Perioperative Assessment and Intraoperative Core Concepts in the Complex Kidney Patient

Purpose: Life span and sense of well-being continue to improve post-transplantation in patients with end-stage kidney disease, despite referral of an older and more medically complex population for transplantation. In this issue of the journal, we review existing evidence about risk assessment in kidney transplant candidates from the perspective of the anesthesiologist. The authors explore cardiovascular assessment and risk in the context of intraoperative events that can influence short- and long-term outcomes. Recent Findings: The number of patients referred for kidney transplantation continues to increase and has far exceeded the number of donor organs available. Many of these patients have become more complex with higher rates of congestive heart failure, diabetes, obesity, collagen vascular disease, and end organ dysfunction. The risk of cardiovascular disease in the end-stage renal disease patient is higher than the general population, and many studies have looked at identifying which patients are higher risk for a post-transplant cardiovascular event. Despite this, tests to detect and guide interventions are not sensitive enough to prevent early cardiovascular complications leading to graft loss and patient death. To address this issue, we explore the strengths and limitations of current cardiovascular risk evaluation paradigms and add information about physiological events during transplant surgery that can affect short- and long-term patient and graft outcomes. Summary: The overall survival of patients with end-stage renal disease has improved over time, but questions persist regarding best practices in the perioperative period. The approach to preoperative evaluation needs to be coherent with anticipated physiological events that occur during surgery. Filling in these gaps in knowledge may help improve the ability to identify and mitigate risk.