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Kidney transplantation in adults: Nontransplant surgery in the kidney transplant recipient

Kidney transplantation in adults: Nontransplant surgery in the kidney transplant recipient
Author:
Ron Shapiro, MD
Section Editor:
Daniel C Brennan, MD, FACP
Deputy Editor:
Albert Q Lam, MD
Literature review current through: Jan 2024.
This topic last updated: Jan 05, 2024.

INTRODUCTION — As both the short- and long-term outcomes after solid organ transplantation continue to improve, an increasing number of recipients require medical care not specifically related to their transplanted organ. Some require elective or emergency surgery.

Many of the principles of peri- and intraoperative management are the same in transplant and nontransplant patients. However, there are a few important differences. It is strongly recommended that the transplant center be consulted prior to any planned surgical intervention in kidney transplant recipients.

Some of the general issues concerning nontransplant surgery in the transplant patient will be discussed here, as well as a few specific surgical problems. General discussions of the pre- and perioperative medical management of patients are presented separately.

GENERAL CONSIDERATIONS — The clinician must integrate information from the history, physical examination, and laboratory tests to develop an initial estimate of perioperative risk. One major issue is the possible presence of significant coronary artery disease among those undergoing noncardiac surgery, a common finding among kidney transplant recipients. (See "Risk factors for cardiovascular disease in the kidney transplant recipient".)

A number of clinical and surgical determinants have been identified that allow cardiac risk stratification. The evaluation of patients with known or suspected cardiac disease prior to noncardiac surgery requires an appraisal of the patient's clinical risk profile in the context of the surgery to be performed and the attendant risks. Discussions of such an evaluation, as well as the general preoperative evaluation of patients, are presented separately:

(See "Preoperative medical evaluation of the healthy adult patient".)

(See "Evaluation of cardiac risk prior to noncardiac surgery".)

(See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient".)

Glucocorticoids — When transplant recipients principally relied upon azathioprine-based immunosuppression regimens, chronic doses of glucocorticoids were relatively high, with characteristic side effects observed in many transplant recipients. Adrenal suppression related to the higher maintenance doses of steroids was common, requiring the administration of high perioperative doses of glucocorticoids.

With the advent of more potent maintenance immunosuppressive agents (such as cyclosporine, tacrolimus, mycophenolate mofetil, and sirolimus), maintenance glucocorticoids are either avoided entirely or the doses are markedly reduced. Thus, adrenal suppression has become much less of a problem.

In general, the administration of high doses of glucocorticoids is usually unnecessary and may be relatively contraindicated. Giving such doses is not entirely benign and can occasionally be associated with gastritis, bleeding, induction of diabetes, and worsening of glycemic control (see "Major adverse effects of systemic glucocorticoids"). Although cumbersome, not always practical, and somewhat unreliable, the cosyntropin stimulation test can be used to help assess adrenal reserve. A discussion on how to assess such patients can be found elsewhere [1-4]. (See "Glucocorticoid withdrawal".)

The following two regimens may be utilized in patients considered to have suppression of the hypothalamic-pituitary-adrenal axis:

One approach is to provide high doses of glucocorticoid to those with proven or suspected adrenal insufficiency, starting at the time of induction of anesthesia. A continuous infusion of 10 mg of hydrocortisone per hour or the equivalent amount of dexamethasone or prednisolone eliminates the possibility of glucocorticoid deficiency as the cause of an adverse event (such as hypotension), thereby allowing the actual cause (hemorrhage or volume depletion) to be identified and treated.

The glucocorticoid dose can be halved the day after surgery, and the maintenance dose usually can be resumed the second postoperative day. This amount of glucocorticoid for this amount of time carries a negligible risk of adverse effects; however, prolonged postoperative pharmacologic glucocorticoid therapy can mask symptoms and signs of infection and produce undesirable side effects.

The other regimen utilizes parenteral hydrocortisone "boosts." Generally, 100 mg of hydrocortisone is given intravenously every eight hours perioperatively, and the dose is slowly reduced (but not the frequency) until the patient can be switched to his or her regular doses of oral medications.

For convenience, we administer intermittent, rather than continuous, parenteral hydrocortisone.

The maintenance immunosuppressive agents that the patient is receiving are continued in the perioperative period; dose modification is usually unnecessary.

Antibiotic prophylaxis — In general, chronically immunosuppressed transplant patients may be considered at higher risk to develop infectious complications after surgical, endoscopic, or dental procedures. Routine antibiotic prophylaxis, either with a first-generation cephalosporin or, in the case of dental procedures, oral amoxicillin, is ordinarily sufficient in most cases [5]. Patients who receive prophylactic antibiotics within a two-hour "window" period before the initial incision have lower rates of surgical-site infection than patients who receive them either too early or postoperatively. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Two macrolides, erythromycin and clarithromycin, should be avoided in patients being administered cyclosporine or tacrolimus as these antibiotics antagonize the CYP 3A4 enzyme system, leading to elevated levels of cyclosporine and tacrolimus. Although azithromycin is also a macrolide, it does not significantly affect this enzyme system, and its use usually does not alter cyclosporine or tacrolimus levels. Other safe alternatives are ciprofloxacin and clindamycin, which also do not significantly affect cyclosporine or tacrolimus levels.

Tissue integrity and wound healing — Chronically immunosuppressed patients, even those on low doses of glucocorticoids, may frequently be noted intraoperatively to have "weak" tissues. Although gentle handling of tissues is an old and well-accepted surgical principle, it is particularly important in the technical performance of surgical procedures in transplant patients. (See "Complications of abdominal surgical incisions".)

Wound healing is generally slower in immunosuppressed patients [6]. As an example, when skin staples are utilized, they may need to be kept in up to three times longer than in nontransplant patients [7].

A related issue is whether specific immunosuppressive agents may enhance wound-healing complications, even during the period immediately posttransplantation. Some evidence suggests that sirolimus may lead to a higher incidence of adverse outcomes in this setting. In a study of 59 and 64 kidney transplant recipients receiving a tacrolimus- or sirolimus-based immunosuppressive regimen, respectively (plus mycophenolate mofetil and glucocorticoids in both groups), the incidence of allograft wound complications was significantly higher in the sirolimus group (47 versus 8 percent, respectively) [8]. Perigraft fluid collections, superficial wound infections, and incisional hernias were reported. A discussion of the details concerning adverse cutaneous effects with this agent can be found elsewhere. (See "Pharmacology of mammalian (mechanistic) target of rapamycin (mTOR) inhibitors".)

SPECIFIC SURGICAL PROBLEMS — The following illustrates a few specific clinical considerations that may be particularly important in the transplant recipient.

Gastrointestinal surgical emergencies — Signs and symptoms of acute abdominal pathology may be masked in transplant patients owing to the administration of chronic immunosuppressive therapy. Although this certainly can occur, a surprising number of patients present in fairly typical and characteristic ways, thereby making the diagnosis relatively straightforward.

Nevertheless, when such complications occur, the morbidity and mortality may be significant. In one retrospective survey of 416 patients following kidney transplantation, 31 experienced major gastrointestinal complications, including 14, 5, and 2 cases of bowel perforations, acute pancreatitis, and acute appendicitis, respectively [9]. The mortality rate was 30 percent, which was principally attributed to immunosuppression and sepsis.

Acute appendicitis — The diagnosis of acute appendicitis may be particularly difficult in a kidney (or pancreatic) transplant patient in whom the transplanted organ is found in the right lower quadrant. The appendix is generally displaced superiorly by the transplanted organ; thus, the symptoms and signs are uncharacteristic. The appendix is frequently perforated by the time the diagnosis is made. (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

Cardiac surgery — Cardiac surgery can affect a kidney (or pancreas) transplant recipient in the following ways:

Perfusion of the allograft may be compromised with cardiopulmonary bypass. The kidney (or pancreas) may sustain an ischemic insult, which may range from a minimal, reversible rise in the serum creatinine concentration to complete shutdown of the organ. Although the latter is unusual, patients with impaired kidney function are more likely to sustain damage to the kidney than those with normal kidney function.

In the unstable cardiac surgical patient who requires an intra-aortic balloon pump, placement of the pump on the side of the kidney allograft will result in arterial thrombosis. Although it seems to be so obvious a point as not to require comment, this complication can occur and has occurred; thus, avoiding the groin on the side of the kidney is critically important.

Abdominal aortic aneurysm — Surgical repair of an abdominal aortic aneurysm (AAA) routinely requires cross-clamping of the abdominal aorta; this allows the vascular prosthesis to be anastomosed to the proximal and distal aorta (or iliac or femoral arteries). To avoid interruption of the arterial blood supply to the transplanted kidney, temporary bypass may be required, usually from the ipsilateral axillary artery to the femoral artery. This will allow precise, unhurried repair of the aneurysm and eliminate the risk of allograft thrombosis. However, some vascular surgeons believe that there is enough collateral flow to allow AAA repair without a temporary shunt. In addition, a temporary shunt may become completely unnecessary with the advent of endovascular AAA repair [10]. (See "Management of asymptomatic abdominal aortic aneurysm" and "Overview of abdominal aortic aneurysm".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Kidney transplantation".)

SUMMARY AND RECOMMENDATIONS

Overview – An increasing number of recipients require medical care not specifically related to their transplanted organ. Some require elective or emergency surgery. Many of the principles of peri- and intraoperative management are the same in transplant and nontransplant patients. However, there are a few important differences. (See 'Introduction' above.)

General considerations – General nontransplant surgical considerations in the kidney transplant recipient include issues relating to glucocorticoids, antibiotic prophylaxis, and tissue integrity and wound healing. The transplant center should be consulted prior to any planned surgical intervention in kidney transplant recipients. (See 'General considerations' above.)

Specific surgical problems – Specific surgical problems include gastrointestinal surgical emergencies, cardiac surgery, and abdominal aortic aneurysm (AAA) surgery. (See 'Specific surgical problems' above.)

Topic 7317 Version 26.0

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