**6. Conclusions**

*Perioperative Care for Organ Transplant Recipient*

sity for more severe infection.

Australia and New Zealand are shown in **Table 9**.

improve clinical outcomes [111, 113–115].

*Acute rejection rates in the first six months post-transplant.*

Living donor 17.4 16.7 Deceased donor 15.2 18.6

*and Transplant Registry, Adelaide, Australia. 2018. http://www.anzdata.org.au.*

*Data from ANZDATA Registry. 41st Report, Chapter 7: Kidney Transplantation. Australia and New Zealand Dialysis* 

**5.8 Rejection**

surgical site infections and septicaemia [98]. Retrospective database studies have estimated a cumulative incidence of 17% in the first 6 months post-transplant, which rises to 60% for women and 47% for men at 3 years [99]. The presentation for UTI is similar to that of the general population and management identical to complicated UTIs with 7–14 days of antibiotic therapy, although the optimal duration has not been well established [98]. Management of post-transplant candiduria is controversial, without definite improvement in clinical outcomes following therapy [100]. Other bacterial pathologies are treated in the same way as in the general population with anticipated more frequent and longer duration antibiotic use due to physician concern over immunosuppressed state and propen-

In the early era of transplantation, hyperacute rejection due to the presence of preformed donor-specific antibodies (DSAs) occurring in the first minutes or hours after perfusion of the transplant was a significant risk. However, with the introduction of the complement-dependent cytotoxic cross-match, as described by Patel and Terasaki [101], and more recently solid phase assays that are able to detect DSAs with high sensitivity, hyperacute rejection is now extremely rare [102]. Nevertheless, early acute rejection remains a common occurrence, with a reported incidence of 7–25% depending on the level of immunological risk and choice of induction immunosuppression [21, 103–106]. Contemporary rejection rates in

In the perioperative period, DGF persisting beyond 4–5 days, decreasing urine output or an unexplained rise in creatinine by >15–20%, should prompt consideration of rejection as the underlying cause (Section 5.4). Unless there is a contraindication such as active bleeding or an unavoidable requirement for anticoagulation, the diagnosis requires a renal biopsy, both to exclude alternative causes of graft dysfunction and to characterise the histological pattern and severity of rejection. Rejection is classified histologically using the Banff criteria into borderline rejection, cell-mediated rejection, antibody-mediated rejection and mixed rejection [107, 108]. Treatment of cellular rejection would usually involve pulsed methylprednisolone 0.25–1.0 g daily for 3 days as first-line treatment, combined with a T-cell depleting therapy such as thymoglobulin/ATG if the rejection is histologically severe rejection (Banff class 2 or greater), or if there is a suboptimal response to methylprednisolone [109]. The optimal therapy for acute antibody-mediated rejection remains unclear, but would typically include pulsed methylprednisolone, plasma exchange (often combined with intravenous immunoglobulin at a dose of 0.1 g/kg following each exchange) outcomes [110–112]. Some centres also advocate the use of a B cell depleting antibody such as rituximab or the proteasome inhibitor bortezomib, although currently there is no strong evidence that these agents

**First allograft (%) Second or subsequent allograft (%)**

**26**

**Table 9.**

Kidney transplantation has evolved from a highly experimental therapy to become recognised as the gold standard treatment for many patients with ESKD [116]. This progress has occurred through the many iterative developments in the surgical and medical management of transplant recipients, not the least of which being the introduction of highly effective immunosuppressive agents. Delivering high standards of clinical care during the perioperative period is a crucial step in achieving excellent allograft outcomes. This chapter provides an overview of the approach to assessing potential recipients admitted for transplantation, and guidance on typical perioperative medication and fluid prescriptions, as well as postoperative monitoring and early complications.
