ANESTHESIA FOR KIDNEY TRANSPLANT SURGERY

The most common causes of end-stage renal disease (ESRD) are diabetes, hypertensive nephrosclerosis, glomerulonephritis, and autosomal dominant polycystic kidney disease. 128 For several reasons, the number of kidney transplants has increased sharply in recent years. Because of considerations of graft success, morbidity and mortality, and quality of life, several recipient groups previously considered as unsuitable candidates (e.g., patients with type II diabetes, advanced cardiomyopathy, various forms of vasculitis, sickle cell disease, and morbid obesity) now may be considered suitable candidates for renal transplantation. With increased knowledge and experience, the pool of potential donors has increased. Generally, patients with type I diabetes and ESRD have been considered good candidates for renal transplantation. Most patients with type II diabetes, however, have not been considered suitable for transplantation and have been maintained on dialysis. In the past, less than 15% of patients with type II diabetes with ESRD have received renal allografts. 53,100 Recent evidence, however, clearly indicates that in the absence of vascular complications, these patients have an improved survival rate with transplantation versus dialysis. 52,53 Traditionally, left ventricular dysfunction has been a contraindication for renal transplantation. It has been shown, however, that left ventricular dysfunction with a low ejection fraction caused by uremic cardiomyopathy is a reversible state. Although there is some increased perioperative cardiac risk, many of these patients now successfully are receiving renal transplants. 22 Several months after a successful transplantation and correction of anemia, myocardial contractility improves measurably in most of these patients. 71,95 Approximately 3% of the patients with kidney failure caused by a systemic vasculitis (e.g., Wegener's granulomatosis, microscopic polyangitis, Henoch-Schönlein purpura, Goodpasture's syndrome, thrombotic thrombocytopenic purpura) receive kidney transplants. The transplantation should be performed during a clinically inactive phase of disease to prevent recurrence of the vasculitis. Unfortunately, the presence of antineutrophil cytoplasmic antibodies in asymptomatic patients often precludes transplantation. Recent evidence, however, indicates that the antibody titers have no predictive value for asymptomatic patients 87 and that the results of kidney transplantation in these patients are as good as in other patients. Sickle cell disease can cause various renal pathologies, including glomerulonephritis, pyelonephritis, and the nephrotic syndrome. The literature has been contradictory when weighing the benefits of transplantation versus long-term dialysis for these patients. A recent study, however, clearly demonstrated advantages of transplantation over dialysis in terms of long-term survival and quality of life. 90 End-stage sickle cell nephropathy has become a new important indication for renal transplantation. Morbid obesity has been considered a contraindication to renal transplantation because of the high perioperative mortality. The high mortality was primarily caused by cardiac risk factors and not obesity itself. Obese patients without cardiac risk factors should not have a significantly higher mortality rate. For this reason, careful screening for ischemic heart disease is indicated in an obese candidate for kidney transplant. 80 Kidneys transplanted from donors with hepatitis B surface antigen (HbsAg) or hepatitis C 46 have a high failure rate, and there is increased morbidity and mortality for the recipient. Kidneys from donors who are hepatitis B core antibody positive (HbcAb) but HbsAg negative, however do not have increased graft failure rate, or entail increased short-term morbidity and mortality for the recipient. 112 Improved understanding and treatment of the comorbid conditions associated with ESRD and improved perioperative treatment of patients undergoing kidney transplantation have resulted in increased long-term graft survival, and have reduced morbidity and mortality. Kidney transplantation is becoming a possibility for wider population of high-risk patients who were, until recently, considered at prohibitive risk. Improved anesthetic management with tight hemodynamic control and fluid management contributes to improved short- and long-term outcome of renal transplantation.