Mod13: Renal Transplantation

Question 1

_{Organ Transplantation}

What is the most common major organ transplant?

Answer 1

Renal Transplantation

Question 2

_{Renal Transplant Physiology}

For which condition is kidney transplant recommended?

Answer 2

Kidney failure

(from glumerular disease, congenital dz, polycistic kidney dz, naphropathies a/w HTN or DM)

Question 3

_{Renal Transplant Physiology}

The presence of which conditions would prevent kidney tpx?

Answer 3

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

Question 4

_{Renal Transplant Physiology}

How many kidney tpx are performed in the US each year?

Answer 4

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

Question 5

_{Renal Transplant Physiology}

Where do kidney tpx recepients get kidneys from?

Answer 5

Living related donors

Living unrelated donors

Deceased donors

Donors must have No known chronic kidney disease

Question 6

_{Renal Transplant Physiology}

Kidneys from deceased donors are placed in cool saline. How long can this keep organ preserved?

Answer 6

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

Question 7

_{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?

Answer 7

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

Question 8

_{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

Answer 8

True

Question 9

_{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

Answer 9

Modern immunosuppressive regimens

Question 10

_{Renal Transplant Overview}

What’s the 3-year survival rate for living related donor grafts?

Answer 10

80–90%

Question 11

_{Renal Transplant Overview}

Restrictions on candidates for renal transplantation have gradually decreased. Which remain absolute contraindications to renal transplantation?

Answer 11

Active infection

Cancer

Question 12

_{Renal Transplant Overview}

Restrictions on candidates for renal transplantation have gradually decreased. What are relative contraindications to renal transplantation?

Answer 12

Advanced age (>60)

Severe cardiovascular disease

Question 13

_{Renal Transplant Overview}

Why are “Advanced age (>60)” and “Severe cardiovascular disease” considered relative contraindications only for renal transplantation?

Answer 13

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

Question 14

_{Renal Transplantation - Preoperative Considerations}

What’s the first preoperative anesthetic consideration with kidney Tpx?

Answer 14

Patient Optimization with dialysis

(Beneficial if fluid overloaded and hyperkalemic)

Question 15

_{Renal Transplantation - Preoperative Considerations}

There is ample time for preoperative dialysis of cadaveric recipients. Why is that?

Answer 15

Because kidney preservation for cadaveric kidney is

24-36 hr

Question 16

_{Renal Transplantation - Preoperative Considerations}

What recipient’s serum potassium concentration is acceptable before kidney tpx

Answer 16

Below 5.5 mEq/L

Question 17

_{Renal Transplantation - Preoperative Considerations}

True or False: Kidney tpx could proceed with ongoing coagulopathies

Answer 17

False

Existing coagulopathies should be corrected

Question 18

_{Renal Transplantation - Preoperative Considerations}

Which types of kidney tpx are performed electively with the donor and recipient anesthetized simultaneously but in separate rooms

Answer 18

Living-related transplants

Question 19

_{Renal Transplantation - Pharmacologic agents}

Why is GETA, possibly with RSI, the preferred anesthetic technique for kidney Tpx?

Answer 19

Aspiration risk

DM

Uremic gastropathy

Question 20

_{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?

Answer 20

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

Question 21

_{Renal Transplantation - Pharmacologic agents}

What’s the NMB of choice in kidney Tpx? and why?

Answer 21

Cisatracurium

Does not rely on kidneys for elimination

Question 22

_{Renal Transplantation - Pharmacologic agents}

What’s a potential disadvantage of using Vec and rocuronium in kidney tpx?

Answer 22

may have prolonged duration of action

Question 23

_{Renal Transplantation - Pharmacologic agents}

Why is it so important to know your hospitals protocol and surgeon preferences when it comes to choosing your anesthetics?

Answer 23

Surgeons preferences and experience matters

Many drugs to choose from

Timing and dose vary

Question 24

_{Renal Transplantation - Pharmacologic agents}

Which other non-anesthesia drugs are commonly used during kidney Tpx for vascular support, anticoagulation, and diuresing?

Answer 24

Dopamine (!?) - Heparin - Mannitol - Lasix

Question 25

_{Renal Transplantation - Monitors}

With which patients could you get away with just standard, non-invasive monitors + large bore IVs during kidney tpx?

Answer 25

Younger, healthier pts

Question 26

_{Renal Transplantation - Monitors}

Which monitors do most pts undergoing kidney tpx require?

Answer 26

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

Question 27

_{Renal Transplantation - Monitors}

Why would a urinary catheter be placed intra-op during kidney tpx?

Answer 27

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