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.