Surgery and Chronic Kidney Disease

Abstract

The number of patients with CKD presenting for major noncardiac or cardiac surgery is increasing as CKD prevalence continues to rise. All CKD patients being referred for surgery should be carefully evaluated through history, physical examination, and investigations to determine the status of their kidney disease and the nature and extent of comorbidities and complications. Echocardiography will assist in anesthesia planning by identifying higher-risk features such as severe hypertrophy, systolic or diastolic impairment, pulmonary hypertension, and aortic sclerosis. The success of surgery in the CKD patient depends to a significant extent on preoperative preparation which centers around optimizing the comorbid diseases and making a clear determination on perioperative risk. Patients with CKD are at higher risk of AKI in the perioperative period, and careful attention is required to minimize tissue trauma, manage medications appropriately, optimize fluid balance, maintain perfusion pressure and cardiac output, and aggressively treat complications throughout the perioperative period. There are no “magic bullets” for renal protection, perhaps with the exception of using off-pump CABG techniques where suitable. CKD patients with significant comorbidity will require more invasive monitoring for surgery. Suitable anesthesia techniques include general anesthesia using intravenous or volatile agents, regional anesthesia (nerve block techniques) for peripheral surgery, or neuraxial anesthesia (spinal or epidural). Postoperatively, drugs such as opioids require careful dosing. Usual medications should be restarted when the patient is sufficiently stable.