The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

https://eprints.ncl.ac.uk/file_store/production/266238/15F1B560-37DA-45A8-BD43-3FDED3E6A14B.pdf

KDIGO Clinical Practice Guideline on the evaluation and management of candidates for kidney transplantation

Background
The Charlson Comorbidity Index (CCI) originally was developed to predict mortality within 1 year of hospital admission in patients without trauma. As it includes factors associated with medical and surgical complexities, it also may be useful as a predictive tool for hospital readmission after orthopaedic surgery, but to our knowledge, this has not been studied.

Higher Charlson Comorbidity Index Scores are associated with readmission after orthopaedic surgery.

Importance The timing of surgery in patients with recent ischemic stroke is an important and inadequately addressed issue. Objective To assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality. Design, Setting, and Participants Danish nationwide cohort study (2005-2011) including all patients aged 20 years or older undergoing elective noncardiac surgeries (n=481 183 surgeries). Exposures Time elapsed between stroke and surgery in categories and as a continuous measure. Main Outcomes and Measures Risk of major adverse cardiovascular events (MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality) and all-cause mortality up to 30 days after surgery. Odds ratios (ORs) were calculated by multivariable logistic regression models. Results Crude incidence rates of MACE among patients with (n = 7137) and without (n = 474 046) prior stroke were 54.4 (95% CI, 49.1-59.9) vs 4.1 (95% CI, 3.9-4.2) per 1000 patients. Compared with patients without stroke, ORs for MACE were 14.23 (95% CI, 11.61-17.45) for stroke less than 3 months prior to surgery, 4.85 (95% CI, 3.32-7.08) for stroke 3 to less than 6 months prior, 3.04 (95% CI, 2.13-4.34) for stroke 6 to less than 12 months prior, and 2.47 (95% CI, 2.07-2.95) for stroke 12 months or more prior. MACE risks were at least as high for low-risk (OR, 9.96; 95% CI, 5.49-18.07 for stroke P  = .003 for interaction). Similar patterns were found for 30-day mortality: ORs were 3.07 (95% CI, 2.30-4.09) for stroke less than 3 months prior, 1.97 (95% CI, 1.22-3.19) for stroke 3 to less than 6 months prior, 1.45 (95% CI, 0.95-2.20) for stroke 6 to less than 12 months prior, and 1.46 (95% CI, 1.21-1.77) for stroke 12 months or more prior to surgery compared with patients without stroke. Cubic regression splines performed on the stroke subgroup supported that risk leveled off after 9 months. Conclusions and Relevance A history of stroke was associated with adverse outcomes following surgery, in particular if time between stroke and surgery was less than 9 months. After 9 months, the associated risk appeared stable yet still increased compared with patients with no stroke. The time dependency of risk may warrant attention in future guidelines.

https://jamanetwork.com/journals/jama/articlepdf/1887763/joi140094.pdf

Time Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Noncardiac Surgery

Background Aseptic surgical trauma provokes a homeostatic neuroinflammatory response to promote healing and protect the organism from further injury. When this response is dysregulated, harmful consequences can follow, including postoperative cognitive decline. Sources of data We performed a comprehensive search on PubMed related to postoperative cognitive dysfunction (POCD). Areas of agreement Although the precise pathogenic mechanisms for POCD remain unclear, certain risk factors are known. Areas of controversy The mechanisms that lead to exaggerated and persistent neuroinflammation and the best way to counteract it are still unknown. AREAS FOR DEVELOPING RESEARCH: It is imperative that we identify the underlying processes that increase the risk of cognitive decline in elderly surgical patients. In this review we explore non-resolution of inflammation as an underlying cause of developing exaggerated and persistent POCD. If interventions can be developed to promote resolution of neuroinflammation, the patient's postoperative recovery will be enhanced and long-term consequences can be prevented.

/pdf/the-neuroinflammatory-response-of-postoperative-cognitive-6p01cgkfxh.pdf

The neuroinflammatory response of postoperative cognitive decline

Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.

/pdf/perioperative-care-of-patients-at-high-risk-for-stroke-1okmrhmy35.pdf

Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care*.

Objective: To identify independent preoperative predictors of outcome for total hip or knee replacement (THKR) and abdominal aortic aneurysm (AAA) repair, including the importance of the time interval between an acute coronary syndrome (ACS) or stroke and surgery. Background: Present guidelines do not advocate a prolonged delay after ACS though recent data suggest delaying operations by 8 weeks. There is a lack of data on when to schedule surgery following stroke. Methods: The Hospital Episode Statistics database was analyzed for elective admissions for THKR and AAA surgery between 2006–2007 and 2009–2010. Patient factors influencing mortality, length of stay, and readmission rates were identified by logistic regression. Results: A total of 414,985 THKRs (mortality: 0.2%) and 14,524 AAA repairs (mortality: 3.5%) were included. Heart failure, renal failure, liver disease, peripheral vascular disease, and non-atrial fibrillation arrhythmia increased the odds of mortality for both surgeries. Among other factors, previous ACS and stroke predicted mortality after THKR but not AAA surgery. Compared with more delayed surgery, THKR surgery performed within 6 months of an ACS (odds ratio [OR]: 3.81; 95% confidence interval [CI]: 1.55–9.34), but

Independent preoperative predictors of outcomes in orthopedic and vascular surgery: the influence of time interval between an acute coronary syndrome or stroke and the operation.

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Independent preoperative predictors of outcomes in orthopedic and vascular surgery: the influence of time interval between an acute coronary syndrome or stroke and the operation.