End-stage renal disease (ESRD) is a major health problem in the United States, with about 650,000 patients affected in 2012. These patients have a higher perioperative mortality rate due to direct effects of ESRD such as bleeding tendency and other comorbidities such as hypertension and diabetes. Cardiac disease accounts for 45% of deaths in patients on dialysis. Here we present a typical case and then review the appropriate preoperative and intraoperative management. Intraoperative management is mainly aimed at treating anemia, bleeding, and hyperkalemia and preventing any further injuries to the kidneys, while optimal medical management, including timing of preoperative dialysis in elective cases, has the potential of reducing serious morbidity and mortality in these patients.
Keywordsdialysis, uremia, hyperkalemia, platelet dysfunction, end-stage renal disease
A 43-year-old African American male gas station attendant is scheduled for emergency exploratory laparotomy after sustaining an abdominal stab wound in an attempted robbery. He is dialysis dependent and awaiting renal transplantation. His last hemodialysis was 52 hours earlier. He is awake and alert. His blood pressure is 102/90 mm Hg; heart rate, 114 beats per minute; and respiratory rate, 24 breaths per minute. His hemoglobin level is 8.2 g/dL after receiving 3 units of packed red blood cells; the serum potassium level before the transfusion was 6.0 mEq/L. While cricoid pressure is applied, anesthesia is induced with etomidate, fentanyl, and rocuronium. Soon after the operation begins, the surgeon complains of difficulty in achieving hemostasis. The T waves on the monitor are tall and peaked.
Chronic kidney disease (CKD) is defined by the National Kidney Foundation as either kidney damage (defined as abnormalities of either imaging studies or laboratory values) or a decrease in glomerular filtration rate to less than 60 mL/min/1.73 m 2 and goes often unnoticed in the early stages. Urine albumin spot checks often serve as a marker for kidney damage from which an albumin/creatinine ratio (ACR) is calculated. The different stages of CKD can be found in Table 6.1 .
|1||eGFR ≥90 mL/min/1.73 m 2 and ACR ≥30 mg/g|
|2||eGFR 60–89 mL/min/1.73 m 2 and ACR ≥30 mg/g|
|3||eGFR 30–59 mL/min/1.73 m 2|
|4||eGFR 15–29 mL/min/1.73 m 2|
|5||eGFR ≤15 mL/min/1.73 m 2|
In 2012, approximately 637,000 patients were affected by end-stage renal disease (ESRD) in the United States, with an estimated incidence of about 353 per 1 million persons (which ranges by 66% across the different regions in the United States) and are slightly declining since 2009 and a prevalence of 1943 per 1 million (ranging across regions by 33%, which represents a slight increase from 2011). The prevalence rate for African Americans is about 4 times higher compared with Caucasians, and Hispanics have a 60% higher prevalence rate than non-Hispanics. Although the incidence rates have been stable for most age groups, they decreased dramatically in the older age groups of greater than 65, which, combined with the increase in prevalence in all age groups, especially the population over 65 (by 30%–50%), suggests longer survival in ESRD patients. About 45% of patients who start hemodialysis have diabetes listed as primary diagnosis, followed by hypertension in 30% and glomerulonephritis in 7%. The remainder is made up by the more rare diseases such as polycystic kidney disease, immunoglobulin A (IgA) and IgM nephropathies, systemic lupus erythematosus, Wegener granulomatosis, multiple myeloma, amyloidosis, and AIDS nephropathy, just to name a few. These patients tend to be younger and are less likely to present with the typical comorbidities of the dialysis patient. In 2012 approximately 100,000 patients initiated treatment for ESRD with hemodialysis or peritoneal dialysis, and 2800 patients received preemptive renal transplantation. Chronic dialysis is usually required when glomerular filtration rate (GFR) falls below 20 mL/min. It is indicated for volume overload refractory to diuretic therapy, severe metabolic acidosis, hyperkalemia, seizures, or other neurologic symptoms, as well as pericarditis, and is usually started when the blood urea nitrogen exceeds 100 mg/mL or creatinine approaches 10 mg/dL. Regardless of the cause, ESRD results in abnormalities in virtually all organ systems and therefore has important implications for patients undergoing surgery ( Box 6.1 ). The abnormalities result from both a failure to excrete urea and other end products of metabolism and a loss of metabolic and endocrine functions normally performed by the kidney.
Increased fragility of red blood cells
Platelet dysfunction with bleeding
Metabolic and endocrine systems
Increased susceptibility to infection
Left ventricular hypertrophy
Congestive cardiac failure
Acid-base balance and electrolytes
Anion gap metabolic acidosis
Hypermagnesemia or hypomagnesemia
Renal osteodystrophy (osteoporosis, osteomalacia)
Perioperative complications of ESRD are listed in Box 6.2 . One of the frequent acute life-threatening perioperative complications of ESRD is hyperkalemia. It is frequently associated with acidosis and with trauma due to the release of potassium from damaged tissue and hematomas. Hyperkalemia can cause progressive cardiac conduction defects, ending in ventricular fibrillation or, less commonly, asystole ( Table 6.2 ). Electrocardiographic changes also depend on the chronicity and the rate of rise of serum potassium.