Investigations
I. Hb (anemia) , CBC
II. Coagulation profile
III. Renal function tests
IV. Liver function tests
V. Serum electrolytes
VI. ECG
VII. CXR
VIII. PFTs
IX. 2D Echo
X. Blood sugars
XI. If patient not anuric urine routine microscopy and c/s
XII. Other tests depending upon presence of other co-morbid conditions : stress test, coronary
angiography etc.
XIII. Specialist assessment : Psychiatry , medicine , cardio, chest med , ENT, Opthal, skin, dentistry
, Gynac, GI med,
XIV. Endo , neuro if required
 Preoperative Management
Preoperative:
Dialysis 12-24 hours prior to surgery
Post dialysis: Hb (≥ 8 gm%) , Haematocrit (>30%), CBC, coagulation profile, BUN (<40), S creatinine
(<5mg%), Serum electrolytes (K+ <5.5 meq/l), arterial blood gas analysis, blood glucose
 Dry weight and weight loss in dialysis
 IJV cannulation done prior to surgery
 Antihypertensives should be continued
Oral hypoglycemics stopped on the day of Surgery
Antibiotic prophylaxis: Cephalosporins/ Vancomycin
Immunosuppressant : morning dose given.
Premedication

■ Antisecretary agent
■ H2 blocker(action unaltered in CKD)
■ Midazolam(No pharmacokinetics alteration, increase sensitivity due to
pharmacodynamic alteration)
■ Metoclopramide (significant reduction in clearance and prolongation
of terminal half life)
 Altered Renal functions and the effects of
anaesthetic Agents
■ Most drug employed during anaesthesia partly depend on renal excretion

■ Absorption of drug may be affected by delayed gastric emptying

■ The volume of distribution may be increased or decreased depending on total body water and
protein binding of drug since last dialysis

■ Protein binding is decreased leading to increased active or free fraction of drug bound to
albumin

■ Alpha 1 acid glycoprotein level increased thereby decrease unbound drug concentration of
basic drug (opioid analgesic and local anaesthetic)

■ Drug eliminated by kidney will have prolonged elimination half life

INDUCTION
■ Rapid sequence induction can be performed in order to reduce risk of aspiration .

■ Succinylcholine can be used for rapid sequence induction, avoid when serum K

more than 5.5 mmol/l

INDUCTION AGENT
■ Thiopentone – no change in distribution or elimination, increased free drug duet to
decrease albumin
■ Propofol-pharmacokinetic is not affected, however careful administration titrated
clinical effect is suggested particularly in post dialysis patient precipitate
hypotension
■ Etomidate - no change in distribution or elimination. Not recommended as it induce
adrenal insuffiency and increase mortality in critically ill patient. But it can be used
used in cardio unstable patient.
Non depolarising muscle relaxant

■ Rocuronium –equally effective, non depolarising agent for RSI when used at dose of
1.5 mg/kg

■ Atracurium and Cis-atracurium- recommended as they are inactivated by

Hoffmann's elimination and hydrolysed by esterases independent of renal function.

-Hoffmann's elimination influenced by blood Ph

-Acidosis in ESRD may prolong the effect of atracurium and cis-atracurium

■ Cis- atracurium is agent of choice.

INHALATIONAL AGENT
■ Isoflurane ,desflurane can be safely used
■ Safety concern of sevoflurane- compound A which is nephrotoxic in rats
■ However ,this effect has never been shown in humans. In contrast, many studies
have shown no effect on renal function
■ Sevoflurane can be used for renal transplant surgery.
■ Enflurane –fluoride ions , should be avoided.
ANALGESICS
■ Fentanyl analogues (including Alfentanyl, Sufentanyl and Remifentanyl) can be used
safely

■ Morphine – morphine-6-glucuronide is an active degradation product of morphine,

renal excretion, monitor for post op respiratory depression

■ NSAIDS- contraindicated
 Use Avoid

Induction agent Propofol, Thiopentone, Etomidate

Inhalational agent Sevoflurane, desflurane, Enflurane

Isoflurane

Neuromuscular blocker Cis –atracurium, Atracurium Pancuronium

Rapid sequence induction Rocuronium, Succinylscoline

Opioid All Fentanyl analogues Morphine

Diuretics Mannitol , Frusemide

 MONITORING
■ Standard ASA monitors
■ CVP measurement
■ Invasive BP monitoring in very high risk cases
■ Temperature and urine output monitoring
■ Neuromuscular junction monitoring
Perioperative management
■ Warming mattress , hot air warmer to maintains normothermia.

■ Attach Standard ASA monitor ,BP cuff on opposite arm of fistula

■ AV fistula site marked, covered and padded with cotton. Check patency intermittently

■ Check all ports of Central venous catheter and transduced catheter for CVP monitoring.

■ Asepsis is paramount

■ Choice of Anaesthesia : GA

■ Concern with routine use of regional Anaesthesia.

-Increased risk of epidural hematoma.

-infection
 Choice of fluid : isotonic crystalloid solution (alternate NS & RL)

 Positioning: supine; prone to pathological fractures

 MAP maintained within 20% of baseline

 CVP built up to 10-15mm Hg prior to anastomosis with the help crystalloids and 20% albumin if
and as required
 Continue…

 Heparin 100 IU/kg if required

 Inj Methylprednisolone 20mg/kg iv slowly prior to anastomosis to avoid hyperacute

graft rejection

 SBP > 140 and CVP > 15 mm hg during anastomosis

 Furosemide bolus of 20 mg/kg followed by infusion of 1mg/cc at 20ml/hr after

releasing clamps; titrated to u/o
Continue…

 Low hematocrit and hemodilution: maintains flow to new kidney

watch for urine output

Hb, S electrolytes after release of clamps

ABGs

Paracetamol and local infiltration

Reversed and extubated once the criteria for extubation fulfilled.

Fluid management
■ Post dialysis patient have intravascular volume depletion.

■ Liberal hydration policy is employed intraoperatively.

■ The systolic BP maintained between 130-160mmHg.CVP between 10-15 mmHg to optimise cardiac
output and renal blood flow.

■ Crystalloid solutions are usually preferred to correct fluid and electrolyte imbalance

■ Balanced crystalloid should be alternated with normal saline 0.9% as large volume of saline could
lead to hyperchloremic acidosis.

■ Potassium containing solution should be avoided.

■ Colloids can induce renal dysfunction impairment.

■ Gelatin substitutes may be safer option

Fluid management
■ Hypotension may occur after unclamping the iliac vessel and reperfusion of graft.

■ CVP may decline by 25-50% ,1-2 hrs after revascularisation despite aggressive fluid
management due to redistribution of fluids, changes in vascular permeability or
increased nitric oxide level.

■ Increased hydration work by atrial distention and subsequent release of ANP and
increased renal perfusion.

■ Fluids are warmed before administration

■ Transfusion when required should be preferably with packed cells that are saline
washed , leucodepleted .
Diuretics
■ Mannitol-200-250 ml of 20% immediately before reperfusion,improve renal
perfusion pressure, act as free radical scavenger, decreased incidence of renal
function immediately after transplant.

■ Frusemide- Commonly given during vascular anastomosis to stimulate diuresis.but

its role is controversial, it increases response to anti diuretic hormone
Postoperative:

 Arterial line removed 1 hour after extubation

 shifted to nephrology HDU

 Monitor ECG, NIBP, SPO2, CVP, U/O, ABGs, S. electrolytes, RFTs

 Paracetamol and Tramadol

 Shifted on diet once bowel function returns

 D J stent removed 3-4 weeks later

Immunosuppressive therapy
■ Aim to prevent graft rejection

■ Form vital part in the management of renal transplant patients.

■ Drugs

 Steroid

 Calcineurin inhibitors- Cyclosporin , tacrolimus

 Target of rapamycin inhibitor- Sirolimus, Everolimus

 Polyclonal antibody- Antilymphocyte globulin

 Monoclonal antibodies—IL2 –Daclizumab, Basilizumab, OKT 3

 Purine synthesis inhibitor- Azathioprine

 Post operative orders

Monitor ECG , SPO2 , BP , CVP Target HR < 90 , RR around 18, BP

100-160/70-90 , CVP 8-10 , SPO2 > 95
U/ O ≥ 50 ml/hr Intervene if U/O ≤ 50 ml/hr for 2 hrs

NGA continuous

Drains to gravity drain output ≤ 50 ml / hr

Thigh girth to rule out iliac vein

thrombosis
Abdominal girth

Passive physiotherapy

Change IV tubing's, dressing every 48

hrly
Doppler to rule renal artery and vein
thrombosis : daily
 Post operative investigations

Chest X ray , ECG , ABGA Immediately after shifting

ABGA Every 6 hrly for 4 days

Renal function test

S electrolytes with Ca+2 and Mg

U electrolytes

CBC and coagulation profile Hb > 8, hematocrit >30 , INR < 1.7

S tacrolimus levels Alternate day