Anesthetic considerations for kidney transplant in an adult

1. READ BY : EKO INDRA PRADONO
SUPERVISOR : Dr. HASANUL, SpAn, KAP, KIC.

2. INTRODUCTION
• Kidney transplantation is a process of attaching new
kidneys to replace previously diseased kidneys.
• The incidence of end stage renal disease (ESRD) has
increased over the past several decades due to an
increased incidence of diabetes, obesity and
hypertension
• Survival and health related quality of life is better
after kidney transplantation than after dialysis
therapy.
• Improvement in immunosuppression regimens which
have reduced rates of acute transplant rejection

3. HISTORY OF KIDNEY TRANSPLANT
• In 1933, first human renal allograft was performed
by Voronoy in the Ukraine.
• The recipient was 26 y.o. woman who attempted
suicide by ingesting mercury chloride, the donor
was 66 y.o man whose kidney was removed 6
hours after death. Patient was death 48 hours
after surgery.

4. In 1933, first human
renal allograft was
performed by Voronoy
in the Ukraine.
In 1995  First
laparoscopic donor
nephrectomy was
done.
In 1977, The first
kidney transplant
surgery in Indonesia
was performed by
Prof. dr. R.P. Sidabutar
and team at Cipto
Mangunkusumo
Hospital, Jakarta
In 2011  First
Laparoscopy living
donor
nephrectomy
(LLDN) was
performed at Cipto
Mangunkusumo
Hospital, Jakarta
Until 2015  there
were over than 200
Laparoscopic Living
Donor Nephrectom
(LLDN) performed in
RSCM.

5. • From 200 cases, 133 donor (66.5%) Man and 67
(33.5%) Women
• The Average age 32,75 YO with SD ±9,45
• 165 LLDN (82,5%) performed in left kidney and 35
procedure (17,5%) performed in right kidney

6. Kidney Transplant Center in Indonesia
– RSCM Jakarta: 3 times / week
– Cikini Hospital
– Surabaya
– RSPAD Gatot Subroto
– Bandung
– Yogyakarta
– Malang
– Medan ?

7. Kidney Transplant in Indonesia
Initiated in 1977
Data for RSCM and Cikini CCI is updated for mid 2012
Data for remaining hospitals is updated for 2010
Courtesy of Situmorang GR, Wahyudi I, Siahaan E, et al

8. Survival Analysis
Courtesy of Situmorang GR, Wahyudi I, Siahaan E, et al

9. RIGHT VS LEFT LLDN
A single-centre RCT
revealed no differences
between left- and
right-sided donor
nephrectomy in donor
hospital stay, donor
quality of life, donor
and acceptor
complication rates, or
graft survival
Parameters Left LLDN
(n=82)
Right LLDN
(n=18)
P value
Operating time (min) 262.9 ± 50.0 253.1 ± 42.0 0.44*
Blood loss (ml) 269.9 ± 52.4 230.6 ± 49.1 0.55*
Length of hospital stay
(days)
4.6± 1.4 4.5 ± 1.4 0.86*
Warm ischemic time (min) 6.2 ± 3.4 5.7 ± 2.5 0.60*
LLDN in Cipto Mangunkusumo Hospital
(Nov 2011 – Now)

10. The Technique
Renal transplantation surgery includes :
A. Retrieval of kidney from live/deceased
donor-Donor nephrectomy
Live/Cadaveric
B. Placement of donor kidney into the
recipient’s body  renal
transplantation
The kidney removal from a prospective
live kidney donor is either by an open
approach or by a laparoscopic approach.

11. Living Donor Nephrectomy
• accepted by law, religion and bioethics, provided that the
donor is aware of the consequences of his/her act and
makes the decision without outside prenure or
commercialism.
• Once the prospective donor is medically fit for donation, the
last step is surgical evaluation  assessment of the
anatomic features of the donor kidney  nephrectomy can
safely be performed?
CT Angiografi

12. POSITION
Modified lateral decubitus position with hips rotated back and arm extended above
the head. The table is flexed to expand the area between the costal margin and
pelvic brim.

13. LLDN

14. LLDN

15. RECIPIENT SURGERY
• The general preparation and selection of recipient
commences with the nephrological evaluation and
ends with evaluation by the transplant surgeon.
• After induction of anesthesia and placement of
central and arterial lines, the recipient is prepared and
draped from nipple to mid thigh.
• A third generation cephalosporin is given at time of
induction.
• A three way urinary catheter is placed with full aseptic
precautions and unobstructed drainage is ensured.

16. PRE-OPERATIVE CONSIDERATIONS

17. MULTISYSTEM DYSFUNCTION
1. Cardiovascular
Hypertension, ischemic heart disease, cardiac failure,
pericarditis
2. Respiratory
Pulmonary edema, pleural effusion, respiratory infection
3. Gastrointestinal
Stress ulceration, delayed gastric emptying, malnutrition
4. Central nervous
Peripheral neuropathy, autonomic neuropathy, mental slowing,
convulsions, coma

18. 5. Renal
Fluid and electrolyte imbalance, altered pharmacokinetics and
pharmacodynamics
6. Hematological
Anemia, coagulopathies
7. Immunological Immunosuppression
8. Dialysis related problems
a. Peritonitis (peritoneal dialysis)
b. Systemic anticoagulation
c. Vascular access
d. Dementia
MULTISYSTEM DYSFUNCTION (2)

21. TIMELINE OF RECIPIENT KIDNEY TRANSPLANT
Expected length of stay 5 days
Preparation at
outpatient clinic
for laboratory test
and imaging
H-1 days  Donor is
hospitalized.
Consultation to others
department
Preparation of surgery
equipment, Blood preparation
300 cc of PRC
Day of
Surgery
H+1  aff drain if
production < 50 ml,
aff epidural
catheter
H+2 aff
urethral catheter
1st week after
surgery  follow up
at outpatient clinic,
aff hecting
1st year after surgery
 follow up at
outpatient clinic,
evaluation general
condition and kidney
function

22. PATIENT SELECTION
• Advanced age is not a contraindication, although
older recipients are at greater risk of perioperative
complications including death.
• Infants less than 1-year of age and geriatric
patients aged 70 years and older are considered
eligible for renal transplant.

23. SPECIAL SITUATIONS
• Mental Retardation
• Retransplantation
• Female renal transplant candidates
• The HIV positive status

24. PREOPERATIVE PREPARATION

25. PREOPERATIVE PREPARATION
• Hemodialysis
• Vascular Access
• Antihypertensive Medication
• Blood Transfusion

26. Premedication
• Benzodiazepine like diazepam or alprazolam take
care of anxiety of the patient.
• H2-receptor blocker like pantocid are prescribed.
• Morning dose of immunosuppressants and
antihypertensives should be taken.

27. CHOICE OF ANESTHESIA
• General anesthesia with controlled ventilation is
the technique of choice for renal transplant
patients.
• Regional anesthesia is also practiced in some
centers

28. • can be done under regional anesthesia– spinal,
epidural and CSE.
• Avoid Intravenous agents that require renal excretion
such as muscle relaxants and opiates.
• The other advantages include avoidance of tracheal
intubation in the immunosuppressed patient.
• In chronic renal failure, the onset of sensory analgesia
occurs faster after subarachnoid blockade
Regional Anesthesia

29. Disadvantages
of Regional Anesthesia
• The central venous pressure lines and arterial lines have to be
inserted while the patient is awake
• There is a concern over the possibility of extradural hematoma
formation in patients with coagulopathies
• There is difficulty in handling major blood loss
• An unpredictable response of a hypertensive renal patient on
drug therapies to vasopressors
• Maintenance of an awake patient’s well being during a long
procedure
• Medicolegal implications of a postoperative peripheral
neuropathy
• Postdural puncture headache

30. INTRAOPERATIVE MANAGEMENT

31. INTRAOPERATIVE MONITORS
• Electrocardiogram
• noninvasive blood pressure
• Pulse oximeter
• Temperature maintenance (Fluid warmer,
Warming blanket (upper body))
• Urine output monitor

32. • Strict asepsis has to be maintained 
immunosuppressants
• Intraoperative arterial blood gas analysis along
with serum electrolytes is done, after induction,
before and after reperfusion.
• Acid base balance and ventilation should be
maintained
• Avoid Hypovolemia and hypotension
INTRAOPERATIVE MANAGEMENT

33. • The transplanted patient should be “wet” with a
“supernormal intravascular volume” after opening the
clamps
• Recommended Central venous pressure of 15–20 mm
• Administration of albumin (1.2 g/kg) was associated
with a reduced incidence of delayed graft function.
• Inotropes like dopamine should not be used routinely.
• Inhalational anesthetic agents and opioids are tailored
in such a manner  systolic at or above 140 mmHg to
INTRAOPERATIVE MANAGEMENT (2)

34. • Drawbacks like prolonged paralysis requiring post-
operative mechanical ventilation, iatrogenic
pulmonary infection and adverse effects of
inhalation agents may be seen.
• Avoiding intraoperative renal insults and
maintaining isovolemia, adequate cardiac output
and renal perfusion pressure are more important
than the choice of a specific anesthetic technique.
INTRAOPERATIVE MANAGEMENT (3)

35. INTRAOPERATIVE FLUID THERAPY
• Crystalloids are distributed  0.9% saline
devoid of potassium thus minimizing the risk of
electrolyte induced cardiac dysrhythmias.
• Recent study : no difference was found when 0.9%
sodium chloride, Ringer’s lactate or plasmalyte
were given during renal transplant.
• Some protocols recommend normal saline
containing sodium bicarbonate (20 mmol/l) for
volume expansion.

36. • one year graft survival decreased from 75% with
immediate urine output to only 49% when onset
of diuresis was delayed >12 hours  the
anesthesiologist should aggressively expand the
vascular volume to promote early diuresis during
anesthesia for kidney transplant.
INTRAOPERATIVE FLUID THERAPY (2)

37. Measures used to Enhance Urine Output
During Kidney Transplant
• Mannitol dose of 0.7–1 g/kg, when renal anastomosis
is commenced
• Loop diuretics: Inhibit na+ K+ ATPase decreasing
tubular oxygen consumption
• An aggressive intraoperative volume expansion by
keeping CVP between 10–15 mmHg is recommended
to avoid acute tubular necrosis secondary to
inadequate intraoperative hydration.
• 20% albumin, 0.8–1.6 ml/kg may improve the graft
survival, urine volume and early graft function

38. Induction Agents
• Propofol
– PK and PD are unchanged in ESRD patients.
– Infusion dose requirements have also been found to be similar
in ESRD patients and patients with normal renal function
although shorter emergence times have been noted in ESRD
patients when compared with patients with normal renal
function.
• Thiopental
– Almost entirely metabolized in the liver
– Its breakdown products are excreted by the kidneys and the
gastrointestinal tract.
– Traces are excreted unchanged in the urine. No permanent
effects of this agent on kidney function have been recorded.

39. Neuromuscular Blocking Agents
• Succinylcholine
– should be used with caution in patients with ESRD
– increase serum potassium concentration  cardiac arrhythmias and even cardiac
arrest
• Cisatracurium
– It is metabolized through Hofmann elimination and produces a metabolite,
Laudanosine, which is partially eliminated through the kidneys hence, has a slightly
prolonged elimination half-life in patients with renal failure.
– Is the preferred muscle relaxant in patients with ESRD
• Vecuronium and Rocuronium
– relatively independent of kidney function.
– Metabolized by the liver, but have metabolites that are excreted by the kidney and
liver.
– The duration of action has been reported to be slightly prolonged and a cumulative
effect has been noted with repetitive administration.

40. Opioids
• Fentanyl, alfentanil, sufentanil
PK and PD are not altered because the metabolites are inactive
and are unlikely to contribute to the opioid effect even if they do
accumulate.
• Remifentanil
- A very short acting opioid,
- metabolized in the peripheral tissues by an esterase enzyme and
requires no change in dosing compared to patients with normal
renal function.

41. Inhalational Agents
• All potent inhalational agents cause a decrease in the renal
blood flow and glomerular fitration rate in proportion to the
dose.
• Isoflurane, the extent of its metabolism is very small such
that the amount of uoride produced is unlikely to cause
renal damage. It can be used in anesthesia for renal
transplantation.
• Low-flow sevoflurane anesthesia can be safely used in renal
transplant recipients
• Desflurane can also be used in patients with renal
dysfunction and no deterioration in renal function has been
found

42. Extubation
• Most patients are awake and can be extubated at the
end of the procedure provided the transplanted
kidney has started functioning.
• Maintaining fluid balance and adequate perfusion of
the transplanted kidney is the main task.
• Arterial blood gas analysis is important to ascertain
the hemodynamic status of the patient and corrective
measures should be taken accordingly.
• Oral hydration can be allowed a couple of hours post
transplant.

43. Postoperative Management
• Kidney transplant unit with skilled staff
• Fluid regimes are variable, depending upon CVP
and urine output of the previous hour. In a stable
patient, oliguria should trigger a surgical review
and urgent doppler imaging of the graft blood
supply.

44. POSTOPERATIVE COMPLICATIONS
• Acidosis : impaired renal excretion and an
overproduction of acid. At the end of surgery
should not be extubated until corrected
sufficiently to support spontaneous ventilation.
• Sodium bicarbonate should be given slowly by
intravenously when the pH is below normal as
indicated by arterial blood gas analysis

45. Postoperative Analgesia
• Effective postoperative pain management
contributes to successful outcome after renal
transplant
• Inadequately controlled pain may lead to
agitation, tachycardia, hypertension and increased
risk of respiratory complications.

46. • Intravenous opioids are the mainstay of analgesia
 Morphine and fentanyl
• Regional blocks like paravertebral block or
transversus abdominal plane block
• Epidural analgesia with narcotics is superior to
parenteral analgesia for postoperative pain relief
 blocks afferent nociceptive stimuli with fewer
side effects.
Postoperative Analgesia (2)

47. • Nonsteroidal anti inflammatory drugs (nSAIDs) can
cause reversible kidney damage with reduction of
renal blood flow and glomerular filtration rate 
BE AVOIDED!
Postoperative Analgesia (3)

48. RISK FACTORS AND COMPLICATIONS
1. Graft dysfunction:
Delayed graft function (DGF) is defined as the need for dialysis in
the first week after transplantation due to ischemia—reperfusion
injury
2. Rejection:
a function of the immune system recognizing the transplanted
organ as a foreign body and attempting to destroy it.
Acute rejection, or
Late after transplantation  chronic rejection or chronic allograft
nephropathy or tubular atrophy/interstitial fibrosis.

49. RISK FACTORS AND COMPLICATIONS (2)
3. Technical complications include:
 Arterial thrombosis or stenosis
 Venous thrombosis
 ureteral leak
 Stenosis or reflux
 Development of fluid collections : hematoma,
seromas, lymphoceles, etc.
 Growth improvement post transplantation ->
controversial

50. CONCLUSION
Kidney transplant under general anesthesia is the
preferred therapy for chronic kidney disease
patients. Regional anesthesia for kidney transplant is
safe, if there is no coagulopathy in the adult patient.

51. REFERENCE