Anesthetic Considerations for Patients with Chronic Kidney Disease

Chronic kidney disease (CKD) is defined as either a glomerular filtration rate (GFR) of <60 ml min⁻¹ 1.73 m⁻² for 3 months or more, irrespective of cause, or kidney damage leading to a decrease in GFR, present for 3 months or more (1). The damage may manifest as abnormalities in the composition of blood or urine, on radiological imaging, or in histology. CKD is classified into five stages depending on GFR, ranging from Stage 1 (normal GFR) to Stage 5 (established renal failure) (1). According to the NIDDK, more than 30 million American adults may have CKD (2). Safe anesthetic management requires an understanding of CKD pathophysiology to prevent aggravation of pre-existing disease (1).  

Depending on the patient’s status and the surgical procedure, the preoperative evaluation may require close communication between the primary care physician, nephrologist, surgeon, and anesthesiologist to determine if a patient is optimized for surgery (3). The following assessments are recommended for patients with CKD: comorbid conditions, severity of CKD assessed by level of kidney function, complications related to level of kidney function, risk for loss of kidney function, and risk for cardiovascular disease (4). The risk for cardiovascular complications should be promptly evaluated. The patient should undergo a routine electrocardiogram. All present preoperative abnormalities, such as anemia, hyperkalemia, and metabolic acidosis, should be preoperatively corrected. A hemoglobin value of 10 g/dl is strongly recommended (4). Calcium chloride, insulin and dextrose, sodium bicarbonate, and resins can be used to correct hyperkalemia. If the patient is under dialysis treatment, the final dialysis prior to surgery should be scheduled 12-24 hours before surgery (4). 

The anesthetic management of patients suffering from CKD is complex. Due to delayed gastric emptying and neuropathy, there is risk of gastric acid aspiration. Gastric aspiration prophylaxis can be managed using sodium citrate, metoclopramide, anti-H2 drugs, and rapid induction (4). Short-acting anesthetic drugs are recommended (propofol, remifentanil, cisatracurium, vecuronium). Sevoflurane can deteriorate renal function by fluoride ion and compound A production, so isoflurane remains the preferred anesthetic inhalator agent (4). When selecting a neuromuscular blocking agent (NMBA) for use in patients with CKD, the anesthesiologist should consider the impact of renal impairment on the elimination of the drug, the potential for drug accumulation with incremental doses, and the production of active metabolites. To prevent postoperative residual curarization (PORC), long-acting NMBAs should be avoided (2). Opioids may be used, as they have no direct toxic effects on the kidney. They do, however, have an antidiuretic effect, and they may cause urinary retention (1). Lastly, patients with Stage 5 CKD who have undergone renal transplantation require immunosuppression. These drugs are usually given by the oral route. If enteral administration is inappropriate, then IV administration with dose adjustment will be required (1).  

After surgery, postoperative pain management should begin. Special emphasis should be placed on preventing further deterioration of renal function as well as protection of existing renal function in patients with moderate to severe impairment from the effects of anesthetics and pain medications. For example, analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) can contribute to a reduction of the residual renal function in CKD and should be avoided. Further clinical studies are required to address the optimal medication regimen that can be used for postoperative pain management in the more severe stages of CKD, including hemodialysis (5). 

References 

1. R. G. Craig, J. M. Hunter, Recent developments in the perioperative management of adult patients with chronic kidney disease, BJA: British Journal of Anaesthesia, Volume 101, Issue 3, September 2008, Pages 296–310, https://doi.org/10.1093/bja/aen203 

1. Centers for Disease Control and Prevention. National Chronic Kidney Disease Fact Sheet, 2017. National Chronic Kidney Disease Fact Sheet, 2017. 

1. Krishnan M. Preoperative care of patients with kidney disease. Am Fam Physician. 2002 Oct 15;66(8):1471-6, 1379. PubMed PMID: 12408421. 

1. Domi R, Huti G, Sula H, Baftiu N, Kaci M, et al. From Pre-Existing Renal Failure to Perioperative Renal Protection: The Anesthesiologist’s Dilemmas, Anesth Pain Med. 2016 ; 6(3):e61545. doi: 10.5812/aapm.32386.