**4.6. Intestine transplant recipients**

**4.4. Liver transplant recipients**

**4.5. Pancreas transplant recipients**

obstruction during sedation and anesthesia [91].

diabetic patient.

Liver synthetic tests should normalize over time pointing out a good liver graft function. There is also gradual decrease of all liver enzyme levels, as graft function becomes normal. Recovery of drug metabolism capacity occurs immediately after reperfusion of the liver graft. Liver transplantation itself results in reversal of the hyperdynamic state that characterizes patients with end-stage liver disease and cardiac performance improves in the months after transplantation. Hypoxemia caused by ventilation/perfusion mismatch is reversed over the course of the first postoperative months. Patients with pre-existing true shunts may require more time to achieve reversal of hypoxemia, or hypoxemia may not resolve at all [86]. Hepatorenal syndrome gradually diminishes, renal function improves over time, and creatinine level may become normal. However, kidneys are still in danger of injury due to immunosuppression side effects [87].

The most severe complication of liver transplantation is hepatic artery thrombosis. It has often been associated with massive transfusion of blood products leading to hemoconcentration. Therefore, liver transplant recipients should have minimal blood viscosity (hematocrit

No individual general anesthetic agents are contraindicated when hepatic and renal function is normal. If an epidural or spinal anesthesia is planned, clotting studies and platelet counts should be normal. Neither regional nor general anesthetic techniques were associated with deterioration

Pancreas transplantation provides the most effective method of glycemic and metabolic control. It can be done as a single organ transplant or simultaneously with kidney (predominantly in type 1 diabetes) (SPKT). SPKT is a treatment of choice for uremic diabetic patients when a living-related kidney donor is unavailable. After successful transplantation, pancreas transplant recipients do not require insulin to compensate for the stress response to surgery [89].

However, due to long-lasting diabetes effect, these patients are in high risk of developing cardiovascular diseases. It is prudent to manage these patients with the assumption that they have coronary artery disease [90]. Pancreas recipients still have persistent complications of diabetes such as gastropathy and neuropathy. Aspiration risk may be increased as a result of delayed gastric emptying. This population is also at increased risk for lymphoproliferative disorders secondary to immunosuppressant drugs and lymphoproliferative growth may compromise any part of the airway or mediastinum and cause life-threatening airway

Amylase levels in serum and urine should be closely monitored. They can be our only window in the graft rejection recognition [92]. Glucose levels should also be monitored perioperatively. In normal functioning grafts, the suppression of endogenous insulin secretion during hypoglycemia is sufficient to enable a normal glucagon response from the transplanted pancreas, even in surgical stress [93]. In patients with failed pancreatic grafts, perioperative management of glucose levels and acid-base status is the same as that for any

of liver function assuming proper anesthetic and intensive care management [3, 25].

approximately 28%) during the perioperative period [88].

244 Organ Donation and Transplantation - Current Status and Future Challenges

There are three types of intestine transplantation: isolated intestinal transplantation, transplantation of combined intestine, and liver graft or multivisceral transplantation. The biggest problem in intestinal transplantation is graft rejection, and it is the main reason for morbidity and mortality. The diagnosis of rejection is confirmed by clinical symptoms, endoscopic appearance, and pathological specimens taken by endoscopy [94].

Denervation and lymphatic dysfunction of the intestine affect intestinal permeability and absorption. If the intestinal mucosa barrier is damaged by ischemia, rejection, or enteritis, bacteria translocate into the bloodstream and infections are often observed [95]. Some of these patients develop diarrhea and lose weight in the early post-transplantation period. Any imbalance in the electrolyte and acid-base status should be timely corrected. Fluid administration should be closely monitored to assure sufficient splanchnic perfusion. Venous access is of major consideration for the anesthesiologist due to chronic use of total parenteral nutrition and its thrombotic complications [96].
