© Springer International Publishing Switzerland 2015
Molly Blackley Jackson, Somnath Mookherjee and Nason P. Hamlin (eds.)The Perioperative Medicine Consult Handbook10.1007/978-3-319-09366-6_3333. Chronic Kidney Disease
(1)
Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
Background
Chronic kidney disease (CKD) affects approximately 1 in 10 of American adults and its incidence is increasing [1, 2]. Patients with CKD are at increased risk of perioperative morbidity and mortality even when adjusting for comorbid conditions such as hypertension and diabetes [3]. Newer data show that even patients with mild to moderate renal disease undergoing intermediate risk orthopedic and general surgery have higher rates of morbidity and increased length of hospital stay [4, 5]. Nonetheless, patients with CKD can safely undergo surgery with appropriate medical management.
Preoperative Evaluation
The major morbidity and mortality in patients with end-stage renal disease (ESRD) is cardiovascular disease.
Given these comorbidities, a thorough preoperative cardiovascular and pulmonary risk assessment is crucial.
Document history of existing renal disease, including etiology, onset, severity (e.g., CKD stage), and history of transplant
Obtain baseline creatinine and electrolytes
Document history of renal problems in the past (e.g., history of contrast nephropathy)
Screen patients at high risk of CKD by obtaining baseline creatinine and electrolytes
CKD affects renal drug elimination, drug absorption, drug distribution, and nonrenal clearance [7]. The normal creatinine clearance (CrCl) is generally >100 mL/min. Patients need adjustments to most commonly used medications when the CrCl falls below 50 mL/min. Glomerular filtration rate and/or CrCl is estimated using the Modification of Diet in Renal Disease (MDRD) study or using Cockcroft–Gault equation. These estimates are less accurate in certain circumstances, including when patients have more or less muscle mass [8].
Care for patients with hemodialysis-dependent ESRD or history of renal transplant should be coordinated with a nephrologist. Obtain the following information preoperatively:
History of vascular access (anatomic location, history of clotting or stenosis).
The patient’s usual dialysis days and length of time is helpful information in coordinating hemodialysis care—it is preferable that hemodialysis (HD) is carried out on the day before surgery to minimize any risks from anticoagulation and from unresolved fluid or electrolyte shifts [8].
The patient’s “dry weight” prior to surgery, to guide management of volume status.
Perioperative Management
Contrast-Induced Nephropathy
Patients with CKD are at increased risk for contrast-induced kidney injury. Prospective data and meta-analysis on the use of oral N-acetylcysteine (NAC) have yielded conflicting results [9] though most practitioners would agree that it does not pose significant risk to the patient and is not excessively costly. IV hydration both before and after contrast is likely beneficial, though the jury is out as to whether isotonic sodium bicarbonate or isotonic normal saline is the preferred IV fluid [10].
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