RENAL DISEASE
ASSESSMENT
Data Gathering
History
Symptoms
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Cause of CKD
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Previous temporary renal replacement therapy (RRT)
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Current renal replacement therapy details: peritoneal or hemodialysis provider/location, days when received, dialysis access catheters/fistulae/grafts, dry weight
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History of volume overload or hyperkalemia, especially after 2 days without dialysis
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Complications of dialysis: frequent hypotension, N/V, access site bleeding, access thrombosis, access infection
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Weight gain
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Orthopnea
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Edema
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Chest pain
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Fever
Exam
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Weight
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Abnormal breath sounds
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S3
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Pericardial rub
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Edema
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Thrill over AV fistulae/grafts
Risk Stratification
Diagnostic Studies
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DO NOT RELY ON GLYCOHEMOGLOBIN (A1c) IN ESRD PATIENTS - significantly underestimates average glucose due to high RBC turnover
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Basic metabolic panel and CBC within 1 month if undergoing non-low-risk surgery (more recently if any change in status)
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If patient on RRT, will have monthly labs through dialysis provider - can use these rather than repeating labs​
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ECG if undergoing non-low risk surgery (author's institution's criterion)
MANAGEMENT
Indications for Surgical Delay
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Active heart failure
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Severe hyperkalemia (ie, hyperkalemic ECG changes, K≥6)
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AKI (KDIGO stage 2 or greater)
Dialysis
Hemodialysis
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Perform surgery the day after hemodialysis whenever possible (to assure best volume status - not hypo- or hypervolemic) (Fielding-Singh et al)
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If surgery scheduling cannot accomodate this, speak with patient's dialysis center and ask them to move dialysis session to occur day before surgery
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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)
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Patient's on daily home dialysis should not dialyze the morning of surgery; if they dialyze overnight, speak with their nephrologist about best management
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Check potassium on morning of surgery unless low-risk procedure​
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If admitted to hospital after surgery, consult nephrology for co-management of dialysis
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Avoid the use of perioperative NSAIDs, gabapentin, and morphine
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Need to adjust doses for renally cleared medications
Peritoneal Dialysis
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Must coordinate all planning with patient's nephrologist since there is more diversity in management of peritoneal dialysis
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Continue usual peritoneal dialysis regimen​​ except abdomen should be drained before surgery (for patients who usually have a daytime "dwell")
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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​
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If undergoing endoscopic GU or GI procedure, may require preoperative prophylactic antibiotics - discuss with patient's nephrologist
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If undergoing an intraabdominal procedure, patient may require hemodialysis after surgery - should be fully planned with nephrology and surgeon in advance of surgery
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Check potassium on morning of surgery unless low-risk procedure​
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If admitted to hospital after surgery, consult nephrology for co-management of dialysis
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Avoid the use of perioperative NSAIDs, gabapentin, and morphine
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Need to adjust doses for renally cleared medications
CKD
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Hold diuretics, ACE inhibitors, and ARBs for 24 hours before surgery unless history of volume overload or CHF
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Do not restart diuretics, ACE inhibitor, and ARBs until confirming patient's BP is adequate and renal function stable
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Avoid the use of perioperative NSAIDs, gabapentin, and morphine
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Treat significant intraoperative BP declines, even if not hypotensive - target within 10-25% of baseline BP (Futier et al)
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Need to adjust doses for renally cleared medications if eGFR <50 ml/min
COMMUNICATION/COUNSELING
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Collaborate with patients' nephrologists
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Document presence of all vascular access devices, fistulae, and grafts
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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) (Wilson et al):
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Risk for mortality & morbidity increased for CKD based on creatinine (mg/dl) [O'Brien et al]:
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1.5-3 mg/dl: mortality aOR 1.44, morbidity aOR 1.18
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>3 mg/dl: mortality aOR 1.93, morbidity aOR 1.19
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Dialysis patients undergoing general surgery have mortality rate of 12.7% and morbidity rate of 28.6% [Gajdos et al]
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Peritoneal dialysis patients have especially high risk for complications with intra-abdominal procedures - discuss with surgeon & nephrology