9/30/2009

Perioperative Management Of
Patients With Chronic Kidney
Disease
Hosny S Gabriel, M.D
Clinical Professor Of Anesthesiology
Joan C.
C Edwards SOM
Marshall University , Huntington
West Virginia, USA

- Patients with chronic kidney disease (CKD)

and dialysis patients are at significant risk
for morbidity and mortality.
- Cardiac dysfunction, sepsis, volume
overload, electrolyte disturbances, bleeding
and hyperkalemia.
y
- The surgical risk depends on co-morbid
medical condition, type of surgical
procedure and whether emergency or
elective.

1
 9/30/2009

Factors That Predict Adverse

Outcome in Patients with CKD
• Patient-Related • Surgery
Surgery-Specific
Specific
Advanced age Aortic surgery
Mild to moderate Kid.dis.
Vascular surgery
Dialysis
Cardiovascular dis. Cardiac surgery
Poor nutrition
Volume overload
Blood Pressure
abnormalities.
Hyperkalemia
Metabolic acidosis

Clinical Abnormalities in
Patients with CKD
• Fl
Fluid
id and
d Electrolyte
El t l t Disturbance
Di t b
Hypervolemia and Hypovolemia
Hypernatremia and Hyponatremia
Hyperkalemia
H
Hyperphosphatemia
h h i
Metabolic acidosis

2
 9/30/2009

Potassium Balance
™Hyperkalemia is more common than
hypokalemia but both are associated with
hypokalemia,
cardiac morbidity
™Normally, ratio of intracellular to extracellular
K is 40:1 ( 160-4 mmol/L)
™Patients with CKD can tolerate K 6-6.5 without
any conduction disturbances
™Preoperative K 6mmol/L or greater should be
corrected before surgery

Causes of Hyperkalemia in
Patients with CKD
™ Acute
cute ac
acidosis
dos s
™ Rhabdomyolosis ( trauma,major surgery)
™ Increased catabolism, sepsis
™ NSAID
™ Angiotensin-converting enzyme inhibitors
™ Potassium sparing diuretics
™ Beta-blockers
™ Nephrotoxic drugs ( cyclosporine and amino-
glycoside.

3
 9/30/2009

• Cardiovascular Disturbances

Hypertension
Coronary Artery Disease
Generalized Arteriosclerosis
Congestive Heart Failure
Pericarditis

Cardiovascular Disturbance

• Coronary Artery Disease (CAD)

- CAD with prevalence of 40%
- Heart failure, HTN and volume-load are
related risk factors
- Inflammatory state elicits a rise in C-reactive
protein and interleukin-6 which contribute to
CAD and are predictors for CVD risk
- The acute-phase C-reactive protein is increased
in up to 66% of dialysis patients

4
 9/30/2009

Hypertension
™ Most common CV p
problem in CKD
Patients.

™ When hypertensive heart disease become

established, Patients present with
arrythmias, CAD or CHF or combination
of these.

™ Long term hemodialysis through A-V

fistula is associated with 40% incidenc of
pulmonary hypertension

• Hematologic and Immunologic

Disturbance

Anemia
Bleeding diathesis
Increased susceptibility
p y to infection

5
 9/30/2009

Anemia and Bleeding Diathesis

™ Anemia is well tolerated (chronic)
™ D
Depressed d erythropoietin
h i i EPO production
d i
™ Iron and folate deficiency
™ Hemolysis and chronic inflammation
™ Human EPO and its analog darbepoietin
improve survival.
™ Bleeding diathesis are due to decreased platelet
factor III ,abnormal Platelets aggregation and
defective release of von Willebrand factor.

• Gasterointestinal Disturbances

Gastritis
Peptic ulcer
Bleeding
Nausea and vomiting
Delayed gastric emptying

6
 9/30/2009

• Neurologic Disturbances

Encephalopathy
Peripheral neuropathy
Autonomic neuropathy
g , gy and impaired
Fatigue,lethargy p
mentation
Hiccups and muscle cramps

Preoperative Evaluation

• Basic evaluation (history and physical)

• Lab Work :
- serum chemistry
- Ca, Phosphate, and Mag level
- CBC, coagulation profile
- ECG
Specific risk factors requiring further preoperative
evaluation and possible intervention

7
 9/30/2009

General / Regional Anesthesia

™ Induction Agents
™ Muscle Relaxant
™ Inhaled Anesthetics
™ Neuroaxial anesthesia
™ Complications

Anesthesia Consideration
• Dialysis Patient
- Type of dialysis, frequency and most
recent treatment should be known
- Ideal timing for dialysis is the day before
surgery
- Euvolumic with K not higher than 6,
the day of surgery and BUN < 100mg

8
 9/30/2009

Pharmacology and CKD

™ Drugs chiefly dependant on Renal excretion
- Gallamine,
Gallamine metocurine
- PNC,cephalosporine,aminoglycosides
- Digoxin
™ Drugs Partially Dependant on Renal exc.
- Atropine, glycopyrolate
- Neostigmine,
N tig i pyridostigmine,
id tig i edrophonium
d h i
- Amrinone, milrinone
- Phenobarbital

Drugs with Active Metabolite

Dependant on Renal excretion
Drug Metabolite Effect
Morphine Morphine-6-glucuronide Analgesic

Meperidine Normeperidine Neuroexcitatory

Diazepam Oxazepam Sedative

Midazolam 1-hydroxy-midazolam Sedative

Pancronium 3-hydroxy-pancronium Relaxant

Procainamide N-Acetylprocainamide Neurotoxic

9
 9/30/2009

Conclusion
™ Patients with CKD needs careful
assessment with particular attention to
those with cardiac disease or on dialysis.

™ Preoperative optimization, perioperative

monitoring and specific intervention are
frequently required to ensure a safe
outcome

And this is Dr. O.G. your anesthesiologist

10
 9/30/2009

g{tÇ~ çÉâ

11