Introduction

Kidney disease encompasses a wide spectrum of disorders, ranging from those with normal glomerular filtration rates (GFR) but with urinary abnormalities (nephrotic syndrome or nephritic syndrome), to those with GFR impairments. Patients with a long-standing history (months to years) of renal disease are deemed to have chronic kidney disease (CKD). A staging system has been developed by the National Kidney Foundation to categorize CKD by GFR levels: Stage 1 (GFR ≥ 90 mL/min, but with persistent urinary abnormalities such as proteinuria); Stage 2, mild CKD (GFR 60–89 mL/min); Stage 3, moderate CKD (GFR 30–59 mL/min); Stage 4, severe CKD (GFR 15–29 mL/min); and finally Stage 5, kidney failure or end-stage renal disease (ESRD) (GFR < 15 mL/min or on some form of renal replacement therapy). There is clinical rationale in dividing CKD into these stages; patients with more advanced stages, especially those at stage 3 or higher, have higher rates of death, cardiovascular events, and hospitalizations [1]. In contrast to established kidney disease, acute kidney injury (AKI), previously termed “acute renal failure,” reflects renal dysfunction that arises in the span of hours to days. AKI can develop in those with previously normal kidney function or can be superimposed upon existing CKD. More advanced CKD stages 3 through 5 and AKI are most commonly associated with perioperative complications, and these patients will be the focus of this chapter.

Introduction

Kidney disease encompasses a wide spectrum of diseases: nephrotic syndrome or nephritic syndrome, mild chronic kidney disease (CKD) (Stage 1 and 2 CCr ≥ 0 ml/min), moderate CKD (Stage 3 CCr 30–59 ml/min), severe CKD (Stage 4 CCr 15–29 ml/min), end-stage renal disease (ESRD) or CKD (Stage 5 CCr < 15 ml/min) on some form of renal replacement therapy, and acute renal failure (ARF). Since CKD, ESRD, and ARF are more common and have more associated perioperative complications, this discussion will focus on patients with renal failure.

In general, patients with CKD, ESRD, and ARF are subject to the same potential complications perioperatively. In the patients with ESRD, there are the added considerations of the dialysis modalities or kidney allograft. Where appropriate, these also will be addressed. However, a thorough discussion of the perioperative management of patients with functioning kidney allografts is beyond the scope of this chapter. Therefore, we will focus on general principles in managing transplant patients.

End-stage renal disease (ESRD) develops in about 3.3 in 10 000 Americans each year and has a four times higher incidence in blacks than in whites. Diabetes mellitus and hypertension are the major causes of CKD and ESRD. More than 275 000 patients are now on dialysis, and the incidence is increasing by 3%–5% a year. Patients with CKD and ESRD are becoming increasingly common as the patient population ages, concomitant with a potential need for more surgical interventions for coronary artery disease, peripheral vascular disease, and vascular access for dialysis.