Authors: Delaporte A et al.
Anesthesiology Open 1(1): e0004 10.1097/ao9.0000000000000004
Summary
This large single-center retrospective cohort study evaluated whether intraoperative hypotension is associated with delayed graft function (DGF) after kidney transplantation. The investigators analyzed 3,825 consecutive first kidney transplants (2013–2024), including both deceased (68%) and living donors (32%). Combined transplants were excluded.
Intraoperative hypotension was quantified using the area under the curve (AUC) for mean arterial pressure (MAP) <65 mmHg, integrating both duration and severity of hypotension. The primary outcome was delayed graft function, defined as the need for dialysis within the first postoperative week.
Delayed graft function occurred in 26.3% overall (37.5% of deceased donor recipients, 3.1% of living donor recipients). The median AUC for MAP <65 mmHg was 12 (0–78) mmHg·min. After multivariable adjustment for prespecified recipient, intraoperative, and donor confounders, each 50 mmHg·min increase in hypotension AUC was associated with increased odds of DGF (adjusted odds ratio 1.08; 95% CI 1.02–1.14; P = 0.009).
The association remained stable across the 11-year study period.
The authors conclude that greater duration and severity of intraoperative hypotension are associated with higher incidence of DGF. While causation cannot be established, the findings suggest hypotension may be a modifiable intraoperative contributor to graft outcomes.
Key Points
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Delayed graft function occurred in more than one in four transplant recipients, predominantly in deceased donor transplants.
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Hypotension was assessed quantitatively using MAP <65 mmHg area-under-the-curve rather than binary thresholds.
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Each additional 50 mmHg·min of hypotension was associated with an 8% increase in odds of DGF.
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The association persisted after multivariable adjustment and across the full study period.
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Causality cannot be inferred from this retrospective design.
What You Should Know
Kidney transplant recipients are uniquely vulnerable to ischemia–reperfusion injury. While donor quality, ischemia time, and recipient comorbidities are often nonmodifiable, intraoperative hemodynamics are directly under anesthetic control.
This study strengthens the signal that “time under 65” may matter in transplant anesthesia, not just in cardiac or general surgery populations. It does not prove that targeting a higher MAP will reduce DGF, but it raises an important physiologic question:
Is a generic MAP threshold of 65 mmHg appropriate for newly transplanted kidneys, especially from marginal or deceased donors?
Prospective trials will be needed to determine whether transplant-specific MAP targets improve graft survival, but for now, this supports heightened vigilance regarding intraoperative hypotension in kidney transplantation.
Thank you to Anesthesiology Open for allowing us to summarize and share this article.