Perioperative Care for Kidney Transplant Recipients

*Sebastian Hultin, Carmel M. Hawley, David W. Johnson and Ross S. Francis*

### **Abstract**

Transplantation carries significant mortality benefit compared to dialysis in end-stage kidney disease. Increased perioperative risk, however, results in a higher mortality in the first 3 months post-transplantation compared to remaining on haemodialysis. Consequently, optimal perioperative management is essential. Patients presenting for kidney transplantation require rapid assessment and preparation for theatre to minimise ischaemic times and improve mortality and graft outcomes. This task is often complicated by the presence of multiple medical comorbidities. Furthermore, early complications of hypotension, delayed graft function, renovascular and ureteric surgical complications and rejection render the perioperative phase of transplant challenging for the recipient and for the transplant team. In this chapter, we outline current practices in the assessment and management of kidney transplant recipients during the perioperative period, particularly focusing on their clinical application and the evidence underpinning them.

**Keywords:** comorbidity, kidney transplantation, perioperative care, risk assessment, treatment outcome

#### **1. Introduction**

Non-communicable diseases now account for 75% of deaths globally, with chronic kidney disease (CKD) rapidly rising up the ranks as a cause of death, reaching eleventh on the list in 2016 [1]. The estimated global crude prevalence of CKD in 2016 was 275.9 million cases associated with a crude mortality of 1.2 million [2].

As CKD patients' renal function declines, mortality rises to an estimated lifespan of 8 years for patients on dialysis of 40–44 years of age and 4.5 years to patients 60–64 years of age. Improvements in dialysis therapy have been accompanied by a decline in mortality rate [3]. Despite this, the long-term mortality on dialysis remains significantly inferior to that following kidney transplantation.

A systematic review in 2011 identified 110 studies including nearly 2 million patients with transplantation conferring a mortality advantage over dialysis. Only studies with follow-up periods <3 months favoured dialysis, attributed largely to perioperative complications and higher immunosuppression post-transplantation [4]. Accordingly, transplant and dialysis registry studies have confirmed increased mortality in transplanted patients compared to dialysis at 3 months (HR 2.0, 1.5–2.7, p < 0.001) with reversal at 6 months (HR 0.27, 0.16–0.47, p < 0.001) with 80% reduction in mortality following transplantation compared to dialysis at 12 months [5].

The increase in mortality associated with kidney transplantation highlights the need for optimal perioperative management to minimise the risks and maximise the benefits associated with transplantation. This chapter focuses on the principles and evidence of perioperative management of transplant patients.
