**2.1. Immunosuppression protocol**

Transplant patients are always under various regimens of immunosuppressive therapy (**Table 1**). Immunosuppression trends for solid organ transplantation have undergone a perceptible shift over the past decade. There are broad therapeutic patterns and numerous immunosuppressive protocols depending on transplanted organ, as well as the regional differences (country, hospital). However, some strategies are similar. We distinguish induction immunosuppressive therapy and maintenance of immunosuppressive therapy. Induction of immunosuppression begins immediately before the organ implantation. Antibodies are prescribed for the majority of kidney, pancreas, and intestine recipients and for just under half of thoracic organ recipients. It is extremely uncommon in liver transplantation [5]. Maintenance of immunosuppression involves one of the drugs from each group: calcineurin inhibitors (CNI), antimetabolites, and steroids.

both supratherapeutic and subtherapeutic drug concentrations can have devastating results. Subtherapeutic levels increase the risk of transplant rejection, and supratherapeutic levels (overimmunosuppression) can lead to infection and/or drug-specific side effects. Importantly, the incidence of acute rejection has declined over the past decade. Treatments for acute rejec-

Alemtuzumab Campath

Chronic immunosuppressive therapy has its adverse effects such as lowered seizure threshold, diabetes, hypertension, hyperlipoproteinemia, decreased glomerular filtration, hyperkalemia, hypomagnesemia, increased risk of infection and tumors, pancytopenia, osteoporosis, and poor wound healing. This may have some impact on perioperative management and

The blood level of both cyclosporine and tacrolimus must be kept within the indicated therapeutic range to get the desired effect. The perioperative fluctuation of the plasma level of these two drugs should be strictly monitored. There is a significant reduction of drug blood level by dilution with volume infusion or cardiopulmonary bypass in cardiac surgery [11]. Both these drugs are metabolized by cytochrome P-450 system of liver, and therefore many of the drugs administered perioperatively can affect their plasma levels [12, 13]. A better understanding of

tion continue to include high-dose corticosteroid and antibody therapies [9].

**General names Generic names Brand names**

Methylprednisolone

Cyclophosphamide Mycophenolate mofetil Mycophenolate sodium

Cyclosporine (or cyclosporine A)

Antithymocyte globulin (equine)

NRATG, NRATS, ALG

Anti-CD3 monoclonal antibodies Muromonab-CD3 Orthoclone OKT3

Basiliximab Daclizumab

TOR inhibitors (or rapamycin) Sirolimus Rapamune

Prograf

Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery

Imuran

Cytoxan, Neosar CellCept Myfortic

Thymoglobulin ATGAM

Simulect Zenapax

Sandimmune, Neoral, Gengraf, Eon, SangCya, generic cyclosporine

http://dx.doi.org/10.5772/intechopen.74329

231

Corticosteroids Prednisone

Antimetabolites Azathioprine

Anti-CD52 monoclonal

Anti-IL-2 receptor monoclonal

antibodies

antibodies

Calcineurin inhibitors Tacrolimus (or FK-506)

Polyclonal antibodies Antithymocyte globulin (rabbit)

**2.2. Side effects and drug interactions**

**Table 1.** Most commonly used immunosuppressive drugs.

choice of anesthetic agents (**Table 2**) [10].

The immunosuppressant strategy has been changing over the years. CNIs are still being used for the maintenance of immunosuppressive therapy, though shifting from cyclosporine to tacrolimus is being observed [6]. Modifications are also made among antimetabolites, from azathioprine to mycophenolate mofetil, and it is more common to decrease corticosteroid use or even implement steroid-free protocol in suitable transplant recipients [7, 8].

Most of the commonly used immunosuppressants have a narrow therapeutic index and display significant variability in blood concentrations between individuals. In transplant recipients,


**Table 1.** Most commonly used immunosuppressive drugs.

the increased surgical needs in this population. These patients cannot always return to the transplant facility for surgery, so it is incumbent on all anesthesiologists to review periopera-

Perioperative anesthetic management in majority of recipients is similar to the standard practice for any patient. However, we must bear in mind some essential considerations: problems of allograft denervation, the adverse effects of immunosuppression and its interaction with anesthetic drugs, the risk of infection, and the potential for organ rejection. When transplant recipients require nontransplant surgery, immune competence can be altered from the stress

Preoperative assessment of any transplant recipient undergoing non-cardiac surgery should focus on graft function and rejection, risks of infection, and function of other organs, particularly those that may be compromised due to either immunosuppressive therapy or dysfunction of the transplanted organ itself and drug interactions. There is no ideal anesthetic for use in organ transplant recipients. However, certain principles can be applied to all transplant

In this chapter, we will give an overview of immunosuppressive therapy and its interaction with anesthetic drugs as well as considerations regarding specific transplanted organs (heart,

Transplant patients are always under various regimens of immunosuppressive therapy (**Table 1**). Immunosuppression trends for solid organ transplantation have undergone a perceptible shift over the past decade. There are broad therapeutic patterns and numerous immunosuppressive protocols depending on transplanted organ, as well as the regional differences (country, hospital). However, some strategies are similar. We distinguish induction immunosuppressive therapy and maintenance of immunosuppressive therapy. Induction of immunosuppression begins immediately before the organ implantation. Antibodies are prescribed for the majority of kidney, pancreas, and intestine recipients and for just under half of thoracic organ recipients. It is extremely uncommon in liver transplantation [5]. Maintenance of immunosuppression involves one of the drugs from

The immunosuppressant strategy has been changing over the years. CNIs are still being used for the maintenance of immunosuppressive therapy, though shifting from cyclosporine to tacrolimus is being observed [6]. Modifications are also made among antimetabolites, from azathioprine to mycophenolate mofetil, and it is more common to decrease corticosteroid use

Most of the commonly used immunosuppressants have a narrow therapeutic index and display significant variability in blood concentrations between individuals. In transplant recipients,

each group: calcineurin inhibitors (CNI), antimetabolites, and steroids.

or even implement steroid-free protocol in suitable transplant recipients [7, 8].

of surgery, acute illness, or disruption of the regimen by inexperienced providers [3].

tive issues associated with transplantation.

230 Organ Donation and Transplantation - Current Status and Future Challenges

patients who undergo anesthesia and surgery [4].

lungs, liver, kidney, pancreas, and intestine).

**2. Immunosuppression**

**2.1. Immunosuppression protocol**

both supratherapeutic and subtherapeutic drug concentrations can have devastating results. Subtherapeutic levels increase the risk of transplant rejection, and supratherapeutic levels (overimmunosuppression) can lead to infection and/or drug-specific side effects. Importantly, the incidence of acute rejection has declined over the past decade. Treatments for acute rejection continue to include high-dose corticosteroid and antibody therapies [9].
