Total intravenous anesthesia in kidney transplantation: A narrative review.

BACKGROUND: Kidney transplantation is the treatment of choice for end-stage renal disease. Whether propofol-based total intravenous anaesthesia (TIVA) confers advantages over volatile anaesthesia for perioperative stability, recovery, and graft outcomes remains debated. AIM: To synthesise the currently available comparative evidence on propofol-based TIVA versus volatile anaesthesia in adult kidney transplantation-focusing on haemodynamic stability, renal injury biomarkers, early graft function, recovery, postoperative nausea and vomiting (PONV), immunologic outcomes, and safety-and to identify the key evidence gaps and priorities for future research. METHODS: We performed a narrative review following the Scale for the Assessment of Narrative Review Articles framework, with structured search and selection consistent with PRISMA-S reporting. PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, Scopus, and Web of Science were searched from inception to February 2026. Quality was appraised using Cochrane Risk of Bias 2 and ROBINS-I. Six studies were directly eligible in adult kidney transplant recipients; four supplementary mechanistic sources informed interpretation. RESULTS: TIVA provided haemodynamic stability and immediate graft function equivalent to volatile anaesthesia. Urinary tubular biomarkers (kidney injury molecule-1, N-acetyl-β-D-glucosaminidase) were modestly lower with propofol in the VAPOR-1 trial (n = 57 living-donor pairs), but this did not translate into differences in delayed graft function, serum creatinine, or one-year graft survival. TIVA was associated with faster extubation and lower PONV, though recovery comparisons were confounded by opioid co-administration. Acute rejection rates did not differ significantly. CONCLUSION: Propofol-based TIVA is a safe and effective alternative to volatile anaesthesia in kidney transplantation. Whether the cellular-level biomarker signal translates into clinically meaningful renoprotection in higher-risk grafts requires adequately powered multicentre trials with standardised perioperative protocols.