Anaesthesia and Renal Disease Dr Cavin Gray Sheffield Teaching Hospitals  Occurrence  Problems associated with renal disease  Pre-operative assessment  Anaesthetic options  Prevention of post-operative AKI Staging of chronic kidney disease Stage Description eGFR (ml/min/1.73m2) I CKD with normal GFR but other renal > 90 damage (e.g. haematuria, proteinuria) II Mild CKD and other kidney damage 60-89 III Moderate CKD 30-59 IV Severe CKD 15-29 V Established ESRF < 15 or on RRT Causes of renal failure  Diabetes 25.6%  Glomerulonephritis 14.0%  Hypertension 7.4%  Polystic kidney disease 6.7%  Pyelonephritis 6.6%  Renal vascular disease 6.1%  Other 17.7%  Uncertain 15.9%  Median life years remaining for incident patients requiring RRT  Aged 25 – 29 18.5 years  Aged 75+ 2.4 years  Overall 5 year survival on HD 30%  More than 50% die from cardiovascular causes Risk of death attributed to cardiovascular causes associated with individual risk factors for anaesthesia -1 Renal failure (serum creatinine > 150 μmol.l ) on admission Age adjusted odds ratio 4.23 (95% CI 1.36 – 13.2), p < 0.013 cf previous MI 4.04 (1.6 – 10.19) p < 0.003 angina 3.55 (1.48 – 8.82) p < 0.004 heart failure requiring 2.80 (1.23 – 13.2) p < 0.014 medical treatment Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foex P - risk factors for cardiovascular death after elective surgery under general anaesthesia BJA 1998; 80:14-9 Systemic effects of renal failure CVS – LVH - Accelerated atherosclerosis - Hypertension - Conduction abnormalities Respiratory - Pulmonary oedema Effects of renal failure  Metabolic acidosis  Altered haemostasis - platelet dysfunction - prothrombotic tendency and reduced fibrinolysis • Autonomic neuropathy - delayed gastric emptying - parasympathetic dysfunction Effects of renal failure  Fluid and electrolytes - volume overload - hyperkalaemia – exacerbated by acidaemia, insulin deficiency and acute β - blockade Causes of hyperkalaemia in chronic renal disease Exogenous administration Transcellular shifts acidaemia insulin deficiency hypertonicity acute beta receptor blockade Drug effects suxamethonium, ACEI, ARBs, spironolactone, amiloride, β- blockers, NSAIDS, digoxin, spironolactone