Chronic renal failure and renal

disorders
Group 4 anesthesia and co existing disease
  The most common causes of chronic kidney disease (CKD) are
hypertensive nephrosclerosis, diabetic nephropathy, chronic
glomerulonephritis, and polycystic kidney disease.

Chronic renal  The uncorrected manifestations of this syndrome are usually

seen only after GFR decreases below 25 mL/min.
disease  Patients with GFR less than 10 mL/min are dependent upon
RRT for survival in the form of hemodialysis, hemofiltration,
or peritoneal dialysis.
  Neurological
 Cardiovascular
1. Peripheral
neuropathy  Fluid overload
Congestive heart
2. Autonomic
failure Hypertension  Pulmonary
neuropathy
Manifestations 3. Muscle twitching
Pericarditis Hyperventilation
Arrhythmia
of chronic 4. Encephalopathy Conduction blocks
Interstitial edema
Alveolar edema
kidney disease. Asterixis Vascular calcification
Accelerated
Pleural effusion
5. Myoclonus Lethargy
atherosclerosis
6. Confusion
7. Seizures
8. Coma
  Hematological Anemia
Platelet dysfunction
 Metabolic Metabolic Leukocyte dysfunction
 Gastrointestinal acidosis  Endocrine
 Anorexia Nausea and Hyperkalemia
Hyponatremia  Glucose intolerance
vomiting Delayed
Secondary
Cont…… gastric emptying
Hyperacidity Mucosal
Hypermagnesemia
Hyperphosphatemia hyperparathyroidism
Hypocalcemia Hypertriglyceridemia
ulcerations
Hemorrhage Hyperuricemia  Skeletal Osteodystrophy
Adynamic ileus Hypoalbuminemia Periarticular calcification
 Skin Hyperpigmentation
Ecchymosis Pruritus
 METABOLIC
 Kidney failure leads to multiple metabolic abnormalities,
including hyperkalemia, hyperphosphatemia, hypocalcemia,
hypermagnesemia, hyperuricemia, and hypoalbuminemia.
 Water and sodium retention in kidney failure can worsen
hyponatremia and cause extracellular fluid overload.
 Failure to excrete nonvolatile acids results in increased anion
Manifestations gap metabolic acidosis.

of renal failure  Hypernatremia and hypokalemia are uncommon complications

in kidney failure.
 Hyperkalemia, a potentially lethal consequence, typically
occurs in patients with very low creatinine clearances but can
also develop rapidly in those with higher clearances under
certain conditions.
  Hypermagnesemia is generally mild unless magnesium intake
is increased, often due to magnesium-containing antacids.
 Hypocalcemia in kidney failure is secondary to parathyroid
hormone resistance, decreased intestinal calcium absorption,
and calcium deposition into bone associated with
hyperphosphatemia.

CONTI….  Symptoms of hypocalcemia are rare unless patients are also

alkalotic.
 Patients with kidney failure experience rapid tissue protein loss,
leading to hypoalbuminemia.
 Contributory factors to hypoalbuminemia in kidney failure
include anorexia, protein restriction, and dialysis.
  Anemia is common when creatinine clearance falls below 30 mL/min, with
hemoglobin concentrations usually ranging from 6 to 8 g/dL in kidney failure
patients.
 Decreased erythropoietin production, red cell production, and red cell survival
contribute to the anemia in kidney failure.
 Factors such as gastrointestinal blood loss, hemodilution, bone marrow
suppression, and blood loss for testing exacerbate anemia, and transfusions
often struggle to maintain hemoglobin levels above 9 g/dL.
Hematologic  Erythropoietin administration can partially correct the anemia in kidney failure.
 Increased levels of 2,3-diphosphoglycerate (2,3-DPG) aid oxygen unloading
from hemoglobin in response to reduced blood oxygen-carrying capacity.
 CKD-related metabolic acidosis shifts the hemoglobin–oxygen dissociation
curve rightward.
 Despite anemia, CKD patients generally tolerate it well in the absence of
symptomatic heart disease.
 Platelet and white cell function are impaired in kidney failure, leading to
prolonged bleeding time and increased susceptibility to infections.
  Cardiac output increases in kidney failure to compensate for decreased
blood oxygen-carrying capacity, maintaining oxygen delivery.
 Sodium retention and abnormalities in the renin–angiotensin system lead to
systemic arterial hypertension.
 Left ventricular hypertrophy is a common occurrence in chronic kidney
disease (CKD).
 CKD patients, with extracellular fluid overload from sodium retention, are

CARDIOVASCUL prone to congestive heart failure and pulmonary edema.

 Increased cardiac demand, anemia, and hypertension contribute to the risk
AR of heart failure in CKD.
 Pulmonary edema in CKD may be linked to increased permeability of the
alveolar–capillary membrane.
 Arrhythmias, including conduction blocks, are common in CKD and may be
related to metabolic abnormalities and calcium deposition.
 CKD patients also develop accelerated peripheral vascular and coronary
artery atherosclerotic disease, and intravascular volume depletion may occur
in high-output acute kidney failure with inadequate fluid replacement or
excessive fluid removal during dialysis.
  Without RRT or bicarbonate therapy, CKD patients may be
dependent on increased minute ventilation as compensation for
metabolic acidosis.
 Pulmonary extravascular water is often increased in the form of

Pulmonary interstitial edema, resulting in a widening of the alveolar to

arterial oxygen gradient and predisposing to hypoxemia.
 Increased permeability of the alveolar–capillary membrane in
some patients can result in pulmonary edema even with normal
pulmonary capillary pressures.
  Abnormal glucose tolerance is common in CKD, usually
resulting from peripheral insulin resistance (type 2 diabetes
mellitus is one of the most common causes of CKD).
 Secondary hyperparathyroidism in patients with chronic kidney
failure can produce metabolic bone disease, predisposing them
to fractures.

Endocrine  Abnormalities in lipid metabolism frequently lead to

hypertriglyceridemia and contribute to accelerated
atherosclerosis.
 Increased circulating levels of proteins and polypeptides
normally degraded by the kidneys are often present, including
parathyroid hormone, insulin, glucagon, growth hormone,
luteinizing hormone, and prolactin.
  Anorexia, nausea, vomiting, and ileus are commonly associated
with uremia.
 Hypersecretion of gastric acid increases the incidence of peptic
ulceration and gastrointestinal hemorrhage, which occurs in
10% to 30% of patients.
Gastrointestinal  Delayed gastric emptying secondary to kidney disease–
associated autonomic neuropathy may predispose patients to
perioperative aspiration.
 Patients with CKD also have an increased incidence of
hepatitis B and C, often with associated hepatic dysfunction.
  Asterixis, lethargy, confusion, seizures, and coma are
manifestations of uremic encephalopathy, and symptoms
usually correlate with the degree of azotemia.

Neurological  Autonomic and peripheral neuropathies are common in patients

with CKD.
 Peripheral neuropathies are typically sensory and involve the
distal lower extremities.
ANESTHESIA
MANAGMEN
T
  Perioperative acute kidney failure is common in critically ill patients,
often associated with trauma or complications from surgery.
 Metabolic catabolism is typical in these patients, and optimal
perioperative management relies on renal replacement therapy (RRT).
 Hemodialysis, achieved via temporary catheters, is more effective than
peritoneal dialysis.
 Continuous renal replacement therapy (CRRT) is used when patients are
Preoperative too hemodynamically unstable for intermittent hemodialysis.

Evaluation  Indications for RRT include fluid overload, hyperkalemia, severe acidosis,
metabolic encephalopathy, pericarditis, coagulopathy, refractory
gastrointestinal symptoms, and drug toxicity.
 Patients with chronic kidney disease (CKD) may undergo dialysis-related
procedures under local or regional anesthesia, with preoperative dialysis
being typical.
 Regardless of the procedure or anesthesia, addressing potentially
reversible manifestations of uremia is crucial.
  History and physical examination should assess cardiac and respiratory
function, fluid status, and signs of volume overload or hypovolemia.
 Preoperative red blood cell transfusions are reserved for severe anemia, and
coagulation studies may be advisable, especially with neuraxial anesthesia.
 Serum electrolyte, BUN, and creatinine measurements help assess dialysis
adequacy, while glucose levels guide insulin therapy.
 Drugs with significant renal elimination should be avoided when possible,
considering dosage adjustments and blood level monitoring.
CONT…..  Drugs with potential renal accumulation include muscle relaxants,
anticholinergics, H2-receptor antagonists, diuretics, antiarrhythmics,
bronchodilators, and antibiotics.
 Premedication with benzodiazepines can be given to stable, alert patients in
reduced doses.
 Chemoprophylaxis for aspiration risk is discussed, and preoperative
medications, especially antihypertensives, should be continued until
surgery.
  The kidney has a substantial functional reserve, with a decrease in
GFR from 120 to 60 mL/min often showing no clinical signs.
 Even at creatinine clearances of 40 to 60 mL/min, patients may be
asymptomatic but are considered to have decreased kidney reserve.
 Preservation of remaining kidney function is crucial and is best
achieved by maintaining normovolemia and normal kidney
perfusion.

CONT…  At creatinine clearances of 25 to 40 mL/min, patients are considered

to have moderate kidney impairment or renal insufficiency.
 Azotemia is always present at this stage, and hypertension and
anemia are common.
 Anesthetic management for patients with renal insufficiency is
critical, especially during procedures with a high risk of
postoperative kidney failure.
  Major risk factors for acute deterioration in kidney function include
intravascular volume depletion, sepsis, obstructive jaundice, crush
injuries, and exposure to certain drugs and toxins.
 Prevention is emphasized in the management of patients with renal
insufficiency, given the mortality rate of postoperative kidney failure
exceeding 50%.
 Diabetes, combined with preexisting kidney disease, significantly

CONT…… increases the perioperative risk of kidney function deterioration and

kidney failure.
 Adequate hydration and maintenance of renal blood flow are crucial
for kidney protection in high-risk perioperative situations, and the
use of certain interventions like mannitol, low-dose dopamine,
fenoldopam, loop diuretics, or bicarbonate infusion remains
controversial. N-acetylcysteine shows efficacy in reducing the risk
of radiocontrast agent-induced acute kidney injury when
administered before their use.
Drugs with a potential for significant
accumulation in patients with renal
impairment.
 Muscle relaxants
Digitalis
Pancuronium Anticholinergics
Metoclopramide H2 - Diuretics
(0.1MG/KG) Atropine(0.01MG/K
receptor antagonists Calcium channel
Anticonvulsants G)
(Cimetidine antagonists
Carbamazepine Glycopyrrolate
Ranitidine ) (Diltiazem
Ethosuximide (0.25MG/DOSE)
Nifedipine)
Primidone

Bronchodilators
Antiarrhythmics
Terbutaline
Antihypertensives Bretylium
Psychiatric( Lithium)
β-Adrenergic Captopril Clonidine Disopyramide
Antibiotics
blockers Enalapril Hydralazine Encainide
Aminoglycosides
Atenolol Nadolol Lisinopril (genetically
Cephalosporins
Pindolol Propranolol Nitroprusside determined)
Penicillins
(thiocyanate) Procainamide
Tetracycline
Tocainide
Vancomycin
  Monitoring: Patients with kidney disease are at increased risk
for perioperative complications. Blood pressure should not be
measured on the arm with an arteriovenous fistula. Continuous
invasive or noninvasive blood pressure monitoring may be

INTRA indicated for poorly controlled hypertension.

 Induction: Patients with nausea, vomiting, or gastrointestinal
OPERATIVE bleeding should undergo rapid-sequence induction and
CONSIDERAT intubation. Induction agent doses should be reduced for

IONNS debilitated or critically ill patients. Propofol or etomidate is

often used, with opioids, β-blockers, or lidocaine to blunt the
hypertensive response. Succinylcholine may be used for
intubation unless hyperkalemia is present.
  Anesthesia Maintenance: Anesthetic maintenance should
control hypertension with minimal impact on cardiac output.
Volatile anesthetics, propofol, and various opioids are suitable.
Meperidine should be avoided due to normeperidine
accumulation. Controlled ventilation is considered for patients
with kidney failure under general anesthesia.
 Fluid Therapy: Superficial procedures require replacement of

CONT…. insensible fluid losses, while significant fluid volume situations

may use isotonic crystalloids or colloids. Balanced crystalloids
are preferable over chloride-rich crystalloids to avoid
hyperchloremia's impact on kidney function. Glucose-free
solutions are recommended due to uremia-associated glucose
intolerance. Blood loss replacement may involve colloid or
packed red blood cells. Hydroxyethyl starch use is
controversial due to associated risks of AKI and death
  Acute Kidney Injury (AKI):
 Definition: Sudden decrease in kidney function, leading to the
accumulation of waste products in the blood.
 Anesthesia Management: Monitor fluid balance, avoid nephrotoxic
drugs, and maintain hemodynamic stability. Careful consideration of
fluid resuscitation is essential.

SOME OTHER  Chronic Kidney Disease (CKD):

 Definition: Gradual loss of kidney function over time.
RENAL  Anesthesia Management: Pay attention to fluid balance, avoid
nephrotoxic drugs, and consider the patient's overall health. Adjust
DISEASE drug dosages based on renal function.

 Nephrolithiasis (Kidney Stones):

 Definition: Formation of hard deposits in the kidneys that can cause
severe pain and complications.
 Anesthesia Management: Address pain management strategies,
considering the potential impact of drugs on renal function. Ensure
adequate hydration.
  Renal Cystic Diseases:
 Definition: Various genetic and acquired conditions leading to the
formation of fluid-filled cysts in the kidneys.
 Anesthesia Management: Monitor kidney size, function, and blood
pressure. Adjust fluid management accordingly.

 Renovascular Hypertension:
 Definition: High blood pressure caused by narrowing or blockage of
the renal arteries.

CONT….  Anesthesia Management: Maintain blood pressure control, avoid

significant drops that may compromise renal perfusion, and be cautious
with nephrotoxic drugs.

 Hemolytic Uremic Syndrome (HUS):

 Definition: Disorder causing kidney failure due to the destruction of
red blood cells.
 Anesthesia Management: Monitor for fluid and electrolyte
imbalances. Be cautious with fluid resuscitation and consider the
patient's overall health status.
  Tubulointerstitial Nephritis:
 Definition: Inflammation of the renal tubules and surrounding
structures.
 Anesthesia Management: Identify and avoid potential
nephrotoxic drugs. Monitor for electrolyte imbalances and
maintain hemodynamic stability.

CONT….  IgA Nephropathy (Berger's Disease):

 Definition: Disorder where the antibody immunoglobulin A (IgA)
builds up in the kidneys.
 Anesthesia Management: Pay attention to fluid balance, avoid
nephrotoxic drugs, and consider the potential impact of systemic
inflammation on the patient's overall health.
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