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See Figures 28-1, 28-2, and 28-3)

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Figure 28-1. Causes of Acute Kidney Injury
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Figure 28-2. Renal Anatomy and Physiology
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Figure 28-3. Relationship of GFR to Serum Creatinine
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The relation between serum creatinine and glomerular filtration rate (GFR) is not linear. Small increases in serum creatinine can reflect large decreases in GFR.

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Estimation of Glomerular Filtration Rate

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  • Only valid in a stable situation, that is, not while in ARF
  • If ARF, measure clearance; a 2-hour clearance is as good as a 24-hour measurement

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Modification of Diet in Renal Disease Study (MDRD) Group formula:

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Estimated creatinine clearance

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Image not available.

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GenderFemale (0.742)Male (1)
RaceBlack (1.21)Non-black (1)
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Cockroft–Gault formula:

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Estimated creatinine clearance (mL/min)

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Image not available.

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Classification of Chronic Renal Disease
StageDescriptionGFR (cm3/(min 1.73 m2))
1Kidney damage with normal or increased GFR>90
2Kidney damage with mild decrease in GFR60–89
3Moderate decrease in GFR30–59
4Severe decrease in GFR15–29
5Kidney failure<15 or dialysis
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Preoperative Evaluation

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  • Estimate creatinine clearance:
    • Using either Cockroft–Gault or MDRD formula
  • Acute or chronic?
    • Previous serum creatinine values
    • Sudden rise?
  • Causes:
    • Low perfusion:
      • Cardiogenic shock
      • Sepsis and infection
      • Hypovolemia
    • Nephrotoxic insults:
      • Radiocontrast
      • Aminoglycosides
      • Calcineurin inhibitors (tacrolimus/FK-506 or cyclosporine)
    • Other causes
    • Urinary tract infections
    • Postrenal obstruction

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Preoperative Management

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  • Consider maintenance fluid while NPO
  • Consider preventive strategies especially for radiographic procedures: no strategy has however been proven to be effective (see below):
    • Sodium bicarbonate
    • N-Acetylcysteine

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Intraoperative Management

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  • Consider invasive monitoring: urine output not necessarily reliable indicator of adequate perfusion:
    • Pulmonary artery catheter
    • Intraoperative transesophageal echocardiography
  • Diligent fluid management:
    • Fluid deficit and maintenance and blood loss
    • Lactated Ringer will cause less acidosis (and hyperkalemia) than normal saline
  • Avoid further insults:
    • Minimize amount of (low osmolar) radiocontrast
    • Avoid hypotension: maintain BP near baseline (not “normal”) BP
  • With marginal renal function/anticipated large blood loss and possibility for hyperkalemia:
    • Frequent monitoring of potassium and pH
    • Prepare insulin/glucose
    • Maintain adequate calcium levels
    • Consider intraoperative continuous venovenous hemodialysis (CVVHD)

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Causes of Renal Injury
PreoperativeIntraoperativePostoperative
  • Chronic renal insufficiency
  • Concomitant liver disease
  • Preoperative radiocontrast
  • Preoperative nephrotoxic drugs
  • Hypovolemia: NPO
  • ...

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