Preventing delayed graft function after kidney transplantation: The emerging role of the perioperative period

The perioperative period involves anesthesiologists, nephrologists and transplant surgeons as key contributors to patients undergoing kidney transplantation (KT). While KT remains the preferred treatment of end-stage renal disease, postoperative complications are common. Delayed graft function occurs in up to 40% of patients undergoing deceased donor KT and is predictive of poor graft and overall survival. Emerging evidence points to several strategies during the perioperative period that may contribute towards optimizing immediate graft function. This review summarizes the available evidence supporting glycemic control through monitoring and administering insulin, patient blood management to minimize exposure to unnecessary blood transfusion, blood pressure targets that differ from routine practice, fluid and electrolyte management to avoid further disruption in homeostasis and the use of intraoperative diuretics. Each of these strategies would be modifiable, are easily tested, and may have a role in minimizing the risk of delayed graft function after KT. Together, these potential strategies form a list of candidate components of a future perioperative bundle-of-care that require prospective testing and careful assessment of benefit and harm. Through supporting immediate graft function, the perioperative team can play a critical role within the multidisciplinary care continuum in improving outcomes after KT and contributing to the success of transplant programs.