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Renal transplant is a well-established therapy for selected individuals with end-stage renal disease (ESRD). Patients that are selected to undergo renal transplant must have a thorough preoperative pulmonary evaluation to assess pulmonary status and to determine the risk of postoperative pulmonary complications (Figure 27-1). Postoperative pulmonary complications in nonthoracic surgery patients have been reported to be seen in 2–19% of patients.1 Effective presurgical pulmonary evaluation can help provide high-value, patient-centered care and helps the clinicians address risk assessment and identify areas for risk modification.2 The purpose of this chapter is to outline the preoperative pulmonary assessment of renal transplant patients.


Management protocol for pulmonary evaluation in renal transplant patients.


  • Concomitant pulmonary comorbidities like chronic obstructive pulmonary disease (COPD) and interstitial lung disease

  • Age

  • Obesity

  • Smoking

  • Severity of pulmonary hypertension

  • Obstructive sleep apnea (OSA)

  • Fragility status

  • Latent tuberculosis

In any surgical procedure, patient-specific risk is attributable to medical comorbidities that affect the overall recovery from the procedure. Age may be nonmodifiable risk factor, but all efforts should be made to treat any associated pulmonary condition (COPD, interstitial lung disease, pulmonary hypertension) prior to the procedure. The history, physical examination, and radiological test (chest examination, computed tomography [CT] scan of the chest, pulmonary function test, echocardiogram) are key components in identifying these risk factors.


Obesity has been recognized by the American Medical Association as a disease state that is a risk factor for all surgical patients. Obesity is defined as a body mass index (BMI) greater than or equal to 30 kg/m2. Obesity has been shown to cause posttransplant surgical complications and delayed graft function,3 and it demonstrated a negative effect, including graft failure, within the first year posttransplant.4

Excess abdominal fat (central or visceral obesity), which is found above the waist, is related to increased risk of diabetes and heart disease. In men, a waist greater than 40 inches and in women, more than 36 inches is of concern. Obesity leads to the following:

  • Decreased lung volumes after surgery is a principal cause of postoperative pulmonary complications.

  • Obesity predisposes to OSA, diabetes mellitus, and hypertension

  • Also a risk factor for delayed graft function

  • Obese renal transplant recipients suffer more surgical complications, including wound infections, delayed wound healing, lymphoceles, and perinephric hematomas

  • Management includes diet, exercise, and nutritional counseling

End-stage kidney disease is also associated with other comorbid conditions like deconditioning, coronary artery disease, venous thromboembolism, anxiety, and depression. Efforts targeted at these comorbidities to optimize the patient and prepare for surgery may reduce the risk for complications and help improve outcomes.



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