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

Figure 28-3. Relationship of GFR to Serum Creatinine

The relation between serum creatinine and glomerular filtration rate (GFR) is not linear. Small increases in serum creatinine can reflect large decreases in GFR.

Estimation of Glomerular Filtration Rate

  • 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

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

Estimated creatinine clearance


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GenderFemale (0.742)Male (1)
RaceBlack (1.21)Non-black (1)

Cockroft–Gault formula:

Estimated creatinine clearance (mL/min)


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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

Preoperative Evaluation

  • 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

Preoperative Management

  • 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

Intraoperative Management

  • 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
  • Chronic renal insufficiency
  • Concomitant liver disease
  • Preoperative radiocontrast
  • Preoperative nephrotoxic drugs
  • Hypovolemia: NPO
  • Cardiopulmonary bypass
  • Aortic ...

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