kidney transplant

Question 1

The 4 most common cause of end-stage renal disease

(ESRD) are:

Answer 1

The most common cause of end-stage renal disease
(ESRD) are:
• diabetes (#1)
• hypertensive nephrosclerosis (#2)
• glomerulonephritis
• autosomal dominant polycystic kidney disease
-sickle cell

Question 2

what complicates transplant patients surgery?

Answer 2

they have multi organ issues/failures

Question 3

1. what issue in renal patient causes cardiac issues?
2. what was the issue with these patients receiving a kidney transplant?
   2b. what are MDs realizing?
3. how long before this resolves post transplant?

Answer 3

1. uremia causes left ventricular dysfunction with low EF (uremic cardiomyopathy)
2. it was a general contraindication,
   2b. they are finding that they may be suitable transplant patients if caused by uremia
3. resolves 6 mos to 1 yr post transplant)

Question 4

what did they find out about transplanting kidneys to type 2 diabetics?

Answer 4

they found that co-morbidities decreased after transplantation

Question 5

assessment of renal patient function:cardiac

1. what is a good assessment of cardiac impairment?
2. what are the best tests for cardiac function?

Answer 5

1. METS score, check for edema, respiratory effort, medications
2. 2-D echo, persantine or dobutamine stress test

Question 6

what tests do you want to have on file with a renal patient?

Answer 6

• bun
• creat
• potassium
• cxr (for sympathetic pleural effusions)
• echo/ cardiac clearance (may have sympathetic pericardial effusions or uremic cardimyopathy)

Question 7

renal patients have what plethera of cardiac issues:

-what are some of them?

Answer 7

CAD
PAD/PVD
poor cardiac output
CHF
valve issues (regurg etc.)
HTN

Question 8

1. what drug can cause hyperkalemia with long term use?

2. what issues can cause hyperkalemia

Answer 8

1. heparin

2. sepsis, acidosis

Question 9

what is the feedback mechanism of erythropoetin?

Answer 9

1. hypoxia triggers releas of erythropoetin
2. erythropoetin triggers retention of fluid to increase volume and flow
3. erythropoetin triggers bone marrow to kick out more RBCs

Question 10

1. what clotting issues do renal patients have?

2. how is this corrected?

Answer 10

1. uremic coagulopathy • A complex syndrome that includes;
   -Abnormal platlet function
   -Ineffective production of factor VIII and
   -Ineffective production ofplatelet von Willebrand factor
2. Correction is not limited to reduction of intra-operative bleeding but one-third of wound hematomas progress to wound infections
   Pre-operative dialysis improves platelet function
   Treatment includes use of conjugated estrogen
   and desmopressin and cryo for bleeding

Question 11

what are general contraindications for renal transplant?

Answer 11

• type II diabetes
• advanced cardiomyopathy
• morbid obesity
• vasculitis
• sickle cell disease

Question 12

obese patient’s needing kidney transplantation:

1. what is the reason why morbid obesity is a contraindication for kidney transplant?
   - what test is indicated prior to transplantation?

Answer 12

1. morbid obesity is a contraindication, not because of the obesity but for the high mortality risk from cardiac issues obesity causes
2. screening for ischemic heart is indicated

Question 13

contraindications for renal transplant:vasculitis and sickle cell

1. with vasculitis, does it make up a large or small percent of renal failure patients?
2. what must occur before a vasculitis patient can receive a kidney?
3. sickle cell disease causes what in kidneys?
4. what have recent studies shown regarding quality of life post renal transplant with sickle cell patients?

Answer 13

1. small percent (3%)
2. vasculitus must be in inactive phase to prevent recurrence
3. polynephritis, glumerulonephritis, and nephrotic syndrome
4. they may have longer survival times and better quality of life vs. dialysis sickle cell life.

Question 14

1. diabetes is so devastating of a disease that it is considered equal to what condition in terms of renal transplant cantidacy?
2. what is the leading cause of death among renal allograft recipients?

Answer 14

1. myocardial infarct

2. myocardial infarct

Question 15

most patients with ESRD have what condition (either as a cause or effect)?

Answer 15

hypertension (70%)

Question 16

if a patient has symptomatic ischemic heart disease, what tests should be done to be cleared for renal transplant (if necessary)?

Answer 16

coronary angioplasty and revascularization

Question 23

1. at what potassium do you not want to use sux?

2. how much can sux increase your K+?

Answer 23

1. greater than 5.5 meq/L

2. increases K+ by 0.6 meq/L

Question 25

1. what is the difference between cisatricurium and atricurium?
2. what does this “difference” cause?

Answer 25

1. cisatricurium doesnt have the byproduct of metabolism called laudanosine (a neurotoxin)
2. can cause seizures in patients with hepatic failure

Question 26

what is the best choice of anesthesia with a renal transplant patient?

a) epidural
b) sab
c) general

Answer 26

general anesthesia is best
(epidural may be contraindicated d/t coagulopathy)
(sab may be contraindicated d/t length of procedure)

Question 28

what 3 periods affect the viability of the transplanted kidney?

Answer 28

• management of the kidney donor (living or cadaveric)
• how the organ is preserved
• periopertive management of the kidney recepient

Question 29

how should cadaveric donors be managed to ensure most viable kidneys?

Answer 29

1. maintain paO2 of >100 mmHg
2. maintain normocapnia (35-45 mmHg)
3. maintain adequate intravascular volume
4. maintain SBP>100 mmHg
5. keep Hct >30%
6. maintain U/O of 1 ml/kg ((~60-150ml/hr) this is done with dopamine, mannitol or lasix)

Question 30

what conditions in the cadaver would cause a cadaveric kidney not viable for transplantation?
–absolute contraindications:

Answer 30

• -absolute contraindications:
  a) prolonged hypotension
  b) prolonged hypothermia
  c) systemic collagen conditions (lupus etc.)
  d) congenital or acquired metabolic conditions
  e) malignancies
  f) generalized bacterial or viral infections
  g) DIC
  h) Hep or HIV (unless transplanted into already infected host)

Question 31

what conditions in the cadaver would cause a cadaveric kidney not viable for transplantation?
– relative contraindications:

Answer 31

• -relative contraindications:
  a) greater than age 70
  b) diabetes
  c) severe vascular disease
  d) high serum creatnine
  f) excessive use of pre terminal vasopressors

Question 32

define these:

• ischemic time:
• warm ischemia:
• cold ischemia:

Answer 32

-ischemic time: starts with clamping of donor renal artery and ends with anastamosis in the recipient
-warm ischemia: begins with clamping of the renal artery and ends with perfusion of cold preservative solution
it begins again when the kidney is placed in the recepient and ends with vascular anastamosis completion
-cold ischemia: when the kidney is stored at 4 degrees celcius (ideally for less than 24 hours). if greater than 24 hours, the results are poorer but can actually be stored for up to 72 hours.

Question 33

what alterations in in pharmacokinetics occur with renal failure?

Answer 33

decreased plasma proteins with azotemia cause higher free fraction of protein bound drugs (water soulble benzodiazapines (versed) is less affected by reduced plasma protein)

Question 34

what is a Udall catheter?

Answer 34

--

Question 35

what effect does the byproduct of sevoflurane have on the kidneys?

Answer 35

inorganic flouride ion blocks antidiuretic hormone causing an inability to concentrate urine in the distal convoluted tubules

Question 36

urine output for kidney recipients: 1. once anastamosis (of ureter, artery and vein) is complete; what is the most important 2. what does anesthesia need to do frequently regarding urine output? 3. what time frame of decreased urine output causes decreased graft survival? 3b. what % is graft survival decreased?

Answer 36

1. early onset of urine output is paramount 2. call out urine output to OR team every 15 minutes 3. if urine output is delayed for longer than 12 hours 3b. decreased 49%

Question 37

1. what is the most important measure to improve likelyhood of immediate graft function? 2. how is this achieved? 3. what should you be aware of (to avoid with achieving this)?

Answer 37

1. maintaining intravascular volume is the MOST important measure to improve graft function 2. hydrate to keep CVP 10-15 mmHg 3. avoid fluid overload which could lead to pulmonary edema

Question 38

1. how do loop diuretics work? | 2. where do they work?

Answer 38

1. counteract surgical stress resopnse of ADH by inhibiting ATPase causing a decrease in active sodium reabsorption and tubular oxygen consumption (which decreases ischemia to kidneys) 2. exert effect on ascending loop of henle

Question 39

1. what is mannitol? 2. how does it work? 3. what are the good effects of its actions?

Answer 39

1. mannitol is an inert sugar (large molecule) 2. prevents water reabsorption in the proximal tubule which expands intravascular volume and increases tubular flow rate 3. diminishes the potential for tubule obstruction acting as a free radical scavenger and increasing the release of intra renal prostaglandins

Question 40

what 2 drugs are used to maintain renal perfusion post renal transplant (1a,2a)? How do they work (1b,2b)?

Answer 40

1. verapamin is directly injected into renal vein, then an oral regimen is started for 14 days 1b. this improves serum creatnine, GFR, renal blood flow and graft survival 2. low dose dopamine (2-3 mcg/kg) 2b. enhances renal perfusion by selectively vasodilating and promoting naturesis

Question 41

1. what is a connon occurence post kidney transplant? 2. what are the causes? 3. what is recommended to prevent one of the complications?

Answer 41

1. infections 2. wound infection, urinary catheter, pneumonia 3. early extubation

Question 42

1. what drugs increase serum concentrations of cyclosporine? 1b. how does this happen? 2. what drugs decrease serum concentrions below theraputic range? 2b. how does this happen?

Answer 42

1. calcium channel blockers 1b. inhibit CYP450 and therefore increase serum concentrations 2. barbituraturates and dilantin 2b. induce CYP450 enzymatic action and therfore decrease serum concentrations

Question 43

1. how is the liver preserved for transplantation? 2. what is in the flush? 3.

Answer 43

1. kidney is flushed with isotonic solution resembling INTRACELLULAR FLUID (higk K, low Na) called "Collin's solution" 2. makeup of flush solution K+=115 meq/L Na+=10 meq/L Cl-=15 meq/L bicarb=10 meq/L dihydrogen phosphate =15 meq/L monohydrogen phosphate 85 me/L ...also contains heparin, procaine and phenoxybenzamine

Question 44

1. what is the best opioid/opiate for renal transplantation? 2. which ones should you not use? 2b. why? 3. what drug is good, but is a waste of time?

Answer 44

1. fentanyl 2. morphine (water soluable--stays around too long); older generation opioids (oxycodone and meperidine also hang around too long and can cause respiratory depression d/t prolonged clearance) 3. remifentanil (too short acting)

Question 47

1. how is versed given to a renal patient? | 2. a normal patient will get how much?

Answer 47

1. based on their mental state (old or confused get little to none) 2. 2-4 mg

Question 48

1. what should any transplant patient be considered? 2. what is the ASA status of a transplant recipient? 2b. what is the exception?

Answer 48

1. full stomach with RSI (they may have been eating when they got the page or d/t effects of diabetes (gastroparesis etc.). 2. 2,3 or 4 and ALWAYS 'E' (because the patient never knows when the kidney will be available so it is emergent situation when it comes 2b. only time they are not 'E' status is when there is a family donor and the situation is planned and controlled.

Question 49

what is the best way to anesthetize a renal patient?

Answer 49

high fentanyl etomidate RSI (sux if K+ is ok or roc or even without MR) -- propofol can be used but slow and controlled (low amount d/t hypotension)

Question 50

1. how is nimbex metabolized? | 2. what factors affect its metabolism?

Answer 50

1. hoffman metabolism (exhaustive methylation- an amine is converted to a tertiary amine and an alkene) and ester hydrolysis (by non specific esterases) 2. temperature and pH

Question 53

1. what is the best inhaled anesthetic for renal patients? | 2. what about the others?

Answer 53

1. forane (isoflurane); maintains renal flow with no metabolites 2. sevo has flouride and compound A metabolites; desflurane is too expensive for a long procedure (desflurane is good for obese because it blows off quickly though)

Question 55

what is the antihypertensive drug of choice in renal patients?

Answer 55

ACE inhibitors

Question 56

1. what issues might the renal transplant patient have at induction? 2. what might have caused this?

Answer 56

1. hypotension | 2. dialysis prior to surgery (hypovolemia), ace inhibitor or beta blocker prior to surgery, cardiac issues

Question 67

what are the biproducts morphine and demerol that cause issues in renal patients.

Answer 67

morphine-3-glucuronide morphine-6-glucuronide normeperidine