Case Summary

Patient: 49-year-old male

History:

The patient underwent a renal transplant in 2011 for IgA nephropathy. Since 2018, he has had graft failure and is maintained on thrice-weekly dialysis via a left internal jugular catheter. He has an ejection fraction of 35% with global hypokinesia and grade II diastolic dysfunction. He also has severe secondary hyperparathyroidism with a parathyroid hormone level of 3248 pg/mL. His medications included clopidogrel (Clopilet) and nebivolol 2.5 mg once daily. He presented after a road traffic accident with complete triceps and quadriceps tendon avulsions. He was transferred directly from dialysis to the operating room for urgent tendon repair.

Why Was Tendon Repair Crucial?

Tendon avulsion in end-stage renal disease patients leads to major disability. Triceps rupture eliminates active elbow extension, while quadriceps rupture renders ambulation impossible. The risk of rupture is amplified in ESRD due to:

• Elevated parathyroid hormone causing weakening at the bone–tendon junction.
• Uremic toxins leading to collagen degradation.
• β2-microglobulin amyloid deposition in tendons.

Reference: Moe SM, Drüeke TB. Adv Chronic Kidney Dis. 2007;14(1):3–12.

Aetiology of Tendon Rupture in ESRD

Molecular Pathophysiology:

Parathyroid hormone upregulates RANKL, increasing osteoclast activity and subperiosteal resorption. Impaired collagen cross-linking contributes to tendon fragility. β2-microglobulin amyloid infiltrates tendons, weakening their structure. Accumulation of advanced glycation end products in uremia stiffens tendons and reduces resilience.

Reference: Delmas PD. Kidney Int. 1993;43(2):279–86.

Preoperative Risk StratificationCardiac

The patient had an ejection fraction of 35%, global hypokinesia, left ventricular hypertrophy, and grade II diastolic dysfunction. Molecular alterations in chronic heart failure include abnormal β1-receptor density and impaired calcium cycling, both of which reduce contractility. Nebivolol was continued to prevent sympathetic surges.

Anesthetic goal: Avoid tachycardia, maintain afterload, and titrate anesthetic drugs to preserve contractility.

Reference: Francis GS. Am J Med. 2001;110(Suppl 7A):37S–46S.

Renal

As an ESRD patient on dialysis, he was at risk of electrolyte shifts, acidosis, and volume instability. Succinylcholine was contraindicated due to the risk of hyperkalemia from denervated and injured muscle. Atracurium was chosen for neuromuscular blockade due to its non-renal Hofmann elimination.

Anesthetic goal: Maintain normovolemia, monitor potassium, and select renal-safe drugs.

Reference: Kopel J, Pena-Hernandez C, Nugent K. Ochsner J. 2019;19(2):147–53.

Hematology

The patient was on clopidogrel, increasing bleeding risk due to platelet dysfunction. Tranexamic acid 1 g was used intraoperatively to reduce fibrinolysis.

Anesthetic goal: Avoid neuraxial anesthesia and closely monitor the surgical field for bleeding.

Reference: Levy JH, Welsby IJ, Goodnough LT. Anesthesiology. 2018;129(5):1171–83.

Preoperative Optimization

Dialysis was performed immediately before surgery to normalize electrolytes, reduce uremia, and minimize post-dialysis hypotension. Laboratory tests after dialysis included potassium, hemoglobin, calcium, and ECG evaluation for QT abnormalities.

Reference: Carrero JJ, Stenvinkel P. Semin Dial. 2010;23(5):498–509.

Anesthetic TechniqueInduction

Dexmedetomidine 20 mcg IV was given to blunt sympathetic tone and reduce opioid requirement. Fentanyl 150 mcg was titrated to blunt the intubation response. Midazolam 1 mg was administered in a minimal dose to avoid delayed emergence. Propofol 30 mg was given in a reduced dose to avoid myocardial depression. Sevoflurane was chosen for its cardiostability and renal safety. Atracurium 30 mg was used for neuromuscular blockade, relying on Hofmann elimination rather than renal clearance.

Reference: Schnider TW, et al. Anesthesiology. 2004;100(2):376–88.

Maintenance

Anesthesia was maintained with sevoflurane in oxygen and air (MAC 0.8–1.0). Atracurium top-ups were titrated with TOF monitoring. Intravenous fluids consisted of 700 mL normal saline over 2 hours, adjusted according to mean arterial pressure and clinical volume status. Paracetamol 1 g IV was administered pre-incision to provide opioid-sparing analgesia.

Reference: Sinatra RS. Anesth Analg. 2005;101(5 Suppl):S5–22.

Positioning and Paddings

Quadriceps tendon repair required supine positioning, while triceps repair was performed in the right lateral decubitus position. Special precautions included meticulous pressure point padding, vascular access protection for the left internal jugular dialysis catheter, and neutral alignment of the head and neck. ESRD patients are prone to pressure sores and neuropathy, making positioning particularly important.

Reference: Kopman AF, et al. Anesth Clin North Am. 2002;20(1):29–45.

Emergence

Wounds were infiltrated with 0.2% ropivacaine for long-lasting local analgesia. Neuromuscular blockade was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg after confirming TOF ratio greater than 0.9. The patient was extubated smoothly and transferred to the ICU for close postoperative monitoring.

Reference: Becker DE. Anesth Prog. 2012;59(2):90–101.

Key Anesthesia Learning Points

Hyperkalemia risk requires avoidance of succinylcholine because denervated or injured muscle can cause potassium release. The low ejection fraction mandates low-dose anesthetic agents to prevent myocardial depression. Uremia prolongs sedative effects, so sedative doses must be minimized to avoid delayed emergence. Analgesia should be multimodal and opioid-sparing, using paracetamol and local infiltration with ropivacaine. Clopidogrel-induced platelet dysfunction requires tranexamic acid to limit fibrinolysis and bleeding. Positioning requires extra care due to neuropathy risk in ESRD. Atracurium is the neuromuscular blocker of choice because of non-renal elimination.

Reference: Kheterpal S, et al. Anesthesiology. 2005;102(3):556–63.

Operating Orthopaedic Surgeon: Dr George Jacob, 7 May 2025.