KIDNEY TRANSPLANTATION
The first description of anesthesia for kidney transplantation
appeared in the early 1960s. It detailed the pioneering efforts in Boston with living
donor kidney transplantation between identical twins.[78]
The only monitors used then were a blood pressure cuff and electrocardiogram (ECG),
and all recipients received spinal anesthesia. Much has changed in the anesthetic
management of these cases. What was once seen as heroic and exceptional is now commonplace.
These patients are challenging to anesthetize because end-stage renal disease (ESRD)
often causes dysfunction of other organ systems, which in turn may produce less predictable
responses to anesthetic drugs and techniques. In addition, these patients are at
high risk for cardiac and other perioperative complications because of their underlying
disease.[79]
In the year 2000, almost 15,000 kidney transplants were performed
in each of three major regions of the world, the United States, Europe, and Asia.
[80]
This number represents a steady increase throughout
the 1990s. Considerable variation in the proportion of organs that come from cadaveric
versus living donors occurs worldwide, with some countries relying almost entirely
on cadaveric donors (China) and some relying largely on living donors (Japan, Taiwan).
In the United States, the number of cadaveric kidneys for transplantation has reached
a plateau at around 8000 per year, whereas the number of living donors continues
to increase. Between 2000 and 2001, the number of living donors increased 13.7%.
Currently, approximately 50,000 patients are awaiting kidney transplantation in
the United States, with an average waiting time of longer than 3 years.[6]
Kidney transplantation is one of the most important,
cost-effective methods of treating ESRD; it confers a 40% to 60% decrease in the
death rate when compared with those remaining on dialysis.[81]
The overall graft survival rate among cadaveric kidney transplant recipients at
3 years is greater than 70%, and it is approximately 80% in recipients who receive
a kidney from a living donor.[82]
Organ Matching and Allocation
Initial testing is done to determine major blood group (ABO) compatibility.
A second test determines the HLA profile of the recipient. Finally, a crossmatch
is performed by mixing recipient blood with donor blood cells to determine the presence
of preformed reactive antibodies against donor antigens.[83]
Kidney transplantation is indicated for patients with ESRD caused by glomerular
disease, diabetes mellitus (DM), hypertensive kidney disease, polycystic kidney disease,
other familial or congenital diseases, and tubulointerstitial disease.
