Pediatric renal transplantation: anesthesia and perioperative complications

The appropriate choice of anesthesia for patients (pts) undergoing renal tr ansplantation (Ktx) requires minimal toxicity and accurate monitoring for p ts at high risk for metabolic, cardiovascular, and respiratory perioperativ e complications. We evaluated the anesthetic management and postoperative f ollow-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: 39 received a graft from a c adaveric donor (CD) and 26 from a living donor (LD). All pts were treated w ith dialysis within 24 h before the procedure. Standard monitoring consiste d of an electrocardiogram, central venous pressure, non-invasive arterial p ressure, pulse oximetry, and inspiratory and expiratory gas analysis. If ne cessary, an arterial cannula and pediatric pulmonary catheter were introduc ed. Anesthesia was induced with sodium thiopental, propofol, halothane, or sevoflurane and maintained with isoflurane and/or fentanyl and droperidol i n O-2:N2O (FiO(2) 0.4%). As muscle relaxants atracurium or cisatracurium be silate 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 relati ng to CD and LD using the chi-square test; differences in mean anesthesia a nd surgical time were evaluated by Student's t-test; survival curves were c alculated from the day of Ktx to death or last follow-up and estimated by t he 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. Me an 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 c oma. Six pts showed cardiovascular and 3 had infective complications, all s uccessfully treated. Three pts (2 CD, 1 LD) died within 2 to 12 months afte r, surgery; 10 (6 CD, 4 LD) had graft failure and are still alive on dialys is; 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 wit hin 72 h postoperatively, 22 (18 CD and 4 LD) are alive in good health. Thi s group showed no statistical difference compared to pts older than 12 year s. Of 16 pts (15 CD and 1 LD) with body weight (BW) less than 25 kg, 6 show ed intraoperative (5 CD, I LD) recovery of RF. The 3 deaths were all in CD pts, 3 within 72 h and one 2 months after surgery; only 1 LD had postoperat ive 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 intraoper ative recovery of RF (P I 0.05). No peri- and postoperative complications o ccurred in all 26 LD pts (100%). Recent advances in surgery, anesthesia, im munosuppression, and antimicrobial prophylaxis have made Ktx a more predict able procedure even in pediatric pts. For high-risk pts, mortality and morb idity 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.