Anaesthesia for renal transplant surgery

Abstract

Editor,The preoperative assessment of the likelihood of a postoperative cardiac event is complex. 1 The Revised Cardiac Risk Index (RCRI) is a commonly used scoring system for the stratification of cardiac risk of patients undergoing major non-cardiac surgery. 2 The RCRI scores patients according to six clinical categories: high-risk surgery (thoracic, abdominal and supra-inguinal vascular surgery); history of ischaemic heart disease (IHD); history of congestive heart failure; cerebrovascular disease; insulin-dependent diabetes; and renal failure. Since the publication of the original article in 1999, the RCRI has become a widely used stratification tool for cardiac risk. A recent meta-analysis has examined the predictive value of the RCRI in these studies. 3 It concluded that the RCRI performed moderately well at discriminating between low and high perioperative risk. However, the authors felt that it performed poorly in vascular cohorts, and that the studies included were of variable quality. This report highlights the need for further studies evaluating the RCRI.We report the results of a single centre observational study of consecutive patients undergoing major vascular surgery (aortic surgery, infra-inguinal bypass surgery, amputation). Ethical approval for this study [REC reference number 04/193(1)] was provided by the West of Scotland Research Ethics Committee (Chairperson Dr A Binning) on 2 March 2004. All patients gave written consent to the study. The patients were preoperatively scored according to the RCRI criteria. 2 The presence of other risk factors was obtained from the patient's history and medical records. Operations were recorded as elective or expedited (within 3 weeks of initial presentation). Patients operated as an emergency, within 24 h of an unplanned admission, were excluded. Postoperative screening for cardiac events was performed by daily clinical assessment, serial ECGs and troponin I measurement. The primary outcomes were major adverse cardiac event (MACE) (non-fatal myocardial infarction and cardiac mortality) and all-cause mortality. Patients were followed-up for 6 weeks following surgery. Statistical analysis was performed using SPSS (Version 15) statistical software package (SPSS, Chicago, IL). Categorical variables are presented with totals and percentages, and analysed with Chi-square, Fisher's exact test or Mann-Whitney test as appropriate. Receiver operating characteristic (ROC) curves were plotted to model the efficacy of the RCRI. The area under the curve (AUC) was calculated.A total of 252 patients were included in the study: aortic surgery 25.8%; bypass surgery 39.7%; and lower limb amputation 34.5%. Thirty-nine patients (15.5%) had a postoperative MACE, and 20 patients (7.9%) died within the postoperative 6-week period. Applying the RCRI to the cohort as a whole, the rate of MACE for RCRI class 1, 2, 3 and 4 was 13.4, 14.9, 18.6 and 16.7%, respectively (P ¼ 0.858) (Table 1). Similarly, the rate of perioperative mortality for these groups was 7.3, 9.2, 6.8 and 8.3%, r...

Long-term health-related quality of life of living kidney donors: a single-center experience

“…Kidney transplantation has become a well-established method in the treatment of patients with end-stage renal failure and has led to an increased overall survival rate compared to patients on hemodialysis [1].The patient and graft survival have improved steadily due to better immunosuppressive regimens [2], improved surgical methods [3], and better anesthetic management [4].…”

The revised cardiac risk index performs poorly in patients undergoing major vascular surgery

“…It is sensible to avoid hypotensive episodes in renal transplant patients, because the harmful effect of low blood pressure outweighs the potential renal vasoconstriction caused by vasopressors. 8 As a general rule, mannitol, especially in large doses, should not be administered to patients with chronic renal failure or to renal transplant patients.…”

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

“…Etomidate could be a safe choice for patients with IHD or impaired ventricular function due to its cardiovascular stability during induction. Etomidate can suppress the adrenal glands, but the use of perioperative methylprednisolone ensures an adequate steroid level [ 85 ].…”

“…HTN caused by high vascular resistance can potentially decrease blood flow and oxygen supply, which are essential for proper mitochondrial function [ 84 ]. Small doses of vasopressors can be used, as the risk of low blood pressure is greater than that of potential renal vasoconstriction [ 85 ]. There is a lack of evidence on vasopressor use and which to use as a first-line treatment [ 79 ].…”