Anesthesia Management in the Renal Transplant Recipient with Recurrent Massive Uremic Pericardial Effusion

Dear Editor, Recurrent massive pericardial effusion is a life-threatening complication in end-stage renal disease (ESRD). Its resolution after renal transplantation strongly indicates an association with underlying uremia. This indicates that recurrent pericardial effusion related to ESRD should not be viewed as a contraindication for renal transplantation. Therefore, renal transplantation should proceed promptly once a suitable donor is available. Managing anesthesia in such cases is particularly challenging. A 31-year-old woman with ESRD, weighing 40 kg, underwent a live donor kidney transplant from her father at our center. She was being treated with hemodialysis thrice weekly, later increased to daily due to orthopnea and moderate pericardial effusion. Despite this, her symptoms worsened, and she developed severe pericardial effusion with impending tamponade, necessitating urgent pericardiocentesis, which drained 1.2 l of fluid. Postpericardiocentesis, the symptoms improved, but effusion recurred. She continued on daily dialysis until the transplant. Her medical history included hypertension, managed with nifedipine 30 mg TDS, prazosin 5 mg BD, and clonidine 0.1 mg TDS. Preanesthetic checkup was insignificant except for pedal edema, hypertension, anemia, and deranged creatinine. A computed tomography scan showed bilateral mild pleural effusion and pericardial effusion with a maximum thickness of 34 mm. Echocardiography confirmed massive pericardial effusion (anteriorly 18 cm, posteriorly 2.8 cm), grade II diastolic dysfunction, and an ejection fraction of 60%. Although a cardiologist recommended pericardial window pretransplant, the patient declined the consent. Preoperatively, high-risk consent was attained, outlining perioperative cardiac risks and possible mechanical ventilation. The perioperative plan involved collaboration with a cardiologist, nephrologist, and intensivist. A day before the surgery, dialysis was conducted. On the day of surgery, screening two-dimensional echo showed moderate-to-severe pericardial effusion [Figure 1a and b]. The cardiology team was on standby for potential intraoperative pericardiocentesis. Injection Grafalon infusion was started preoperatively at a rate of 6 mg/kg over 4 h as per institutional protocol. In the operating room, after standard monitoring, the left radial arterial line was secured under local anesthesia. General anesthesia was induced using intravenous midazolam 1 mg, fentanyl 80 mcg, etomidate 12 mg, and succinylcholine 80 mg. The patient was intubated with a 7.5-sized cuffed endotracheal tube, and the left subclavian vein was cannulated. Inotropes, vasopressors, and anti-arrhythmic drugs with a defibrillator were prepared. Anesthesia was maintained with oxygen, air, isoflurane, and cisatracurium. Volume-controlled mechanical ventilation with low inspiratory pressure and low positive end-expiratory pressure was used, maintaining a mean arterial pressure of 90–100 mmHg and a central venous pressure (CVP) of 10–15 mmHg. Methylprednisolone 1 g was given pregraft placement, and mannitol (0.5 g/kg) was administered during vascular anastomosis. Furosemide (2 mg/kg) was given just before releasing the vascular clamp to promote renal graft diuresis. A transplanted kidney functioned well with a 600-ml urine output. Intraoperative analgesia was managed with paracetamol and fentanyl boluses, guided by pulse pressure variation and CVP. The patient remained hemodynamically stable throughout the 5-h surgery. She was extubated after demonstrating good spontaneous respiratory efforts and transferred to the posttransplant unit for observation. Postoperative analgesia was managed with a fentanyl patch (12.5 mcg/h) and intravenous paracetamol. Postoperatively, the patient was hemodynamically stable with improved kidney function and a gradual decrease in pericardial effusion, which resolved completely on day 19 [Figure 1c and d].Figure 1: (a and b) Pre Operative two dimensional echo images, (c and d) Post Operative two dimensional echo images, LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricleThere are very few documented cases on the complete resolution of pericardial effusion in recipients post renal transplant.[1-3] The preanesthetic evaluation in such patients mainly focuses on assessing the severity of pericardial effusion and determining the presence of tamponade through typical signs, symptoms, and investigations. Hemodynamically stable patients with chronic pericardial effusion undergoing noncardiac surgeries usually do not require preoperative drainage.[4] Due to the chronicity and hypertension in such patients, hemodynamic compromise is rare, making general anesthesia well-tolerated. Intraoperative challenges include managing the effects of anesthetic agents that cause vasodilation and myocardial depression, as well as positive pressure ventilation that decreases venous return and increases right ventricular afterload. These factors can lead to severe hemodynamic compromise and potential acute tamponade in previously compensating patients.[4,5] Additionally, volume depletion may reduce CVP below the intrapericardial pressure, leading to hemodynamic decompensation.[5] Our case is rare in the literature, demonstrating successful anesthesia management during renal transplantation in a recipient with massive pericardial effusion. This was achieved through the above-outlined perioperative approach and multidisciplinary teamwork, resulting in good renal graft function and a complete resolution of pericardial effusion posttransplant. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.