By the way, I have a transplant..

Transcription

1 By the way, I have a transplant.. Transplant patient for non-transplant surgery David Elliott

2 No relevant disclosures

3 Organ donation in Australia Survival rates following organ donation have increased in the past two decades improved surgical techniques immunosuppressive therapy antibiotic prophylaxis Living donor kidney transplants 1 year survival ~ 95% 10 year survival > 75% average survival ~ 20 yrs

4 Organ donation in Australia Kidneys 832 Livers 281 Hearts 98 Lungs 206 Pancreas 51 Intestine 1 Total 1,469

5 Non-transplant related surgery Could be any type of surgery, but as a group more likely to present than in a non-transplant cohort diverticular disease laparotomy for small bowel obstruction lymph node excision and biopsy due to increased rate of malignancy ureteric stent and other plumbing revisions post renal transplant hip arthroplasty for hip fracture secondary to steroid immunosuppression bronchoscopy in lung transplants biliary tract strictures / rebores in liver recipients

6 General principles of care Routine preop assessment as for any patient Identify co-morbidities particularly relating to the underlying organ that has been transplanted Immunosuppressants side effects/other organ system toxicity continuation in periop period for dose sensitive agents risk of infection (which may be masked) Specific strategies to protect the transplanted organ Physiological and pharmacological problems relating to allograft denervation

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8 Preoperative evaluation Standard thorough history and examination, but with emphasis on graft function + recent acute rejection EUC and egfr especially for renal transplant LFTs and coags especially for liver transplant Cardiac function especially for heart transplant Lung function tests especially for lung transplant

9 Patients with > 4 metabolic equivalents can proceed to surgery without further testing 2014 American College of Cardiology/American Heart Association Guidelines for perioperative cardiovascular evaluation of patients undergoing non-cardiac surgery

10 Preoperative evaluation Anaemia Post-transplant anaemia is present in 45 78% of patients with solid organ transplants presenting for surgery Secondary to; antimetabolite immunosuppressants cytomegalovirus chronic renal failure Preop Hb optimisation nutritional supplements adjustment of immunosuppressants erythrocyte stimulating agents aim for Hb ~ 11 g/dl

11 Preoperative evaluation Blood bank Red blood cells are leukocyte depleted by the blood bank, but are still antibody sensitising CMV negative blood for CMV negative patients Leukocyte filters for pooled platelets platelets are especially sensitising for HLA Class 1 antibodies

12 Immunosuppressants Corticosteroids hypertension central obesity hyperlipidaemia diabetes osteoporosis Calcineurin inhibitors (tacrolimus, cyclosporine) nephrotoxicity neurotoxicity diabetes

13 Immunosuppressants Antiproliferatives (mycophenylate, azathioprine,) GIT upset diarrhoea & malabsorption leukopenia anaemia CMV infection Inhibitors of protein kinase mtor (everolimus, sirolimus) thrombocytopenia anaemia mouth ulcers diarrhoea

14 Immunosuppressants Emerging agents ( biologics ) Monoclonal antibodies (basiliximab, alemtumuzab) acute hypersensitivity fevers, rigors, rash, nausea, diarrhoea but.. very promising in terms of reduced rejection will mainly only see in early post-tx period May also see antithymocyte globulin (ATG) for management of acute rejection

15 Post transplant sepsis Immediately post-transplant - bacterial wound infection staph aureus catheter related e. coli pneumonia pneumococcus Late (> 30 days) opportunistic CMV herpetic varicella pneumocystis carinii

16 Conduct of anaesthesia General anaesthesia All inhalational and intravenous anaesthetics can be used Nitrous oxide is controversial Benzodiazepines reduced dose with hepatic or renal dysfunction Cyclosporine enhances NDMB use sugammadex No specific monitoring Attention to asepsis is critical Neuraxial and regional anaesthesia No contraindications over and above usual

17 Kidney transplant Most common solid organ transplant (cadaver or living related donor) Often have underlying diabetes +/- cardiovascular disease Impaired renal function even in a successful graft egfr decreases by about 20% chronic low grade rejection immunosuppressive drugs

18 Kidney transplant Try to choose drugs that are eliminated independent of renal function (eg. atracurium for muscle relaxation, fentanyl rather than morphine for analgesia) Avoid nephrotoxic drugs NSAIDs diuretics IV contrast Maintain perfusion pressure / volume Schedule 1 st on list Might still have an AV fistula

19 By the way, I m going to have a transplant. 34 year old multiparous woman from a family with Autosomal Dominant Polycystic Kidney Disease 3 children aged 15,12,10 Strong family history of ESRD father and grandfather on dialysis Creatinine 350 commences work up for living donor kidney transplantation On erythropoietin, vitamins, phosphate binders

20 Adult Polycystic Kidney Disease Potential Donor Unaffected mother comes forward as a donor Aged 59 Blood Group O Normotensive, Nil past history Nil meds Creatinine 80 GFR 102ml/min 24 hour urine protein <0.05g/24 hour

21 Tissue Typing Negative T and B CDC cross match and negative FCM No Donor Specific HLA antibodies 4 /6 HLA match 2 mismatches B18 and DR 15 Proceed to work up transplant date set Age BG A B DR DQ CMV EBV D 59 O+ 2, 2 8,18 3, 15 2, R 35 A 2, 3 7, 8 3, 4 2,7 - +

22 Progress of recipient Worked up as living donor from tertiary hospital Country patient cervical smear high grade CIN decision hysterectomy Admitted under gynaecology unit at regional hospital Noted to be anaemic by gynaecology intern at admission Hb 85

23 Progress Transfused 2 Units Routine hysterectomy Reviewed in final week assessment clinic Repeat CDC cross match positive 3 new DSA anti-b18 m10912, DR51*01:01 m3791, DQB1*06 m2720 (but CDC score 8 positive) Retested 3 month later anti-b18 m16101, DR51*01:01 m3607, DQB1*06 m 2302

24 Progress Pre-emptive LRD Transplant cancelled AVF created for dialysis Patient relocates from country to city for haemodialysis Listed for deceased donor on waiting list

25 Liver transplant First successful liver transplant was in 1967 High rate (70%) of post-transplant hypertension reversal of systemic vasodilatation sympathetic stimulation from the calcineurins mineralocorticoid effects of corticosteroids Coexisting renal impairment as a result of nephrogenic drugs Hyperlipidaemia leading to cardiovascular disease

26 Heart transplant Specific problem relates to denervation of parasympathetic nervous system (vagus) resting HR increased to BPM absence of usual PSN acceleration in stress & exercise increase in cardiac output dependent on circulating catecholamines which remains intact Variable response to sympathomimetics drugs that work on the ANS (atropine, glycopyrrolate) are ineffective indirect acting sympathomimetics(ephedrine) have reduced effect direct acting sympathomimetics (adrenaline, noradrenaline, isoprenaline, dopamine) act normally

27 Summary Long term solid organ survival rates continue to improve hence we will see increasing numbers presenting for unrelated post-transplant surgery Underlying comorbidities do not necessarily go away Immunosuppressants are improving, but still cause many side effects Patients are often the best source of information. They have a lot invested in their donated organ!

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