National Board Ex- 6 Book .pmd - National Board Of Examination

Cardiovascularl Hypertension- Over 50% ofadult patients with renaldisease need treatment forhypertension, which is oftenresistant to drug therapy 3 , andthese patients are on multipleantihypertensives, e.g. ACEinhibitors, calcium channelblockers, â - blockers,diuretics, clonidine.l Coronary artery disease- Theincidence of myocardialischaemia in renal transplantpatients is ten times that ingeneral population of thesame age and sex 4 . Angina isfrequent, probably partlydue to severe anaemia.Arrhythmias are alsocommon, exacerbated byelectrolyte imbalances.l Pulmonary oedema- It maybe due to fluid overload,hypoproteinemia or leftventricular failure.l Pericarditis and pericardialeffusion are also common inCRF.Haematologicl Anaemia- It is normocyticnormochromic in type. Itoccurs due to decreasedproduction and haemolysisof red blood cells. Thisanaemia is unresponsive tooral iron therapy. Pallor,tachycardia, and presence ofa systolic murmur should belooked for and noted. Usuallythese patients are taking oralerythropoietin. 5 . Preoperativehaematocrit of atleast 25% should be achieved.l Platelet dysfunction- In spiteof having normal counts,there can be thrombastheniaand prolonged bleedingtimes.l Heparin- This drug is usedduring haemodialysis, andwould potentates bleedingduring surgery if surgicalintervention is carried outsoon after the dialysis.Respiratory-The presence ofpulmonary infections as well aspleural effusion should be ruledout in these patients. It should bekept in mind that they have anincreased risk of postoperativeatelectasis due to decreasedsurfactant levels in lung. Bothcardiogenic and non-cardiogenicpulmonary oedema can occur inthese patients.Nutritional-These patients canby hyperglycaemic andhyperlipidaemic, and also havesevere malnutrition due toprotein loss, anorexia anddecreased appetite due togastritis. A rise in blood sugarmay be accompanied by a rise inserum potassium, makingarrhythmias more likely 6 .Gastro-intestinal- They havegastroparesis and are prone forregurgitation, and may havehepatic dysfunction.Neurological - A detailedhistory of depression, excessivesomnolence, seizures, polyneuropathyand autonomic dysfunctionshould be elicited, as theseare common in ESRD patients,and have anaesthetic implications.Immunological - These patientsare immunosuppressed and areprone to repeated bouts ofinfections.Biochemical-These may not beevident by history andexamination, but only byinvestigations.Potassium – There is an excessof this electrolyte in the body dueto reduced excretion, whichis exacerbated by drugs,hypercarbia and surgical trauma.Hyperkalemia can lead to cardiacarrhythmias, even ventriculararrhythmias and cardiac arrestintra-operatively. So, preoperativedialysis, and a serumelectrolyte level after dialysis isessential in these patients. Drugsthat may cause hyperkalemiainclude the following:Drugs that inhibit reninangiotensin-aldosteronesysteml Inhibitors of renin synthesis:â-blockers (eg, metoprolol,atenolol), clonidine, methyldopa,some nonsteroidalanti-inflammatory drugs(NSAIDs, eg, ibuprofen,naproxen), cyclooxygenase-2inhibitors (eg, celecoxib)l Inhibitors of angiotensin IIsynthesis: ACE inhibitors (eg,enalapril, fosinopril)l Inhibitors of aldosteronesynthesis: Angiotensin II receptorblockers (eg, losartan,candesartan), heparin, lowmolecular weight heparin (eg,enoxaparin), immunosuppressivedrugs (eg,cyclosporin, tacrolimus)l Inhibitors of aldosterone receptor:Potassium-sparing diuretics(eg, spirolactone)l Blockers of distal Na + /K +channels: Potassium-sparingdiuretics (eg, triamterene,amiloride), antibiotics (eg,trimethoprim sulfamethoxazole,pentamidine)Drugs that cause release of K +from muscles: Succinylcholine,antipsychotics (eg, haloperidol).52Journal of Postgraduate Medical Education, Training & ResearchVol. II, No. 5, September-October 2007