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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2015  |  Volume : 26  |  Issue : 3  |  Page : 447-452
Comparison of safety and efficacy of general and spinal anesthesia in kidney transplantation: Evaluation of the peri-operative outcome


1 Urology and Nephrology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
2 Department of Anesthesiology, Hamadan University of Medical Sciences, Hamadan, Iran
3 Research Center for Behavioral Disorders and Substance Abuse, Hamadan University of Medical Sciences, Hamadan, Iran

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Date of Web Publication20-May-2015
 

   Abstract 

General anesthesia is a routine anesthetic technique for kidney transplantation. This study evaluated and compared the peri-operative hemodynamic, cardiopulmonary and general condition status in patients in whom spinal anesthesia (SA) or general anesthesia (GA) was used for kidney transplantation. A prospective study was carried out on 49 consecutive patients who underwent kidney transplantation with either GA (19 patients, mean age 37.53 ± 11.78 years) or SA (30 patients, mean age 42.17 ± 14.89 years), without any selection bias. One obese patient with a body mass index of 32.52 kg/m 2 died 22 days after transplantation in the GA group. One other patient, who developed severe nausea and vomiting, was changed from SA to GA. There were no statistical differences in gender, mean age, body mass index and hemodynamic and cardiopulmonary status between the two groups. Time to post-operative diet tolerance, defecation, ambulation and adequate urination were significantly better in the SA group. The mean operation time was 264.32 ± 18.91 and 233 ± 15.12 min in the GA and SA groups, respectively. Brisk diuresis was seen in all patients except one in the SA group. Our study suggests that kidney transplantation under SA is feasible and safe, particularly for patients who cannot receive GA.

How to cite this article:
Amir-Zargar MA, Gholyaf M, Kashkouli AI, Moradi A, Torabian S. Comparison of safety and efficacy of general and spinal anesthesia in kidney transplantation: Evaluation of the peri-operative outcome. Saudi J Kidney Dis Transpl 2015;26:447-52

How to cite this URL:
Amir-Zargar MA, Gholyaf M, Kashkouli AI, Moradi A, Torabian S. Comparison of safety and efficacy of general and spinal anesthesia in kidney transplantation: Evaluation of the peri-operative outcome. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jul 26];26:447-52. Available from: https://www.sjkdt.org/text.asp?2015/26/3/447/157300

   Introduction Top


Since the original description of human renal allograft transplantation by Voronoy in 1933, it has been described as the first-line replacement therapy for chronic kidney disease (CKD). [1] Many of the CKD patients have cardiopulmonary and/or metabolic problems secondary to their renal failure; nevertheless, to receive a donated kidney, one should undergo a major surgery under anesthesia and tolerate subsequent major hemodynamic changes. Thus, their condition increases the complexity and importance of anesthesia for providing optimal peri-operative stable hemodynamics and pain management. [2],[3],[4],[5] In recent decades, several attempts have been made to improve peri-operative hemodynamic status and pain management and also to reduce anaphylaxis due to using multiple drugs during kidney transplantation. One of these attempts is regional anesthesia instead of general anesthesia (GA). [6],[7] However, there are inadequate published reports on the beneficial effects of regional anesthesia in kidney transplantation. This study is one of the relatively large reviews assessing the use of spinal anesthesia (SA) for kidney transplantation.


   Materials and Method Top


Study population

This prospective study was approved by the Urology and Nephrology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran and performed at the Shahid Beheshti Hospital from May 2009 to July 2012 based on the Helsinki Declaration of 1975 (revised in 1983). This hospital is the main center for kidney transplantation in Hamadan province, with a population of more than 1,700,000 people in northwestern Iran. During the period of about three years, all patients who required kidney transplantation were enrolled into the study without any selection bias and only one surgeon and one anesthesiologist were involved. The study population included patients of all ages. The only selection criterion for the technique was the preference of the anesthesiologist and surgeon. The exclusion criteria for patient selection included any contraindication for kidney transplantation, such as active invasive infection, a high probability of operative mortality, non-compliance, active malignancy and unsuitable conditions for technical success, and also contraindications for GA or SA. Finally, 49 patients were selected, including 19 in the GA group and 30 in the SA group. After complete preoperative evaluation and work-up including assessment of medical history, general physical and laboratory examinations including complete blood count, fasting blood sugar, blood urea nitrogen, creatinine, sodium, potassium, calcium, phosphorous, urine analysis, urine culture and diagnostic studies such as ultrasonography, isotope scan and HLA typing, the patients were admitted to the hospital for transplantation the day before the procedure for living donor or, when required, for deceased donor transplantation. Data such as important peri-operative laboratory parameters (hemoglobin, blood urea nitrogen, creatinine, sodium, potassium and calcium), cardiopulmonary status, blood pressure, blood transfusion rate and post-operative general condition including urine output, diet tolerance, defecation and ambulation were compared between the two groups.

Anesthesia management

After complete pre-operative evaluation, the anesthesiologist explained about GA and SA to the patients and informed written consent was obtained. Following this, an intravenous (i.v.) line was secured and adequate hemodynamic monitoring was provided in the form of non-invasive blood pressure (NIBP) monitoring, electrocardiogram, saturation of peripheral arterial oxygen (SPO 2 ) and urine output. In patients selected for GA, after appropriate monitoring and pre-hydration with 300- 500 mL of i.v. normal saline and pre-oxygenation for three minutes, anesthesia was induced with i.v. propofol 2 mg/kg, atracurium 0.5 mg/kg, fentanyl 100 μg and lidocaine 1 mg/kg to attenuate the pressure response to laryngoscopy and intubation. After three minutes, intubation was performed with a portex 7.5 mm cuffed tube and anesthesia maintained with oxygen + nitrous oxide + atracurium + isoflurane (0.6-1%). Intra-operatively, the patients received 4-5 L of i.v. isotonic crystalloid fluid for maintaining normal blood pressure. Post-operative residual muscle paralysis was reversed and the patients were extubated when awake. Post-operative pain relief was provided with injection of meperidine (20-50 mg), if required. In the SA group, preloading was carried out with 500 mL of i.v. normal saline. Lumbar puncture was performed with strict aseptic precautions at the L3-L4 inter-space with a 23-25 gauge spinal needle in the sitting position; 10-15 mg of 0.5% bupivacaine, with 5 μg of sufentanil, was injected into the sub-arachnoid space and then the table was adjusted for appropriate anesthesia level (T5-T6). i.v. ephedrine (10-20 mg) was administered if systemic blood pressure decreased over 30% of baseline or below 100 mm Hg and i.v. midazolam was administered if more sedation or muscle relaxation was required. All patients in the SA group were fully conscious and alert during the operation procedure.

Surgical procedure

Immunosuppressive drugs were administered on the night before the operation. Prophylactic antibiotic was administered just before surgery. After inducing anesthesia and placing the patient in the supine position, followed by Foley's catheter insertion, a rectus-preserving Gibson or para-median incision (especially in obese patients), usually on the right side, was made. The anastomoses of renal artery and vein were performed. Following this, an extra-vesical anti-refluxing uretero-neo-cystostomy was performed and a ureteral stent was placed for all patients.

All patients were evaluated for laboratory parameters daily for one week after operation followed by once weekly for one month. Urethral catheter, drain and ureteral stent removal times were variable according to the patients' condition. Generally, the urethral catheter and drain were removed less than a week after surgery while the stent was removed about six weeks later. The patients were discharged two to three weeks after the surgery and, if any complications occurred at home, the patient was referred to the emergency room and immediately managed. All patients were followed-up monthly till the end of one year post-transplantation and evaluated for laboratory parameters and ultrasonography for assessment of vascular status and kidney functions and also for assessing the possibility of hydronephrosis or lymphocele. Subsequent follow-up was based on the discretion of the treating nephrologist. Additionally, a technetium 99 m-diethylene triamine (Tc 99m DTPA) scan was performed once in the early post-operative period and again three months later.


   Results Top


Demographic characteristics and laboratory data of patients who received GA or SA are summarized in [Table 1]. One obese patient in the GA group, with a body mass index of 32.52 kg/m 2 , died in the ward 22 days after transplantation due to dehiscence of renal artery anastomosis. Two patients refused SA and had to be given GA and one patient developed severe nausea and vomiting following SA and hence was changed to GA. Local hematoma or abscess formation did not occur at the site of spinal puncture in the SA group. There were no differences in terms of gender, mean age, body mass index, hospitalization time and hemodynamics and cardiopulmonary status between the two groups (P > 0.05). The mean age of the patients who received GA was 37.53 ± 11.78 years (range 17-68 years) and of those who received SA was 42.17 ± 14.89 years (range 19-60 years). The mean operation time from skin incision to termination of surgery was 264.32 ± 18.91 min in the GA group and 233 ± 15.12 min in the SA group (P = 0.009). The amount of blood transfusion during operation was similar between the groups (21.1% versus 23.3%, P = 0.570). The time to post-operative diet tolerance, defecation, ambulation and adequate urination were statistically better in the SA group than in the GA group (P <0.05). Brisk diuresis was seen in all patients except one in the SA group, in whom diuresis started 11 min after clamp removal. The important hemodynamic and cardiopulmonary parameters in the two study groups are shown in [Table 2].
Table 1: Demographic characteristics and laboratory results of the 49 study patients who underwent kidney transplantation.

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Table 2: Important hemodynamic and cardiopulmonary and peri-operative parameters in the 49 study patients who underwent kidney transplantation.

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   Discussion Top


It has been suggested that kidney transplantation has a considerable role in the management of patients with CKD. Even with advances in anesthesia and surgical techniques, patients had to put up with the ill effects of GA and related complications in the past. Therefore, we investigated the feasibility of using a safer procedure in the form of SA for kidney transplantation. Although some studies have been carried out previously to show the feasibility of performing kidney transplantation under SA, adequate data are still not available. Bhosale and Shah [8] reported the outcome of 50 consecutive patients who underwent renal transplantation under combined spinal-epidural anesthesia and concluded that this protocol provided reliable anesthesia for this major operation. Shah and colleagues [9] also studied the impact of combined epidural and SA on intra-operative hemodynamics in 46 pediatric patients who underwent kidney transplantation and showed that it provided stable intra-operative hemodynamics and good post-operative analgesia. Sener et al [10] did not find significant differences between GA and combined spinal-epidural anesthesia regarding renal perfusion and function, creatinine clearance, urine microalbuminuria and biochemistry. Haberal et al [11] reported no difference in surgeon satisfaction between GA and combined spinal-epidural anesthesia in donor nephrectomy. Akpek et al [7] studied the effect of regional anesthesia in patients who received a donated kidney in Turkey and reported appropriate pain relief and maintenance of good renal function. Sprung et al [12] described that proper hemodynamic and fluid management during anesthesia improved the shortand long-term outcomes of renal transplantation.

In our study, GA and SA were compared for some of the most critical parameters in kidney transplantation, such as peri-operative cardiopulmonary and hemodynamic status. Although clinically not important, shorter mean operation time in the latter group was observed. Similar to GA, SA-related complications as well as subsequent surgery-related complications were negligible in our study, a finding that carries positive implications. One important rationale for designing this study was the evaluation of early post-operative diet tolerance, defecation, ambulation and adequate urination, all of which were seen to be better after SA. Although early ambulation following SA can induce headache, appropriate perioperative hydration can prevent this.

Although GA provided better control of the diaphragm and proper muscle relaxation, as well as good patient comfort, the operating surgeon and other members of the transplantation team and the patients were satisfied with SA. Based on these advantages, many authors have expressed their interest in substituting SA for GA for renal transplantation.

Some limitations of this study, however, are worth mentioning. Obviously, enrolling more patients, and also designing prospective randomized studies would enhance the power of the investigation. Because only one surgeon was involved, surgeon's satisfaction could not be evaluated. Although we attempted to eliminate possible confounding factors, our present study focused on the intra-operative and early post-operative phases only, and long-term follow-up for determination of adverse effects of anesthesia techniques on renal transplantation outcome is needed.


   Conclusion Top


Surgery under SA is feasible, safe and well tolerated in the management of patients undergoing kidney transplantation for CKD. In addition, it is a very good alternative for GA, improving the early post-operative condition and making surgery feasible for patients with significant co-morbidities such as pulmonary disease in whom GA may be difficult to deliver.

Conflict of Interest

The authors have no conflicts of interest to declare.

 
   References Top

1.
John MB, Michael JC. Renal Transplantation. In: Vein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell -Walsh Urology. 9th Edition; 2011. p. 1227  Back to cited text no. 1
    
2.
David AG, Emilio DP. Etiology, Pathogenesis, and Management of Renal Failure. In: Vein AJ, Kavousi LR, Novick AC, Partin AW, Peters CA. Campbell -Walsh Urology. 9th Edition; 2011. p. 1218  Back to cited text no. 2
    
3.
Krishnan M. Preoperative Care of Patients with Kidney Disease. Virginia Nephrology Group, Arlington, Virginia. Am Fam Physician 2002;66:1471-7.  Back to cited text no. 3
    
4.
Drüeke TB, Locatelli F, Clyne N, et al. Normalization of Hemoglobin Level in Patients with Chronic Kidney Disease and Anemia. N Engl J Med 2006;355:2071-84.  Back to cited text no. 4
    
5.
Mark D, Stephen TW. Perioperative management of the patient with chronic kidney disease. Surgery (Oxford) 2010;28:433-6.  Back to cited text no. 5
    
6.
Solonynko I, Loba M, Orel J, Kobza I, Zhuk R, Yeliseev G. Renal transplantation choice of anesthesia. Wiad Lek 1997;50 suppl 1:447-8.  Back to cited text no. 6
    
7.
Akpek EA, Kayhan Z, Donmez A, Moray G, Arslan G. Early postoperative renal function following renal transplantation surgery: Effect of anesthetic technique. J Anesth 2002;16:114-8.  Back to cited text no. 7
    
8.
Bhosale G, Shah V. Combined spinal-epidural anesthesia for renal transplantation. Transplant Proc 2008;40:1122-4.  Back to cited text no. 8
    
9.
Shah VR, Butala BP, Parikh GP, et al. Combined epidural and general anesthesia for pediatric renal transplantation: A single center experience. Transplant Proc 2008;40:3451-4.  Back to cited text no. 9
    
10.
Sener M, Torgay A, Akpek E, et al. Regional versus general anesthesia for donor nephrectomy: Effects on graft function. Transplant Proc 2004;36:2954-8.  Back to cited text no. 10
    
11.
Haberal M, Emiroğlu R, Arslan G, Apek E, Karakayali H, Bilgin N. Living donor nephrectomy under combined spinal-epidural anesthesia. Transplant Proc 2002;34:2448.  Back to cited text no. 11
    
12.
Sprung J, Kapural L, Bourke DL, O'Hara JF Jr. Anesthesia for kidney transplantation surgery. Anesthesiol Clin North Am Des 2000;18:919-51.  Back to cited text no. 12
    

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Correspondence Address:
Dr. Abdolmajid Iloon Kashkouli
Urology and Nephrology Research Center, Hamadan University of Medical Sciences, Hamadan
Iran
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DOI: 10.4103/1319-2442.157300

PMID: 26022013

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