© 2018 Kurt Pfeifer.

RENAL DISEASE

ASSESSMENT

Data Gathering

History

Symptoms

  • Cause of CKD

  • Previous temporary renal replacement therapy (RRT)

  • Current renal replacement therapy details: peritoneal or hemodialysis provider/location, days when received, dialysis access catheters/fistulae/grafts, dry weight

  • History of volume overload or hyperkalemia, especially after 2 days without dialysis

  • Complications of dialysis: frequent hypotension, N/V, access site bleeding, access thrombosis, access infection

  • Weight gain

  • Orthopnea

  • Edema

  • Chest pain

  • Fever

Exam

  • Weight

  • Abnormal breath sounds

  • S3

  • Pericardial rub

  • Edema

  • Thrill over AV fistulae/grafts

Risk Stratification

Diagnostic Studies

  • Basic metabolic panel and CBC within 1 month if undergoing non-low-risk surgery (more recently if any change in status)

    • If patient on RRT, will have monthly labs through dialysis provider - can use these rather than repeating labs​

  • ECG if undergoing non-low risk surgery (author's institution's criterion)

AKI risk factors.jpg
AKI risk.jpg

MANAGEMENT

Indications for Surgical Delay

  • Active heart failure

  • Severe hyperkalemia (ie, hyperkalemic ECG changes, K≥6)

  • AKI (KDIGO stage 2 or greater)

Dialysis

Hemodialysis

  • Perform surgery the day after hemodialysis whenever possible (to assure best volume status - not hypo- or hypervolemic)

    • If surgery scheduling cannot accomodate this, speak with patient's dialysis center and ask them to move dialysis session to occur day before surgery

    • This is not usually possible​ for surgeries scheduled on a Monday - speak with surgeon and anesthesiology about best management in this scenario (likely do dialysis on Saturday)

    • Patient's on daily home dialysis should not dialyze the morning of surgery; if they dialyze overnight, speak with their nephrologist about best management

  • Check potassium on morning of surgery unless low-risk procedure​

  • If admitted to hospital after surgery, consult nephrology for co-management of dialysis

  • Avoid the use of perioperative NSAIDs, gabapentin, and morphine

  • Need to adjust doses for renally cleared medications

Peritoneal Dialysis

  • Must coordinate all planning with patient's nephrologist since there is more diversity in management of peritoneal dialysis

  • Continue usual peritoneal dialysis regimen​ except abdomen should be drained before surgery (for patients who usually have a daytime "dwell")

    • If will be admitted after surgery, need to determine if hospital has the correct equipment & dialysate for patient - if not, patient may have to bring in

  • If undergoing endoscopic GU or GI procedure, may require preoperative prophylactic antibiotics - discuss with patient's nephrologist

  • If undergoing an intraabdominal procedure, patient may require hemodialysis after surgery - should be fully planned with nephrology and surgeon in advance of surgery

  • Check potassium on morning of surgery unless low-risk procedure​

  • If admitted to hospital after surgery, consult nephrology for co-management of dialysis

  • Avoid the use of perioperative NSAIDs, gabapentin, and morphine

  • Need to adjust doses for renally cleared medications

CKD

  • Hold diuretics, ACE inhibitors, and ARBs for 24 hours before surgery unless history of volume overload or CHF

  • Do not restart diuretics, ACE inhibitor, and ARBs until confirming patient's BP is adequate and renal function stable

  • Avoid the use of perioperative NSAIDs, gabapentin, and morphine

  • Treat significant intraoperative BP declines, even if not hypotensive - target within 10-25% of baseline BP (Futier et al)

  • Need to adjust doses for renally cleared medications if eGFR <50 ml/min

COMMUNICATION/COUNSELING

  • Collaborate with patients' nephrologists

  • Document presence of all vascular access devices, fistulae, and grafts

  • Inform patients with CKD stage 3 or greater of the risks of AKI and the potential of progression of their CKD and requirement of dialysis (particularly those with CKD stage 4 or higher)

  • Risk for mortality & morbidity increased for CKD based on creatinine (mg/dl) [O'Brien et al]:

    • 1.5-3 mg/dl: mortality aOR 1.44, morbidity aOR 1.18

    • >3 mg/dl: mortality aOR 1.93, morbidity aOR 1.19

  • Dialysis patients undergoing general surgery have mortality rate of 12.7% and morbidity rate of 28.6% [Gajdos et al]

  • Peritoneal dialysis patients have especially high risk for complications with intra-abdominal procedures - discuss with surgeon & nephrology