TABLE 6.1 Prognosis of Chronic Kidney Disease by Glomerular Filtration Rate and Albuminuria Categories
4%. In patients who undergo cardiac surgery, the estimated mortality rates are 10% to 20%. Increased levels of inflammatory markers in CKD and a strong association with other significant comorbidities, such as hypertension, hyperlipidemia, diabetes mellitus, and cardiovascular disease, may explain why CKD acts as a “risk multiplier” for morbidity, mortality, and cost in the perioperative period (Table 6.2).
TABLE 6.2 Common Causes of Perioperative Mortality and Morbidity in Patients With CKD
screen for risk factors, measuring the patient’s blood pressure, and obtaining routine laboratory studies (Table 6.3).
TABLE 6.3 Risk Factors for Susceptibility to CKD
TABLE 6.4 Preoperative Assessment and Optimization of Patients at Increased Risk of CKD
of prolonged intraoperative hypotension due to continuation of these agents in the preoperative period.
TABLE 6.5 Comorbidities That Decrease Survival in ESRD
Patients with CKD are more likely to die from a myocardial infarction or cerebrovascular accident than from their kidney disease. Even small decreases in GFR increase the risk of developing vascular disease.
Anemia: Develops due to a decrease in erythropoietin, a hormone secreted by the kidneys that directs red blood cell production.
TABLE 6.6 Modified Karnofsky scale: (70-100 = better prognosis) versus (<30-69 = worse prognosis)
Normal function, no disability
Minor signs and symptoms, full activity
Independent, limited to home
Needs assistance with errands
Home attendant, not totally disabled
Nursing home for chronic care
Hospitalized, fair condition
Hospitalized, poor condition
Hospitalized, progressive fatal process
Modified with permission from Ifudu O, Mayers J, Matthew J, et al. Dismal rehabilitation in geriatric inner-city hemodialysis patients. JAMA. 1994;271(1):29-33. ©1994 American Medical Association. All rights reserved.
TABLE 6.7 Common Causes of End-Stage Renal Disease
High blood pressure
Polycystic kidney disease
Severe anatomical problems of the urinary tract
Secondary hyperparathyroidism develops due to hyperphosphatemia, vitamin D deficiency and resistance.
Osteodystrophy is due to high levels of parathyroid hormone.
Chronic metabolic acidosis and hyperkalemia are both a consequence of, and a contributor to, the progression of CKD.
Hypertension is a common diagnosis in the dialysis population. Volume overload may be a contributing factor, so optimization of preoperative fluid status with dialysis should be a first-line consideration. Discontinuing ACEIs and ARBs preoperatively to mitigate intraoperative hypotension and possible increased risk of AKI may be prudent. Patients continue all other antihypertensive medications preoperatively.
Pulmonary hypertension is found in a high proportion of dialysis patients with an arteriovenous fistula.
Cardiac autonomic neuropathy with elevated resting heart rate (>100 bpm) and lack of heart rate variability during exercise or deep breathing tests are common.
Systolic dysfunction due to myocardial fibrosis and calcium overload from secondary hyperparathyroidism occurs.
Heart failure with volume overload is due to impaired renal excretion of sodium and water, and low oncotic pressure can cause pulmonary edema.
Pericarditis may occur in the terminal stage of uremia.
Elevated serum cardiac troponin T levels may be chronically elevated due to concentration during dialysis. Diagnosing an ACS perioperatively may be affected.
Hyperkalemia is common and no recommendations exist for safe preoperative potassium values. Patients with ESRD may be more tolerant of chronic hyperkalemia. Patients with significantly elevated serum potassium concentration should have a 12-lead electrocardiogram (ECG).
Metabolic acidosis may decrease the efficacy of some local anesthetics.
Platelet dysfunction due to uremia may be attenuated by dialysis preoperatively. Caution is advised with the administration and/or continuation of antiplatelet agents or
other medications that may increase bleeding risk. Intraoperative hemorrhage related to uremic platelet dysfunction may be treated with desmopressin or cryoprecipitate.
Anemia is common and no preoperative-specific standard exists regarding safe hemoglobin (Hgb) levels in patients with ESRD. The NKF DOQI guidelines recommend an Hgb 11 to 12 g/dL, not to exceed 13 g/dL in all patients with CKD. Red cell transfusions, erythropoiesis-stimulating agents, and intravenous iron therapy can treat anemia associated with ESRD. The potential benefit of a perioperative blood transfusion to mitigate complications from perioperative bleeding is weighed against the risk of transfusion-induced antibody formation. HLA sensitization prolongs the waiting time for renal transplantation and reduces graft survival. Women are at greater risk of HLA sensitization than men.
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