Anästhesie und Organprotektion – Nephroprotektion: anästhesiologisches Management bei Nierentransplantation

Zusammenfassung

Die Nierentransplantation ist ein operatives Standardverfahren. Die Verbesserungen der Immunsuppression, der Spenderkonditionierung und der chirurgischen Technik konnten die perioperativen Komplikationen reduzieren und die Transplantatfunktion positiv beeinflussen. Dieser Artikel erläutert das anästhesiologische Management bei Nierentransplantation und die Strategien der Nephroprotektion: Reduktion des Ischämie-Reperfusionsschadens, optimale Transplantatperfusion, Meidung nephrotoxischer Substanzen und effektive Immunsuppression.

Abstract

Kidney transplantation is a standard surgical procedure. Improvements of immunosuppressive therapy, donor management and surgical technique reduced perioperative complications and improved graft survival. In this review the authors discuss the anaesthetic management of kidney transplantation and nephroprotective strategies: reduction of ischemia-reperfusion injury, maintenance of optimal graft perfusion, avoidance of nephrotoxic agents and effective immunosuppression.

Kernaussagen

• Intraoperativ können bei Nierentransplantationen v.a. kardiale und metabolische Komplikationen auftreten.

• Zu den nephroprotektiven Strategien gehören die Reduktion des Ischämie-Reperfusionsschadens, die optimale Transplantatperfusion, die Meidung nephrotoxischer Substanzen sowie die effektive Immunsuppression.

• Die Reduktion der Ischämiezeit gilt als essenzielle Strategie der Organprotektion.

• Jede Stunde, um welche die Ischämiezeit reduziert werden kann, verringert die Wahrscheinlichkeit verzögerter Transplantatfunktion.

• Während des Ischämie-Reperfusionsschadens werden intrazelluläre Mechanismen angestoßen, die für Inflammation und Apoptose verantwortlich sind.

• Balancierte Allgemeinanästhesie mit endotrachealer Intubation gilt als Standardverfahren der Nierentransplantation und gewährt neben stabiler Hämodynamik einen optimalen chirurgischen Zugang.

• Ist die Transplantatperfusion durch anhaltende Hypotension (Vasoplegie oder geringes Herzzeitvolumen) trotz Normovolämie gefährdet, sollten Vasopressoren bzw. Inotropika moderat und differenziert nach angepasstem hämodynamischen Monitoring eingesetzt werden.

• Das potenzielle Risiko der renalen Vasokonstriktion durch Katecholamintherapie (Noradrenalin, Dobutamin) muss mit den Vorteilen der dadurch verbesserten Kreislaufsituation abgewogen werden.

• Eine optimale Transplantatperfusion sichert die Transplantatfunktion.

• Intraoperative Flüssigkeitsgabe gilt als primäre Maßnahme zur Erhaltung der Transplantatperfusion und als nephroprotektive Strategie.

• Die medikamentöse Immunsuppression verhindert die akute Abstoßung und die chronische Allograftnephropathie.

Schlüsselwörter:

Organprotektion - Nierentransplantation - Anästhesie - Ischämie-Reperfusionsschaden

Key words:

organ protection - kidney - renal transplantation - anaesthesia - ischaemia-reperfusion injuryA

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