Mod13: Renal Transplantation Flashcards
Organ Transplantation
What is the most common major organ transplant?
Renal Transplantation
Renal Transplant Physiology
For which condition is kidney transplant recommended?
Kidney failure
(from glumerular disease, congenital dz, polycistic kidney dz, naphropathies a/w HTN or DM)
Renal Transplant Physiology
The presence of which conditions would prevent kidney tpx?
Significant heart, lung or liver dz
Other life threatening dz
Certain infections such as TB, osteomylitis
High suspicion for post op non compliance with anti-rejection therapy
Renal Transplant Physiology
How many kidney tpx are performed in the US each year?
over 10, 000
second only to cornea tpx
Pts awaiting kidney tpx will continue dialysis
Many long-term dialysis pts are on the tpx list
Renal Transplant Physiology
Where do kidney tpx recepients get kidneys from?
Living related donors
Living unrelated donors
Deceased donors
Donors must have No known chronic kidney disease
Renal Transplant Physiology
Kidneys from deceased donors are placed in cool saline. How long can this keep organ preserved?
for about 24 to 36 hours
Allows time to perform blood and tissue donor matching test
Gives the pt time to get dialysis and ensure optimization prior to surgery
Renal Transplant Physiology
During a kidney transplant, vasculature is taken away from the non-functioning kidney. How is it disposed of after the transplanted kidney is vascularized?
It is left in the body
There is no benefit to remove the non-functioning kidney
Non-functioning kidney is left inside the abdominal cavity
Renal Transplant Overview
True or False: The success of renal transplantation has greatly improved the quality of life for patients with end-stage renal disease
True
Renal Transplant Overview
What is a possible explanation to why cadaveric transplants have achieved nearly the same 3-year graft survival rates (80–90%) as living related donor grafts
Modern immunosuppressive regimens
Renal Transplant Overview
What’s the 3-year survival rate for living related donor grafts?
80–90%
Renal Transplant Overview
Restrictions on candidates for renal transplantation have gradually decreased. Which remain absolute contraindications to renal transplantation?
Active infection
Cancer
Renal Transplant Overview
Restrictions on candidates for renal transplantation have gradually decreased. What are relative contraindications to renal transplantation?
Advanced age (>60)
Severe cardiovascular disease
Renal Transplant Overview
Why are “Advanced age (>60)” and “Severe cardiovascular disease” considered relative contraindications only for renal transplantation?
Morbidity and mortality goes up
Graft survival rate goes down
Morbidity and mortality and graft survival rate change dramatically once you have these factors dialed in
These happen onced you factor in Advanced age (>60) and Severe cardiovascular disease
Renal Transplantation - Preoperative Considerations
What’s the first preoperative anesthetic consideration with kidney Tpx?
Patient Optimization with dialysis
(Beneficial if fluid overloaded and hyperkalemic)
Renal Transplantation - Preoperative Considerations
There is ample time for preoperative dialysis of cadaveric recipients. Why is that?
Because kidney preservation for cadaveric kidney is
24-36 hr
Renal Transplantation - Preoperative Considerations
What recipient’s serum potassium concentration is acceptable before kidney tpx
Below 5.5 mEq/L
Renal Transplantation - Preoperative Considerations
True or False: Kidney tpx could proceed with ongoing coagulopathies
False
Existing coagulopathies should be corrected
Renal Transplantation - Preoperative Considerations
Which types of kidney tpx are performed electively with the donor and recipient anesthetized simultaneously but in separate rooms
Living-related transplants
Renal Transplantation - Pharmacologic agents
Why is GETA, possibly with RSI, the preferred anesthetic technique for kidney Tpx?
Aspiration risk
DM
Uremic gastropathy
Renal Transplantation - Pharmacologic agents
All general anesthetic agents have been employed without any apparent detrimental effect on graft function; nonetheless, which inhalation agent is best avoided? and why?
Sevoflurane
Due to floride accumulation at low flows
Iso and Desflurane are not associated with nephrotoxicity
However, there is no documented increase in morbidity or mortality when Sevoflurane is used
Renal Transplantation - Pharmacologic agents
What’s the NMB of choice in kidney Tpx? and why?
Cisatracurium
Does not rely on kidneys for elimination
Renal Transplantation - Pharmacologic agents
What’s a potential disadvantage of using Vec and rocuronium in kidney tpx?
may have prolonged duration of action
Renal Transplantation - Pharmacologic agents
Why is it so important to know your hospitals protocol and surgeon preferences when it comes to choosing your anesthetics?
Surgeons preferences and experience matters
Many drugs to choose from
Timing and dose vary
Renal Transplantation - Pharmacologic agents
Which other non-anesthesia drugs are commonly used during kidney Tpx for vascular support, anticoagulation, and diuresing?
Dopamine (!?) - Heparin - Mannitol - Lasix
Renal Transplantation - Monitors
With which patients could you get away with just standard, non-invasive monitors + large bore IVs during kidney tpx?
Younger, healthier pts
Renal Transplantation - Monitors
Which monitors do most pts undergoing kidney tpx require?
A-line
CVP
(monitoring for hydration but avoiding fluid overload)
PAC
(most center are moving away from these, except for cardiac)
TEE
(becoming common)
Foley catheter
Renal Transplantation - Monitors
Why would a urinary catheter be placed intra-op during kidney tpx?
To assess graft function postoperatively
Urine output is closely monitored post-op to ensure that the transplanted kidney starts making urine as it is being perfused
If no urine, pt may be taken back to the OR for re-exploration
