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According to the Centers for Disease Control and Prevention (CDC), in 2019, approximately 37 million Americans were reported to have chronic kidney disease (CKD), with nearly 118,000 requiring initiation of treatment for kidney failure known as end-stage renal disease (ESRD) each year. Kidney transplantation is the treatment of choice for most patients with ESRD.
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Kidney transplant provides a significant improvement in quality of life and mortality benefits over dialysis in the treatment of ESRD, but optimizing access to kidney transplant and graft survival are ongoing challenges.
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The number of kidney transplants increased in 2019 for the fifth year in a row, having been relatively stagnant for many years prior. The increase occurred across age groups (except ages under 18), gender, and racial groups and revealed different causes of kidney disease.
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Patients diagnosed with ESRD frequently present a significant degree of comorbidities. This drives us to perform a careful assessment to detect and treat the coexisting illness that can alter the risk and survival related to the perioperative period. The patients within this specific clinical group present with fluid, electrolyte, or acid–base disorders.
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Knowledge of such imbalances and their pathophysiological basis is of prime importance not only for the proper management of the preoperative and immediate postoperative periods but also to optimize the maintenance period.
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PREOPERATIVE APPROACH
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Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines on the evaluation and management of kidney transplantation candidates (2020) give recommendations, among which it is worth emphasizing the following:
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All patients with CKD G4–G5 (glomerular filtration rate [GFR] <30 mL/min/1.73 m2) who are expected to reach ESRD should be informed of, educated about, and considered for kidney transplantation, regardless of socioeconomic status, gender or gender identity, race, and ethnicity.
Refer potential kidney transplant candidates for evaluation at least 6 to 12 months before anticipated dialysis initiation to facilitate living donors identification and workup and plan for possible preemptive transplantation.
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These recommendations should be followed according to the group of patients undergoing a preemptive transplant. They frequently have a GFR that is less than 20–30 mL/min, and most of the patients never receive preoperative optimization with dialysis.
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Thus, in the preoperative approach, fluids, electrolytes, and acid–base disorders must be analyzed within the context of a series of variables grouped into two categories: underlying diseases and current pharmacological management.
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The foremost illnesses leading to renal failure with dialysis or kidney transplant requirements (or both) are hypertension, diabetes, and glomerulonephritis.
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Drugs often used in these clinical entities can be summarized as diuretics, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs).
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One of the most critical goals before surgery is to avoid volume overload. In ...