- Creatinine clearance measurements are the
most accurate method available for clinically assessing overall
- The accumulation of morphine and meperidine metabolites
has been reported to prolong respiratory depression in some patients
with renal failure.
- Succinylcholine can be used safely in the presence
of renal failure if the serum potassium concentration is less than
5 mEq/L at the time of induction.
- The extracellular fluid overload from sodium
retention—together with the increased demand imposed by
anemia and hypertension—makes patients with chronic renal
failure particularly prone to congestive heart failure and pulmonary
- Delayed gastric emptying secondary to autonomic
neuropathy in some patients can predispose patients with chronic
renal failure to aspiration perioperatively.
- Controlled ventilation should be considered for
patients with renal failure. Inadequate spontaneous or assisted
ventilation with progressive hypercarbia under anesthesia can result
in respiratory acidosis that may exacerbate preexisting acidemia,
lead to potentially severe circulatory depression, and dangerously
increase serum potassium concentration.
- Procedures associated with a relatively high
incidence of postoperative renal failure include cardiac and aortic
- Intravascular volume depletion, sepsis, obstructive
jaundice, crush injuries, recent contrast dye injections, and aminoglycoside,
angiotensin-converting enzyme inhibitor, or nonsteroidal antiinflammatory
drug therapy are additional major risk factors for an acute deterioration
in renal function. Prophylaxis against renal failure with generous
hydration together with solute diuresis appears to be effective
and indicated in high-risk patients undergoing cardiac, major aortic
reconstructive, and possibly other surgical procedures.
- The consequences of excessive fluid overload—namely,
pulmonary congestion or edema—are easier to treat than
those of acute renal failure.
Diseases affecting the kidneys are often grouped into syndromes
based on common clinical and laboratory findings: nephrotic syndrome,
acute renal failure, chronic renal failure, nephritis, nephrolithiasis,
and urinary tract obstruction and infection. The anesthetic care
of patients with these syndromes is facilitated by grouping patients
according to the status of their preoperative renal function rather
than by syndrome. This chapter examines the basis for this approach
and the anesthetic considerations applicable within each group.
Renal physiology and the effects of anesthesia on renal function
are discussed in Chapter 31.
Accurate assessment of renal function relies heavily on laboratory
determinations (Table 32–1). Renal
impairment can be due to glomerular dysfunction, tubular dysfunction,
or obstruction of the urinary tract. Because abnormalities of glomerular
function cause the greatest derangements and are most readily detectable,
the most useful laboratory tests are those related to the glomerular filtration
rate (GFR; see Chapter 31).
32–1. Grouping of Patients According to Glomerular Function. |Favorite Table|Download (.pdf)
32–1. Grouping of Patients According to Glomerular Function.
|Creatinine Clearance (mL/min)|
|Decreased renal reserve||60–100|
|Mild renal impairment||40–60|
|Moderate renal insufficiency||25–40|
|Renal failure||< 25|
|End-stage renal disease1||< 10|
applies to patients with chronic renal failure.|
The primary source of urea in the body is the liver. ...