Perioperative Kidney Transplant Care: A Narrative Review of Preoperative Optimization, Intraoperative Management, and...

Kidney transplantation is the preferred kidney replacement therapy for eligible patients with kidney failure; however, early allograft function remains vulnerable to potentially modifiable events across the perioperative continuum. Delayed graft function (DGF), hemodynamic instability, electrolyte and acid-base disturbances, vascular compromise, and surgical complications can adversely affect early recovery, prolong hospitalization, and influence subsequent graft outcomes. This narrative review summarizes evidence-based perioperative strategies designed to reduce preventable contributors to DGF and optimize early kidney allograft function, spanning recipient preparation before surgery, intraoperative anesthetic and surgical management, and structured surveillance during the immediate postoperative period. Preoperative optimization includes assessment of cardiovascular reserve, volume status, frailty, anemia, electrolyte and acid-base abnormalities, timing of dialysis, anticoagulant and antiplatelet therapy, and immunologic risk, including crossmatch and donor-specific antibody status. Donor and graft-related determinants, particularly deceased-donor status, ischemia times, donation after circulatory death, and donor quality, should be integrated into perioperative risk stratification and monitoring intensity. During transplantation, avoidance of sustained hypotension, individualized fluid administration, use of balanced crystalloids where appropriate, early vasopressor support for vasodilatory hypotension, temperature and glucose control, and proactive management of hyperkalemia and metabolic acidosis are central to perfusion protection. Reperfusion should be treated as a critical diagnostic interval requiring prompt assessment for arterial or venous thrombosis, graft malposition, anastomotic compromise, and inadequate perfusion. Immediate postoperative care should incorporate structured handoff, serial assessment of urine output and biochemical parameters, early Doppler ultrasonography when graft dysfunction is suspected, and timely differentiation of DGF from reversible vascular, urological, or hemodynamic complications. Enhanced Recovery After Surgery pathways may facilitate consistent multidisciplinary communication, early mobilization, analgesic optimization, and protocolized escalation. The ultimate clinical goal of this coordinated, risk-adapted perioperative strategy is to reduce preventable DGF, accelerate recognition of reversible complications, and support early allograft recovery.