BACKGROUND: Kidney transplantation offers clear survival and quality-of-life advantages over dialysis, but severe pulmonary disease can complicate perioperative planning. In patients with substantially reduced respiratory reserve after pneumonectomy, general anesthesia may be considered high risk, creating uncertainty about transplant feasibility.

CASE REPORT: A 33-year-old man with end-stage kidney disease secondary to biopsy-proven AA amyloidosis was evaluated for preemptive living-donor kidney transplantation. He had undergone left pneumonectomy in 2015 because of bronchiectasis. Pulmonary function testing showed a mixed restrictive-obstructive pattern, with a forced vital capacity of 1.6 L (33% predicted), a forced expiratory volume in 1 second of 1.05 L (30% predicted), and a forced expiratory volume in 1 second/forced vital capacity ratio of 65%, indicating severe pulmonary impairment. Thoracic computed tomography demonstrated leftward mediastinal shift and diffuse bronchiectatic changes in the remaining right lung. Given the anticipated risk associated with general anesthesia, combined spinal-epidural anesthesia was selected. The transplant was successfully performed using a kidney from the patient’s human leukocyte antigen (HLA)-identical sister. No intraoperative respiratory or hemodynamic instability occurred. Renal function rapidly improved after surgery: serum creatinine decreased from 6.6 mg/dL preoperatively to 0.63 mg/dL on postoperative day 3. Heavy proteinuria also greatly improved during follow-up.

CONCLUSIONS: This case demonstrates that kidney transplantation can be successfully performed under combined spinal-epidural anesthesia in carefully selected patients with severely limited pulmonary reserve after pneumonectomy. It also highlights the importance of individualized anesthetic planning and close multidisciplinary coordination for complex transplant candidates with major pulmonary comorbidities.

Keywords: Anesthesia, Epidural, Anesthesia, Local, Bronchiectasis, Kidney Transplantation