management of post kidney transplant case posted for non-transplant surgery

1. MANAGEMENT OF A CASE OF
POST - KIDNEY TRANSPLANT
PATIENT POSTED FOR
SURGERY
Dr Anil Kumar Majhi
Anaesthesia
MKCGMCH, BERHAMPUR

2. GOALS
 Identify complications, their anesthetic implications
 Toxicity of immunosuppressant's
 Drug interactions with immunosuppressant's
 Rejections
 Infections

3. CONCERNS IN A TRANSPLANT
RECIPIENT
 Altered physiology related to transplanted kidney.
 Altered function due to
◦ immuno-supression
◦ Infections
◦ malignancies
 Toxicity of immuno-supressive drugs
 Potential interaction of immuno-supressive drugs
with other drugs
 Potential for rejection of the transplanted organ

4.  Post transplant patient are prone to development of
hyperlipidemia, hypertension, diabetes(more so in
patient who has pre-existing CAD).
 Cardiovascular disease is the most common cause
of death in kidney recipients.
 GFR- usually reduced(despite normal creatinine),
electrolyte abnormalities and altered drug
metabolism.

5. COMPLICATION AFTER RENAL
TRANSPLANTATION
 Early
◦ Hemorrhagic cystitis
◦ Capillary leak
◦ AGVHD(acute graft versus host disease)
◦ Pan-cytopenia
◦ Cardio-myopathy
◦ Veno-occlusive liver disease
◦ Interstitial pneumonitis

6.  Late
◦ CGVHD(chronic graft versus host disease)
◦ Leuko-encephalopathy
◦ Infection
◦ Secondary malignancies
◦ Obstructive/restrictive lung disease
◦ Hypothyroidism
◦ cataract

7. IMMUNOSUPRESSANTS AND THEIR
TOXICITY
 CALCINERIN INHIBITORS
◦ Cyclosporin-A(CsA)
◦ Tacrolimus
 ANTIMETABOLITE/ANTIPROLIFERATIVES
◦ Mycophenolate mofetil
◦ Mycophenolate sodium
◦ Azathioprine
 M-TOR INHIBITORS
◦ sirolimus
 STEROIDS
◦ Methylprednisolone

8.  Cyclosporine
◦ Nephtotoxicity
 Increase renal vascular resistance
 Decrease renal blood flow
 Apparent with in a week of therapy
 Chronic toxicity
 Aminoglycoside + CsA therapy potentiate
nephrotoxicity of CsA

9.  Neurotoxicity
◦ Headache, paraesthesia, tremor, confusion,
flushing, neuropathies, generalised seizures
 Vascular effects
◦ Hypertension, diabetes, hyperlipidemia
◦ Coronary artery disease
 Metabolic effects
◦ Hyperkalemia, hypermagnesemia
 Others
◦ Hirsutism, gum hyperplasia, anorexia,
lymphoproliferative diseases, infectious
diseases

10.  Tacrolimus
◦ Inhibit cell proliferation
◦ 100 times potent than CsA
◦ Adverse effects
 Nephrotoxic
 Diabetogenic
 Tremor, Headache
 Alopecia,Bone marrow supression,
Lymphoproliferative diseases

11.  Mycophenolate mofetil
 Inhibit lymphocyte proliferation and antibody
production
 Nephrotoxic
 Hepatotoxic
 Bone marrow supression
◦ Azathioprine
 Bone marrow supression
 Hepatotoxic

12.  Sirolimus
◦ Anemia
◦ Leukopenia
◦ Thrombocytopenia

13.  Methylprednisolone
 Obesity
 Glucose intolerance
 Increased lipid levels
 Accelerate cardiovascular ds.
 Marked skin fragility(minimise adhesive tapes,
padded BP cuffs, eyes lubricated)
 Delayed wound healing
 Osteoporosis
 Gastric irritant

14. DRUGS AFFECTING CsA & Tacrolimus
BLOOD LEVELS
 Increase blood levels
◦ Metoclopramide
◦ Verapamil
◦ Nicardipine
◦ Cimetidine
◦ Diltiazem
◦ Bromocriptine
◦ Erythromycin
◦ KetoconazoleChloro
quine
 Decrease blood levels
◦ Carbamazepine
◦ Phenobarbitone
◦ Phenytion
◦ Rifampicin
◦ Octeotride
◦ iclopidine

15. DRUGS THAT MAY CAUSE RENAL
DYSFUNTION WHEN GIVEN WITH CsA &
Tacrolimus
◦ NSAID
◦ Ranitidine
◦ Cimetidine
◦ Amphotericin
◦ Cotrimoxazole
◦ Gentamycin
◦ Melphalan

16. IMMUNOSUPRESSANTS AND
ANESTHETICS
 CsA
◦ Potentiate barbiturates, fentanyl,NDMR’s esp
Atra/Vec(smaller doses used and recovery may
be prolonged)
◦ Reduces seizure threshold due to its neurotoxic
effect
 Azathioprine
◦ Antagonize NDMR’s (larger doses may be used)
◦ May prolong the effect of Sch
 Tacrolimus
◦ Reduces seizure threshold

17. DRUGS WHICH GET ACCUMULATED
IN RENAL IMPAIRMENT

18. INFECTIONS IN IMMUNOSUPRESSED
 Major cause of morbidity and mortality
 1st month(after transplant) – bacterial infections
◦ Wound infection- Staph. Aureus
◦ Urinary catheter- E.coli
◦ Pneumonia- Pneumococci
 30-180days(after transplant) – opportunistic
infections
◦ CMV- commonest
◦ Herpes
◦ VZV
◦ Pneumocystis carinii

19.  Mycobacterial infections
 Systemic mycoses
 Nocardiosis
 Parasitic infections
◦ Strongyloides
◦ Entameba
◦ Acanthameba

20. ANESTHETIC CONSIDERATION
 The main anesthetic goal is to maintain renal
perfusion and prevent hypoxia, hypovolemia,
hypervolemia and hypotension.

21. PRE-OP EVALUATION
 History
 Establish the cause of renal failure(prior to
transplant) and duration of treatment
 Need for dialysis post operatively
 Enquire about liquid restriction if any and about
daily urine output.
 H/o co morbidities(HTN,DM, IHD,connective tissue
disorder) and whether controlled and on what
treatment.

22.  Enquire about –
◦ Exercise tolerance
◦ Anemia
◦ LVF
◦ Electrolyte abnormalities
◦ Gastro esophageal reflux
 Seek nephrology opinion regarding need for
dialysis in the post operative period.

23. EXAMINATION
 BP- standing & sitting
 Auscultation
◦ Flow murmur- anemia
◦ Pericardial rub- uremic pericarditis
◦ Crepitations
 Edema – ankle/sacral

24. INVESTIGATIONS
 CBC- anemia type(normocytic normochromic), r/o
acute infection if present
 COAGULATION PROFILE- when uremia is severe
 KIDNEY FUNCTION TESTS-BUN, creatinine,
electrolytes
 ECG-ischemia, arrhythmia, LVH, conduction blocks,
hyperkalemia
 CXR- pleural effusion, cardiomegaly, pulmonary
edema
 ABG- acid-base status
 LFT

25. PRE-OPERATIVE OPTIMIZATION AND
PREPARATION
 Postpone elective surgery- when infection/rejection
is suspected
 Continue- immunosuppressant's, antihypertensive
 Adjust dosages acc. to blood level of drugs
 For elective surgery – optimize BP, serum K+
levels
 Blood transfusion- avoid if not required(can
sensitize future transplantation)
 If patient have GERD- metoclopramide, H2
receptor antagonists(ranitidine)

26. SPECIFIC ANESTHETIC
CONSIDERATION
 Renal function-
◦ should be assessed esp. patient who are on
CsA & Tacrolimus.
◦ Prolonged drug action may be expected for the
drugs that are excreted through kidney.
◦ Choose drugs independent of kidney excretion.
◦ Avoid nephrotoxic drugs.
 Cardiovascular Ds-
◦ Risk increases esp. in DM & elderly.
 Hypertention-
◦ High incidence in patient who are already on
antihypertensive

27. REJECTION
 Leading cause for delayed mortality
 Surgery during period of rejection have higher
morbidity
• Adequate level of immuno-supressive agents
should be maintained throughout the peri-operative
period
 Progressive deterioration in renal function tests

28.  PRESENTATION
◦ Progressive deterioration of renal function or
minimal symptoms from transplanted organ
and/or with non-specific symptoms(poor appetite,
irritability, fatigue,pain abd etc.)
 TIMING
◦ Majority(with in 3 mths)
◦ Peak(4-6 wk post transplant)
 TREATMENT
◦ Increasing immuno-suppressive treatment
◦ Addition of additional drugs(methotrexate)
◦ Augmentation of steroid use

29. GENERAL ANESTHESIA
 PREMEDICATION
 PREOXYGENATION
 INDUCTION –
◦ Avoid hypotension, titrate BP with MAP, go for
inhalational induction when required
 MUSCLE RELAXATION –
◦ When RSI Sch (when K+ < 5.5meq/l), modified
RSI (rocuronium)
◦ Atracuronium, vecuronium
 INTUBATION

30.  MAINTAINANCE –
◦ N2O –controversial ? ( although do not affect
renal function but it has adverse effect on bone
marrow and immune system)
◦ Isoflurane(inhalational agent of choice – only
0.2% undergoes metabolism) but inhalational
agents are considered safe
◦ controlled ventilation for long procedure
◦ Atracurium is preferred(Hoffman’s elimination)
◦ Vecuronium/Rocuronium can be used(smaller
top-up doses are required less frequently)

31.  INTRAOP / MONITORING
◦ ECG, NIBP/IBP, ETCO2, pulse
oximetry,temperature, neuromuscular monitoring.
◦ IV fliuds should be adminstered cautiously
◦ If large fliud shift/blood loss is anticipated
invasive monitoring(CVP,Invasive arterial BP)
should be established to guide fluid therapy.
◦ HES may accumulate and worsen renal
impairment if present(so better avoided). Gelatin
may be considered if required.
◦ RL can be used if serum potassium is with in
normal limits.

32. ◦ Neuromuscular blockade monitored using nerve
stimulator and top-up doses administered
accordingly.
◦ Fentanyl, alfentanyl, sufentanyl, remifentanyl can
be administered safely (half life may be
prolonged particularly if used as an infusion)
◦ Butorphanol, nalbuphine, buprenorphine can be
used safely
◦ Morphine can be used with care as clearance is
reduced(monitor for respiratory depression in the
post-operative period)
◦ Forced air warmer and fluid warmer should be
used to maintain normothermia.

33. ◦ Over transfusion of blood to correct anemia
should be avoided as increase in hematocrit can
decrease renal perfusion and further compromise
the renal function.
◦ Urine out put monitoring done hourly(maintained
at 0.5-1 ml/kg/hr).
◦ When urine output is low despite good hydration
and BP, Mannitol may be considered for 1st line
therapy followed by frusemide.

34.  REVERSAL
◦ Neostigmine
◦ Inadequate reversal – it is better to ventilate the
patient for short-term till complete neuromuscular
recovery.

35. RECOVERY AND POST-OPERATIVE
CARE
 O2, ECG, BP, SPO2
 Analgesia
◦ Acetamenophen(avoid NSAID)
◦ Epidural block
◦ Wound infiltration
◦ Peripheral nerve block
◦ Early mobilization and physiotherapy.
 Dosages of medications should be administered as per
creatinine clearance-
◦ Cockcroft-Gault equation(eCCR=estimated creatinine
clearance)
◦ eCCR=(140-Age)*lean body wt(kg)[0.85 if
female]/72*plasma creatinine(mg/dl)

36. REGIONAL ANESTHESIA
 Only if coagulation status and platelet count are
normal with valid consent from the patient.
 Epidural/Spinal/CSE
 Stable hemodynamics with epidural, post op
analgesia, risk for epidural hematoma.
 Chance of fluid overload- CVP and urine output
monitoring
 Sensitivity to LA may be there but most are proven
safe

37. PREGNANCY
 Avoid pregnancy for a period of at least 2 years
after transplantation.
 Effect of pregnancy on allograft is minimal but fetal
outcome is less favorable.
◦ 45% pregnancy beyond 25 weeks – adverse
outcome.
 Risk of infection from the use of IUD’s is increased
in immuno-compromised patients.

38. FAVOURABLE PREGNANCY OUTCOME
 Good general health for about 2 yrs after
transplantation.
 No graft rejection in last 1 yr.
 Adequate and stable graft function.
 No acute infections that might affect the fetus.
 Maintenance immuno-supression at stable
doses.
 Patient compliance
 Normal blood pressure or blood pressure that
is controlled with single medication.
 Normal allograft USG results.

39. PREGNANCY WORSENS !
 Etiology of the original disease
 Chronic allograft dysfunction
 Renal insuffciency
 Cardio-pulmonary ds.
 Hypertention
 Diabetes mellitus
 Obesity
 Maternal infection with Hepatitis B/C/CMV

40. EFFECT ON FETUS
 Good prognosis seen with:-
1. Good general condition for 2yrs after surgery
2. Stature compatible with good obstetrical
outcome
3. No protenuria
4. No significant hypertension
5. No feature of graft rejection
6. DRUG THERAPY –
Prednisolone =15 mg/d or less
Azathioprine=2mg/kg/d or less

41. TAKE HOME MESSAGE
 Detail history, patient examination, evaluation and
optimization.
 Adequate risk stratification and consent
 Give peri-operative antibiotics and
immunosupressives.
 Careful drug dose and titration
 Adequate intraoperative monitoring
 Avoid nephrotoxic drugs
 Avoid hypotension, fluid overload
 Titer BP according to MAP
 Meticulous post operative care and follow-up
 Be in touch with the transplant surgeon