Anesthesia Monitoring

The standard monitorization proposed by the American Society of Anesthesia will be sufficient for both the donor and the recipient [1]. ECG (ideally with ST segment analysis), pulse oximeter, capnography, urine volume, non-invasive blood pressure, neuromuscular monitoring are required. While renal transplant candidates are cardiac patients, central vein catheterization is used as a standard in some centers, while some centers are not preferred because they are not a good indicator of fluid need or response [2]. Wide IV routes should be opened, but IV route interventions may not always be easy in these patients. Difficulty becomes even more pronounced, especially in patients with arteriovenous (AV) fistulas or who have had frequent central venous dialysis catheters. Central vein catheterization under ultrasound provides a great advantage in this respect. Central vein catheterization should be done from the side without AV fistula if possible. Invasive blood pressure monitoring is not indicated in every patient. Because donors are generally healthy patients, they rarely need invasive follow-up. In the recipients, depending on the AV fistulas present, the process may be inconvenient and also pose a risk for future fistulas. Therefore, intraoperative invasive blood pressure follow-up is recommended only in renal transplant candidates with advanced cardiac disease. Instead, non-invasive blood pressure monitoring is sufficient. Care should be taken to use the leg in the contralateral side of the side to which the allograft will be attached if the cuff is placed on the arm without AV fistula, if it cannot be used in both arms for some reason and the measurement will be made from the lower extremity [3]. Transesophageal echocardiography can be used in patients with ventricular insufficiency, pulmonary hypertension, or advanced coronary artery disease. New invasive monitoring techniques analysis is not preferred because it requires artery monitoring, but it is a good alternative to central vein pressure monitoring [4]. Inhibition of hypothermia is of great importance for direct graft function. Therefore, monitoring the body temperature is very important in the intraoperative period.

Anesthesia maintenance

Appropriate anesthesia technique should be selected taking into account the existing diseases of the patient, the duration of surgery and the possibilities of renal protection [5]. Regardless of the method of anesthesia, varicose stockings and blankets in which active heating can be provided should be used to prevent the destructive effect of hypothermia on the graft in terms of mechanical thrombophylaxis [3]. The use of central regional methods is rare and controversial in patients with chronic renal failure [6-8]. However, in the literature, successful use of regional anesthesia in both donors and recipients has been reported many times during renal transplant. (4.6 to 8). Epidural anesthesia can be used both alone and in combination with general anesthesia and has a positive effect on graft by suppressing surgical stress in the intraoperative and postoperative period [4]. General anesthesia is the most preferred anesthesia method [1]. Induction and intubation may cause exaggerated hemodynamic changes in patients with cardiac pathologies and diabetes [1]. Especially in patients with diabetes, rapid serial intubation may be necessary due to gastroparesis due to autonomic disfunction.

End-stage renal failure affects the pharmacokinetics and pharmacodynamics of drugs. In addition, changes in body fluid distribution also affect drug distribution, causing changes in the metabolism of drugs used in the perioperative period [9]. It is important that these changes are known to the anesthetist. Midazolam can be used safely for premedication as its distribution and excretion do not change [10]. Propofol and thiopental are hypnotic agents that can be used safely during anesthesia induction [9]. Both agents are metabolized in the liver. In the intraoperative period, analgesia can be achieved with synthetic opioids independent of renal function such as fentanyl, sulfentanil, alfentanil or remifentanil. Unlike these agents that do not have an active metabolite, morphine and meperidine should not be used because they have active metabolites that can accumulate due to reduced kidney function. Due to the accumulation of morphine-6-glucoronide, these patients may experience prolonged respiratory failure in the postoperative period. Succinylcholine is a depolarizing neuromuscular blocker, the use of which should be avoided as it can cause hyperkalemia. Atracurium and cisatracurium, which are non depolarizing neuromuscular agents, are the first-choice muscle relaxants. They can be used safely in patients with kidney failure, since their metabolism is independent of any organ and is broken down by Hoffman elimination and ester hydrolysis. Since vecuronium and rocuronium clearance are dependent on both kidney and hepatic metabolism, their duration of action is observed. For this reason, it has been shown that rocuronium can be used safely in renal transplant patients, and that neuromuscular effect can be successfully reversed with sugammadex if they should be used with caution [11].

Maintenance of anesthesia can be done with both inhalation anesthetics and propofol induction. In a study in which propofol and sevoflurane were compared, it was reported that although there was no difference in terms of graft functions, lower 2-year rejection rates with sevoflurane were observed [12]. Although it is stated in the literature that sevoflurane may have a nephrotoxic effect due to compound A formation and floride, no significant nephrotoxic effect has been observed with clinical studies [13,14]. This effect can be prevented by keeping the fresh gas flow above 4 l / min [5]. Isoflurane, desflurane are inhalation agents that can be used safely.