MANAGING CHRONIC RENAL INSUFFICIENCY: PERIOPERATIVE CARE
As with other patients, the renally impaired should undergo preoperative cardiac assessment to assign risk level prior to surgery or any invasive procedure. In patients with advanced chronic renal failure (glomerular filtration rate <20 ml/min), bleeding time determination should be performed before invasive surgery and if bleeding time is prolonged, desmopressin (l-desamino-8-d-arginine vasopressin) should be given intravenously at least 60-minutes before surgery (0.3 Fg per kilogram in 50 cc of normal saline over 30 minutes). For active uncontrolled bleeding, fresh frozen plasma or cryoprecipitate may be given.
For postoperative analgesia, meperidine should be avoided because its metabolites accumulate in renal failure and may induce seizures.
ADEQUATE PREPARATION FOR RENAL REPLACEMENT THERAPY
Patient Education and Psychological Support
Patients should be given simple written materials in their native language describing their disease and its treatment. Members of the renal team should encourage patients to ask questions. As the need for renal replacement therapy approaches, many patients and their families need intensified psychosocial support to help with the adjustment of the stresses of uremia and its therapy.
Options of Uremia Therapy
Discussion of options in uremia therapy should begin long before the need for renal replacement therapy arrives. If maintenance hemodialysis is the chosen modality for renal replacement therapy, vascular access should be created when the patient’s glomerular filtration rate is less than 25 ml/minute or within one year of the anticipated need to start dialysis. If continuous ambulatory peritoneal dialysis is the chosen modality, a peritoneal dialysis catheter should be placed weeks in advance. Native arteriovenous fistulae are superior to polytetrafluoroethylene grafts because of longer lifespan and lower incidence of thrombosis and infection, and should be the access of choice in all hemodialysis patients.
Kidney transplantation should be encouraged in patients whose general health is satisfactory and potential living, related donors should be evaluated. Readiness for transplantation entails a workup to exclude any significant cardiovascular, pulmonary or infectious disease complications that might complicate the post-transplant period. Screening for panel reactive antibodies should be done monthly. Patients also need to be screened for malignancies and have an evaluation to determine the proper functioning of the urinary tract system and the vasculature.
Timely Initiation of Renal Replacement Therapy
ESRD therapy is usually initiated on the basis of the presence of uremic symptoms (nausea, reversed sleep pattern) and laboratory values such as serum creatinine concentration and blood urea nitrogen. However, evolution of uremic symptoms is often not predictable, and varies from patient to patient, making it essential that patients with advanced renal failure be monitored closely.
Though the specific values of laboratory parameters signaling the need for renal replacement therapy are not established, consensus finds that initiation of dialysis is inappropriately delayed in many US ESRD patients. Without scientific data, the consensus is that renal replacement therapy be started at a creatinine clearance of 10 to 15 ml per minute, in the absence of more acute presentation of uremia that would compel an earlier start.
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In the 1980s, Bonomini et al. of Italy found that starting haematolysis “early” at creatinine clearances greater than 10 ml per minute, and up to 25 ml per minute, resulted in enhanced survival and less debility. Such “early” hemodialysis limited hospitalizations and reduced mortality, attaining higher rates of employment than in the US—thus, resulting in substantial costsaving. Scribner and others, however, contested the value of Bonomini’s report, 13 beginning a debate that continues today over when to start ESRD therapy.