1. Anaesthetic implications of
chronic kidney disease and
transplantation
Dr Peter Sherren
Specialist trainee
Anaesthesia and Intensive care
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2. Introduction
 UK estimates suggest that 8.8% of the population of Great
Britain and Northern Ireland have symptomatic CKD.
 A large number of stage IV/V CKD require long term renal
replacement therapy.
 Annual mortality rates for patients requiring dialysis range
from 21%-25% vs <8% with cadaveric and <4% with
living-related transplant recipients.
 Cadaveric transplantation within the trust have recently
been source of some significant drug administration errors.
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3. Objectives
 Basics about CKD vs ESRF
 CKD complications.
 Anaesthesia for CKD and renal transplantation.
 Pertinent pharmacology for renal patients.
 Immunosuppression drugs.
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4. CKD- background
 Progressive loss in renal function over a period of
months or years.
 Stage I-V based on GFR.
 The decline in GFR <15ml/min/1.73m3, also known as
CKD V, typically results in the initiation of renal
replacement therapy.
 Multitude of causes, however DM, HTN, PCKD and
glomerulonephritis account for 75% CKD.
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5. CKD- Complications
 Anemia- Erythropoietin  Acid-base abnormalities
 Cardiovascular abnormalities-  GI abnormalities
 RAAS  Endocrine disturbances
 BP  Hyperphosphataemia
 High incidence of IHD  Hypocalcaemia (D3 def)
 Uraemia  Later tertiary
 Platelet dysfunction hyperparathyroidism
hypercalcaemia
 CNS dysfunction
 Pericarditis  Dialysis-related problems
 Altered O2-carrying capacity  Peripheral neuropathy
 Electrolyte and fluid
disturbances
 K+/ Ca 2+/ PO3-
 Intravascular volume
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6. CKD- treatment
 The goal of therapy is to slow down the progression to CKD V.
 Control of blood pressure and treatment of the original disease.
 Generally, ACEIs or angiotensin II receptor antagonists are used, as
they have been found to slow the progression of CKD V.
 Replacement of erythropoietin and calcitriol is often necessary in
patients with advanced CKD. Phosphate binders are also used to
control the serum phosphate levels, which are usually elevated in
advanced chronic kidney disease.
 Stage V CKD often warrants renal replacement therapy, in the form
of either dialysis (PD vs HD) or a transplant.
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7. Renal Transplantation
 Since the first successful human kidney transplant in
1954 renal transplantation has become the treatment
of choice for most patients with CKD Stage V.
 Over recent years the demand for renal transplants
has continued to rise, however, there are limited
availability of organs.
 Living related vs Living unrelated vs Cadaveric
(Beating and Non-beating heart).
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9. Matching
Matching of the organ to recipient
can
be divided into three phases-
 ABO
 Tissue matching – HLA class I and
II (6 types, major transplant
antigens)
 Cross matching
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10. Pre-op Assessment
 CV diseases  Neurology
 DM  Encephalopathy
 BP  GIT
 CHF (50% long-term RRT)  Delayed gastric
 CAD emptying
 Pericarditis/effusions  PUD
 Respiratory  Haematology
 Interstitial/Pleural fluid  FBC
 Renal  Coagulation
(Platelet deplete vs
 Cause of Renal disease whole blood/NPT)
 Mode and timing of RRT
 Endocrine
 Presence/location of AVF
 U&E (K+)
 Dry weight
 Usual UO/24hrs
 Intravascular volume
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11. Peri-operative management
 Induction
 IV induction- agent? RSI/modified
RSI?
 NMBA, depolarising vs non?
 Large bore IV access
 CVC?
 Arterial line?
 Antibiotics/Immunosuppressants
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12. Peri-operative management
cont.
 Maintenance
 Balanced Volatile technique
 Analgesia- multi modal
 Fluid balance- saline vs CSL and CVP vs CO
monitoring
 Inotropes
 Diuretics
 Temperature control
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13. Peri-operative management
cont.
 Emergence-
 Low level of plasma cholinesterases hence effects on Sux
metabolism.
 Neostigmine can be used as normal, however, half life is
prolonged in uraemic patients.
 Postoperative care-
 Majority extubated and go to renal unit
 Usual post-anaesthetic considerations
 Fentanyl PCA
 Careful fluid balance monitoring. In otherwise stable
patients falling UO needs prompt surgical involvement ±
doppler graft blood supply.
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14. Drugs in Renal transplantation
 Antibiotics (Flucloxacillin, Co-Amoxiclav)
 Diuretics
 Immunosuppression
 Inotropes
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15. Mannitol
 Intravascular volume expander and osmotic diuretic
 Protection against renal cortical and increasing tubular
flow
 Diminishing potential for tubular obstruction
 Acting as a radical scavenger
 Risk for heart failure or pulmonary oedema
 Low dose:0.25-0.5mg/kg
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16. Loop Diuretics (Frusemide)
 Inhibition of the Na-K ATPase pump and may result in
resistance against ischemic injury.
 Given as a bolus prior to reperfusion, in a varying dose
depending on local protocol (40 –250mg).
 Aim is to inducing diuresis, promoting urine flow in the graft
and so avoiding oliguria.
 This can occasionally promote massive diuresis resulting in
difficult fluid management post operatively.
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17. Immunosuppression
 Glucocorticoids (Methylprednisolone 5-7mg/kg,
~500mg).
 Anti-T-Lymphocyte Globulin (ATG), 9mg/kg. Ongoing
RCT. Many vial reconstitution, run over 12HRS!!
Anaphylactoid reactions and vasoplegic agent.
 Antimetabolites (Azathioprine), Immunophilin-binding
agents (Cyclosporin, Tacrolimus)
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18. Questions?
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19. Summary
 CKD IV and V hardly ever single organ disease, and often
have multiple co-morbidities.
 Use knowledge of co-morbidities and applied
pharmacology to deliver safe anaesthetic care.
 Make sure you are familiar with the multiple antibiotics
and immunosuppressants prior to administering them.
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20. References
 The Association of Public Health Observatories – Chronic Kidney
Disease Prevalence Estimates; Available from:
http://www.apho.org.uk/resource/item.aspx?RID=63798
 Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G.
Renal function and requirement for dialysis in chronic nephropathy
patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano
di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in
Nephropathy. Lancet 352 (9136): 1252–6.
 Ruggenenti P, Perna A, Gherardi G, et al. Renoprotective properties
of ACE-inhibition in non-diabetic nephropathies with non-nephrotic
proteinuria. Lancet 354 (9176): 359–64.
 De Gasperi A, Narcisi S, et al. Periopertive fluid management in
kidney transplantation: is volume overload still mandatory for graft
function? Transplant Proc 2006;38:807-9
 Peters T; RENALIFE 2001 Special edition; Vol 17.
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