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“Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.” Paracelsus

  • Kidneys were the first organ to be successfully transplanted. Today, the kidney is the most frequently transplanted organ. Before the advancement of kidney transplant and dialysis, end-stage renal disease (ESRD) was a fatal disease.

  • ESRD is the most common pathology leading to kidney transplant. In adults, ESRD is mostly caused by diabetic nephropathy, hypertensive kidney disease, and cystic kidney diseases. Less frequently, glomerular diseases, tubulointerstitial diseases, urinary tract infections or obstruction can result in ESRD. A small number of kidney transplants are represented by other familial or congenital diseases. In children, ESRD is primarily caused by kidney and urinary tract congenital anomalies as well as focal segmental glomerulosclerosis.

  • Regardless of the ESRD causation, kidney transplant is the best therapeutic option for patient survival and quality of life. The 5-year survival rate after kidney transplant is 80%, doubling the ~40%, 5-year survival of chronic dialysis patients. The 3-year survival rate posttransplant is 96% for living donor kidney transplants and 90% for deceased-transplants. Acute and chronic graft rejection are less frequent in living kidney transplants.

  • In the medium and long term, the overall economic cost of kidney transplant is lower than chronic dialysis. Kidney transplant has shown additional benefits over dialysis, including improvements in comorbidities such as hypertension, metabolic diseases, and sleep-related breathing disorders.

  • Previously, conditions such as HIV, Hepatitis C, advanced CHF, ABO blood group incompatibility, donor urolithiasis, and age >65 were considered contraindications for kidney transplant. Although associated with higher morbidity and mortality, these contraindications have been relativized. Unfortunately, even with decreasing contraindications, on average, in the United States, 12 people die every day of ESRD while on the transplantation waitlist.

  • Common comorbidities in ESRD patients include hypertension, diabetes mellitus, congestive heart failure, coronary artery disease, arrhythmias, fluid overload, hyperlipidemia, cerebrovascular disease, peripheral vascular disease, anemia, secondary hyperparathyroidism, pulmonary hypertension, and pericarditis (Extended in Table 45-1).

  • Cardiac events and autonomic nervous system dysfunction are the most common causes of morbidity and mortality within the year after kidney and pancreas transplantation.

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TABLE 45-1 Preanesthetic considerations of chronic kidney disease comorbidities by system




Cerebrovascular disease


  • Heart failure/Volume overload

  • Accelerated coronary artery disease

  • Arrhythmias

  • Hypertension

  • Left ventricular hypertrophy

  • Dyslipidemia

  • Endothelial dysfunction


  • Pulmonary hypertension

  • Atelectasis


Gastroparesis/Delayed gastric emptying (*DM patients in particular)


Diabetes Mellitus


  • Anemia

  • Coagulopathy

  • Uremic platelet dysfunction (⇒ bleeding)

  • Increased factor VIII and von Willebrand factor (VWF)(⇒ thrombosis)


  • Hyperkalemia

  • Hyponatremia

  • Hyperparathyroidism

  • Hyperphosphatemia

  • Metabolic acidosis

  • Bicarbonate deficiency

  • Hypercalcemia

  • Hypocalcemia

  • Malabsorption syndromes


  • Infections – Hep B, Hep C, HIV

  • Frailty

  • Osteopenia

  • Hypoalbuminemia


  • Patients with chronic kidney disease frequently have multisystem ...

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