Preoperative care of patients with kidney disease

Patients with chronic kidney disease often require surgical interventions for vascular access and for medical problems related to comorbid conditions. Perioperative morbidity and mortality rates are increased in these patients. Preoperative attention to common medical problems that occur in patients with impaired renal function can lower some surgical risks. Hyperkalemia can be temporarily improved by the intravenous administration of an insulin-dextrose combination or bicarbonate, and polystyrene binding resins or dialysis can remove excess stores of potassium. Increased bleeding related to uremic platelet dysfunction can be managed by the administration of desmopressin, cryoprecipitate, or estrogens, and by avoiding the use of medications with antiplatelet effects close to the time of surgery. Transfusions of red blood cells should be reserved for use in patients with clinically significant anemia, because antibody formation may decrease the likelihood of successful renal transplantation in the future. Cardiovascular disease is the most common cause of death in patients with renal disease. Patients with chronic kidney disease may have hypertension and hypoglycemia in the perioperative period. Preoperative testing may be necessary in patients with cardiac risk factors. If future vascular access grafting is contemplated, intravenous line placement and blood draws should be avoided in a patient's nondominant arm.