High-risk Cadaveric Renal Transplantation: Anesthetic Management in a Patient of Chronic Kidney Disease with Hypertrophic Obstructive Cardiomyopathy
Year: 2025
Type: article
Abstract: Dear Editor, Patients with chronic kidney disease (CKD) often present with multiple comorbidities, making their management complex, especially in the context of high-risk surgical procedures such as renal transplantation. When CKD coexists with hypertrophic obstructive cardiomyopathy (HOCM) with low ejection fraction (EF), the anesthetic management becomes particularly challenging.[1] HOCM is characterized by abnormal thickening of the heart muscle, leading to diastolic dysfunction and dynamic outflow tract obstruction, which can be exacerbated by hemodynamic fluctuations during surgery.[2] In the setting of a renal transplant, these patients are at an increased risk of preoperative complications due to the combined effects of their cardiac and renal conditions, necessitating meticulous anesthetic planning to optimize cardiovascular stability, minimize obstructive cardiac events, and ensure adequate perfusion to the newly transplanted kidney. This case explores the anesthetic management of a 55-year-old male patient with end-stage renal disease (ESRD) due to immunoglobulin A nephropathy-induced CKD, for the past 9 years. He has been undergoing dialysis twice weekly through an arteriovenous fistula for the last 4 years and is now presenting for an emergency cadaveric renal transplant. The patient’s medical history was complicated by preexisting coronary artery disease and a 4-year history of hypertension. In addition, he had been diagnosed with HOCM 2 years prior. His ongoing pharmacotherapy included metoprolol succinate 50 mg OD, isosorbide dinitrate 20 mg three times daily (TDS), hydralazine 37.5 mg TDS, aspirin 75 mg OD, and atorvastatin 40 mg at night (HS). He also suffered from chronic obstructive pulmonary disease (COPD), managed with rota caps formoterol 6 μg and budesonide 200 μg, two inhalations BD. Perioperative assessment revealed a heart rate of 65 beats per minute, blood pressure of 157/98 mmHg, and oxygen saturation of 94% on room air. Although a systolic ejection murmur was detected, the patient exhibited no symptoms attributable to HOCM. Pulmonary auscultation revealed bilateral fine rhonchi at the lower lung bases. An electrocardiogram showed evidence of left ventricular hypertrophy and nonspecific ST-T segment changes [Figure 1]. Two-dimensional echocardiography [Figure 2] revealed a reduced EF of 30%, asymmetrical septal hypertrophy, left ventricular hypertrophy, a dilated left atrium, Grade II mitral regurgitation, trivial tricuspid regurgitation, with a right ventricular systolic pressure of 40 mmHg, and a left ventricular outflow tract (LVOT) gradient of 50 mmHg. Pulmonary function tests suggested mild obstructive changes with no significant postbronchodilator reversibility.Figure 1: ElectrocardiogramFigure 2: Two-dimensional echocardiography. LVH: Left ventricular hypertrophy, IVS: Interventricular septum, SAM: Systolic anterior motionHe had dialysis the day before surgery. Preoperative treatment included salbutamol and budesonide nebulization and grafalon infusion at 6 ml/h over 3 h per institutional protocol. Transesophageal echocardiography (TOE) was used in addition to routine intraoperative monitoring. Local anesthetic was used to insert a left radial artery line before induction. Midazolam 1 mg, fentanyl 100 μg, etomidate 20 mg, and rocuronium 100 mg were injected intravenously to establish general anesthesia, followed with 8.0 cuffed endotracheal intubation. After that, the right internal jugular vein was cannulated. Anesthesia was maintained by oxygen, air, isoflurane, and cisatracurium. Pressure-controlled mechanical ventilation with low peak inspiratory pressures, high PEEP, and high frequency maintained normal end-tidal CO2 levels, MAP of 90–100 mmHg, and central venous pressure (CVP) of 10–15 mmHg. Blood loss during surgery increased the severity of LVOT obstruction (LVOTO). With a 100-mmHg gradient, the TOE showed an empty LV, increased systolic anterior motion, and substantial LVOTO. To stabilize MAP, stop tachycardia and keep perfusion going; volume resuscitation and a 1 μg/kg/min phenylephrine infusion were needed because of blood loss and low blood pressure. We avoided inotropes. We gave methylprednisolone 1g pregraft implantation and furosemide (1 mg/kg) before vascular clamp release to induce renal graft diuresis. The transplanted kidney produced 250 ml of urine immediately. Paracetamol (1g) and intermittent fentanyl boluses provided intraoperative analgesia. We extubated the patient once his spontaneous breathing had sufficiently recovered and shifted him to the posttransplant unit. We used fentanyl (12.5 μg/h) and paracetamol for pain management after the surgery. After surgery, the patient was hemodynamically stable and had better renal function. Kidney transplantation (KT) in patients with ESRD, complicated by low EF, HOCM, and COPD, is feasible but poses significant anesthetic challenges. The presence of HOCM necessitates careful management due to the risk of arrhythmias and significant fluctuations in systemic vascular resistance, both of which are common in ESRD patients. Dialysis and KT can exacerbate blood loss and hypotension, further impairing hemodynamics in patients with HOCM by severely compromising early diastolic filling.[3,4] Thus, maintaining elevated afterload and preload, low heart rate, and negative inotropy is crucial in optimizing outcomes for these patients.[5] Declaration of patient consent The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Authors: Shilpa Sarang Kore, Jayant Bhatia, Hashika Jani
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4408969384