**4.2. Lung transplant recipients**

Denervation of the lungs after transplantation is associated with a lack of cough reflex below the tracheal anastomosis level and are unable to clear secretions unless they are awake. Therefore, they are prone to retention of secretions and silent aspiration [74]. These conditions may lead potential hazardous conditions especially in general anesthesia, such as bronchoconstriction and the increased risk of chest infection. In light of potential complications, it is preferable to perform a regional anesthesia whenever possible and if there is no contraindication [75].

Before elective surgery patients should undergo chest radiograph and spirometry to exclude chronic rejection and infection [76]. If allograft rejection or infection is suspected, elective surgery should be postponed and appropriate investigations should be performed.

Altered lymphatic drainage in the transplanted lung may cause interstitial fluid accumulation. It has been recommended that these patients be treated with diuretics and limited crystalloid infusion [77, 78]. Invasive hemodynamic monitoring is often required in heart-lung transplant recipients since there is a narrow line between the pulmonary edema occurrence and maintaining cardiac output with fluid load [79].

#### **4.3. Kidney transplant recipients**

**Drugs SA node** 

used drugs for resuscitation.

Digoxin 0 ↓

– heart rate; 0 – no effect; and E – equivocal.

**rate**

**AV conduction**

can lead to significant systolic and diastolic dysfunction [70, 71].

242 Organ Donation and Transplantation - Current Status and Future Challenges

Dopamine ↑ ↑ 0 E ↑

Adrenaline ↑ ↑ 0 ↑ ↑ Noradrenaline ↑ ↑ 0 ↑ E Isoprenaline ↑ ↑ 0 ↓ ↑ Phenylephrine 0 0 0 ↑ E

Milrinone 0 0 ↓ ↑ ↑ Levosimendan 0 0 ↓ ↑ ↑

**Table 6.** Response of denervated heart to various cardiovascular drugs.

**SVR BP CO Remark**

heart

Atropine 0 0 0 0 0 Cannot be used in bradycardia

that of normal heart because intact sympathetic nerves are required for the normal uptake and metabolism of catecholamines. The receptor density, however, remains unchanged, and the transplanted heart can respond to direct-acting drugs (adrenaline and noradrenaline) [67]. Isoprenaline and dobutamine have similar effects in both transplanted and normal heart. Because atropine has no effect on a transplanted heart, isoprenaline and adrenaline should be readily available to manage bradycardia and hypotensive emergencies. In recent years, milrinone and levosimendan, inotropic vasodilators, have been included in the pharmacological arsenal. These drugs increase myocardial contractility without myocardial oxygen consumption (unlike catecholamines). In addition, they lead to arterial and venous vasodilatation and afterload decrease [68, 69]. **Table 6** summarizes the hemodynamic response of some commonly

Heart transplant recipients may present with ongoing rejection with myocardial dysfunction, accelerated coronary atherosclerosis, or severe dysrhythmias, all of which must be diagnosed before surgery. Chronic allograft rejection usually presents as accelerated coronary artery disease. Therefore, heart transplant recipients may have significant myocardial ischemia without any clinical symptoms of pain and silent myocardial infarction on the ECG. Severe rejection

General anesthesia is usually preferred, as there is a possibility of impaired response to hypotension after spinal or epidural anesthesia. A goal of anesthesia in this setting is the avoidance of significant vasodilation and acute decrease of the preload. Invasive hemodynamic monitoring is extremely useful during surgery that involves large volume shifts, due to the fact that these patients are preload-dependent and may be prone to myocardial dysfunction and/or

Dobutamine ↑ ↑ 0 ↑ ↑ Effect on HR is more than normal

SA – sinoatrial; V – atrioventricular; SVR – systemic vascular resistance; BP – blood pressure; CO – cardiac output; HR

Kidney transplant recipient have high incidence of cardiovascular diseases, especially elderly patients with diabetes and after years of dialysis procedures. Spectrum of disease can range from hypertension to severe coronary disease. It is wisely to approach them with caution. Cardiovascular complications are the leading cause of death in renal transplant recipients, accounting for 32% of all deaths [80].

After successful transplantation, renal function is restored, with no need for renal replacement therapy. Still, beware of prolonged drug action and excretion in kidney transplant recipients, due to the fact that their glomerular filtration rate and effective plasma flow can be significantly lower than in healthy subjects [81].

You should suspect at chronic graft rejection when azotemia, proteinuria, and hypertension are seen [82, 83]. One of the important parameters to consider in the prevention of graft failure is the maintenance of appropriate renal perfusion pressure. Perioperative fluid management must ensure restoration and maintenance of intravascular volume, in order to obtain good graft function. Diuretics should not be given without careful evaluation of the patient's volume status.

In anesthetic management, it is prudent to choose drugs that do not rely on the kidney for excretion. Nephrotoxic drugs should be avoided [84]. Cardiovascular instability can be present after a recipient has been recently hemodialysed due to hypovolemia and hypokalemia, causing arrhythmias and increased susceptibility to muscle relaxants [85].
