Dear Editor, Renal transplantation is a standard treatment for end-stage renal disease (ESRD), enhancing patients’ quality of life and longevity.1-3 However, in patients undergoing cadaveric renal transplants, it usually occurs as emergencies, giving less time for optimization. Preoperative preparation involves identifying and addressing risk factors to mitigate complications, as these recipients might have multiple comorbidities.4 The role of the anesthesiologist is crucial for the success of renal transplantation. Careful anesthetic management is critical in these cases to enhance surgical success and reduce the risk of complications. This case report highlights the anesthetic challenges encountered in a patient with ischemic heart disease (IHD), diabetes mellitus (DM), and hypertension (HTN) during a cadaveric renal transplant.4 A 54-year-old female with ESRD, weighing 68 kg, height of 142 cm, with a body mass index (BMI) of 33.7 kg/m2 was planned for cadaveric renal transplantation. The patient had suffered from uremic encephalopathy, for which she was on prolonged ventilatory support and needed tracheostomy later. Since then, she has been on hemodialysis thrice weekly. Her comorbidities included diabetes for 25 years, managed with insulin aspart and insulin glargine, HTN for 18 years, controlled with prazosin, nicardipine, isosorbide, and hydralazine, and clinical depression for 5 years, managed with an antidepressant. Additionally, she had IHD for 4 years, underwent percutaneous transluminal coronary angioplasty 2 years back with a drug-eluting stent, and was maintained on 75 mg of aspirin daily. Given her cardiac history and ongoing aspirin therapy, careful optimization of anticoagulation was essential to balance thrombotic and bleeding risks during the perioperative period. She was also treated for extrapulmonary mediastinal tuberculosis 3 years ago. Ear–nose–tongue (ENT) evaluation confirmed normal vocal cord mobility with no active tracheal stenosis. High-resolution computed tomography (CT) thorax revealed consolidation in the posterior segment of the left lower lobe and bilateral lower zone parenchymal bands. The tracheal lumen appeared patent on axial and sagittal reconstructions, with no narrowing or calcifications observed. However, considering the prior tracheostomy and prolonged intubation, a difficult airway plan was prepared, which included fiberoptic bronchoscopy, an emergency tracheostomy set, and an ENT specialist standby Figure 1. General examination showed a moderately nourished, obese female, vitally stable female with a post-tracheostomy scar over the midline of the neck. Investigations revealed old ischemic changes on ECG Figure 2, including prominent Q waves and ST depression. A two-dimensional echocardiography revealed mild concentric left ventricular hypertrophy, an ejection fraction of 50%, trivial tricuspid regurgitation, and grade one diastolic dysfunction. Given these multiple conditions, a thorough preoperative assessment and collaboration among anesthesiologists, nephrologists, intensivists, and cardiologists were essential for optimizing the patient for surgery.Figure 1: X-ray antero-posterior lateral view (red circle showing tracheostomy part and stenosis part)Figure 2: ECG showing prominent Q wave and mild ST changesThe risks associated with anesthesia and surgery were discussed with the patient and her relatives. Consent for intensive care unit (ICU) and ventilatory support, along with potential invasive procedures, was obtained. Preoperative optimization of her comorbidities was carefully performed. Antihypertensives were continued with cautious titration to avoid hypotension and maintain optimal renal perfusion. Strict glucose control was maintained perioperatively to reduce infection risk and delayed wound healing, with insulin infusion adjusted to maintain euglycemia. In the operating room, general anesthesia was induced with fentanyl (2 mcg/kg) and etomidate (0.3 mg/kg), followed by cis-atracurium (0.2 mg/kg). After preoxygenation with 100% O2 for 3 min, the airway was secured with a 7 mm endotracheal tube, intubation assisted by video laryngoscopy, and 10% lignocaine sprayed to reduce the laryngoscopy response. Anesthesia maintenance involved O2: Air and isoflurane. The right arterial line, right central line, was secured for invasive monitoring. Normal saline was chosen as the primary intraoperative fluid owing to institutional protocol and the patient’s ongoing metabolic acidosis, despite balanced salt solutions being favored in the current literature. This decision was guided by electrolyte trends and close arterial blood gas (ABG) monitoring. Euvolemia was maintained to optimize graft perfusion while avoiding fluid overload. Nephrotoxic drugs were avoided, and renal ischemia time was minimized. The intraoperative course remained uneventful. The patient was extubated and transferred to the ICU for close monitoring of vital signs and renal function. Postoperative analgesia included paracetamol and dexmedetomidine infusion was kept at 0.5 mcg/kg/h dose, and fentanyl patch (25 mcg/h) was attached over the left shoulder below the clavicle. Although other modalities include epidural/TAP block/morphine, oxycodone, or fentanyl IV, patient-controlled anlagesia is preferred over morphine due to a better safety profile in patients with ESRD. These options help minimize the risk of accumulation and adverse effects in renal-compromised individuals. Her recovery was stable, with well-controlled cardiac function, blood glucose levels, and blood pressure. Post-transplant renal function showed improvement. Anesthetic management of patients with IHD, DM, and HTN poses significant challenges due to factors such as poor left ventricular systolic function, ventricular enlargement, diabetic cardiomyopathy, and autonomic neuropathy.3,5 The prevalence of coronary artery disease (CAD) among dialysis patients is approximately 40%–50%, with many cases being asymptomatic due to uremia-related alterations in pain perception.6 Advanced monitoring devices like transesophageal echocardiography and invasive BP monitoring can assess ventricular function.1 ESRD patients often have a higher incidence of CAD, increasing morbidity and mortality. Altered pharmacodynamics and pharmacokinetics of anesthetic drugs, along with risks of fluid overload, left ventricular hypertrophy, and electrolyte imbalances, must be considered. Close monitoring of ABG and serum electrolytes is necessary, with particular attention to hyperkalemia. Adequate aspiration prophylaxis is also recommended to mitigate gastrointestinal risks.1 Immunocompromised patients require stringent infection control measures and adjustments in immunosuppressive therapy to protect against infections. These conditions necessitate a thorough and individualized approach to ensure patient safety and successful transplantation.3,7 Specific consideration in this case was the post-tracheostomy status of the patient, as they may end up in difficulty. Other important considerations are perioperative management of input–output and blood sugar levels, optimal fluid management, and avoiding nephrotoxic drugs and drugs causing hyperkalemia. Care was also taken to prevent the use of drugs that could increase myocardial oxygen demand. Intraoperatively, mean arterial pressure was maintained within the range of 80–90 mmHg, and central venous pressure was kept between 8 and 11 mmHg to support adequate graft perfusion and cardiovascular stability throughout the procedure.8-10 Renal transplantation is an intermediate-risk procedure, with transplant patients often being among the most complex. Extensive preoperative workup is essential for risk stratification and developing a tailored perioperative treatment plan.1 In conclusion, this case illustrates the successful perioperative management of a patient with IHD, DM, and HTN undergoing cadaveric renal transplantation. Although challenging, the process is highly rewarding when performed with meticulous attention to the pathophysiological changes associated with ESRD. The collaborative team effort involving anesthesiologists, nephrologists, cardiologists, and intensivists was crucial for achieving optimal outcomes. Thorough presurgical evaluation, vigilant intraoperative monitoring, and meticulous postoperative care are essential to optimizing outcomes and minimizing complications. Future research and guidelines may further refine the perioperative care of such complex patients, enhancing success rates in cadaveric renal transplants.7 Declaration of patient consent Appropriate written informed consent of the patient and her father was obtained for publication of images and other clinical information in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Data availability statement All data generated or analyzed in this case report are included in this published article. No additional data sets were generated or analyzed. Authorship criteria All authors have contributed to the patient management, manuscript design, drafting and revision, and approving the final version, and are accountable for aspects of the work. This letter has not been presented at any meet or submitted for publication. This letter has been read and approved by all the authors; all above mentioned authorship criteria have been met; and the authors believe that the letter represents honest work. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Veer et al. (Fri,) studied this question.