Society of Cardiovascular Anesthesiologists

Chronic Renal Failure after Transplantation of a Nonrenal Organ

Ojo AO, Held PJ, Port FK, Wolfe RA, Leichtman AB, Young EW, Arndorfer J, Christensen L, Merion RM. N Engl J Med 2003; 349: 931-940

Reviewers: William J. Vernick, MD; Albert T. Cheung, MD

Philadelphia, PA

The high incidence and morbidity of chronic renal failure in non-renal transplant recipients reported in this issue of the New England Journal of Medicine raised a few eyebrows among anesthesiologists who routinely are involved in the perioperative care of organ transplant recipients. The study was a population based cohort analysis performed on patients who received heart (n=24,024), lung (n=7,644), heart-lung (n=576), liver (n=36,849), or intestine transplants (n=228) in the United States from 1990 to 2000 with a median follow-up time of 36 months. There were 69,321 patients enrolled, all of whom were receiving their first organ. The mean duration of follow-up was 3 years. Chronic renal failure (CRF) developed in 11,426 patients (16.5%) and end stage renal failure (ESRD) developed in 3,297 patients (28.9%). The incidence among individual organ groups varied from 6.9% for heart-lung transplants to 21.3% for intestine transplants. Chronic renal failure was defined as a glomerular filtration rate (GFR) of 29 ml/minute per 1.73 meters squared of body surface area or less and ESRD was defined by the need for renal replacement therapy or renal transplant. In comparison with transplant recipients who did not develop CRF, those with CRF had a significant increased relative risk of death, 4.55 (P<0.001).

The incidence of CRF increased progressively over time after transplantation. Although this disease course would suggest that perioperative management had little effect on the development of this complication, many of the organ recipients had pre-existing risk factors highly associated with CRF as well as perioperative acute renal failure (ARF). Hypertension (HTN) was present in 10.2%, diabetes mellitus in 8.1%, and hepatitis C in 12.1%. The relative risk of CRF in patients with Hepatitis C was 1.15 (P<0.001), HTN was 1.18 (P<0.001), and diabetes mellitus was 1.42 (P<0.001). In addition, pre-existing renal insufficiency was present in varying degrees in many of the study patients who had a mean GFR of 75ñ31 ml per minute per 1.73 meters squared. The pre-existing GFR was less than 60 in 23.8% of patients and 1.5% were already on renal replacement. Another major contributor to post-transplant CRF was the use of cyclosporine or tacrolimus in 88.4% of patients during the initial hospitalization.

The finding that postoperative ARF was the greatest risk factor for developing CRF (relative risk of 2.13, P<0.001), suggested that perioperative management may have an important impact on the subsequent incidence of this complication after organ transplantation. Postoperative ARF was defined as a reduction of GFR by 50% or the need for urgent dialysis. Postoperative ARF occurred in 7.6% of patients. Those at greatest risk for postoperative ARF were those with the same high risk factors for subsequent CRF: HTN, diabetes, hepatitis C, or pre-existing CRI. Identifying the preoperative characteristics or condition of patients at greatest risk of developing postoperative ARF after transplantation may help to predict those at greatest risk for postoperative ARF and subsequent CRF. Perioperative risk factors for subsequent CRF may not be immediately obvious because renal dysfunction may progress gradually. Determining whether perioperative factors such as blood pressure management, intravascular volume status, vasopressor use, or other drug therapy was associated with postoperative ARF may help to identify additional risk factors for CRF or management strategies to decrease the risk of CRF after transplantation. Although the primary concern is often directed at the transplanted organ, the high mortality associated with CRF in this patient population indicated that it would be wise to also direct attention to strategies for protecting and preserving renal function in patients undergoing organ transplants.

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Chronic Renal Failure after Transplantation of a Nonrenal Organ