Chronic kidney disease (CKD) is a general term for a group of heterogenous disorders affecting kidney structure and function.1 CKD is classified according to disease severity, which is based on glomerular filtration rate (GFR) and albuminuria, and clinical diagnosis, which involves cause and pathology.1 Worldwide, diabetes mellitus is the most common cause of CKD, but herbal and environmental toxins can also play a role.2 Though CKD can be detected with routine laboratory tests1 and prevented with interventions,2 it can lead to various health complications and ultimately mortality.2 Awareness of CKD remains low in many communities and even among physicians,2 so health professionals of all specialties should look for signs of possible CKD in their patients. For example, anesthesia providers must account for CKD before, during and after a procedure to avoid complications or fatality. Given the higher rates of perioperative morbidity and mortality among patients with CKD,3 anesthesiology practitioners should be especially cautious with patient care.
Before a procedure begins, the anesthesiologist is responsible for screening for CKD and comorbid conditions.3,4 Patients with CKD may present with chronic or acute renal failure, may be undergoing dialysis or may have impaired renal function after a transplant.3 Mortality rates for patients with CKD are particularly high, with estimated mortality rates of 10 to 20 percent for patients with end-stage renal disease who undergo cardiac surgery.3 Given these data, anesthesia providers should do their best to prepare patients for surgery. For one, obtaining an acceptable potassium level before surgery may be important to avoiding complications.3 Treatment for high potassium levels include polystyrene binding resins, insulin in combination with intravenously administered dextrose, intravenously administered bicarbonate and even dialysis.3 Other CKD-related preoperative conditions include acid-base disorders, bleeding, anemia and hypertension, all of which should be controlled before surgery.3 An anesthesiology practitioner can also provide CKD patients with antibiotic prophylaxis to avoid postoperative infection.3 Finally, as cardiovascular disease is the greatest cause of mortality in patients with CKD, preoperative cardiac evaluation—such as exercise testing, radionuclide scanning and stress echocardiography—is crucial to an anesthesiologist’s practice.3,4 In order to prevent intraoperative or postoperative issues, any comorbid disorders should be treated adequately before surgery in a patient with CKD.3
Once surgery is underway, the anesthesia provider should follow strict, standardized guidelines for patients with CKD. A paper by Olivero suggests precautions for anesthesia in patients with renal failure, including not administering large amounts of intravenous (IV) fluids, choosing the proper IV solution according to electrolyte levels, avoiding ACE inhibitors and beta-blockers and lowering calcium levels with citrate administrations.5 Also, according to Tsubokawa, GFR in patients with CKD is correlated with drug or metabolite clearance.6 When drugs such as anesthetics, morphine, muscle relaxants, antibiotics and phosphodiesterase III inhibitors are administered to a CKD patient, drug concentrations are increased and pharmacological effects last longer than in other patients.6 Therefore, dosages of these drugs should be adjusted based on renal function factors, such as creatinine clearance.6 Patients with CKD can also be at higher risk for aspiration due to delayed gastric emptying,7 and their ventilation should be highly controlled to avoid circulatory depression.7 Overall, the anesthesia provider’s foci during the intraoperative period for CKD patients should be fluid management, glucose control and ventilation.4,7,8
Postoperative management is also key in a CKD patient’s care. If morphine or other opioids were used, the patient should be carefully monitored after the procedure for delayed onset respiratory depression.9 Also, because the dose required to maintain a neuromuscular block in CKD patients is lower than normal, these patients are at risk for postoperative residual curarization (PORC; i.e., residual paresis after emergence from anesthesia).9 Additionally, a systematic review found that preoperative renal dysfunction was a common predictor of postoperative renal failure,10 so anesthesia providers should monitor patients for postoperative signs of renal failure. Finally, a study by Ackland et al. found that lower preoperative GFR was associated with more frequent morbidity and longer hospital stay for CKD patients undergoing orthopedic surgery.11 Taken together, these results show that anesthesia providers should account for intraoperative anesthetics and preoperative conditions in CKD patients’ postoperative care.
Anesthesia for patients with CKD can be complex. Before a procedure, an anesthesiologist should assess the patient’s level of CKD with laboratory testing and provide treatment for comorbid conditions. Intraoperative fluid management, glycemic control and ventilation are crucial to avoiding complications. Postoperative management includes close patient monitoring for signs of renal and other issues. Given the potential gravity of CKD, anesthesiology organizations should create standardized care recommendations for patients with CKD based on their disease severity and diagnosis.
1. Levey AS, Coresh J. Chronic kidney disease. The Lancet. 2012;379(9811):165–180.
2. Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: Global dimension and perspectives. The Lancet. 2013;382(9888):260–272.
3. Krishnan M. Preoperative care of patients with kidney disease. American Family Physician. 2002;66(8):1471–1476.
4. Meersch M, Schmidt C, Zarbock A. Patient with chronic renal failure undergoing surgery. Current Opinion in Anesthesiology. 2016;29(3):413–420.
5. Olivero JJ, Sr. Administration of Anesthesia to Patients with Renal Failure. Methodist DeBakey Cardiovascular Journal. 2015;11(3):197.
6. Tsubokawa T. Pharmacokinetics of anesthesia related drugs in patients with chronic kidney disease. Masui. 2013;62(11):1293–1303.
7. Butterworth JF, Mackey DC, Wasnick JD. Anesthesia for Patients with Kidney Disease. Morgan and Mikhail’s Clinical Anesthesiology: McGraw-Hill Education; 2013.
8. Campbell JP, Cousins JM. Anesthesia for dialysis patients. In: Jones SB, Berns JS, O’Connor MF, eds. UpToDate November 10, 2018.
9. Craig RG, Hunter JM. Recent developments in the perioperative management of adult patients with chronic kidney disease. British Journal of Anaesthesia. 2008;101(3):296–310.
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11. Ackland GL, Moran N, Cone S, Grocott MPW, Mythen MG. Chronic Kidney Disease and Postoperative Morbidity After Elective Orthopedic Surgery. Anesthesia & Analgesia. 2011;112(6):1375–1381.