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KEY POINTS

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KEY POINTS

  1. The 5-year survival of patients on chronic hemo- or peritoneal dialysis is only 40%. In contrast, the 5-year survival following transplantation for end-stage renal disease is 80%. Therefore, transplantation is considered the treatment of choice for patients with renal failure.

  2. Living related kidney transplant is associated with fewer episodes of acute and chronic rejection than cadaveric organ transplant.

  3. Cardiac events related to coronary artery disease and autonomic nervous system dysfunction are the most common causes of morbidity and mortality in the first year following kidney or pancreas transplant.

  4. Significant hypotension upon induction of general anesthesia is common in recently hemodialyzed patients. Diabetics with autonomic neuropathy are at increased risk for severe hypotension and bradycardia during induction of general anesthesia.

  5. According to the most recent ACC/AHA guidelines for those receiving β-blocker therapy, these drugs should be continued in patients who are receiving them preoperatively. Although the evidence suggests that long term β-blocker use is beneficial in high-risk patients, initiating β-blockers the day of surgery may increase mortality and the risk of stroke.

  6. Patients with long-standing diabetes often develop stiff joints due to glycosylation of the connective tissue that results from elevated blood sugars. The inability to oppose the palms of the hands is one sign in a diabetic patient that stiff connective tissue may be present. Patients with stiff joints may be difficult to intubate and may require an awake, fiberoptic intubation.

  7. Adults and children who receive hematopoietic stem cell transplantation (HSCT) are at risk for complications, including respiratory failure or acute graft-versus-host disease (GVHD). Acute graft versus host disease is the most important complication that significantly influences clinical outcome. HSCT recipients are at risk for airway complications during the first 2 months of transplantation.

  8. Because of the high incidence of venous thrombosis in patients on long-term hyperalimentation, all patients referred for intestinal transplantation should undergo preliminary mapping of their venous access by Doppler ultrasound, and patients with multiple thrombosed vessels should be considered for additional angiographic evaluation.

  9. Small bowel transplantation is a long surgical procedure that can take up to 17 hours. It can be associated with large fluid shifts due to abdominal manipulation and significant intraoperative bleeding, dehydration, vascular clamping, long ischemia times, visceral exposure, and lymphatic interruption. Therefore, adequate vascular access is essential.

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KIDNEY TRANSPLANTATION

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The kidneys were the first organs to be transplanted in humans. This led to the development of immunobiology along with surgical and anesthesia advancement, allowing other organs to be transplanted. In this chapter we discuss the anesthesia care, perioperative considerations, and outcome in patients undergoing transplantation of the kidneys, pancreas, islet cells, hematopoietic stem cells, and small intestine.

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HISTORY AND INTRODUCTION

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The first successful kidney transplant, performed in the mid-1950s, was between identical twins.1 Transplantation between identical twins resulted in excellent long-term graft and patient survival. However, the growth of kidney transplantation began in earnest with the ...

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