Long dedication to his country and his legacy as a unifying Long dedication to his country and his legacy as a unifying national leader…respected internationallynational leader…respected internationally

Ban KiBan Ki--Moon: Moon: PastPast UN chief UN chief

The Most Beloved King ForeverThe Most Beloved King Forever

King Bhumibol Adulyadej King Bhumibol Adulyadej

Perioperative Care forPerioperative Care forKidney Kidney TransplantionTransplantion

Anesthetic Point of View Anesthetic Point of View

Experience from Experience from 22,,000 000 casescases

Siriwan JirasirithamSiriwan JirasirithamProfessor Emeritus of Anesthesiology Professor Emeritus of Anesthesiology

Department of Anesthesiology Ramathibodi Hospital Mahidol University THAILAND

Sirikit Building for Sirikit Building for Excellent Center of Organ TransplantationExcellent Center of Organ Transplantation

Safe Anesthesia for Kidney Transplantation

• Topics for discussion :

- Deceased donor management

- Recipient evaluation and preparation

- Anesthesia for kidney transplantation

Ramathibodi Hsp

Annual Rate of Kidney Transplantationin Thailand

Ramathibodi Hsp

Accumulated Rate of Kidney Transplantationin Thailand

106111

118122

148

138

186

120

140

160

180

200

No.

Kidney Transplantation

In Ramathibodi Hospital

Today Today --23102310//15215231 31 October October 20172017

311

33

20

36 38 3439

43 46

58

7680 78

44

5766

91

45 44

61

75 72

82

106

0

20

40

60

80

100

86 88 90 92 94 96 98 00 02 04 '06

'08 10 12 14 16 Yr.

Total = 1839 casesTotal = Total = 2309 2309 casescases

Kidney graft survival : Rama vs UNOS

0.50

0.75

1.00

Kaplan-Meier survival estimates

0.00

0.25

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15years

Living DDKT

Donor type 5-year graft survival 10-year graft survival

RAMA KT UNOS RAMA KT UNOS

DDKT 93% 70% 80% 40%

LRKT 94% 82% 78% 60%

Atiporn Ingsathit Ramathibodi Transplant Registry

The Real Hero The Real Hero

Deceased Donor Kidney Procurement

27/12/16

Ramathibodi Organ Procurement TeamRamathibodi Organ Procurement Team

Donor Promotion in Thailand

Education, workshop all over the country

Extended criteria donors

Extreme age : Newborn, pediatrics

: Elderly upto 72 year-old

Donor with comobid diseases

Donor with increasing creatinine level Donor with increasing creatinine level

Donor with HBs Ag

Future TrendsFuture Trends

-- Donation after circulatory death (DCD)Donation after circulatory death (DCD)

-- Kidney pair donation (KPD)Kidney pair donation (KPD)

-- Donor with HIVDonor with HIV

Deceased donor: CharacteristicsDeceased donor: CharacteristicsP

erce

nt o

f gi

ven

ch

arac

teri

stic

s Hypotension, 92.8%

Last creatinine

Per

cent

of

giv

en c

har

acte

rist

ics

Year

Age >50 yr, 25.3%

Last creatinine >1.5 mg/dl, 53.1%

Stroke, 32.4%

CPR, 15.6%

Thai Red Cross National Organ Donation CenterThai Red Cross National Organ Donation Center

1. Shortage of organ donation

2. Family denying or refusing to donate the organ

3. Loss of potential donor at ward ; ICU

Problems of organ donation :

Rapid deterioration of potential donor’s hemodynamic

Declaration of brain death : not in time

Cardiac arrest and failure of resuscitation process

Criteria for Criteria for IDEALIDEAL Potential Cadaveric Donor Potential Cadaveric Donor

1. Age < 65 years

2. No previous kidney disease

3. Anti HIV negative

4. No history of malignancy.4. No history of malignancy.

5. No active generalized infection

6. Normal BUN , Cr

7. Urine output > 0.5 mL / kg

8. No intraperitoneal contamination

9. Not in state of shock

10.Warm ischemic time < 60 minutes

Unsuitable of potential donor : Unsuitable of potential donor :

High fever with sepsis

High baseline creatinine level High baseline creatinine level

Hepatitis infection : Hepatitis B, C

Exclusion criteria : AIDS , Cancer

Recipients : Recipients : Severe comorbidity or uncontrolled underlying

diseases

Active disease at the moment : acute diarrhea.

Not well prepared, dialysed , anemia, volume ,

electrolyte , coagulopathy , antiplatelet

Positive Cross Match

Potential donor care and Potential donor care and

management management : :

Criteria of potential donor

Progression of brain death

Criteria of declaration of brain death

Management of brain death donor

Diagnosis of Brain Death

Preconditioning : apnoeic coma following known etiology

: resulting in irreversible brain damage

Exclusions : reversible causes of coma must be excluded

Sedative drugs (narcotics, hypnotics, tranquillizers, elicits)

NMB drugs (use nerve stimulator : TOF) NMB drugs (use nerve stimulator : TOF)

Hypothermia (must be > 34oC)

Circulatory, metabolic, endocrine disturbances

Physiological consequence of BD

Must be corrected ( consciousness)

Level of hormone concentration

E’lytes, BS, ABG

• Clinical Testing :

- Apnea at PaCO2 = 50 mmHg

Clinical Diagnosis of Brainstem Death

- 5 Brain stem reflexes:

1. No pupilary response to light

2. No corneal reflexes

3. No vestibule-ocular reflexes

4. No motor response, CN,somatic

5. No gag reflex- to bronchial stimuli

In Thailand In Thailand 6 6 hours duration for clinical Tests ofhours duration for clinical Tests of

Brain Stem function absence Brain Stem function absence Brain Stem function absence Brain Stem function absence

CV parameters Target range

HR 60-120 beats min-1

SAP >100 mmHg

MAP >70 mmHg but < 95 mgHg

CVP 6-10 mmHg

Cardiovascular Targets for Potential Cardiovascular Targets for Potential OOrgan rgan DDonorsonors

CVP 6-10 mmHg

PAOP 10-15 mmHg

SV variation <10%

FTc (Flow time corrected) on esophageal Doppler 330-360 ms

CI >2.1 L. min-1 m-2

Mixed venous saturation >60%

Continuing Education in Anaesthesia. Critical Care & Pain, MAY, 2012.

Cardiovascular Management

GOAL

Normovolemia

Maintain adequate blood pressure Maintain adequate blood pressure

Optimize cardiac output

Promote organ perfusion

Early management to potential organ donor

Donor for Lung Retrieval

Minimized crystalloid infusion

Avoid high CVP (<10 cmH2O)

MAP > 70 mmHg, Systolic BP > 85 mmHg MAP > 70 mmHg, Systolic BP > 85 mmHg

Early inotropic support

Keep urine flow ~ 1 mL/kg/hr

Donor for Heart retrieval :

Best choice of inotrope alpha - adrenergic agent

(metaraminol, phenylephrine)

Maintain coronary perfusion pressure

Limit in myocardial O2 consumption

(heart rate)

1. myocardial energy

2. glycogen storage

3. lactate accumulation and free fatty acids

ADVANTAGE OF HORMONE

THERAPY IN BRAIN DEAD DONOR

3. lactate accumulation and free fatty acids

4. Inhibit natural course of metabolic deterioration

5. Improve cardiac, renal functional stability in recipient

6. inotropic and bicarbonate requirement

7. Improve graft function *

Inflammatory process => role of steroid therapy

methylprednisolone 14.5 mg/kg/day

significant improve oxygenation

Follette DM, et al. J Heart Lung Transplant 1998:17:423-9.

Crit Care and Pain : 2012.

Institutional Guideline after Brain DeathInstitutional Guideline after Brain Death

Sequels Cause Management

1. Hypotension - Neurogenic shock - IV fluid resuscitation

- Hypovolemia - Inotropic support• Diuretics Dopamine 10 mcq/kg/min• Fluid restriction Dobutamine <15 mcq/kg/min• Diabetes Incipidus DI Epinephrine <0.1 mcq/kg/min

• • • • Diabetes Incipidus DI Epinephrine <0.1 mcq/kg/minNE and dopamine 2-4 mcq/kg/min

- Myocardial contussion- E’lyte imbalance- Hormonal imbalance- Catecholamine-induced

cardiomyopathy

• •

Sequela Cause Management

2. Arrhythmia -- CNS injury - Possible atropine resistant

: Bradycardia - Hypothermia - Chronotropic drugs

- E’lyte imbalance - Temporary venous pacing

- Acid-base abnormal

Institutional Guideline after Brain DeathInstitutional Guideline after Brain Death

- Acid-base abnormal

- MI

3. Hypoxemia - Central or pulmonary - PaOPaO22 100100--150150 mmHgmmHg

PaCOPaCO22 3535--45 45 mmHgmmHg

pH pH 77..3535--77..4545 mmHgmmHg

PEEP PEEP < < 77..55 cmHcmH22OO

FiOFiO2 2 < < 00..4 4 (heart(heart--lungs)lungs)

SequelSequelss CauseCause ManagementManagement

4. DI - Pituitary or - Volume replacementhypothalamic - Vasopressin (0.1u/min)dysfunction DDAVP (0.3ug/kgIV.)

- Keep urine 1.5-3 mL/kg/hr

Institutional Guideline after Brain DeathInstitutional Guideline after Brain Death

- Keep urine 1.5-3 mL/kg/hr- Correct E’lytes- Inotropic support

5. Hypothermia -Loss of hypothalamic - Early aggressive warming Temp. regulation - Maintain T > 35oC

6. Anemia - Hemorrhage - Blood transfusion :- Hemodilution Keep Hct > 30%

Kidney Transplantation Kidney Transplantation ::

Indication : ESRD

Donor : Living donor

Deceased donorDeceased donor

Technique : Kidney procurement

Kidney implantation

Immunosuppression : Cyclosporine

: Tacrolimus

: Mycophenolate Mofetil

: Steroids

ESRD–patient : high risk for Anesthesia / Surgery

Complication in peri-operative period

Cardiovascular diseasesCardiovascular diseases

Atherosclerosis

Hypertension: poorly controlled Hypertension: poorly controlled

Diabetes mellitus

Coronary artery disease : MI, CABG, PCI with stent

Congestive heart failure

Antiplatelet / Anticoagulants

Safety and Mortality Factors :

Effective and adequate hemodialysis : pre/post transplantation

Surgical technique : Experienced surgical team

Modern, new anesthetic agents Modern, new anesthetic agents

New immunosuppression drugs

Monitorings * *

Coronary artery disease cause of death

Stroke

Myocardial infarction

Ischemic limbs

Waiting list : CVS evaluationWaiting list : CVS evaluation

: Genetics

: Smoking

: History of HT, dyslipidemia

: Hyperparathyroid disease

CVS evaluation :

Physical examination

Electorcardiogram

Chest X-ray

Exercise stress test Exercise stress test

Echocardiogram

Thallium scan

Coronary angiography

CABG, angioplasty

Hemodialysis

: severity of HT from fluid overloaded

: Fluid status evaluation (over ; under ?)

: Volume loss from dialysis (BW)

: 24 hr. before surgery

: 4 hr duration of HD

body fluid volume, plasma volume

K, HCO3

Hct, platelet function

Acid-base status, electrolyte imbalance :

Metabolic acidosis

Na , Cl , K , CO2

NaHCONaHCO33 if • HCO3 < 15 mEq/L

• pH < 7.2

Respiratory acidosis

Clinical of • dyspnea

• conscious change

• pH < 7.2

Metabolic acidosis protein binding to drugs

Muscle relaxants

Local anesthetics Local anesthetics

Opioids

Inert agent after binding with proteins

Respiratory system : Fluid overloaded

Pulmonary edema

Pleural effusion

Pneumonia Pneumonia

Atelectasis

hypoxemia, hypoxemia, hypocapniahypocapnia

CXR : uremic lung

(perihilar pulmonary venous congestion)

Previous lung disease

Smoker PFT, ABG, SpO2

Abnormal CXR

lung infection after kidney transplantation

from immunosuppressive drugs

Aseptic technique !! Aseptic technique !!

Hb level ~ 6-8 gm/dL

Hct ~ 20-25%

Compensate with : CO, 2, 3 DPG

Anemia : Occurs when creatinine > 3 mg/dL

Compensate with : CO, 2, 3 DPG

: hyperdynamic circulation

If Hb <6 gm/dL : Red blood cell transfusion

: synthetic erythropoietin

Now : keep Hb 10 – 12 gm/dL

Hct 32 – 34%

Coagulation :

Abnormal bleeding

Coagulopathy

Occurs when Cr > 6 mg/dL

Abnormal platelet function Abnormal platelet function

platelet factor III

platelet counts

Heparin during HD

Uremic toxin

Central nervous system :

Fatique

Memory loss

Myoclonus

Seizure

Coma

Death

adequate hemodialysisadequate hemodialysis

Chronic HD

DDSDDS early H/D

rapidly change in ECF, E’lytes

•

• Dialysis dysequilibrium syndrome (DDS)

• Dialysis dementia (DD)

and cerebral edema

DDDD very severe form

chronic H/D

abnormal speech, dementia

seizure (death within death within 6 6 month)month)

CNS evaluation :

Neuropathy : peripheral ?

If + HD ( cause : demyelination)

: autonomic ?

Valsava’s maneuver

baroreceptor reflex

Postural hypotension

Endocrine system :

DM

growth retardation

reproductive system

Hyperparathyroidism

Uremic osteodystrophy

DMDM :: keep BS ~ 100-200 mg/dL

GI system :

Nausea vomiting

Hiccup

Anorexia

GI bleeding GI bleeding

Diarrhoea / constipation

DELAYED gastric emptying timeDELAYED gastric emptying time

Ascites, albumin

Hepatitis B,C

**

Immune system :

Decreasing immune response

Increasing sepsis

Aseptic technique Aseptic technique !!

Problems resulting from Hemodialysis :

Residual heparinization … 10 hr.

Fluid shift : depletion / overloaded

Blood transmitted disease : Hepatitis

: HIV: HIV

: CMV

Bleeding/thrombosis of vascular access

Inadequate H/D

Other pre-anesthetic evalulation :

Need - Well prepared and well evaluated patients

Look for : Congestive heart failure

: Pericardial, pleural effusions

: Myocardial ischemia : Myocardial ischemia

: DM autonomic neuropathy?

Consultation, referring systems

Hemodialysis within 24 hr. (if possible in DD)

BW : pre, post H/D, E’lyte , Hb/Hct, Platelet

Vascular access precaution :

NotNot measuring NIBP at the vascular access site

NotNot starting IV line

Prevention of thrombosis

(Avoid hypotensive episode)

Non-anesthetic drugs preparations :

Preparing : Methylprednisolone 1 gram

: Lasix 250 mg.

: 20% mannitol 250 mL: 20% mannitol 250 mL

: Antibiotics

: cefuroxime 1500 mg (zinacef®)

Muscle relaxant for KT :

Cisatracurium

Atracurium

Mivacurium Mivacurium

Rocuronium

Inhalation Anesthetics :

O2 : N2O / O2 : Air

Isoflurane

Sevoflurane Sevoflurane

Desflurane

Nitrous oxide :

Routinely used with O2 : N2O = 50:50 / 60:40

Avoid using N2O … ileus

… surgical space

in pediatric Tx

… prolonged surgical time

… N/V

Fluid management :

Isotonic saline --> adequate fluid volume

BV < 70 mL/kg --> delayed urine production

CVP guide (PA catheter)

NSS/BSS + colloid if large volume needed

Maximized hydration > Maximized hydration > 11,,500 500 mL mL ------ ATNATN

Pulmonary congestion ! in CHF patient

Anesthesia for Kidney Transplantation :Anesthesia for Kidney Transplantation :

1. Preanesthetic evaluation and preparation :

Living related-recipient :

• Routine preparation : well prepared

• Elective case• Elective case

Deceased donor – recipient :

• Emergency : full stomach

: coexisting disease

: uncorrected ; uncontrolled underlying disease

old age donor / recipient

Maximized / optimized condition

H/D … frequency / wk

… last H/D < 24 hr.

… B.W. pre-post H/D

Fluid overload / K / acidosis / HT

Preop. check E’lyte ; BUN ; Cr. ; CBC ; Ca ; Mg

DM : delayed GET

: control DM : BS ~ 100 - 200 mg/dL

E’lyte : K < 5.5 mEq/L

LFT : albumin ; liver enzymes

Coagulogram, INR, Platelet function Coagulogram, INR, Platelet function

Severity of anemia

: Hct ~ 22 - 25%

: PRC 2 – 4 units FFP 2 - 4 units

: Avoid whole blood Transfusion

Do Not Transfuse Blood or Blood product before TransplantationDo Not Transfuse Blood or Blood product before Transplantation

Premedication

: Benzodiazepine orally : MDZ / Lorazepam

: Avoid narcotics : morphine ; meperidine

: Anticholinergic : atropine IV

: Antihypertensive agent : precaution !

: Aspiration prophylaxis

Supplement steroid

Labs ; blood ; blood components

Oxygen supplementation

2. Monitoring during anesthesia :

IHD, HT (severe), pulmonary disease :

ECG, NIBP

Invasive BP pediatric KT, comorbid diseases

CVP : IJV, subclavian : 10-12 cmH2O

: CHF, pulmonary edema, CAD, inadequate H/D

End tidal CO2

Pulse oximeter

Nerve stimulator

Temperature (esophageal > nasopharynx)

Labs : Hb, Hct, E’lytes, BS, Cr. Labs : Hb, Hct, E’lytes, BS, Cr.

Bacterial filters

Aseptic techniques !

Choice of anesthesia

Site : iliac fossa : Rt/Lt, extraperitoneal

Small children : retroperitoneal

Supine position Supine position

GA / RA (CEB)

A. General anesthesia :

Anesthetic of choice : modern agents / machine

IV. Line ; large ; 2 lines

Induction : ? full stomach “rapid-sequence induction”

• Sleep dose • thiopental 3 mg/kg• Sleep dose

• Fentanyl 1 - 2 g/kg

• MDZ 2 - 3 mg

• thiopental 3 mg/kg

• propofol 0.5 – 1 mg/kg

Intubation

Preoperative K – level = ?

NPO time : type / amount / time of meal

Succinylcholine K <5.0 ; 1-2 mg/kg ; full stomach

Nondepol. MR K >5.0 ; good NPO Nondepol. MR K >5.0 ; good NPO

atracurium ; cisatracurium

rocuronium

Awake intubation

ET-tube : Sterile, PVC, low pressure cuff

: Oral approach

N2O : O2 = 1:1 (50% O2) / air : O2

Sevoflurane (FGF ~ 2 L/min) Sevoflurane (FGF ~ 2 L/min)

Desflurane (low flow < 1.5 L/min)

NG tube (orogastric tube)

Antibiotics: Cefuroxime 1.5 g

Maintenance of general anesthesia

Maintain BP~ control level ( > 110-120 mmHg) **

Control ventilation : ventilator (ETCO2) + PEEP

Atracurium, cisatracurium : infusion route

: IV titrate route

Declamping

: Bleeding acute volume loss

: Bradycardia : DM

: on -blocker

: Atropine, isoproterenol: Atropine, isoproterenol

: Cause : hyper K+ , acidosis,Temp

: Transient

Hyper K+ during KT

Other drugs : during maintenance

• Dopamine : renal dose 1 - 2 g/kg/min

• 20% mannitol 1 gm/kg infusion (250 mL)

• Methyl prednisolone 1 gm. IV

• Lasix 250 mg. IVbefore declamping

• Lasix 250 mg. IV

Ischemic time : WIT, CIT, r-WIT : living - related

: CIT, r-WIT : deceased

LPRC, FFP, Platelets Transfusion

Emergence : reversal agents

: extubation

: O2 supplement P.O

On mechanical ventilator if :On mechanical ventilator if :

• Old age, weak, conscious +

• Multiple coexisting diseases

• Not well prepared H/D

• Emergency case with unstable hemodynamics

• Fluid overload, pulmonary congestion

• Acute tubular necrosis (ATN) with massive fluid transfusion

Emergency H/D

Maximize hydration : > Maximize hydration : > 11,,500 500 mL before mL before declampingdeclamping

Early graft function :

• Well prepared kidney graft

• Adequate blood volume

• Normal hemodynamics

Maximum hydration : graft failure 30% 5%

: incidence of ATN P.O

If blood volume < 70 mL/kg … delayed urination > 5 min.

GoalGoal : CVP 10-12 / PCWP 12-15 mmHg

: system BP 140 – 160 mmHg

If If

• Infuse crystalloid > 40-90 mL/kg colloid

• Severe anemia ; blood loss > 200 mL.

: LPRC Tx after declamping

: keep Hct 25 - 28% 30% – 32% (now)

(especially in CAD patient)

*

Hyperkalemia : causes :

Preoperative hyperkalemia ( > 5.5 mEq/L)

Succinylcholine intubation

Perfusate with high K+ (125 mEq/L)

Acidosis

Old age – blood donation

Monitors : Electrolytes ; Ca ; Mg.

: ECG : peak-T, deep-S, QT, PR prolonged

: flat-P wave

CriticalCritical if : K > if : K > 66..5 5 mEqmEq/L/L

No urine from new kidney ( delayed graft functioning)

Serious arrhythmia Serious arrhythmia cardiac arrestcardiac arrest

Treatment : NaHCO3

: hyperventilation

: 10% CaCl2 10 mL IV

: glucose-insulin IV: glucose-insulin IV

: lasix 250 mg. IV : 2nd dose

Postoperative hemodialysis

Retained ET + mechanical ventilator

Keep mild respiratory alkalosis

pulmonary congestion / edema

ATN or AKI ATN or AKI (deceased donor - 30% ): potential causes

: Not well hemodialysis before KT

: Fluid balance : volume depletion

: Vital Signs : unstable

: Cold Ischemic Time ( CIT ) > 24 hr.

: Conditions of deceased donor

: old age : old age

: nephrotoxic / vasopressor dose

: terminal Serum Cr. level

: not well perfused graft

: Surgical causes : injury of graft during procurement

: difficult surgical technique

Steps of Kidney TransplantationSteps of Kidney Transplantation

• Deceased donor kidney donation

• Deceased donor management

• Deceased donor kidney procurement

•• Organ transportation

• Kidney implantation

• Kidney transplantation

Kidney from Deceased donorKidney from Deceased donor

Kidney from Deceased donorKidney from Deceased donor

Kidney from Deceased donorKidney from Deceased donor

การผา่ตดัเปลี�ยนไตKidney Transplantation

28/07/12

Organ Transplant is the Miracle Organ Transplant is the Miracle

PostPost--anesthetic care :anesthetic care :

1. Emergence :

- Turn off anesthetic agent

- Reversal of muscle relaxant - Reversal of muscle relaxant

- Extubate PACU / ICU (isolated ward)

- On O2 nebulizer ~50%

2. Blood pressure :

- Keep ~ control level >120/70 – 150/160 mmHg

- Avoid hypertension :

MI, CHF

Pulmonary edema

Intracranial hemorrhage

Bleeding at anastomotic siteBleeding at anastomotic site

Anti hypertensive agent treatment : evaluate

LV function

Filling pressure

HR

- Hypotension : if good CVP dopamine infusion

3. Fluid management :

Good graft functioning

Keep CVP ~ intraoperative level

Urine output > 500-1,000 mL/hr … up to 40 L/day

IV fluid : BSS + 5% D/W or 0.45% NSS

: 0.9% NSS + 5% D/N/2: 0.9% NSS + 5% D/N/2

Last hour urine + 50-100 mL/hr

300 ml + 100-200 mL/hr

Check E’lytes : K, Na, Ca, mg

ATN / AKI ATN / AKI Hemodialysis

keep maintenance volume

4. Oliguria / anuria :

11. . PrerenalPrerenal : inadequate renal BF

: LV dysfunction : compliance

BP : drugs

Fluid therapy

Px arrhythmiaPx arrhythmia

Correct abn. E’lytes

If correct sys. BP < 120 mmHg ; CI < 2.5 L/min/m2

start inotropic support

22. . InfrarenalInfrarenal ::

Bleeding : CVP ; anemia ; BP … acute

Anastomosis – stenosis/leakage … delayed

Anuria thrombosis of artery / vein graft

U/S, renal scan

Emergency reexploration surgical correction

Graft loss ?

Renal biopsy

33. . PostrenalPostrenal ::

Kinking / blood clot in urinary system

Irrigation urinary catheter

fluid, lasix 250 mg. infusion

Investigate --> renogram, renal scan, U/S

4. Postoperative pain control :

Opioid : Oral ; IV ; PCA

: MO 3-4 mg IV prn.

NSAID : renal clearanceNSAID : renal clearance

: GFR

: interstitial nephritis

avoidavoid decrease in renal function

5. Postanesthetic complication :

Nausea – vomitting

Respiratory function

Cardiovascular system

complication complication ------ 3333%%

HTHT

arrhythmia … cardiac arrestarrhythmia … cardiac arrest

hypo/hypertensionhypo/hypertension

Pulmonary : Atelectasis

: Emergency management :- infection

: Pulmonary edema

DM : 3-16% P.O 4% need insulin treatment DM : 3-16% P.O 4% need insulin treatment

: Onset 3 mo. after KT, high dose steroid

: Risk factor : glucose intolerance

: HLA type B28

Mortality rate after kidney transplantation

0.03 - 0.06 %

Risk : Age > 60 yearsRisk : Age > 60 years

: CAD

: DM

Thank you for your attention Thank you for your attention