Chronic Renal Insufficiency and ESRD
GENERAL PRINCIPLES
• Chronic renal insufficiency (CRI) is an independent risk factor for perioperative cardiac complications, so all patients with renal disease need appropriate cardiac risk stratification.11
• Patients with ESRD have a substantial mortality risk when undergoing surgery.107
• Most general anesthetic agents have no appreciable nephrotoxicity or effect on renal function other than that mediated through hemodynamic changes.108
TREATMENT
• Volume status
î Every effort should be made to achieve euvolemia preoperatively to reduce the incidence of volume-related complications intraoperatively and postoperatively.109
î Patients with CRI not receiving hemodialysis may require treatment with loop diuretics.
î Patients being treated with hemodialysis should undergo dialysis preoperatively, which is commonly performed on the day prior to surgery. Hemodialysis can be performed on the day of surgery as well, but the possibility should be considered that transient electrolyte abnormalities and hemodynamic changes post dialysis can occur.
• Electrolyte abnormalities
î Hyperkalemia in the preoperative setting should be treated, particularly because tissue breakdown associated with surgery may elevate the potassium level further postoperatively.
■ For patients on dialysis, preoperative dialysis should be undertaken.
■ For patients with CRI not undergoing dialysis, alternative methods of potassium excretion will be necessary.
? Loop diuretics can be used, particularly if the patient is also hypervolemic.
? Sodium zirconium cyclosilicate is an option if volume status is not an issue.
î Although chronic metabolic acidosis has not been associated with elevated perioperative risk, some local anesthetics have reduced efficacy in acidotic patients. Preoperative metabolic acidosis should be corrected with sodium bicarbonate infusions or dialysis.
• Bleeding diathesis
î Platelet dysfunction has long been associated with uremia.
■ The value of a preoperative bleeding time in predicting postoperative bleeding has been
questioned.110 A preoperative bleeding time is, therefore, not recommended.
■ Patients with evidence of perioperative bleeding should, however, be treated.
? Dialysis for patients with ESRD will improve platelet function.
? Desmopressin (0.3 μg∕kg IV or intranasally) can be utilized.
? Cryoprecipitate, 10 units over 30 minutes IV, is an additional option.
? In patients with coexisting anemia, RBC transfusions can improve uremic bleeding.
? For patients with a history of prior uremic bleeding, preoperative desmopressin or conjugated estrogens (0.5 mg/kg/d IV for 5 days) should be considered.
î Heparin given with dialysis can increase bleeding risk. Heparin-free dialysis should be discussed with the patient's nephrologist when surgery is planned.