Chapter 59. Anesthesia for Kidney, Pancreas, or Other Organ Transplantation

1. The 5-year survival of patients on chronic hemo- or peritoneal dialysis is only 30%. In contrast, the 5-year survival following transplantation for end-stage renal disease is 70%. 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 preoperatively, or initiated in patients with a positive stress test. The evidence also favors perioperative β-blockers in high-risk patients (more than 3 risk factors: high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, renal failure—creatinine >2.0 mg/dL). Use of β-blockers in low- and intermediate-risk patients is not supported by current available data.

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 1 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. 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. Due to 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.

The kidneys were the first organs to be transplanted in humans. This led to the development of the field 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.

History and Introduction

The first successful kidney transplant, performed in the mid 1950s, was between identical twins.1 Transplantation between identical twins resulted in excellent long-term ...