Year : 2016 | Volume
: 9 | Issue : 2 | Page : 311--313
Four kidneys and a tumor: Laparoscopic radical nephrectomy in a renal transplant recipient
Binod K Naithani, Uma Hariharan, Shagun B Shah
Department of Anesthesia and Oncosurgical Intensive Care, Rajiv Gandhi Cancer Institute and Research Centre (RGCI & RC), Sector 5, Rohini, Delhi, India
Fellowship Oncoanesthesia, Assistant Professor, Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Hospital and PGIMER, Central Health Services, BH 41, East Shalimar Bagh, Delhi 110088
Ever since the advent of organ transplantation, the survival rate and future encounter of recipients with anesthesiologists has increased. There have been several case reports and reviews on anesthesia for renal transplant recipients. We present a unique case of a patient who had previously undergone double renal transplantation, presenting to the anesthesiologist with four kidneys for laparoscopic radical nephrectomy for renal cell carcinoma. To the best of our knowledge, there has been no reported case of a postrenal transplant patient with four kidneys presenting for minimally invasive radical nephrectomy. Hemodynamic stability, preservation of renal function, careful choice of anesthetic agents, protection of fistula sites, complete asepsis, institution of extensive monitoring, cautious positioning, and use of ultrasound-guided regional block for pain management are some of the clinical pearls gained from this unique and rare case.
|How to cite this article:|
Naithani BK, Hariharan U, Shah SB. Four kidneys and a tumor: Laparoscopic radical nephrectomy in a renal transplant recipient.Ain-Shams J Anaesthesiol 2016;9:311-313
|How to cite this URL:|
Naithani BK, Hariharan U, Shah SB. Four kidneys and a tumor: Laparoscopic radical nephrectomy in a renal transplant recipient. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Dec 3 ];9:311-313
Available from: http://www.asja.eg.net/text.asp?2016/9/2/311/182290
Renal transplantation is now the standard operative procedure for end-stage kidney disease. Transplant recipients can present for various nontransplant surgeries . Renal cell carcinoma can occur in the native kidneys, which require radical nephrectomy. We present a unique case of a patient with four kidneys following bilateral renal transplantation and renal cell carcinoma developing in one of the kidneys, which was resected by means of a minimally invasive technique.
A 56-year-old male patient of ASA grade 3 was posted for laparoscopic radical nephrectomy for renal cell carcinoma of the left kidney. He was a known diabetic, controlled on oral hypoglycemic agents, and a known hypertensive, on regular medication. He was on the following antihypertensive medications: Tab ramipril 2.5 mg OD and tab amlodepine 5 mg BD. He had past history of end-stage kidney disease, for which he underwent bilateral renal transplantation. The first kidney transplant was performed 4 years back, and the second transplant was performed 2 years back. As, in renal transplants, the native kidney is left behind and the donor kidney is placed in the abdomen, this particular patient had in total four kidneys. This was the first time that we were encountering a patient with four kidneys for major radical surgery, with no similar case reported in the literature. His renal tumor was detected on routine scanning after transplantation, as he had no active symptoms pertaining to the cancer. His computed tomography scan revealed the following: both native kidneys that were atrophic bilaterally (suggestive of chronic kidney disease); a mass lesion at the lower pole of the left native kidney measuring 3.8 × 3.7 × 3.5 cm suggestive of neoplastic pathology with no evidence of metastasis; a simple cyst at the upper pole of the right transplanted kidney along with mild hydronephrosis in the transplanted left kidney; and incisional hernia in the right lower abdomen with omentum as its content as an incidental finding.
On preoperative evaluation, all his blood investigations were within normal limits, including renal profile. His serum sodium levels were 139 mEq/l and potassium levels were 4.4 mEq/l. His cardiac echocardiography suggested left ventricular hypertrophy and an ejection fraction of 50%, with no evidence of regional wall motion abnormalities. All his medications, except oral hypoglycemics, were continued until the day of surgery. In view of major cancer surgery, he was shifted to insulin, and tight control regime was practiced for better glycemic control intraoperatively. He had arteriovenous fistula in his left arm, which was specifically protected for future dialysis. The left upper limb was totally spared - that is no intravenous cannula or blood pressure cuff or invasive lines were applied on the left arm. Ultrasound-guided right internal jugular venous catheterization under local anesthesia was performed before induction for central venous pressure monitoring. Invasive blood pressure monitoring was accomplished with right radial artery catheterization (after Allen's test). Apart from standard ASA monitors, other monitors that were also instituted included neuromuscular monitor, bispectral index (BIS), airway pressure, multigas monitor, cuff pressure, urine output, and hourly blood sugar measurements. After adequate preoxygenation, intravenous induction was conducted with midazolam 1 mg, etomidate 8 mg, fentanyl 100 mg, and atracurium 40 mg. Intubation response was blunted with intravenous esmolol boluses (100 mg). His preinduction blood pressure was 126/78 mmHg and his postintubation blood pressure was 148/90. Intra-abdominal pressures were limited during pneumoperitoneum to 10-12 cmH 2 O. Renal perfusion pressures were maintained by ensuring a mean arterial pressure above 80 mmHg during the entire perioperative period. Anesthesia was maintained with O 2 +air+isoflurane, along with propofol infusion and continuous atracurium infusion (under BIS and neuromuscular monitor monitoring). Hemodynamic responses to pneumoperitoneum and position changes were minimized by adjusting the propofol infusion rate and esmolol boluses. The procedure was performed in the lateral decubitus position (left-side up), with opening up of kidney bridge. Continuous insulin infusion was given according to the blood sugar readings, piggybacked with neutralizing drip of 5% dextrose at a rate of 100 ml/h. The blood sugar was maintained between 120 and 150 mg/dl. An adequate urine output of 50 ml/h was maintained by adjusting fluid therapy. Slow mannitol infusion (100 ml) was administered following application of renal clamps, and intravenous furosemide 20 mg was administered after release of clamps. Active measures were taken to ensure normothermia and normocarbia. In view of minimally invasive surgery, the blood loss was minimal. The patient was turned supine after delivery of the dissected diseased kidney and release of pneumoperitoneum. Analgesia was planned with ultrasound-guided left-sided transversus abdominis plane (TAP) block (20 ml of 0.25% bupivacaine), intravenous paracetamol (1 g), and continuous postoperative fentanyl infusion (30-40 mg/h for a total of 8 h). The patient was extubated after adequate reversal, under neuromuscular monitoring. Extubation response was controlled with intravenous esmolol bolus (100 mg). Postoperatively, the patient was shifted to the oncosurgical intensive care unit for continued monitoring, and all his vital parameters were within normal limits. The procedure lasted for nearly 3 h and a total of 1.5 l of intravenous fluids was adminstered. The patient was later shifted out of the ICU and discharged, with advice for regular follow-up with the oncologist, oncosurgeon, and nephrologists.
Renal transplant recipients have good survival rates  to the tune of 90% at 3 years due to the advancements in surgery and immunosuppressive medication. After transplant, these patients can present for various elective and emergency surgeries, both early and late during the post-transplant period. The two most feared problems in such patients are graft rejection and infections . Absolute asepsis must be maintained under all costs. Graft function  can be maintained by preserving renal blood flow, avoiding nephrotoxic drugs, and maintaining a good diuresis. Preoperative assessment of renal function tests, including serum electrolytes, can give a fair estimate of the graft status. Pre-existing arteriovenous fistula sites need to be protected , in case the patient needs a future dialysis. Coexisting conditions such as diabetes and hypertension need to be optimized. Cardiovascular and functional assessment must be carried out for risk stratification, especially before major surgeries. Our patient had diabetes, which was controlled on oral hypoglycemic agents (OHA). He was shifted to insulin during the perioperative period, and, in view of major cancer surgery in a transplant recipient, a tight control of blood sugar  was achieved with background insulin infusion with hourly blood sugar charting. Central venous pressure monitoring was carried out intraoperatively as the transplanted kidney is sensitive to hypovolemia and concurrent diuretic use can deplete the intravascular volume. Beat-to-beat heart rate and invasive blood pressure measurement were carried out for stringent cardiovascular monitoring and blood gas analysis. To improve accuracy and avoid complications, ultrasound-guidance was utilized to secure invasive lines. Etomidate  was used for intravenous induction for maintaining cardiovascular stability, and hypotension was prevented at all costs. We used etomidate as it does not cause hypotension, which can compromise the kidney function by decreasing renal blood flow. Etomidate is also known to be beneficial in diabetic patients. Hypertensive response to both intubation and extubation were blunted with an ultra-short-acting b-blocker, Esmolol, as well as by means of gentle airway handling. Atracurium was chosen in view of its non-renal-dependent Hoffmann elimination. Neuromuscular monitoring was carried out for maintaining adequate muscle relaxation as well as for aiding reversal. Nitrous oxide was avoided and anesthesia was maintained with medical air along with oxygen, isoflurane, and continuous propofol infusion (under BIS monitoring). Nitrous oxide was avoided, as we wanted to avoid air embolism during laparoscopic surgery. Moreover, it is also known to cause bowel distension, which can interfere with the surgical access. Propofol infusion was given as part of intravenous anesthesia to prevent awareness under BIS and hemodynamic monitoring as air was used instead of nitrous oxide. Physiological responses to pneumoperitoneum and positioning were controlled with adjustments in ventilatory parameters, inhalational and intravenous anesthetic agents. Proper positioning precautions to prevent neurovascular or musculoskeletal injury were also taken. Pain management was given paramount importance for better patient outcome. Ultrasound-guided TAP blocks  are routinely administered for laparoscopic surgeries, especially in patients with absolute or relative contraindications to epidural insertions. Analgesia was supplemented with intravenous paracetamol and fentanyl infusion for better efficacy. There were no untoward events during the entire perioperative period.
Improvements in survival rates after renal transplantation have led to an increase in the number of patients presenting for surgery any time after the transplant. Our case is unique as the patient had undergone twin renal transplants and was presenting for nephrectomy of his native cancerous kidney. This was the first time we had encountered a patient with four kidneys, with one presenting with renal cell carcinoma. Preservation of renal function and fistula sites for possible dialysis is the main concern. Acid-base and fluid-electrolyte balance is of overriding importance in such patients. It must be remembered that cancer chemotherapy would further increase the immunosuppression and predispose these patients to serious infections and sepsis. Minimally invasive surgery is preferable for a faster postoperative recovery. Pain management with TAP block supplemented with paracetamol and low-dose opioid was well tolerated by the transplanted patient.
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