1. Moderator - Prof Chandralekha Dr Jyotsna www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com

2.  DM  Hypertension  Glomerulonephritis  Pyelonephritis  Polycystic kidney  Others

3. Hemodialysis Peritoneal dialysis Transplantation

4.  Diffusion of solutes across a semipermeable membrane down conc gradient  Hemodialysis - shunt / fistula  Peritoneal dialysis – IPD, CAPD,CCPD

5.  Hyperkalemia unresponsive to conservative means  Refractory acidosis  Volume overload  Uremic pericarditis  Uremic neuropathy

6.  Predominant technique  Done three times a week  Duration 2.5 - 5 hrs

7. Hemodialysis :  Arteriovenous fistula - long term  Arteriovenous shunt - short term  Temporary venous catheters – short term

8.  Needs 4 weeks to mature Complications :  Thrombosis  Infection  Haemorrage  Steal Precautions-  Padding of fistula  Avoid BP cuff  No sampling  Avoid hypotension

9.  Peritoneum as endogenous dialysis membrane  CAPD /CCPD  Access via silastic catheter

10. advantagesdisadvantages Hemodialysis – short time, better small solute removal Need heparin,vascular access, hypotension, poor BP control Peritonial : steady state, higher hematocrit, better BP control, large solute removal, source of nutrition Peritonitis, hernia back pain, obesity

11. Acute :  Hypovolemia  Electrolyte imbalance  Disequilibrium syndrome Chronic :  Dialysis dementia  Hypoproteinemia  infections

12.  Better quality of life  Better 5 yr survival rates 70% vs 30%  Improves anaemia, peripheral neuropathy, autonomic neuropathy and cardiomyopathy  Dialysis negatively affects success of transplantation

13.  Patients with ESRD with expected 5 yr survival

14. Absolute contraindications :  Disseminated or untreated cancer  Severe psychiatric disease  Irresolvable psychosocial problems  Persistent substance abuse  Severe mental retardation  Un-reconstructable coronary artery disease or refractory congestive heart failure

15.  Treated malignancy  Chronic liver disease  History of substance abuse  Structural genitourinary tract anomaly  Past psychosocial abnormality

16. LIVE or CADAVER Live -> related or unrelated Ideal donor Age = 18 - 60yrs Compatible blood group No DM or HTN Psychologically motivated Viral markers ( - )

17.  Fully informed of risk and benefits  Aware of alternative methods  Willing to donate  Psychosocially capable Unrelated donors –  Need permission from authorization committee

18.  Hemogram,KFT, LFT  CT angiography and urography  Psychiatry, dental,opthalmologic and cardiac evaluation  CMV antibodies  DTPA scan and global GFR  Immunological testing

19.  Good physical health ASA 1or 2  Open / laparoscopic  Flank position – risk of hypotension  Maintain good hydration and diuresis  Mannitol before cross clamping  Avoid direct acting vasopressors  Post op pain – iv opioids, no NSAIDS

20. Brain dead donors or non heart beating : Brain dead donors :  Need peri op hemodynamic stabilization  Metabolic and electrolyte disturbances Intra op goals ( rule of 100 ):  Systolic BP >100 mm hg  Pao2 > 100mm hg  Urine output > 100ml /hr  Hemoglobin > 10 gm/dl  CVP between 5 -10 mm Hg

21.  Muscle relaxation needed  Analgesia not required  Volatile and opioids needed for hemodynamic stability Non heart beating donors : Long warm ischemia time

22.  CVS : ◦ Control hypertension ◦ Accelerated CAD - dyslipidemia, hypertension, Calcium & phosphate metabolism ◦ volume overload - dialysis

23.  Chronic anemia  Maintain hematocrit close to 25%  Erythropoietin supplementation Uremic coagulopathy :  deficient factor VIII, VWf and abnormal platelet function  Dialysis,conjugated estrogen, desmopressin, cryoprecipitate, FFP

24.  Hyperkalemia – K >5.5 need treatment  Dialysis or pharmacological intervention  Calcium phosphate product > 60 - calcification in vessel  Hypermagnesemia - enhance muscle relaxants

25.  Hypoalbuminemia or volume overload– risk of pulmonary edema  Pleural effusion  Dialysis, albumin supplementation

26. 26  Stiff joint syndrome  Autonomic neuropathy  Silent MI  Peripheral neuropathy  Electrolyte imbalance  Diffuse atherosclerosis  Ensure blood sugar control

27.  Risk of haemodynamic fluctuation  Risk of gastric aspiration  Reduced heart rate variability >15 / min is normal

28.  Site of AV fistula  Previous cannulation  Ascites

29.  ABO compatibility  HLA matching  Crossmatching negative  PRA( panel reactive antibody) levels ideally less than10%

30.  Hemoglobin, platelets,KFT,LFT, CXR,ECG, echo,MCU, viral markers,immunological testing  Pre op dialysis - a day prior to surgery  Patients native urine output  Post dialysis inv : serum electrolytes,urea, ECG, CXR, pt weight (<2kg difference)

31.  Aspiration prophylaxis – delayed gastric emptying  Dose reduction of H2 antagonists  Continue antihypertensives  Anxiolysis - midazolam (water solubility )

32. Standard ASA monitoring ->  5 lead ECG  Pulse oximeter  eTCO2  Temp  NIBP ( non fistula arm )  CVP ( PAC – sig LV dysfunction )  NMT

33.  Thiopentone - ↑free fraction needs reduced dosing, slow rate of administration  Etomidate – minimal cardiodepressant effect  Ketamine - hypertensive effect ; avoid  Propofol - titrated doses

34.  Enflurane, methoxyflurane – flouride toxicity  Desflurane, sevoflurane – safe  Halothane – reduces RBF, cardiac depressant effect  Isoflurane – preserves RBF, mild cardiodepressive effect, low renal toxicity Anesthetic agent of choice

35.  Morphine, meperidine – metabolites renally excreted  Fentanyl  Sufentanil  Alfentanil  Remifentanil  Doses reduced by 30-50%

36.  Atracurium and cisatracurium - organ independent elimination  Rapid sequence induction –  Succinylcholine - K < 5.5 meq/L  Rocuronium – 1.5mg/kg, hepatobiliary elimination  Vecuronium – metabolite accumulation

37.  Maintain asepsis  Supine position, fistula care  Preoxygenation  Rapid sequence intubation – diabetics  IV agents - thiopentone most popular

38.  Adequate intravascular volume - improves graft function  Maintain CVP – 10 -15 mm hg Mannitol - 0.5-1 g/kg  Increases renal cortical blood flow and intravascular volume, free radical scavenger, increases release of prostaglandins

39. 39  Low dose Dopamine has been proved neither a reduction in acute renal failure nor an improvement in renal function in patient with renal failure  It also did not demonstrate improved renal protection when used in cadaveric renal transplantation.  Dopexamine has been shown some renal protection during aortic surgery but its potential benefit during renal transplant has not been evaluated.

40.  Furosemide - counteracts action of stress induced ADH release, inhibits Na –K ATPase to decrease O2 consumption, converts oliguric to non oliguric  Calcium channel blockers – verapamil injection in renal artery.Preserves RBF, reduces effects of cold ischemia

41.  Avoid potassium containing fluids in stage 5 CKD  Medium / low molecular weight HES can be used  Albumin can be used

42.  Adequate volume status  Maintain blood pressure  Avoid renal vasoconstriction  Prevent tubular obstruction  diuretics

43. Extra caution :  Intubation – avoid hypertension and tachycardia  Anastomosis - avoid hypotension, hypovolemia and hyperkalemia  Extubation - NMB fully reversed, awake patient

44.  Monitor urine output  Post op analgesia – intermittent boluses of fentanyl /morphine or PCA  Potassium levels, urea and creatinine levels measure daily  Maintain adequate hydration

45. TIVA – propofol with fentanyl /alfentanyl/ remifentanil /atracurium Neuraxial blocks – epidural / CSE  Advantages – avoids intubation, opioids and relaxants,good post op analgesia  Disadvantages : uremic coagulopathy,peripheral neuropathy,hypotension,duration of surgery

46.  Local anaesthetics –  Faster onset and offset  Dose reduction by 25% to avoid CVS and CNS effects

47.  Warm ischemia time – from clamping of donor vessels to cold perfusion and placement to anastomosis in recipient  Duration affects acute tubular necrosis  < 30 min  Cold ischemia time : storage in preservation solution to implantation in recipient  Ideally < 24 hrs upto 72 hrs

48.  Mediators of ischemic injury :  ATP depletion ->loss of Na K ATPase pump  Movement of ions along conc gradient -> edema and cell swelling  Ischemia -> anaerobic metabolism causing acidosis -> lysosomal disruption  Free radical production

49.  Euro Collins solution  University of Wisconsin solution  Bretscheider HTK solution Compositon :  Rich in potassium,low Na,free radical scavengers and other ions  Static or perfused storage

50. University of wisconsin soltion CollinsHTK custodial Modified HES Potassium phosphate Magnesium sulphate Adenosine Allopurinol glutathione Potassium phosphate Potassium chloride Sodium bicarbonate Glucose Magnesium sulphate Histidine Tryptophan Low potassium Ketoglutrate Calcium Magnesium mannitol

51.  Local anaesthetics –  Faster onset and offset  Dose reduction by 25% to avoid CVS and CNS effects

52. agenteffecttoxicity steroids ↓ interleukin production Hyperglycemia myopathy osteoporosis hypertension azathioprineInhibits DNA synthesisAnaemia thrombocytopenia cyclosporineInhibits T cellsHyperkalemia hypertension nephrotoxicity hepatotocicity TacrolimusInhibits IL 2 production Nephrotoxicity hyperkalemia hypertension,seizures OKT 3Inactivates T cellCytokine release syndromne

53.  Induction therapy –iv tacrolimus,MMF and methylprednisolone (2 days prior to surgery )  Maintainance therapy – same drugs on post op day 0  All three drugs continued through out life

54. 1. Criteria compliance with HARRT CD4 count > 200 undetectable viral load no systemic manifestation of disease/infection

55.  Thank you www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com