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Pediatric renal transplantation: anesthesia and perioperative complications
G Della Rocca1, M G Costa, K Bruno
1Istituto di Anestesiologia e Rianimazione, University of Rome La Sapienza, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
Insights
Pediatric kidney transplantation (Ktx) requires careful anesthetic management for high-risk patients. This study found that while Ktx is predictable, younger children and those with lower body weight face increased complications, emphasizing the need for precise perioperative care.
Area of Science:
- Anesthesiology
- Pediatric Surgery
- Nephrology
Background:
- Pediatric kidney transplantation (Ktx) demands anesthetic strategies minimizing toxicity and managing high-risk patients.
- Patients undergoing Ktx often present with metabolic, cardiovascular, and respiratory challenges.
- Evaluating anesthetic management and outcomes is crucial for improving pediatric Ktx procedures.
Purpose of the Study:
- To assess anesthetic management and postoperative outcomes in pediatric kidney transplant recipients.
- To identify factors influencing complications and renal function recovery post-Ktx.
- To analyze the impact of donor type (cadaveric vs. living donor) and patient characteristics on Ktx success.
Main Methods:
- Retrospective analysis of 75 pediatric Ktx patients (1988-1999).
- Detailed review of anesthetic agents, monitoring techniques, and perioperative care.
- Statistical evaluation of complications, renal function recovery, and survival rates using chi-square, Student's t-test, and Kaplan-Meier methods.
Main Results:
- Overall survival was high, with 58 patients alive and well after a mean follow-up of 57.6 months.
- No peri- or postoperative complications were observed in living donor (LD) recipients.
- Patients younger than 12 years and weighing less than 25 kg showed lower intraoperative renal function recovery (P < 0.05).
Conclusions:
- Pediatric Ktx can be a predictable procedure with advances in surgical and anesthetic care.
- Meticulous anesthetic and postoperative management is vital for controlling mortality and morbidity in high-risk pediatric transplant patients.
- Younger children and those with lower body weight require specialized attention due to increased complication risks.
Abstract:
The appropriate choice of anesthesia for patients (pts) undergoing renal transplantation (Ktx) requires minimal toxicity and accurate monitoring for pts at high risk for metabolic, cardiovascular, and respiratory perioperative complications. We evaluated the anesthetic management and postoperative follow-up in pediatric Ktx performed in the last 12 years in our institution. From 1988 to 1999, 75 ASA class II-III pts (45 males, 22 females) younger than 18 years scheduled for Ktx were studied: 49 received a graft from a cadaveric donor (CD) and 26 from a living donor (LD). All pts were treated with dialysis within 24 h before the procedure. Standard monitoring consisted of an electrocardiogram, central venous pressure, non-invasive arterial pressure, pulse oximetry, and inspiratory and expiratory gas analysis. If necessary, an arterial cannula and pediatric pulmonary catheter were introduced. Anesthesia was induced with sodium thiopental, propofol, halothane, or sevoflurane and maintained with isoflurane and/or fentanyl and droperidol in O2:N2O (FiO2 0.4%). As muscle relaxants atracurium or cisatracurium besilate were used, except in allergic pts, in whom vecuronium or rocuronium bromide was administered. Dopamine, 20% mannitol, and furosemide were used to increase diuresis. Continuous morphine and ketoralac infusions were used for postoperative pain relief. The surgical technique was the same in all cases. Complications and renal-function (RF) recovery were evaluated relating to CD and LD using the chi-square test; differences in mean anesthesia and surgical time were evaluated by Student's t-test; survival curves were calculated from the day of Ktx to death or last follow-up and estimated by the Kaplan-Meier method. Values of P below 0.05 were considered significant. Postoperative immunosuppressive therapy was based on cyclosporine together with other conventional drugs. Mean anesthesia time was 228 +/- 65 min. Mean kidney ischemia time for CD was 16.5 +/- 4 h. Four pts (3 CD, 1 LD) died within 72 h postoperatively: 3 due to cardiac failure and 1 to metabolic coma. Six pts showed cardiovascular and 3 had infective complications, all successfully treated. Three pts (2 CD, 1 LD) died within 2 to 12 months after, surgery; 10 (6 CD, 4 LD) had graft failure and are still alive on dialysis; 58 (38 CD, 20 LD) are alive in good health after a mean follow-up of 57.6 +/- 36.6 months (range 12-120 months). Fifteen of 26 pts younger than 12 years (21 CD and 5 LD) recovered RF intraoperatively (10 CD, 5 LD); 1 with CD and 1 with LD showed postoperative graft failure and 2 with CD died within 72 h postoperatively, 22 (18 CD and 4 LD) are alive in good health. This group showed no statistical difference compared to pts older than 12 years. Of 16 pts (15 CD and 1 LD) with body weight (BW) less than 25 kg, 6 showed intraoperative (5 CD, 1 LD) recovery of RF. The 3 deaths were all in CD pts, 2 within 72 h and one 2 months after surgery; only 1 LD had postoperative graft failure. Twelve pts (75%) (12 CD, 80%) are alive in good health. Compared to pts with BW of 25 kg or more, this group showed lower intraoperative recovery of RF (P < or = 0.05). No peri- and postoperative complications occurred in all 26 LD pts (100%). Recent advances in surgery, anesthesia, immunosuppression, and antimicrobial prophylaxis have made Ktx a more predictable procedure even in pediatric pts. For high-risk pts, mortality and morbidity can be controlled by accurate surgical, anesthetic, and postoperative management. Pts younger than 12 years and with BW less than 25 kg are more likely to develop peri- and postoperative complications.