Pre-anesthesia evaluation in patients with chronic renal disease (emphasis on cardiovascular risk)
Chronic renal disease is a public health problem worldwide. Several times these patients will undergo surgical procedures related to dialysis or surgeries related to their co-morbidities. The purpose of the pre-anesthesia evaluation is to assess the risk of cardiovascular events and initiate interventions that may influence morbidity and mortality.
This article describes the relevant epidemiological data of chronic kidney disease and its cardiovascular risk and provides a guide on clinical assessment, diagnostic tools and strategies to reduce surgical risk. This narrative literature review is based on articles written in both English and Spanish limited to the last 10 years, information from basic textbooks and primary databases (i.e., PUBMED - EMBASE - LILACS), supported by articles referenced in the above-mentioned search.
2. Jones D, Lee HT. Surgery in the patient with renal dysfunction. Med Clin N Am. 2009;93:1083-93.
3. US Renal Data System. USRDS 2010 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2010.
4. Trainor D, Borthwick E, Ferguson A. Perioperative management of the hemodialysis patient. Semin Dial. 2011;24:314-26.
5. Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis. 2002;39:930-6.
6. Gómez R. Renal disease in Colombia. Ren Fail. 2006;28: 643-7.
7. Joseph A, Cohn S. Perioperative care of the patient with renal failure. Med Clin N Am. 2003;87:193-210.
8. National Kidney Foundation, Kidney Disease Outcomes Quality Initiative - K/DOQI. Clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis. 2002;39:S1-266.
9. Eilers H, Liu KD, Gruber A, Niemann CU. Chronic kidney disease: implications for the perioperative period. Minerva Anestesiol. 2010 Sep;76:725-36.
10. Palevsky P. Perioperative management of patients with chronic kidney disease or ESRD. Best Pract Res Clin Anesthesiol. 2004;18:129-44.
11. Cockcroft D, Gault M. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31-41.
12. Levey A, Bosch J, Breyer J, Greene T, Rogers N, Roth N. More accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med. 1999;130:461-70.
13. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro 3rd AF, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604-12.
14. Manjunath G, Tighiouart H, Ibrahim H, MacLeod B, Salem D, Griffith JL, et al. Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community. J Am Coll Cardiol. 2003;41:47-55.
15. Mann JF, Gerstein HC, Pogue J, Bosch JSY. Renal insufficiency as a predictor of cardiovascular outcomes and the impact of ramipril: the HOPE randomized trial. Ann Intern Med. 2001;134:629-36.
16. Furuhashi T, Moroi M, Joki N, Hase H, Masai H, Kunimasa T, et al. The impact of chronic kidney disease as a predictor of major cardiac events in patients with no evidence of coronary artery disease. J Cardiol. 2010;55:328-36.
17. O'Hare AM, Feinglass J, Sidawy AN, Bacchetti P, Rodriguez RA, Daley J, et al. Impact of renal insufficiency on short-term morbidity and mortality after lower extremity revascularization: data from the Department of Veterans Affairs' National Surgical Quality Improvement Program. J Am Soc Nephrol. 2003;14:1287-95.
18. Lok CE, Austin PC, Wang HJVT. Impact of renal insufficiency on short- and long-term outcomes after cardiac surgery. Am Heart J. 2004;148:430-8.
19. Detsky AS, Abrams HB, Forbath N, Scott JG, Hilliard JR. Cardiac assessment for patients undergoing noncardiac surgery. A multifactorial clinical risk index. Arch Intern Med. 1986;146:2131-4.
20. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogst ad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845-50.
21. Poldermans D, Bax J, Boersma E, De Hert S, Eeckhout E, Fowkes G, et al. Guía de práctica clínica para la valoración del riesgo cardiaco preoperatorio y el manejo cardiaco perioperatorio en la cirugía nocardiaca. Rev Esp Cardiol. 2009;62:e1-56.
22. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043-9.
23. Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, et al. Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med. 2005;118:1134-41.
24. Jones DH, Lee HT. Surgery in the patient with renal dysfunction. Anesthesiology. 2009;27:739-49.
25. Jetté M, Sidney K, Blümchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol. 1990;13:555-65.
26. Miller R, Eriksson L, Fleisher L, Wiener-Kronish J, Young W. In: Físcher S, Bader A, Sweitzer B, editors. Anesthesia. Chap 34. Preoperative evaluation. Philadelphia: Churchill Livingstone; 2009.
27. Foley RN, Parfrey PS, Harnett JD, Kent GM, Martin CJ, Murray DC, et al. Clinical and echocardiographic disease in patients starting end-stage renal disease therapy. Kidney Int. 1995;47:186-92.
28. Elsner D. How to diagnose and treat coronary artery disease in the uremic patient: an update. Nephrol Dial Transplant. 2001;16:1103-8.
29. Herzog CA, Marwick TH, Pheley AM, White CW, Rao VK, Dick CD. Dobutamine stress echocardiography for the detection of significant coronary artery disease in renal transplant candidates. Am J Kidney Dis. 1999;33:1080-90.
30. Tita C, Karthikeyan V, Stroe A, Jacobsen G, Ananthasubramaniam K. Stress echocardiography for risk stratification in patients with end-stage renal disease undergoing renal transplantation. J Am Soc Echocardiogr. 2008;21:321-6.
31. Ferreira PA, de Lima VC, Campos Filho O, Gil MA, Cordovil A, Machado CV, et al. Feasibility, safety and accuracy of dobutamine/atropine stress echocardiography for the detection of coronary artery disease in renal transplant candidates. Arq Bras Cardiol. 2007;88:45-51.
32. Lentine KL, Hurst FP, Jindal RM, Villines TC, Kunz JS, Yuan CM, et al. Cardiovascular risk assessment among potential kidney transplant candidates: approaches and controversies. Am J Kidney Dis. 2010;55:152-67.
33. Joseph AJ, Cohn SL. Perioperative care on the patient with renal failure. Med Clin N Am. 2003;87:193-210.
34. Brienza N, Giglio MT, Marucci M. Preventing acute kidney injury after noncardiac surgery. Curr Opin Crit Care. 2010;16:353-8.
35. Mangano CM, Diamondstone LS, Ramsay JG, Aqqarwal A, Herskowitz A, Mangano DT, The multicenter study of perioperative ischemia research group. Renal disfunction after myocardial revascularization: risk factors, adverse outcomes and hospital resource utilization. Ann Intern Med. 1998;128:194
36. Jarnberg PO. Renal protection strategies in the perioperative period. Best Pract Res Clin Anesthesiol. 2004;18: 645-60.
37. Tang IY, Murray PT. Prevention of perioperative acute renal failure: What works? Best Pract Res Clin Anaesthesiol. 2004;18:91-111.
38. European Society of Cardiology, European Society of Anesthesiology. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J. 2009;30:2769-812.
39. Maioli M, Toso A, Leoncini M, Gallopin M, Tedeschi D, Micheletti C, et al. Sodium bicarbonate versus saline for the prevention of contrast-induced nephropathy in patients with renal dysfunction undergoing coronary angiography or intervention. J Am Coll Cardiol. 2008;52:599-604.
40. Krishnan, Mahesh. Preoperative care of patients with kidney disease. Am Fam Physician. 2002;66:1471-7.
41. Mannuccio P, Levi M. Prevention and treatment of major blood loss. N Engl J Med. 2007;356:2301-11.
42. Eikelboom J, Hirsh J. Bleeding and management of bleeding. Eur Heart J Suppl. 2006;8 Suppl. G:G38-45.
43. O'Riordan JM, Margey RJ, Blake G, O'Connell PR. Antiplatelet agents in the perioperative period. Arch Surg. 2009;144:69-76.
44. Croinin DF, Shorten GD. Anesthesia and renal disease. Curr Opin Anaesthesiol. 2002;15:359-63.
45. Cittanova ML, Zubicki A, Savu C, Montalvan C, Nefaa N, Zaier K, et al. The chronic inhibition of angiotensin-converting enzyme impairs postoperative renal function. Anesth Analg. 2001;93:1111-5.
46. Comfere T, Sprung J, Kumar M, Draper M, Wilson DP, Williams BA, et al. Angiotensin system inhibitors in a general surgical population. Anesth Analg. 2005;100:636-44.
47. Landoni G, Biondi-Zoccai G, Tumlin J, Bove T, De Luca M, Calabró M. Beneficial impact of fenoldopam in critically ill patients with or at risk for acute failure: a meta-analysis of randomized clinical trials. Am J Kidney Dis. 2007;49:56-68.
48. Lardizabal JA, Deedwania PC. Benefits of statin therapy and compliance in high risk cardiovascular patients. Vasc Health Risk Manag. 2010;6:843-53.
49. Kalarickal PL, Fox CJ, Tsai JY, Liu HADK. Perioperative statin use: an update. Anesthesiol Clin. 2010;28:739-51.
50. Fabbian F, De Giorgi A, Pala M, Tiseo R, Manfredini R, Portaluppi F. Evidence-based statin prescription for cardiovascular protection in renal impairment. Clin Exp Nephrol. 2011;15:456-63.
51. O'Neil-Callahan K, Katsimaglis G, Tepper MR, Ryan J, Mosby C, Ioannidis JP, et al. Statins decrease perioperative cardiac complications in patients undergoing no cardiac vascular surgery: the Statins for Risk Reduction in Surgery (StaRRS) study. J Am Coll Cardiol. 2005;45: 336-42.
52. Elliot M, Ronksley P, Clase C, Ahmed S, Hemmelgarn B. Management of patients with acute hypekalemia. CMAJ. 2010;182:1631-5.
53. Raymond CB, Sood AR, Wazny LD. Treatment of hyperkalemia in patients with chronic kidney disease, a focus on medications. CANNT J. 2010;20:49-53.
54. Putcha N, Allon M. Management of hyperkalemia in dialysis patients. Semin Dial. 2007;20:431-9.
55. Stewart P, Harris D. Anaesthesia and chronic renal failure. Update Anesth. 2000:7-10.
The Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.) is the owner of all copyrights to any articles published in the journal. Published manuscripts become the permanent property of S.C.A.R.E. and may not be published elsewhere without written permission. S.C.A.R.E. keeps the right to use these manuscripts in any form, including print, video, audio and digital.
Creative Commons License
Open-access articles can be read, downloaded and shared on a free basis upon publication. The Journal publishes all articles under the CCBY- NC-ND license. Attribution-NonCommercial-NoDerivs: CC BY- NC-ND. Of the six main licenses, this is the most restrictive because it only allows others to download and share articles as long as they give credit to the author, but they cannot in any way change the paper or use it commercially.