Preoperative evaluation of patients with chronic kidney disease requires a thorough history and physical examination, with particular attention to the etiology and severity of the renal impairment. Assessing the patient’s fluid status is crucial, as these patients are prone to fluid overload or dehydration, both of which can complicate anesthesia management. Capillary refill time, skin turgor, and auscultatory findings are useful clinical markers to assess fluid status. The patient’s dry weight and ability to produce urine should be evaluated, especially if they are undergoing dialysis.
Renal replacement therapy (RRT) modality and the timing of the last dialysis session should be documented. Patients on dialysis are often at risk for volume overload or electrolyte disturbances, and adjusting their fluid balance preoperatively is essential. If immunosuppressant therapy or long-term corticosteroid use is present, perioperative steroid supplementation may be necessary. In patients with an arteriovenous fistula (AVF) for dialysis access, care must be taken to avoid damaging the AVF during vascular access attempts.
Clinical Investigations
In addition to a full blood count (FBC) and urea and electrolytes (U&E), patients with CKD should have their coagulation profile evaluated if coagulopathy is suspected. Anemia is common in CKD due to reduced erythropoietin production, and its severity should be assessed. If fluid overload is suspected, a chest X-ray should be performed to evaluate for pulmonary edema or pleural effusions. An electrocardiogram (ECG) is necessary to screen for left ventricular hypertrophy, arrhythmias, and ischemia, which are common in patients with CKD. An echocardiogram may be indicated in those with suspected cardiac impairment or pericardial effusion.
Chronic disease-specific treatments, such as antihypertensive medications and immunosuppressants, should be continued where possible. The use of angiotensin-converting enzyme (ACE) inhibitors in the perioperative setting remains controversial, and their discontinuation should be considered on an individual basis. Liaison with the nephrology team is recommended if dialysis is required before surgery, particularly to optimize fluid and electrolyte balance. The management of hypertension should be individualized, as strict blood pressure control is essential to prevent renal hypoperfusion during anesthesia.
