Onconephrology shield the kidney while fighting cancer , dr ayman seddik
Anaesthetic implications of chronic kidney disease and transplantation
1. Anaesthetic implications of
chronic kidney disease and
transplantation
Dr Peter Sherren
Specialist trainee
Anaesthesia and Intensive care
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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.
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3. Objectives
Basics about CKD vs ESRF
CKD complications.
Anaesthesia for CKD and renal transplantation.
Pertinent pharmacology for renal patients.
Immunosuppression drugs.
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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.
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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 volume
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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.
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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).
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9. Matching
Matching of the organ to recipient
can
be divided into three phases-
ABO
Tissue matching – HLA class I and
II (6 types, major transplant
antigens)
Cross matching
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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 volume
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11. Peri-operative management
Induction
IV induction- agent? RSI/modified
RSI?
NMBA, depolarising vs non?
Large bore IV access
CVC?
Arterial line?
Antibiotics/Immunosuppressants
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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 control
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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.
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14. Drugs in Renal transplantation
Antibiotics (Flucloxacillin, Co-Amoxiclav)
Diuretics
Immunosuppression
Inotropes
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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/kg
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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.
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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)
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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.
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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.
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Notas del editor
Intrinsic -Vascular,large renal artery stenosis and small vessel disease such as ischemic nephropathy, hemolytic-uremic syndrome and vasculitis -Glomerular primary vs secondary IgA/bergers vs Lupus -Nephrotic/nephritic -Tubulointerstitial including polycystic kidney disease, drug and toxin-induced chronic tubulointerstitial nephritis and reflux nephropathy
This relates to genetic matching between donors and recipients. Currently six specific antigens, called major histo-compatibility complex, are defined in each donor and recipient. The best compatibility is a six-antigen match between donor and recipient, this match occurs 25 percent of the time between siblings and occasionally at random in the general population found on chromesome 6
Bloods/ECG/Cxr/TTE/Stress TTE
Surgical stress? Not really big deal-extraperitoneal plumbing into Lt ext iliac artery Anaesthetic concerns and comorbidities