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The Anesthetic Management of Adult Patients with Organ Transplants Undergoing Nontransplant Surgery

      The United Network for Organ Sharing reports that in 2008 and 2009 there were more than 54,000 organs transplanted in the United States. Survival rates have continued to increase in the past several decades as surgical techniques, immunosuppressive therapy, and infection prophylaxis have improved. On October 31, 2009 there were nearly 280,000 surviving organ recipients who underwent transplantation between 1987 and 2009 (Table 1). Several organ types now have 1-year survival rates of 85% or greater, with some approaching 95%, and 3-year survival rates of 80% or better. Living donor kidney transplants, for example, have 1-year survival rates of 95% and 10-year survival rates greater than 75% [
      • Bloom R.
      • Goldberg L.
      • Wang A.
      • et al.
      An overview of solid organ transplantation.
      ]. As the number of people surviving organ transplant steadily increases, more of these patients are likely to present for nontransplant-related surgery, either elective or emergent, in centers that are not normally involved in transplant procedures. This population may be more likely to present for surgery than those without previous transplant for many reasons. Laparotomy for small bowel obstruction, hip arthroplasty given the increased risk of fracture and avascular necrosis as a result of chronic steroid use, lymph node excision and biopsy because of increased risk of lymphoproliferative disease, ureteral stent placement and removal and native nephrectomy in kidney transplant recipients, bronchoscopy in lung recipients, and biliary tract interventions in liver recipients are just a few of the increased surgical needs in this population. Incisional hernias rates are increased because of the effects of immunosuppressive drugs on wound healing and, abscess drainage because of increased risk of infection are additional problems requiring surgical intervention [
      • Leapman S.
      • Vidne B.
      • Butt K.
      • et al.
      Elective and emergency surgery in renal transplant patients.
      ,
      • Tran S.
      Anesthetic considerations for patients post-organ transplantation.
      ].
      Table 1United Network for Organ Sharing: patients transplanted in the United States,
      The number of unique people who received each type of transplant between 1 October 1987 and 31 October 2009.
      1 October 1987 to 31 October 2009 by organ received and most recent status
      The patient status is based on a combination of the most recent follow-up data received for each patient and any information found from the Social Security Death Master File (SSDMF). A patient is known to be dead when a death follow-up is received or a death is found in the SSDMF data. It is not known that all other patients are alive. This assumption could be false in cases where the patient is lost to follow-up, or the notification of death was not entered into the Organ Procurement and Transplantation Network data before January 1, 2010. Similarly, a graft is known to have failed when a graft loss follow-up is received. However, it is not known that all other grafts are currently functioning. For kidney and kidney-pancreas grafts, the availability of the US Center for Medicare & Medicaid Services medical evidence data was also examined to determine whether dialysis was performed after the date of the kidney transplant.
      Organ Number of recipients (1 Oct 1987 to 31 Oct 2009) Number of recipients reported with a failed graft but not reported dead
      The patient status is based on a combination of the most recent follow-up data received for each patient and any information found from the Social Security Death Master File (SSDMF). A patient is known to be dead when a death follow-up is received or a death is found in the SSDMF data. It is not known that all other patients are alive. This assumption could be false in cases where the patient is lost to follow-up, or the notification of death was not entered into the Organ Procurement and Transplantation Network data before January 1, 2010. Similarly, a graft is known to have failed when a graft loss follow-up is received. However, it is not known that all other grafts are currently functioning. For kidney and kidney-pancreas grafts, the availability of the US Center for Medicare & Medicaid Services medical evidence data was also examined to determine whether dialysis was performed after the date of the kidney transplant.
      Number of recipients reported dead
      The patient status is based on a combination of the most recent follow-up data received for each patient and any information found from the Social Security Death Master File (SSDMF). A patient is known to be dead when a death follow-up is received or a death is found in the SSDMF data. It is not known that all other patients are alive. This assumption could be false in cases where the patient is lost to follow-up, or the notification of death was not entered into the Organ Procurement and Transplantation Network data before January 1, 2010. Similarly, a graft is known to have failed when a graft loss follow-up is received. However, it is not known that all other grafts are currently functioning. For kidney and kidney-pancreas grafts, the availability of the US Center for Medicare & Medicaid Services medical evidence data was also examined to determine whether dialysis was performed after the date of the kidney transplant.
      Number of recipients not reported dead or with failed graft
      The patient status is based on a combination of the most recent follow-up data received for each patient and any information found from the Social Security Death Master File (SSDMF). A patient is known to be dead when a death follow-up is received or a death is found in the SSDMF data. It is not known that all other patients are alive. This assumption could be false in cases where the patient is lost to follow-up, or the notification of death was not entered into the Organ Procurement and Transplantation Network data before January 1, 2010. Similarly, a graft is known to have failed when a graft loss follow-up is received. However, it is not known that all other grafts are currently functioning. For kidney and kidney-pancreas grafts, the availability of the US Center for Medicare & Medicaid Services medical evidence data was also examined to determine whether dialysis was performed after the date of the kidney transplant.
      Kidney 261492 25135 80223 156134
      Kidney-pancreas 16449 3186 4777 8486
      Pancreas 5933 1195 1573 3165
      Intestine 1694 8 767 919
      Liver 90713 176 33164 57373
      Heart 46214 34 22289 23891
      Lung 18850 15 10735 8100
      Heart-lung 1012 2 729 281
      Total
      The total does not equal the sum of all organs because some patients received more than 1 type of organ transplant during the time period.
      427689 29358 149368 248963
      a The number of unique people who received each type of transplant between 1 October 1987 and 31 October 2009.
      b The patient status is based on a combination of the most recent follow-up data received for each patient and any information found from the Social Security Death Master File (SSDMF). A patient is known to be dead when a death follow-up is received or a death is found in the SSDMF data. It is not known that all other patients are alive. This assumption could be false in cases where the patient is lost to follow-up, or the notification of death was not entered into the Organ Procurement and Transplantation Network data before January 1, 2010. Similarly, a graft is known to have failed when a graft loss follow-up is received. However, it is not known that all other grafts are currently functioning. For kidney and kidney-pancreas grafts, the availability of the US Center for Medicare & Medicaid Services medical evidence data was also examined to determine whether dialysis was performed after the date of the kidney transplant.
      c The total does not equal the sum of all organs because some patients received more than 1 type of organ transplant during the time period.
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