Pathology associated with kidney failure and anesthesia

Chronic kidney disease (CKD) is defined as either a glomerular filtration rate (GFR) of <60 ml min−1 1.73 m−2 for 3 months or more, irrespective of cause, or kidney damage leading to a decrease in GFR, present for 3 months or more. The damage may manifest as abnormalities in the composition of blood or urine, on radiological imaging, or in histology. CKD is classified into five stages depending on GFR, ranging from Stage 1 - normal GFR to Stage 5 - established renal failure. Patients with kidney disease undergoing surgery and anesthesia are at high risk for increased adverse events that include, cardiovascular complications and mortality, and further deterioration of renal function and development of acute kidney injury (AKI) due to perioperative injuries that are caused by hemodynamic instability, hypovolemia, or drug toxicity. Special consideration should be placed on preventing further deterioration of renal function as well as protection of existing renal function in patients with moderate to severe impairment from the effects of anesthetics and pain medications. Analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) can contribute to a reduction of the residual renal function in CKD and should be avoided. Renal IR injury is a risk factor for acute renal failure and delayed graft function. Pathogenic factors for renal IR include, but are not limited to, the following: oxidative stress, inflammation, cellular necrosis, and apoptosis. Further clinical studies are required to address the optimal medication regimen that can be used for postoperative pain management in the more severe stages of CKD, including hemodialysis.