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Revascularization in renal transplant patients - why and when: Our experience.

Rupinder kaur Kaiche, Rahul Kaiche, Nagesh Aghor

Background:Ample documentation suggesting Renal Transplant patients undergoing CABG exists, few proved the benefits of revascularization prior to transplantation. Aim: We performed revascularization before transplantation. Methods:Presenting two patients for live donor transplantation, with echocardiographic findings prompting angiography. CABG was planned followed 6 months later by transplantation allowing physical, psychological, emotional recovery. CABG ? Strict B.P and sugar control with Inotropes and insulin. ? Fluid management using TEE. ? BIS between 45-60 ? Off-pump surgery. ? Fast-tracking-extubated within 2 hours. ? Prompt acidosis, potassium and hypothermia correction. ? Dialysis day1 postop. ? Transplant ? Good hemodynamic stability intra and post-op ? Generous intravenous fluids. ? Good urine output, no ma?or cardiovascular events intra,postop,2 years follow-up. Result:Meticulously given anaesthesia, diligent postop management and fine surgical skills helped decrease morbidity and mortality. Renal transplantation offers best outcome for ESRD 37-53%asymptomatic ESRD patients have significant stenosis. 10% have CCF due to dilated cardiomyopathy, hypertrophic hyperkinetic disease, anemia, hyperparathyroidism, diastolic dysfunction. This prompted pre-transplant angiography. Revascularisation followed by transplantation had 98% and 88.4% cardiac event free survival at 1 and 3 years.3.Optimal medical management, in a meta-analysis shows no difference in post-transplant cardiovascular outcomes.5. Revascularization entails dual anti-platelet therapy with bleeding risks. With newer drug-eluting stents dual anti-platelets can be stopped after 3-6months.During transplantation there were 36 events in revascularization group and 57 in Medical management group.5.The severity of these events were not specified hence needs more analysis. Conclusion:With advanced anesthetic and surgical techniques, it is safe to undertake revascularization pre-transplant. Further research is required to formulate guidelines to categorize patients into medical and interventional groups.