|Ahead of print publication
End-stage renal disease and dilated cardiomyopathy: A retrospective analysis in renal transplant patients
Vipin Kumar Goyal, Khayyam Moin, Mangilal Deganwa, Vishnu Kumar Garg, Ganesh Nimje
Department of Anesthesiology, Critical Care and Pain Management, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
|Date of Submission||12-Jul-2021|
|Date of Decision||07-Aug-2021|
|Date of Acceptance||07-Aug-2021|
Vishnu Kumar Garg,
Department of Anesthesiology, Critical Care and Pain Management, Mahatma Gandhi Medical College and Hospital, Sitapura, Jaipur - 302 022, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: End-stage renal disease is the last stage of progressive renal failure that is almost always accompanied by cardiovascular complications such as systemic and/or pulmonary hypertension, atherosclerosis, dilated cardiomyopathy (DCM), valvular regurgitation, and so on. Among these, DCM is a common preoperative echocardiographic finding that necessitates specialized treatment. Materials and Methods: Patients with DCM who underwent renal transplantation using an intraoperative goal-directed strategy for fluids, inotropes, and vasopressors were included in this retrospective study. The demographics of the patients, their preoperative comorbidities, investigations, echocardiographic data, intraoperative parameters, and postoperative data and complications were all recorded and analyzed. Results: Hypotension was the most common intraoperative complication in 10 out of 22 patients (95% confidence interval: 0.24–0.66). There were no other major cardiopulmonary complications in any of the patients. There were no renal complications, such as delayed graft function or acute tubular necrosis, in any of the patients. Conclusions: Fluids, inotropes, and vasopressors must all be managed carefully during the perioperative period in DCM patients. The use of advanced dynamic indices is critical not only for achieving goals but also for avoiding complications.
Keywords: Chronic kidney disease, complications, dilated cardiomyopathy, end-stage renal disease, goal directed, renal transplantation
|How to cite this URL:|
Goyal VK, Moin K, Deganwa M, Garg VK, Nimje G. End-stage renal disease and dilated cardiomyopathy: A retrospective analysis in renal transplant patients. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 1]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=336713
| Introduction|| |
End-stage renal disease (ESRD) is the final stage of chronic kidney disease (CKD) and defined as glomerular filtration rate <15 ml/min/1.73 m2. Dialysis (peritoneal or hemodialysis) and renal transplantation are the best available treatment modalities for these patients. Long-term renal disease causes a variety of physiological changes, including cardiovascular (systemic and pulmonary hypertension, dilated cardiomyopathy (DCM), coronary atherosclerosis, left ventricular failure, and/or pericardial effusion), pulmonary (pleural effusion and restrictive lung disease), anemia, coagulopathies, acid–base and electrolyte imbalance, and so on. Out of these, cardiovascular complications are the most common causes of morbidity and mortality in these patients. Patients on long-term dialysis very often develop DCM. It is characterized as progressive heart muscle weakness that results in chamber dilatation and impaired ventricular wall contraction in one or both ventricles. Left ventricular ejection fraction (EF) 40% and fractional shortening 25% on transthoracic echocardiography are diagnostic criteria for DCM. Although the exact pathophysiology of DCM in patients with ESRD is unknown, recurrent volume overload, elevated blood pressure, and pulmonary hypertension are typical etiologies. Dysrhythmias, left ventricular failure, pulmonary edema, need for postoperative ventilation, need for vasopressor or inotropic support, need for ventricular support device, and sudden cardiac death are the most common perioperative complications in patients with DCM undergoing major noncardiac surgery.,,,,, In particular with renal transplant surgery, perioperative factors such as dialysis, acid–base imbalance, anemia, blood loss, and the release of inflammatory mediators are major determinants of constant changes in fluid status and tissue perfusion. In addition to the cardiopulmonary effects, poor tissue perfusion causes tubular necrosis in newly grafted kidneys, resulting in reduced urine output and increased creatinine. Optimal management of hemodynamics, fluids, inotropes, and vasopressors is crucial for better graft and patient survival.
Most centers have traditionally used pressure-based hemodynamic parameters including mean arterial pressure (MAP) and central venous pressure (CVP) as targets for fluid guidance during renal transplantation. These criteria have been shown to be inconsistent and substandard in a variety of studies.,, In moderate-to-high-risk abdominal surgeries, goal-directed therapy using newer flow-based indices is a better predictor of fluid responsiveness., In this retrospective study, we investigated the perioperative outcome of goal-directed therapy in patients with DCM who underwent renal transplantation.
| Materials and Methods|| |
This retrospective analysis was carried out in the department of anesthesiology after getting approval from the hospital ethical committee (MGMCH/IEC/JPR/2019/02). Medical records of patients who underwent a renal transplant at our center between June 2018 and December 2019 were collected from the medical record department, and data of recipients with an EF of <40% on two-dimensional echocardiography the day before surgery were shorted out and analyzed in detail [Figure 1].
All patients underwent an extensive preoperative workup for renal transplantation candidacy and fitness, as per institutional protocol, which included clearance from various specialties such as nephrology, urology, cardiology, and a chest physician, among others. All transplant candidates underwent routine general and systemic examinations as well as laboratory testing. Patients with an EF of <40% on two-dimensional echocardiography the day before surgery, as well as their families, were informed regarding their poor cardiac status and potential perioperative complications. All patients signed a written informed high-risk consent form. Before surgery, a tablet of alprazolam 0.5 mg was given at night, and overnight fasting was confirmed. Cardiac drugs and immunosuppressants were kept on schedule until the morning of surgery.
The patient was attached with standard anesthesia monitors, including a 5-lead electrocardiogram and an oxygen saturation (Spo2) monitor. Following local infiltration, a 20 G arterial catheter was inserted in the radial artery and a 7.5 F triple-lumen CVP catheter was inserted in the internal jugular vein under strict aseptic conditions and linked to the EV1000 platform through FloTrac transducer (Edwards Lifesciences, Irvine, CA). The baseline MAP, stroke volume variance (SVV), cardiac index (CI), CVP, and systemic vascular resistance index (SVRI), as well as other vital parameters, were all documented and tracked during surgery. Following intravenous injections of fentanyl 3 g/kg and midazolam 1 mg, anesthesia was induced with intravenous etomidate 0.3 mg/kg. The trachea was intubated 3 min after receiving a 0.2 mg/kg cisatracurium intubation dose and connected to positive pressure ventilation, with a tidal volume of 8 ml/kg based on ideal body weight. During surgery, anesthesia was maintained using oxygen with nitrous oxide (40:60), isoflurane, and cisatracurium infusion. During surgery, crystalloids were given 0.9% saline and a balanced salt solution (Kabilyte, Fresenius Kabi) at a rate of 5 ml/kg/h. In patients with a preoperative serum albumin level of <3 g/dL, 100 mL of 20% albumin was used. If hemoglobin was <7 g/dL, packed red cells were transfused. After induction, monoclonal or polyclonal antibodies were administered through a separate central line port as per protocol. Before and after reperfusion, the MAP hemodynamic target was kept ≥70 mmHg and ≥90 mmHg, respectively. SVV was used to guide intraoperative fluid (SVV ≤10 = no fluid and SVV >15 = 200 ml bolus of 0.9% saline). When SVRI and CI were <2000 dyne-s/cm-5/m2 and <2.5 ml/kg/m2, respectively, norepinephrine or dobutamine infusions were used [Figure 2]. Arterial blood was drawn after the insertion of an arterial catheter and at the completion of surgery for measurement of any changes in blood gas, acidbase balance, and electrolytes. After adequate anesthesia reversal, the trachea was extubated, and the patients were transferred to the renal transplant unit for postoperative care.
Any perioperative complications were recorded, including cardiac arrhythmia, the need for vasopressors or inotropes, oxygen desaturation, pulmonary edema, postoperative ventilator support, left ventricular assist device, pacing, decreased urine production, increased creatinine, and the need for hemodialysis.
| Results|| |
Between June 2018 and December 2019, a total of 295 patients underwent a renal transplantation at our hospital. We excluded patients who had received an organ from a deceased donor and had an EF of <40% or who had a re-exploration in the postoperative period. Finally, this study involved 22 patients with DCM on preoperative echocardiography and intraoperative fluid guidance with a goal-directed approach.
Patient demographics (age, gender, height, weight, duration of CKD, and dialysis), associated medical illnesses (hypertension, coronary artery disease, diabetes mellitus, pulmonary tuberculosis, thyroid disorders, and so on), preoperative hemoglobin, serum albumin, and EF were all recorded [Table 1]. DCM was found to be 7.45% (95% confidence interval [CI]: 0.0446–0.1046) in our study. The average age of the recipients was 35.86 ± 11.02 years. This study revealed a high rate of DCM in young patients with a male preponderance. The median CKD and hemodialysis durations were 18 and 4 months, respectively. There was no history of peritoneal dialysis or preemptive transplantation in any of the patients. Hypertension was the most prevalent comorbid condition, followed by pulmonary tuberculosis, pleural effusion, diabetes mellitus, and hypothyroidism. The majority of the patients were anemic, with a mean hemoglobin of 10.09 g/dL and a low serum albumin of 3.37 g/dL. On preoperative echocardiography, the mean EF was 31.6 ± 5.6%. Only one patient had the lowest EF on preoperative echocardiography, which was 15%. In addition to low EF, global hypokinesia, concentric left ventricular hypertrophy, pulmonary hypertension, valvular regurgitation, and diastolic dysfunction were other common echocardiographic findings.
The average time for anesthesia and surgery was 2.5–3 h. Intraoperative fluids were mostly 0.9% saline and Kabilyte in almost equal quantities (913.64 ± 126.45 ml and 959.09 ± 95.45 ml, respectively). Only one patient received red blood cells, whereas seven others received albumin 20% (preoperative albumin of 3 g/dL). The amount of blood loss during surgery was 274.55 ± 25.95 ml. The majority of the donors were women, and all prospective donors had undergone a routine medical examination and clearance from different departments to be eligible to donate an organ. The average warm ischemia time was between 3 and 5 min. Harvested kidneys were perfused with cold solutions of lactated Ringer with papaverine, 2% lignocaine, hydrocortisone, and heparin. The times for cold ischemia and anastomosis were 39.55 ± 6.86 and 29.36 ± 4.03, respectively. Before renal reperfusion, all patients were given 500 mg of methylprednisolone. Urine production began almost immediately after the vessels were declamped. No mannitol or loop diuretics were given to any of the recipients. There was no evidence of rejection in any of the patients in the operating room [Table 2]. At the completion of surgery, arterial blood gas analysis showed no change in serum sodium or potassium, but slight increases in serum lactate, chloride, and glucose, as well as a mild decrease in blood pH and bicarbonates from baseline [Table 3].
Perioperative hypotension was the most common observed complication, with a 45.45% (95% CI: 0.240.66) overall occurrence. To achieve intraoperative goals, nine patients required low-dose norepinephrine infusions (low SVRI), whereas one patient required dobutamine (low CI). Other observed cardiopulmonary complications were not reported in any of the patients, with the exception of one patient who experienced desaturation during the intraoperative period, which was managed with the addition of positive end-expiratory pressure and an increase in the fraction of inspired oxygen. On the first postoperative day, the mean urine output was 13.33 ± 2.69 liters and the mean serum creatinine was 2 ± 0.52 mg/dL. There was no evidence of acute tubular necrosis or delayed graft function in any of the patients [Table 4]. All of the patients were discharged with stable vital signs and good kidney function.
| Discussion|| |
With the increasing prevalence of hypertension and diabetes mellitus in society, ESRD, the end result of long-term CKD, has risen considerably in recent decades. Cadaveric organ donation is not common in developing countries like India, resulting in an increase in the number of dialysis patients. Cardiopulmonary (hypertension, coronary artery disease, DCM, left ventricular failure, pleural effusion, and restrictive lung disease), metabolic and electrolyte imbalance (hyperkalemia, hypocalcemia, and acidosis), hematologic (anemia and platelet dysfunction), and/or endocrine alterations are the most common systemic changes associated with CKD and dialysis. Among these, cardiopulmonary diseases are the most common cause of death during dialysis and transplantation. DCM is very common in renal transplant recipients who undergo a preoperative workup. Because symptoms and signs of cardiac failure, such as dyspnea on exertion, pedal edema, or poor exercise tolerance, conflict with renal disease, most patients require preoperative transthoracic echocardiography. Uremia-induced cardiac weakness and dilatation is the primary cause of DCM in affected individuals, particularly the young. Other possible etiologies of DCM, such as ischemic, drug-induced, toxic, or infectious, must be ruled out.,
Patients with DCM who are undergoing a renal transplant need a multidisciplinary approach that includes an anesthesiologist, surgeon, intensivist, nephrologist, and cardiologist. Overall evaluation of the perioperative risk involved, as well as clarification to the patient and family about the condition and its effects, is important, as is documentation.
Before inducing anesthesia, invasive lines (arterial and central) must be inserted. For better hemodynamic control, general anesthesia with minimally depressing anesthetic agents is preferred over neuraxial anesthesia., Typical intraoperative challenges for anesthesiologists include maintaining different hemodynamic targets before and after reperfusion, optimum fluid, vasopressor, and/or inotropes for proper renal perfusion without cardiopulmonary derangement, and maintaining normal metabolic and electrolyte levels. CVP of 12–15 mmHg and MAP ≥85 mmHg were used as hemodynamic goals in previous studies to achieve sufficient graft perfusion. None of these parameters were effective to avoid hypo- or hypervolemia-related complications., Only 57% of patients in the intensive care unit and operating room who appeared to be hypovolemic based on CVP were fluid responders, according to Marik et al. meta-analysis, whereas the rest were unnecessarily loaded with fluids. Furthermore, a high CVP can disrupt renal flow, especially when the arterial pressure is low. Traditional hemodynamic monitoring with CVP and MAP is associated with a large number of complications in renal recipients with DCM during the perioperative period.
In moderate-to-high-risk surgeries, flow-based hemodynamic variables (SVV, pulse pressure variation, and stroke volume) are a better predictor of fluid responsiveness and are linked to fewer postoperative complications and earlier hospital discharge., Studies in kidney transplant recipients by Cavaleri et al. and Srivastva et al. support these findings., In a study of kidney transplant patients, Cavaleri et al. found that Perioperative goal-directed therapy (PGDT) decreases the rate of major complications and overall morbidity. Furthermore, in patients undergoing renal transplantation, intraoperative transesophageal Doppler-guided fluid therapy is associated with similar immediate graft functions but fewer postoperative complications.
The vascular response to released inflammatory mediators, fluctuations in blood pressure and fluid status, and rapid changes in acid–base and electrolytes make the immediate postoperative period, particularly vulnerable to complications. Hypovolemia can cause a decrease in urine output, which can lead to an increase in serum creatinine, necessitating dialysis. Fluid overload, on the other hand, can result in acute left ventricular failure, which can lead to oxygen desaturation, pulmonary edema, or the need for intubation and ventilatory support. CVP decreases in the immediate postoperative period for a variety of reasons, and targeting fluid through CVP can be dangerous. Our study's retrospective nature is a limitation. Prospective, case–control studies are needed in the future.
| Conclusions|| |
Renal transplantation in DCM patients almost always results in perioperative fluid imbalance complications, and traditional pressure-based parameters are insufficient to prevent complications. In high-risk patients undergoing renal transplantation, goal-directed therapy using advanced dynamic variables is desirable and appropriate.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]