Dear friends
A 24, year old male was sent by our nephrologists today. He is a case of renal failure on dialysis. He has undergone live donor transplant and the graft was rejected. Now he has graft rejection and reaction. Hematuria and is likely to undergo graft nephrectomy. To compound his woes, he has been unable to walk since 6 months. He has bilateral steroid induced osteonecrosis of hips. He is severely painful.
He has a related donor ready and is in queue for a transplant also.
No doubt he needs a total hip bilaterally
My queries after a detailed discussion with the senior transplant nephrologist who referred me this case, one of many we will need to tackle in the future.
1. Timing-- Do we do the hips before or after the transplant. Nephrologist feels preoperative management is easier before . afterwards he will be on multiple immune suppressants and steroids. They do not plan a steroid sparing regimen.
If the hips are not done first he will remain severely handicapped following the transplant for an extended period of time till he gets fit for surgery and the risks are higher following the transplant
2. Cemented or uncemented
I would go uncemented as I want to save time. The difference with cemented hips is that i end up spending longer in component implantation.
3. Risks-- Is the risk of infection higher-- As far as knees go we have excellent data from the scottish registry which says the risk is higher with patients with renal failure. (BJJ- published somewhere in the last two years). What other significant risks exist?
Do we change antibiotic prophylaxis? What happens if he does get infected, it will screw up his chances for a replacement as well as a transplant.
4. One side or both at a time. Honestly, we don't have the set up for one sitting bilateral hips. But here my advantage is that preoperatively the nephrologists will take over.
5. Cannot use alendronate and head conserving surgeries. I believe THA is the least invasive and best option here. All subject to how my anaesthetists view the patient.
Requesting experiences and opinions
Murali Poduval
Pondicherry
India
Dear Prof Poduval,
I would like to share my thoughts and experience on the topic and hope you will find this helpful.
#1. Timing: As you pointed out this is a dilemma. There is limited data on the optimal time point, I am unaware of high quality trials on the topic. The risk for preoperative complications is generally higher in patients with chronic kidney disease (CKD) as compared to those with normal renal function. Following transplantation patients are particularly susceptible to infection due to immunosuppressive therapy. On the other hand, perioperative VTE prophylaxis is more complicated in patients on hemodialysis (HD). Anticoagulants are usually eliminated renally (NOADs are contraindicated) so there is a marked risk for overdosing and subsequent coagulopathy in CKD patients. This is why patients on HD undergoing THA are at higher risk for hematoma.
Prosthetic joint infection (PJI) is, however, the most dreadful complication. Moreover, in case of PJI immuno-suppressive therapy can not be stopped in transplanted patients and control of infection becomes even more difficult. Personally, I would therefore definitely go for THA before transplantation (btw this is in accordance with a study of Shrader et al. published in J Arthroplasty in 2006) In an effort to reduce the risk of preoperative bleeding and hematoma we usually recommend
a) using a citrate-based (as opposed to heparine-based) HD protocol for the perioperative period
b) daily controls of factor Xa activity (4 hours after last VTE prophylaxis shot) until a proper level has been established
c) use of at least one drain (I am aware of the evidence...)
#2. Cemented or uncemented:
In a 24 yr old patient I would go for uncemented THA. Despite steroid therapy and CKD most of those young patients will have a bone stock good enough for uncemented arthroplasty.
#3. I have pointed out on the risks. Personally, I do not change my antibiotic regime (single shot cefuroxime, if on HD no dose adjustment necessary either) as compared to those with normal renal function. As said above the risk for infection is higher in CKD patients but to my knowledge there is no clear evidence indicating that this can be further reduced by additional antibiotics.
#4. You said the patient has unable to walk for 6 months and is on the transplantation list. I would therefore recommend one-stage bilateral THA. If Hb is low (as often in CKD patients), you might want to consider using a cell-saver or preoperative EPO. However, I think it would not be a major problem to do one side at a time with a short interval.
#5: I can´t really say much about indication. But a patient unable to walk with AVN is usually a good candidate for THA.
Kind regards,
Oliver Hauschild
Dear Dr Hauschild
Thank you very much for the exhaustive reply.
Murali Poduval
Dear Murali
I agree completely with Oliver, on the timing although I would prefer it before the transplant. Non cemented would be better for him and I would continue the Cefuroxine regime as usual. I will stress that bilateral in one stage will be better and as he is in renal failure already you do not have the risk of potential post-operative kidney "block" in the early stages due to the surgical trauma.
regards
Reorge
Recently one of our paper entitled "Life and Consciousness - The Vedāntic View" has been published in the Journal Communicative & Integrative Biology. An interesting discussion on this paper can be found at: https://groups.google.com/forum/#!topic/online_sadhu_sanga/Mcv2O-yhqLE
From paper:
"The scientific confirmation of the existence of consciousness in unicellular organisms and plants certainly establishes that the brain is not the source of consciousness. Several decades back, research in medical science has also proven that the brain is not the source of consciousness. In 1970, Robert White and his team successfully transferred the head of a rhesus monkey to the headless body of another monkey. The monkey survived for 8 days.68 Researchers are also attempting to perform the same scenario with human beings.69 It is reported that if a human head has been detached under controlled conditions, it must be reconnected to the circulatory flow of other person's body (which is conscious or living) within one hour.70 Therefore, brain-based analysis for understanding consciousness (neuronal analysis) does not have very bright prospects."
Paper: Life and Consciousness - The Vedāntic View
DOI: http://dx.doi.org/10.1080/19420889.2015.1085138
Journal: Communicative & Integrative Biology
Publication date - 09 Oct 2015
Author: Bhakti Niskama Shanta - http://orcid.org/0000-0002-2039-3249
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