418 Juneja et al. Management of a Renal Transplanted Patient for CABG Indian Heart J 2002; 54: 418–421 Perioperative Management of a Renal Transplanted Patient for Coronary Artery Bypass Grafting Rajiv Juneja, Sarab Mohan Singh, Yatin Mehta, Yugal Mishra, Naresh Trehan Department of Anaesthesia, Escorts Heart Institute and Research Centre, New Delhi A therosclerotic cardiovascular disease is common in patients with end-stage renal disease (ESRD) and patients with renal transplants, due to associated hypertension, abnormal lipid metabolism and diabetes mellitus. 1 They are also predisposed to valvular endocarditis due to vascular punctures for hemodialysis 2 and valvular stenosis due to hypercalcemia, 3 both requiring valve replacement. The first successful coronary artery bypass graft (CABG) surgery following renal transplant was reported in 1975. 4 As renal transplantation is now performed more frequently, there is an increasing number of such patients who present for cardiac surgery. This report describes the perioperative management of a patient with a renal transplant undergoing CABG, and a review of the literature. Case Report A 46-year-old male hypertensive, nondiabetic, nonsmoker with a history of inferior wall myocardial infarction 8 years ago was admitted with NYHA functional class III angina. He had undergone left renal transplantation 5 years ago from a related live donor and was on oral prednisolone 10 mg and azathioprine 100 mg once a day, and cyclosporin 75 mg in the morning and 50 mg at night. He was also receiving nitrate and metoprolol for coronary artery disease. Coronary angiography revealed triple-vessel disease and he was scheduled for elective CABG. On clinical examination, no icterus, ascites or hepatomegaly was Brief Report Correspondence: Dr Rajiv Juneja, Senior Consultant, Department of Anaesthesia, Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025. e-mail: ehirc@vsnl.com Following renal transplantation, patients for coronary artery bypass grafting are subjected to high morbidity and mortality during the perioperative period because of the risk of major infections, renal impairment or rejection, and myocardial infarction. We describe the perioperative management of one such high-risk patient. (Indian Heart J 2002; 54: 418–421) Key Words: Renal transplant, Coronary artery bypass graft surgery, Perioperative management detected. Transthoracic echocardiography showed a hypokinetic basal inferior wall, left ventricular ejection fraction of 50% and mild mitral regurgitation. Carotid artery Doppler scan revealed bilateral normal flow and ECG showed old inferior wall infarction. Baseline blood urea nitrogen (BUN) was 32 mg%, serum creatinine 1.1 mg% and creatinine clearance 65 ml/min. The hematocrit, coagulation profile, liver function tests, blood sugar and serum electrolytes were within normal limits. Blood was screened preoperatively for hepatitis B surface antigen, antibodies to hepatitis C virus (HCV) and antibodies to human immunodeficiency virus 1 and 2 after obtaining the patient’s consent. He was found to be anti-HCV positive. Polymerase chain reaction (PCR) test for HCV was also positive, which suggested chronic active hepatitis. He received 5 mg oral diazepam and 150 mg ranitidine hydrochloride on the night before surgery and was premedicated with 2 mg lorazepam and 150 mg ranitidine hydrochloride 2 hours before the procedure. Cardiac and immunosuppressant medications were continued till the morning of the surgery. Intraoperative monitoring included 5-lead ECG, direct arterial and central venous pressures, rectal temperature, urine output, pulse oximetry and capnography. An arterial line was inserted into the right femoral artery. Anesthesia was induced with intravenous midazolam, fentanyl citrate and thiopentone sodium, orotracheal intubation was facilitated with atracurium bromide and anesthesia maintained with isoflurane, oxygen in air and intermittent doses of fentanyl and atracurium. Intravenous hydrocortisone succinate 100 mg and frusemide 20 mg were administered at induction and 3 mg/kg dopamine infusion was started. Breathing system filters (BB 22-15M, Pall Biomedical, Cornwall, UK), which IHJ-320-02.p65 11/10/02, 3:13 PM 418