This document discusses considerations for anesthesia after renal transplantation. It notes that most transplant recipients have stage 2-3 chronic kidney disease, with GFR declining over time. A thorough pre-operative evaluation assesses renal function, risk of rejection, comorbidities, medications, and infections. Intraoperatively, regional or general anesthesia can be used while avoiding nephrotoxic drugs and carefully monitoring renal function and fluid status. Post-operatively, renal function, electrolytes, infections, and analgesia must be monitored closely.

1. ANESTHESIA AFTER
RENAL TRANSPLANT
DR. DAVIS KURIAN

3.  Most patients classified as National Kidney
foundation – stage 2 or 3 CKD.
 GFR deteriorates by 1.4-2.4ml/min/yr in
recipients.
 Pre operative workup very important.

4. CONCERNS
 Renal physiology and renal function.
 Rejection – acute or chronic.
 Pharmacotherapy.
 Immunosupression.

5. PRE OP EVALUATION
The level of renal function - RFTs – despite
normal creatinine, GFR is decreased.
Records of transplant – sought and
examined for pre transplant functional
status and post transplant.
Rejection – must be ruled out.

6. PRE OP EVALUATION
 Anemia, dysfunctional platelets –
coagulation parameters assessed.
 Acid-base status – baseline ABG.

7. PRE OP EVALUATION
 Patients at increased risk of post
transplant malignancies, anemia,
osteodystrophy.
 Increased susceptibility to opportunistic
and community acquired infections – CMV
being the most common – if transfusion
needed – CMV negative blood must be
used in CMV negative pts

8. PRE OP EVALUATION
 Renal function impairment – can
predispose to electrolyte abnormalities,
altered drug metabolism.
 Dosage of all immunosuppressant
medications – noted – patient instructed to
continue in the peri-operative period.

9. PRE OP EVALUATION
 Assessment of complications of
immunosuppressant therapy -
hyperglycemia and adrenal suppression
(steroids)
hypertension, infection and renal insufficiency
(steroids, cyclosporine & tacrolimus),
myelosuppression – anemia,
thrombocytopenia, leukopenia (azathioprine,
sirolimus)
Cytokine release and fever (mistaken preop).

10. PRE OP EVALUATION
No need for increased
antibiotics.
Doppler study to assess blood flow to
the graft.

11. PRE OP EVALUATION
 Careful cardiac evaluation –
CVS also affected in CKD
Impact of underlying d/s – DM/HTN in the
pathogenesis of CKD
Potential for drug regimens, transplantation
and rejection episodes to worsen CVS status.
Metabolic syndrome – common in 1-6 yrs.
IHD, CVA, PVD – significantly affect survival.

12. REJECTION
 Hyperacute – rejection in minute to hrs –
destruction of vascularity (preformed
antibodies).
 Acute – after 1 wk – antibodies – if no
immunosuppressant therapy.
 Chronic – in months to years.

13. SIGNS & SYMPTOMS OF
REJECTION
 Increased temp.
 Dec in urine output.
 Pain, tenderness, swollen graft.
 Increased BP.
 Sudden increase in weight or ankle
swelling.
 Elevated creatinine.

14. PRE OP EVALUATION
 Other co-morbidities
 Airway and spine examination.
 Blood workup – Hb, TC, PLC,
S.electrolytes, RFT, Blood sugars, ABG
 CXR, ECG.
 Doppler study.

15. PRE OP EVALUATION
 Patient instructed to
Continue all medications in the peri-operative
period in the same dose.
Appropriate thromboprophylaxis in all
transplant pateints.
All nephrotoxic drugs to be avoided.

16. INTRA OPERATIVE
Regional, local, GA.
Sterile precautions to be followed.
All nephrotoxic drugs to be avoided – as
patients have a low GFR.
Serial monitoring of renal functions and
electrolytes with urine output whenever
possible.
Very high risk for cardiovascular complications
than general population.

17. INTRA OPERATIVE
 Renal transplant- adequate hydration -
BSS
 Difficult and edematous airway.
 Full stomach.
 Prolonged elimination half life of drugs
eliminated by kidneys

18. REGIONAL ANESTHESIA
 Epidural/spinal/CSE.
 Stable hemodynamics with epidural, post
op analgesia, risk for epidural hematoma.
 Chance of fluid overload – CVP and urine
output monitoring.
 Increased sensitivity to LA.

19. GENERAL ANESTHESIA
 Aspiration prophylaxis (esp emergencies).
 Induction with low dose TPS/propofol
(hypotension), not ketamine (worsen HTN)
 Cis atracurium/atracurium – ms relaxant

20. GENERAL ANESTHESIA
 O2+N2O/air + iso/sevo/des maintenance
 Opioid – fentanyl (preferred)
 Ms relaxant action – monitored with PNS
and reversal confirmed.

21. GENERAL ANESTHESIA
 CVP and urine output monitoring
 Avoid excess fluid.
 Serial monitoring of renal function,
electrolytes, blood glucose, acid-base
status and urine output.

22. POST OPERATIVE
 Monitor renal functions and serum
electrolytes.
 Avoid nephrotoxic drugs – like NSAIDs,
COX – 2 inhibitors.
 Adequate antibiotic coverage to prevent
infections.
 Analgesia – epidural / fentanyl infusions.