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CASE REPORT
Year : 2009  |  Volume : 53  |  Issue : 4  |  Page : 489-491 Table of Contents     

Paediatric Auto Renal Transplantation-Anaesthetic Challenge


1 Asst Professor, Department of Anaesthesia and critical care, Christian Medical College & Hospital, Vellore-632004, India
2 Professor, Department of Anaesthesia and critical care, Christian Medical College & Hospital, Vellore-632004, India

Date of Web Publication3-Mar-2010

Correspondence Address:
P A Saravanan
Department of Anaesthesia and critical care, Christian Medical College & Hospital, Vellore-632004
India
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Source of Support: None, Conflict of Interest: None


PMID: 20640215

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Takayasu's arteritis is described to be the single most important cause of renovascular hypertension. Anaesthetising a child with Takayasu's arteritis for auto renal transplantation is a challenge as it is complicated by severe uncon­trolled hypertension, end-organ dysfunction resulting from hypertension, stenosis of major blood vessels affecting regional circulation, and difficulties encountered in monitoring arterial blood pressure. Abalanced anaesthetic tech­nique, maintenance of stable haemodynamics with monitoring is required for a successful outcome. We describe the anaesthetic management of a child with Takayasu's arteritis and severe hypertension refractory to medical treatment requiring auto renal transplantation.

Keywords: Takayasu′s arteritis, Paediatric, Auto renal transplantation, Anaesthesia


How to cite this article:
Saravanan P A, Jacob R, Sahajanandan R, Joselyn AS. Paediatric Auto Renal Transplantation-Anaesthetic Challenge. Indian J Anaesth 2009;53:489-91

How to cite this URL:
Saravanan P A, Jacob R, Sahajanandan R, Joselyn AS. Paediatric Auto Renal Transplantation-Anaesthetic Challenge. Indian J Anaesth [serial online] 2009 [cited 2020 Oct 19];53:489-91. Available from: https://www.ijaweb.org/text.asp?2009/53/4/489/60324


   Introduction Top


Severe persistent hypertension in childhood is mainly due to renal parenchymal disease with renovas­cular lesions being the second most common cause. Takayasu's arteritis is the single mostimportant cause of renovascular hypertension in non white children [1] . Takayasu's arteritis is characterizedby a focal stenosis process involving the aorta and the proximal segment of its major branches [2] . We present the anaesthetic management of a child with Takayasu's arteritis and severe hypertension refractoryto medical ireatmentre­quiring auto renal transplantation.


   Case report Top


A 4-year-old male child weighing 13 kg, pre­sented withhistory ofdyspnoea on exertion for 3 month duration. On examination, all peripheral pulses were palpable except on the right upperlimb. His blood pres­sure was 1401100 mm Hg in the left upper limb and was not recordable on the right upper limb. He was evaluated for secondary hypertension and foundto have Type III Takayasu's arteritis with aortography reveal­ing 99% stenosis of left main renal artery and 60% stenosis of the right main renal artery as well as occlu­sion of the right subclavian artery [Figure 1]. He had clini­cal and echocardiographic evidence of left ventricular dysfunction with normal renal functions. He was stabi­lized on tab.nifedepine 5mg Q4H, prazosinlmg Q6H, aldomet250mg Q8H, minoxidil 5mg Q12H, fiusemide 10 mg, digoxin 0.25 mg and aspirin once a day. He underwent balloon angiop las ty and stenting of left renal artery. He presented subsequently with a history of recurrent episodes of seizures and persistently elevated blood pressure. IVIRI brain revealed vasculitis induced multiple infarcts. Right auto renal transplantation was considered due to refractory hypertension and ongo­ing complication. Preoperative vitals revealed GCS of 14/15, heart rate of 96,lmin, absent right radial pulse with blood pressure in left upper limb of 170/110mmHg. His blood investigations were normal with serum crea­tinine of 0.9mg%. Chest roentgenogram revealed car­diomegaly and electrocardiogram left ventricular hy­pertrophy.

The patient was fasted and premedicated with Syp.Triclofos 75mg.kg -l . Under standard monitoring (Sp0 2 , non-invasive blood pressure, ECGy end-tidal CO, monitor, temperature), anaesthesia was induced with au; oxygen and sevoflurane. The trachea was in­tubated following atracurium administration and the patient mechanically ventilated. Underultrasound guid­ance, a SF triple lumen catheter was sited in the right internal jugular vein. The left femoral artery was se­lected for direct arterial pressure monitoring. Anaes­thesia was maintained with 50% mixture of air and oxygen, end-tidal is of lurane concentration of 1% with morphine, fentanyl and atracurium boluses as needed. Normocarhia was maintained to preserve cerebral per­fusion. Surgery was done in supine position. A good perfusion pressure of the transplanted kidney was en­sured by maintaining a systolic blood pressure of 130 mm Hg, C VP of 13-15 mmHg. Mannito10.5g.kg -1 was infused 20 minutes before clamp release. Blood loss was replaced with fresh whole blood. Urine output was more than 0.5 ml.kg -l .hr -1 after the anastamosis. The intraoperative period was uneventful. Arterialblood gas analysis was within normal knit and trachea extubated at the end of the procedure. Postoperatively, the child was monitored in the high dependency unit and had an unremarkable stay. Outpatient visit at 8 weeks revealed improved sensorium and blood pressure of 130 / 85mmHg in left upperlimb. Diethylene Tetramine Penta Acetate(D'1'PA) scan done at 8 weeks showed func­tioning of auto transplanted kidney [Figure 2] and antihypertensives were tapered. Colour doppler re­vealed good peifusion of transplanted kidney as char­acterizedby the reduction in the peaksystolic velocity from 244.1 cm/sec to 120.5 cm/sec. [Figure 3]


   Discussion Top


Patients with Takayasu's arteritis (TA) present for surgery either incidentally or more frequently for cor­rection of the consequences ofvascularocclusive dis­ease. Anaesthetising such a child for auto renal trans­plantation is a challenge as it is complicated by severe uncontrolled hypertension, end-organ dysfunction re­sulting from hypertension, steno sis ofmajor blood ves­sels affecting regional ciiwlation, and difficulties encoun­tered in monitoring arterial blood pressure [3] . Surgery is indicated in patients with uncontrolled hypertension, deteriorating renal function, lesions not amenable to angioplasty and transient response to angioplasty [4]. In our patient, auto renal transplantation was resorted to as he was not responding to antihypertensives and stenting of the steno sed left renal artery. Regional anal­gesia with epidural was not initiated in our patient as the risk of decrease in blood pressuremay be hazard­ous in ap atient with compromised regional circulation because of stenosed arteries [5],[6] . This haemodynamic instability can also result in reduced graft function [7] .We used isoflurane to maintain the blood pressure at basal preoperative levels, decrease the cerebral metabolic rate of oxygen and produce cerebral vasodilatation.

Sudden hypertensive orhypotensive episodes are avoided intraopemtively so as to prevent possible cere­bro vascular or cardiovascular crises [1] . Invasive arterial and venous pressuremonitoring is considered manda­tory as excessive hemo dynamic variations could have serious consequences for regional organ perfusion. However, pulmonary artery catheterization was not performed in view of the potential risks exceeding the possible benefits in a small child [1],[3] .The factors affect­ingthe transplanted kidney's viability are intravascular volume and perfusion pressure. Adequate intravascu­larvolume is the single most important determinant of immediate graft function. ACVP of 12- 14 mmHg is recommended to maintain optimal intravascular volume [8]. Acute tubular necrosis can result from inadequate hydration and leads to delayed graft function, decreased graft survival and increased patient morbidity. Manni­tol when combined with volume expansion has been shown to decrease the incidence of acute tubular ne­crosis after transplantation.Routine use of inotropes is not warranted and vasopressors should be given as the last resort [3]. Unexplained hypotension and inad­equateresp onse to inotropes may be due to underlying metabolic acidosis and should be corrected. These patients warrant intensive care stay in post operative period. Our patient had stable haemodynamics during the intraoperative period probably due to a balanced anaesthetic technique and CVP guided volume replace­ment.

Anaesthetising a child with Takayasu's arteritis for an auto renal transplantation is a challenge due to the various pathological and hemodynamic changes in­volved. Successful outcome depends on preoperative optimisation, intra operative maintenance of stable he­modynamics and invasive monitoring during perioperative period.



 
   References Top

1.Rozwadowski MA, Downing SW Anaesthetic manage­ment for nephrectomy in a child with Takayasu's arteri­tis and severe renovascular hypertension. S Mr Med J 1985;67:898-900.  Back to cited text no. 1      
2.Wang PK, Luo BH, Chen A, YiLee, Lai HY Anesthetic considerations in Takayasu's arteritis-Acase report. Tzu ChiMedJ2006;18:53-56.  Back to cited text no. 2      
3.Kathirvel S, Chavan S, Arya V K, RehmanI, Babu V Malhotra N, et al. Anesthetic management of patients with Takayasu's arteritis: A Case Series and Review . Anesth Analg 2001;93:60-5.  Back to cited text no. 3      
4.Bha11aA, D' Cruz S, Lehl SS, SinghR. Renovascular hy­pertension-Its evaluation and management. JIACM 2003;4:139-46.  Back to cited text no. 4      
5.Ishikawa K, Matsuura S. Occlusive thromboaortopathy (Takayasu's disease) and pregnancy: clinical course and management of 33 pregnancies and deliveries. Am J Cardiol 1982;50: 1293-300.  Back to cited text no. 5      
6.Wiebers DO. Ischemic cerebrovascular complications of pregnancy. ArchNeurol 1985; 42: 1106-13.  Back to cited text no. 6      
7.Sahajananda H, Jyothi, Punithavathy. Renal transplan­tation with and without epidural analgesia-A review of 6 years of experience. Indian JAnaesth 2006; 50:187­192.  Back to cited text no. 7      
8.Reyle-Hahn M, Max M, Kuhlen R, Rossaint R. Preop­erative and postoperative anaesthesiological manage­ment in patients undergoing liver or kidney trans­plantation. Acta Anaesthesiol Scand Suppl 1997;41:80-84.  Back to cited text no. 8      


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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