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Anaesthetic implications of chronic kidney disease and       transplantation                         Dr Peter Sherren     ...
Introduction      UK estimates suggest that 8.8% of the population of Great       Britain and Northern Ireland have sympt...
Objectives      Basics about CKD vs ESRF      CKD complications.      Anaesthesia for CKD and renal transplantation.   ...
CKD- background      Progressive loss in renal function over a period of       months or years.      Stage I-V based on ...
CKD- Complications      Anemia- Erythropoietin             Acid-base abnormalities      Cardiovascular abnormalities-  ...
CKD- treatment      The goal of therapy is to slow down the progression to CKD V.      Control of blood pressure and tre...
Renal Transplantation      Since the first successful human kidney transplant in       1954 renal transplantation has bec...
Bringing excellence to life
MatchingMatching of the organ to recipient  canbe divided into three phases-     ABO     Tissue matching – HLA class I a...
Pre-op Assessment      CV diseases                          Neurology           DM                                    ...
Peri-operative management   Induction       IV induction- agent? RSI/modified        RSI?       NMBA, depolarising vs n...
Peri-operative management            cont.      Maintenance          Balanced Volatile technique          Analgesia- mu...
Peri-operative management            cont.      Emergence-          Low level of plasma cholinesterases hence effects on...
Drugs in Renal transplantation      Antibiotics (Flucloxacillin, Co-Amoxiclav)      Diuretics      Immunosuppression   ...
Mannitol   Intravascular volume expander and osmotic diuretic   Protection against renal cortical and increasing tubular...
Loop Diuretics (Frusemide)      Inhibition of the Na-K ATPase pump and may result in       resistance against ischemic in...
Immunosuppression      Glucocorticoids (Methylprednisolone 5-7mg/kg,       ~500mg).      Anti-T-Lymphocyte Globulin (ATG...
Questions?Bringing excellence to life
Summary   CKD IV and V hardly ever single organ disease, and often    have multiple co-morbidities.   Use knowledge of c...
References      The Association of Public Health Observatories – Chronic Kidney       Disease Prevalence Estimates; Avail...
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Anaesthetic implications of chronic kidney disease and transplantation

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Anaesthetic implications of chronic kidney disease and transplantation

  1. 1. Anaesthetic implications of chronic kidney disease and transplantation Dr Peter Sherren Specialist trainee Anaesthesia and Intensive careBringing excellence to life
  2. 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.Bringing excellence to life
  3. 3. Objectives  Basics about CKD vs ESRF  CKD complications.  Anaesthesia for CKD and renal transplantation.  Pertinent pharmacology for renal patients.  Immunosuppression drugs.Bringing excellence to life
  4. 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.Bringing excellence to life
  5. 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 volumeBringing excellence to life
  6. 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.Bringing excellence to life
  7. 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).Bringing excellence to life
  8. 8. Bringing excellence to life
  9. 9. MatchingMatching of the organ to recipient canbe divided into three phases-  ABO  Tissue matching – HLA class I and II (6 types, major transplant antigens)  Cross matchingBringing excellence to life
  10. 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 volumeBringing excellence to life
  11. 11. Peri-operative management Induction  IV induction- agent? RSI/modified RSI?  NMBA, depolarising vs non?  Large bore IV access  CVC?  Arterial line?  Antibiotics/ImmunosuppressantsBringing excellence to life
  12. 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 controlBringing excellence to life
  13. 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.Bringing excellence to life
  14. 14. Drugs in Renal transplantation  Antibiotics (Flucloxacillin, Co-Amoxiclav)  Diuretics  Immunosuppression  InotropesBringing excellence to life
  15. 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/kgBringing excellence to life
  16. 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.Bringing excellence to life
  17. 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)Bringing excellence to life
  18. 18. Questions?Bringing excellence to life
  19. 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.Bringing excellence to life
  20. 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.Bringing excellence to life

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