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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 1051-1055
Anesthetic management of laparoscopic dual renal transplantation


Department of Anesthesiology and Critical Care Unit, Institute of Kidney Diseases and Research Center and Institute of Transplantation, Ahmedabad, India

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Date of Web Publication2-Sep-2014
 

   Abstract 

Since the first laparoscopic nephrectomy was reported in 1991, this technique has evolved rapidly and laparoscopic donor nephrectomy has emerged as a standard of care in many institutions. However, recipient renal transplantation is still performed by the traditional open approach. There is only one case report of laparoscopic kidney transplantation (LKT) from Spain in 2009. LKT is a technically demanding surgery for a urologist and equally challenging for an anesthesiologist as he has to be vigilant because of the major perturbations in the cardiorespiratory system due to steep trendelenberg position and pneumoperitoneum; additionally, the pneumoperitoneum can have deleterious effects on blood flow and function of the transplanted kidney. We herewith present our experience with anesthesia of the first laparoscopic dual kidney transplantation from a deceased donor performed in our center.

How to cite this article:
Kadam P, Butala B, Shah V. Anesthetic management of laparoscopic dual renal transplantation. Saudi J Kidney Dis Transpl 2014;25:1051-5

How to cite this URL:
Kadam P, Butala B, Shah V. Anesthetic management of laparoscopic dual renal transplantation. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Nov 21];25:1051-5. Available from: http://www.sjkdt.org/text.asp?2014/25/5/1051/139938

   Introduction Top


Renal transplantation is a better option for patients with end-stage renal disease (ESRD) compared with dialysis because of its asso­ciation with better quality of life, better cost/ benefit ratio and, possibly, longer survival. [1] Unfortunately, the demand for kidneys has greatly outstripped the supply of organs from both living and deceased donors. [2] To increase the availability of kidneys from deceased do­nors, marginal donors with sub-optimal nephron mass are being considered for transplantation. Dual kidney transplantation (DKT), the trans­plantation of both deceased donor kidneys into a single recipient, is one such option that allows use of organs from expanded criteria donors. [2],[3]

In the transplantation scenario, living donor laparoscopic nephrectomy has emerged as a standard of care in many institutions; however, recipient surgery is still performed by the standard open approach. [4],[5] There is only one case report of laparoscopic renal transplan­tation performed using a kidney from a living donor from Spain in 2009. [6] At our institution, we started laparoscopic recipient surgery in 2010 with approval from the Internal Review Board, initially with deceased donors followed by living donors and, till the time of reporting, 72 renal recipient surgeries have been per­formed laparoscopically. Herewith, we present our experience with administering anesthesia during the first laparoscopic DKT from a deceased donor.


   Case Report Top


A 55-year-old female with a body mass index of 22.5 kg/m 2 with ESRD due to long-standing diabetes mellitus and hypertension was sche­duled for laparoscopic cadaveric dual renal transplant. She was on maintenance hemo-dialysis through an arterio-venous (AV) fistula in the left arm since two months. At the time of enrollment in the cadaver list, she was thoroughly evaluated. She required five anti-hypertensives to control her blood pressure and 16 units of human mixtard insulin (30% regular insulin + 70% isophane insulin) for control of blood sugar. All her investigations, including coronary angiography, were normal except for deranged renal function tests (blood urea 64 mg% and serum creatinine 4 mg%).

The kidneys were procured from a 70-year-old female individual who had a road traffic accident and was declared brain-dead. Her baseline serum creatinine was 1.4 mg%. The kidneys were retrieved in a standard en-bloc fashion, flushed and preserved in HTK solu­tion and transported to our institution. Because of the age, the donor was considered to be a marginal donor and a DKT was planned. The recipient was informed about the decision to transplant two kidneys laparoscopically and a written and informed consent was taken.

On immediate pre-anesthetic work-up, X-ray chest revealed bilateral mild pleural effusion. After consultation with the nephrologists, she was given pre-operative immunosuppressants, antihypertensives and regular insulin to achieve tight perioperative control of blood sugar. The patient was dialyzed for 4 h before she was posted for the surgery and her post-dialysis reports of hemogram, coagulation profile, se­rum electrolytes and electrocardiogram (ECG) were normal.

In the operation theater, monitors like non invasive blood pressure (NIBP), pulse oximetry and ECG were applied. Her baseline pulse rate was 58/min and her blood pressure was 130/80 mm Hg. She was pre-medicated with ranitidine 50 mg, ondensetron 4 mg, glycopyrrolate 0.2 mg and fentanyl 5 μg/kg, intravenously.

After pre-oxygenation and rapid sequence in­duction of anesthesia with thiopentone sodium 7 mg/kg and succinyl choline 2 mg/kg, she was intubated with 7.5 mm cuffed portex endotracheal tube, and the correct placement of the tube was checked by noting bilateral equal air entry on auscultation and capno-graphy. Anesthesia was maintained with O 2 + air + Isoflurane + intermittent fentanyl + atracurium infusion (0.5 mg/kg/h) with peripheral nerve stimulator (PNS) monitoring. Urinary catheter, Ryles tube and nasopharyngeal tem­perature probe were inserted and a Bair Hugger convective warming system was used to prevent hypothermia. Ventilation was con­trolled to keep Et carbon dioxide (CO 2 ) bet­ween 30 and 40 mm Hg and pulmonary artery pressure (PAP) <35 cm water (H 2 O).

After induction, the right internal jugular vein and right radial artery were cannulated. Pneu-moperitoneum was created and four ports were introduced. A 30° trendelenberg position was adopted and the right external iliac vessels were dissected through the peritoneum. The dual renal allografts were introduced into the iliac fossa through a small infra-umbilical midline incision and the common cuff of infe­rior vena cava (IVC) and aorta of allograft was anastomosed end-to-side with recipient's ex-ternal iliac vessels. Intra-arterial pressure (IAP) was kept between 10 and 15 mm Hg throughout the surgery. The total blood loss was 200 mL, and 1.5 L of normal saline was infused during the surgery. Mannitol (20%) 0.5 g/kg and furosemide 2 mg/kg were given half an hour before release of the vascular clamps. Urine output was established within two min of release of the clamps. Both the ureters were implanted into the bladder sepa­rately, the pneumoperitoneum was released and wound closure was performed in the su­pine position. The cold ischemia time was 10 h and the surgical time was 5 h and 30 min (55 min for vascular anastomosis and 45 min for ureteric implantation). At the end of the sur­gery, muscle paralysis was reversed with neostigmine (3.5 mg) and glycolpyrrolate (0.4 mg) and the patient was transferred to the intensive care unit. Monitoring was continued for 24 h post-operatively and analgesia was provided with intravenous tramadol.

[Table 1] shows the cardiovascular and respira­tory parameters along with arterial blood gas (ABG) at specific times during the surgery. The mean arterial pressure (MAP), central ve­nous pressure (CVP) and pulmonary artery pressure (PAP) increased significantly from baseline with trendelenberg position and pneu-moperitoneum. There was mild hypoxia, fall in pH with significant increase in PaCO 2 - PetCO 2 gradient (12 mm Hg) after release of clamps that were corrected at the end of surgery.
Table 1: Comprehensive monitoring of the patient during the transplant.

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   Discussion Top


One of the indications for DKT is deceased donor's age >60 years to double the nephron mass. [2] DKTs can be performed with each allo-graft implanted in separate iliac fossae (bila­teral) or with both allografts placed separately in one iliac fossa (unilateral), or they can be transplanted enbloc. The advantages of unil­ateral and en-bloc transplant are reduced sur­gical trauma thus facilitating immediate post­operative recovery and also leaving the contralateral iliac fossa intact for a future trans­plantation in the event of graft loss. However, it is technically more demanding even when performed by open approach and more so if performed laparoscopically requiring skill in laparoscopy and vascular surgery.

Although laparoscopic approach confers many advantages like less tissue trauma, decreased blood loss, early ambulation, shorter hospital stay, less post-operative pain and reduction in wound-related morbidity, [7] it requires pneumo-peritoneum and steep trendelenberg position, both of which can cause severe perturbation of major organ systems like hypertension, increased cardiac afterload, decreased chest compliance, hypercarbia, ventilation-perfusion mismatch and decreased renal blood flow and function. [8],[9],[10] The goal of anesthetic management was to have respiratory and hemodynamic stability and, at the same time, optimize function of the transplanted kidney.

Open renal transplants are performed in the supine position with minimal effects on the cardiorespiratory system. In laparoscopic renal transplantation, the MAP increased significantly in our patient with trendelenberg position and pneumoperitoneum, possibly due to increased IAP compressing the aorta and increased afterload. [10],[11],[12] This rise in MAP was controlled with intravenous infusion of nitroglycerine and by increasing the concentration of Isoflurane. The peak airway pressure too increased from 25-40 cmH 2 O, which required decrease in the tidal volume from 10 mL/kg to 7 mL/kg with increase in respiratory rate to keep Et CO 2 and PAP within acceptable limits. Usually, Et CO 2 bears a close relationship (3-5 mm Hg) to the arterial PCO 2 (PaCO 2 ); however, it may not be true in a patient with bilateral pleural effusion undergoing laparoscopy in the trendelenberg position. [13],[14] We used ABG analysis not only to know the acidbase status of the patient but also to assess the adequacy of ventilation (PaCO 2 - PetCO 2 gradient 12 mm Hg) and reset the ventilatory parameters to maintain normal PaCO 2 .

Development of mild hypoxia and fall in pH with increase in PaCO 2 - PetCO 2 gradient on release of clamp may be due to release of metabolites from ischemic graft and leg on reperfusion. It did not require any specific treatment except increase in respiratory rate.

Another concern exclusively related to lapa-roscopic transplant is the deleterious effect of CO 2 pneumoperitoneum on blood flow and function of the transplanted kidney. Experi­mental and clinical studies in animals and humans indicate that renal blood flow as well as function decreases temporarily during pneu-moperitoneum due to pressure on renal vasculature as well as release of anti-diuretic hor­mone, renin and aldosterone, returning to nor­mal after variable period on release of pneu-moperitoneum. [15] The magnitude of this dec­rease depends on the degree and duration of pneumoperitoneum, patient position and level of hydration. In addition, the ischemic period du­ring organ procurement and preservation may expose the transplanted kidney to an increased risk of early post-operative dysfunction. [16],[17] In our patient, urine output was established immediately despite a long cold ischemia time. Because the transplanted kidney is denervated, whether pressure and neuro-endocrine effects produce similar changes in renal blood flow and function remains to be further inves­tigated.

Measures to ensure excellent perfusion of the grafted kidney on release of vascular clamps requires a well-filled, warm patient with a good mean blood pressure. [18],[19],[20] To achieve this goal, the central venous pressure (CVP) is usually maintained in the range of 10-15 mm Hg and MAP ≥100 mm Hg in open renal transplant. [20],[21] In laparoscopic surgery, CVP is unreliable as a measure of preload due to increased intra-thoracic pressure and head down position; hence, we used the trend of CVP and response to fluid challenge as a guide to intra-vascular volume status rather than absolute value of CVP. Moreover, after release of clamps in dual transplant, a greater fraction of cardiac output is diverted to the two kidneys and hypotension is a possibility. We therefore kept the CVP on a higher side before clamp release (25 mm Hg) and used mannitol and furosemide to stimulate urine production and improve early graft function.

In conclusion, we believe that laparoscopic DKT is a feasible and well-tolerated procedure in patients with ESRD without significant co­morbidities. However, it mandates extra vigi­lance on the part of the anesthetist to avoid deleterious effects of the pneumoperitoneum and trendelenberg position on the cardiovascu­lar, respiratory and renal systems. In the future, it may become a standard of care like donor surgery and the anesthetists will have to be prepared to meet the challenges involved in the safe management of these patients with multiple co-morbidities.

 
   References Top

1.Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol 2001;12:589-97.  Back to cited text no. 1
    
2.Vidas Z, Kocman B, Knotek M, Skegro D. Dual kidney transplantation: Case Report. Coll Antropol 2010;34:697-700.  Back to cited text no. 2
    
3.Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria for donor kidney transplantation. Am J Transplant 2003;3 Suppl 4:114-25.  Back to cited text no. 3
    
4.Brook NR, Harper SJ, Bagul A, Elwell R, Nicholson ML. Laparoscopic donor nephrec-tomy yields kidney with structure and function equivalent to those retrieved by open surgery. Transplant Proc 2005;37:625-6.  Back to cited text no. 4
    
5.Oyen O, Andersen M, Mathisen L, et al. Lapa-roscopic versus open living donor nephrec-tomy: Experience from a prospective, rando­mized single center study focusing on donor safety. Transplantation 2005;79:1236-40.  Back to cited text no. 5
    
6.Rosales A, Salvador JT, Urdaneta G, et al. Laparoscopic kidney transplantation. Eur Urol 2010;57:164-7.  Back to cited text no. 6
    
7.Ashcraft EE, Baillie GM, Shafizadeh SF, et al. Further improvement in laparoscopic donor nephrectomy: Decreased pain and accelerated recovery. Clin Transplant 2001;15 Suppl 6:59-61.  Back to cited text no. 7
    
8.Whalley DG, Berrigan MJ. Anaesthesia for radical prostatectomy, cystectomy, nephrec-tomy, pheochromocytoma, and laparoscopic procedures. Anaesthesiol Clin N Am 2000; 18:899-917.  Back to cited text no. 8
    
9.Abreu SC, Goldfarb DA, Derweesh I, et al. Factors related to delayed graft function after laparoscopic live donor nephrectomty. Am J Urol 2004;171:52-7.  Back to cited text no. 9
    
10.Falabella A, Moore-Jeffries E, Sullivan MJ, Nelson R, Lew M. Cardiac function during steep Trendelenberg position and CO2 pneu-moperitoneum for robotic-assisted prostatec­tomy: A trans-oesophageal Doppler probe study. Int J Med Robot 2007;3:312-5.  Back to cited text no. 10
    
11.Malley O, Cunningham AJ. Physiological changes during laparoscopy. Anaesthesiol Clin N Am 2001;1:1-18.  Back to cited text no. 11
    
12.Alfonsi P, Vieillard-Baron A, Coggia M, et al. Cardiac function during intraperitoneal CO2 insufflation for aortic surgery: A trans-oeso-phageal echocardiographic study. Anaesth Analg 2006;102:1304-10.  Back to cited text no. 12
    
13.Klopfenstein CE, Schiffer E, Pastor CM, et al. Laparoscopic colon surgery: Unreliability of end tidal CO2 monitoring. Acta Anaesthesiol Scand 2008;52:700-7.  Back to cited text no. 13
    
14.Tang CS, Tsai LK, Lee TH, et al. The hemodynamic and ventilatory effects between Trendelenberg and reverse Trendelenberg posi­tion during laparoscopy with CO 2 insufflation. Ma Zui Xue Za Zhi 1993;31:217-24.  Back to cited text no. 14
    
15.Demyttenaere S, Feldman LS, Fried GM. Effect of pneumoperitoneum on renal perfusion and function: A systematic review. Surg Endosc 2007;21:152-60.  Back to cited text no. 15
    
16.Halloran P, Aprile M. Factors influencing early renal function in cadaver kidney transplant: A case-control study. Transplantation 1988;45: 122-7.  Back to cited text no. 16
    
17.de Fijter JW, Mallat MJ, Doxiadis II, et al. Increased immunogenicity and cause of graft loss of old donor kidney. J Am Soc Nephrol 2001;12:1538-46.  Back to cited text no. 17
    
18.Tiggler RG, Berden JH, Hoitsma AJ, Koene RA. Prevention of ATN in cadaveric kidney transplant by the combined use of mannitol and moderate hydration. Ann Surg 1985;201: 246-51.  Back to cited text no. 18
    
19.Schnuelle P, Johannes van der Woude F. Perioperative fluid management in renal trans­plantation: A narrative review of literature. Transpl Int 2006;19:947-59.  Back to cited text no. 19
    
20.Lemmens HJ. Kidney transplantation: Recent developments and recommendations for anaes­thetic management. Anaesthesiol Clin N Am 2004;22:651-62.  Back to cited text no. 20
    
21.Othman MM, Ismael AZ, Hammouda GE. The impact of timing of maximal crystalloid hydra-tion on early graft function during kidney trans­plantation. Anaesth Analg 2010;110:1440-6.  Back to cited text no. 21
    

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Correspondence Address:
Dr. Prachi Kadam
Department of Anesthesiology and Critical Care Unit, Institute of Kidney Diseases and Research Center and Institute of Transplantation, Ahmedabad
India
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DOI: 10.4103/1319-2442.139938

PMID: 25193906

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