Perioperative assessment of
ESRD
Dr. Ahmed Kamal
Mansoura Urology and Nephrology Center
Mansoura University

Agenda
1. WHY?
2. Pre-operative assessment.
3. Pathophysiological effects of ESRF
4. Influence of ESRF on pharmacokinetics and
metabolism of the anesthetic agents and
other medications applied perioperatively
5. Influence of anesthesia on the renal function
6. Influence of surgery on RRF

Why?
• High incidence of coronary artery disease and
myocardial dysfunction.
• Difficulty adjusting fluid, acid base and
electrolytes in the perioperative period in
patients.
• Failure to normally excrete and/or metabolize
anesthetics and analgesics, leading to toxic levels
of these agents.
• Increased bleeding complications.
• Poor blood pressure control.

• Great challenge for the medical team
participating in the preparation
(anesthesiologists, surgeons, nephrologists...)
• General surgery mortality 4% morbidity 54%
• Cardiac surgery 10% and 46%.

Cherng, YG . et al, PLoS One. 2013;8(3) 2013 Mar 14.

Lin, CY. et al, Medicine (Baltimore). 2016 Mar;95(9)

Lin, CY. et al, Medicine (Baltimore). 2016 Mar;95(9)

Lin, CY. et al, Medicine (Baltimore). 2016 Mar;95(9)

• American College of Cardiology/American
Heart Association (ACC /AHA) guidelines on
perioperative cardiovascular evaluation of
noncardiac surgery, patients with a creatinine
level greater than or equal to 2 are considered
to have a clinical predictor of at least
intermediate pretest probability of increased
perioperative cardiovascular risk.

Pre-operative assessment

History
• CRF cause
• Daily diuresis, RRF.
• AVF.
• Method of dialysis, number of dialysis sessions per
week, their duration in hours, tolerance.
• Side effects.
• Systemic diseases.
• CRF complications (bleeding, encephalopathy,
neuropathy).
• Recent treatment, previous anesthesia as well as
current therapy

Physical examination
• Bleeding (bruises, petechiae).
• Anemia (hyperdynamic circulation, systolic
murmur, pallor).
• Hydration or dehydration, inflammations,
pericardial effusion and pneumonia.
• Encephalopathy, neuropathy.
• AVF examination.
• Peritoneal catheter should be examined.

Laboratory
• Hematocrit, total blood cell count (type of
anemia, leukocytosis).
• Urine analysis (blood, proteins, infection).
• Electrolytes (Na, K, Ca, phosphates).
• ABG.
• Urea, creatinine.
• Coagulation testing (PT, PTT, TT, platelet count,
bleeding time).

Preoperative dialysis
• Day prior surgery
• Volume status, hyperkalemia and acidosis
• Not of help for sepsis, wound healing and
thrombocytopenia.
• Improve uremic environment
• Improve immune system functionality.
• heparin-free.

PATHOPHYSIOLOGICAL EFFECTS
RELEVANT FOR PREOPERATIVE
PREPARATION

PATHOPHYSIOLOGICAL EFFECTS
• Fluid balance.
• Electrolytes and metabolic.
• Nutritive disorders.
• Functional disorders of the organs and systems of
organs.
– Cardiovascular diseases.
– Hemolytic changes.
– Pulmonary function.
– Nervous systems.

CVS

CVS
• Higher incidence of coronary artery disease (CAD)
and peripheral vascular disease (PVD).
• Risk factors:
– Advanced age
– Diabetes, hypertension.
– Lipid disorders.
– Hyperhomocysteinemia.
– Abnormal calcium phosphate metabolism.
– Anemia, increased oxidative stress and uremic toxins

CVS
• Hypertension:
– Hyperreninemic
– Hypervolemia
– Increased sympathetic activity
• Atherosclerosis
• With hyperlipidemia  IHD

Cardiac assessment
• Electrocardiogram (ECG) is mandatory due to
possible myocardial ischemia, left ventricular
hypertrophy, arrhythmia and potassium level
determination.
• ECG changes  consultative examination with
the cardiologist.
• X ray

CVS
• Risk stratification:
– Age (less than or greater than 50 years old).
– History of angina.
– Type 1 diabetes.
– Congestive heart failure, or the presence of an
abnormal electrocardiogram (excluding left
ventricular hypertrophy)
Dobutamine stress echocardiography

Pre-operative preparation
• Hypertension:
– Controlled by multiple drugs & dialysis
– Emergency operation:
• IV antihypertensive “ enalaprilat, labetalol, hydralazine
and diltiazem.
• Transdermal clonidine “slow”
– Discontinuation is not recommended
– ACEIs withdrawal may be attempted:
• development of hypotension and large volume
distribution is expected

Fluid and metabolic balance
• Anuric or oliguric (<500 ml/day).
• Lack of concentration ability.
• Increase anion gap metabolic
acidosis
• Retention of phosphates and
sulphates.

Fluid management
• Residual kidney function.
• Anuric patients replace with 800 cc to I L/day 
normal saline and 5% glucose
• 3rd space loss differs according to surgery.
• Forced diuresis “furosemide” with RRF
• Optimal Weight:
– Hypervolemic  pulmonary edema
– Hypovolemic  hypotension “anesthesia induced VD

K

K
• Ratio 35:1
• Na-k atpase pump.
• K rises 0.5 mmol/L per 0.1 decrease in PH
• Hyperkalamia in ESRD due to catabolic states
as surgery, acute acidosis and drugs.
• Correction in ECG changes “bradycardia, PR
prolongation, QRS widening, peaked T waves,
and AV block.

K
Weir MR, Curr Opin Nephrol Hypertens. 2014 May;23(3):306-13.

K
After one hour of HD

Pre-operative preparation
• Hyperkalemia:
– Elective  dialysis
– Emergency :
• Antagonize effect on cell membrane level “ Ca chloride”
• Translocation “mechanical hyperventilation, sodium
bicarbonates or glucose insulin infusion”
• oral/rectal cation exchange resins.
• ALS and monitoring.

Ca, PO4 and Mg

Ca, PO4 and Mg
• Hypocalcaemia and hyperphosphatemia
• Hypophosphatemia “ antacids and aggressive
dialysis”
– Muscle weakness.
– Tremor.
– ventilatory failure.
– Osteoporosis
– hemolytic anemia.
• Hypermagnesemia

Hematology
• Anemia
– Disturbed erythropoiesis
– Shorter half life
– BM suppression by uremia
– Frequent blood loss
– Activation of hemolysis
– AL toxicity
– Iorn, B6, B12 and folate deficiency.

Hematology
• Coagulopathy:
– PT, PTT, TT  Normal
– BT prolonged
– Decreased and poor release of VWF and VIII
– Important for aggregation
– Increase risk of bleeding

Pre-operative preparation
• Preoperative transfusion:
– not indicated in patients with chronic, stable
anemia and hematocrit value above 0.25.
– Unnecessary transfusion increases the chances of
infection, overfilling of the vascular bed and onset
of edema.
– should be applied in the course of dialysis.
– potassium level and blood pH.

Pre-operative preparation
• Correction of coagulopathy:
– Thrombocytopenic conditions characterized by diffuse
petechiae and bleeding time longer than 15 minutes.
In such conditions.
– platelet transfusion should be administered regardless
of their count above 100000/mm3.
– administration of 8-deamino-D-arginine vasopressin
(DDAVP) in dose of 0.3 mg/kg i.v. for approximately 6
to 12 hours. Therefore, it would be best to apply it 1
hour before the surgery as slow infusion (20 - 30
minutes) in order to avoid hypotension.
– Cryoprecipitate infusion.

Hematology
Douketis, J. Can Fam Physician. 2014 Nov;60(11):997-1001.

Hematology
Maura K Wychowski and Peter A Kouides, JAnn Pharmacother. 2012 Apr;46(4): 2012 Apr 10.

DM
• 44% of dialysis “10 % Type I”
• Diabetic status:
– Utmost importance “glucose, electrolytes and
complication”
– Level of stress
– Pre-operative glycemic control.
– Difficult:
• Surgery schedule
• Change physical activity
• Co-morbid conditions

Pulmonary
• threshold for development of the pulmonary
edema.
• postoperative atelectasis
• Difficulties in ventilation in abdominal
distension in PD.
• Pneumonia and pleural effusion.

GIT
• Chronic irritation “uremic entropathy” due to
high urea.
• anorexia, nausea, vomiting, GIT bleeding,
diarrhea and hiccups.
• Intestinal passage with increased acidity and
gastric volume.

CNS
• Uremic encephalopathy “ drowsiness,
decreased mental capacity to epileptic
seizures”.
• Disequilibrium syndrome
• Dementia.
• Peripheral neuropathy “ mainly lower half”
• Autonomic dysfunction

CNS
AbuRahma, A.F. et alJ Vasc Surg. 2015 Mar;61(3):675-82. Epub 2014 Dec 9.

CNS
AbuRahma, A.F. et alJ Vasc Surg. 2015 Mar;61(3):675-82. Epub 2014 Dec 9.

Nutritional
• Hyperglycemia and TG “ peripheral
resistance to insulin and LPL”  IHD.
• Malnutrition  infections, delayed wound
healing.

Nutritional
Kawahito, K. et al,J Artif Organs. 2016 Jan 9. [Epub ahead of print]

Nutritional
Kawahito, K. et al,J Artif Organs. 2016 Jan 9. [Epub ahead of print]

Nutritional
Kawahito, K. et al,J Artif Organs. 2016 Jan 9. [Epub ahead of print]

EFFECTS OF ESRF ON PHARMACOKINETICS
AND METABOLISM OF DRUGS AND
ANESTHETIC AGENTS

PHARMACOKINETICS AND
METABOLISM
• liposoluble, highly ionized drugs.
• Duration of action
– Bolus “ volume of distribution”
– Repeated “ elimination”

Renal dependent drugs
• Anticholinergics (atropin, glycopyrrolate).
• Cholinergics (neostigmine, pyridostigmine,
edrophonium),
• Muscle relaxants (pancuronium, pipecuronium, d-
tubocurarine, vecuronium, doxacurium)
• Barbiturates (phenobarbital).
• Anesthetic agents.
• Cardiovascular drugs (milrinone, amrinone,
amphetamine)

Active metabolites
• Morphine (antianalgesic metabolite),
• Meperidine (neuroexcitatory metabolite),
diazepam (metabolite oxazepam is a sedative)
• Enflurane (produces nephrotoxic fluorides).
• Vecuronium and pancuronium (metabolites
have relaxant activity).
• Procainamide (NAPA metabolite is
neurotoxic).

Anesthesia effect
• Anesthesia-related:
– Hypertension
– Ischemic heart disease
– Congestive heart failure
– Anemia, metabolic acidosis
– Hyperkalemia, hyponatremia
– Circulatory collapse

Effect of surgery on residual function
• Anesthesia induced hypotension  loss RRF
• MAP> 60 mmHg
• Fall of MAP by 50% for > 3hours  loss of RRF
in 80%
• Hypoventilation  renal VC  RBF
• Ventilation MAP:
– Increase intrathoracic pressure
– VD due to hypocapnia

• Intraoperative bleeding
• Nephrotoxic drugs:
– sodium-potassium ATPse and calcium ATPase
transport system mechanisms.
– accumulation of calcium in the cell, which has
noxious effects on the mitochondria.
– Certain halogen anesthetics release highly toxic
fluorides.
– Drugs may also influence lysosomal membranes
Effect of surgery on residual function

Effect of surgery
Most common complication is closure of AVF
Yu YH et al Spine. 2011 Apr 15;36(8):660-6.

CABG
Off-pump better than on-pump
Over all outcome less but acceptable
Combined  higher mortality

ANP in cardiac surgery
Sezai, A. Ann Thorac Cardiovasc Surg. 2014;20(3):217-22. Epub 2013 Apr 11.

ANP in cardiac surgery
Sezai, A. Ann Thorac Cardiovasc Surg. 2014;20(3):217-22. Epub 2013 Apr 11.

ANP in cardiac surgery
Sezai, A. Ann Thorac Cardiovasc Surg. 2016 Mar 30. [Epub ahead of print]

ANP in cardiac surgery
Sezai, A. Ann Thorac Cardiovasc Surg. 2016 Mar 30. [Epub ahead of print]

Post-operative
• Hemodialysis as scheduled.
• Wound care
• Immunological dysfunction:
– Prophylactic antibiotics
– Careful wound management
– Minimize invasive maneuver.

Post-operative
Tawfic, QA et al, J Anaesthesiol Clin Pharmacol. 2015 Jan-Mar;31(1):6-13. Review

Conclusion
• Intravenous access and blood pressure
monitoring.
• Cardiac assessment.
• Managing electrolyte abnormalities.
• Nutritional status.
• Type and rate of intravenous fluids.
• Hemodialysis pre and post-operative.

Thank you