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[Perioperative fluid therapy for surgical patients with chronic kidney disease]
1Division of Anesthesiology, Department of Perioperative Medicine, Showa University, School of Dentistry, Tokyo 145-8515.
Insights
Fluid overload in chronic kidney disease (CKD) patients undergoing surgery can cause harm. A "zero-fluid balance policy" and endocrine system modulation may improve outcomes, rather than simply managing fluid quantity.
Area of Science:
- Nephrology
- Anesthesiology
- Critical Care Medicine
Background:
- Chronic kidney disease (CKD) frequently leads to cardiovascular complications, increasing surgical risks.
- Fluid and electrolyte imbalances in CKD patients can exacerbate postoperative morbidity.
- Aggressive fluid therapy and forced diuresis have shown no renoprotective benefits and can be detrimental.
Purpose of the Study:
- To evaluate the impact of fluid therapy strategies on surgical patients with CKD.
- To explore the potential benefits of a "zero-fluid balance policy" in this population.
- To investigate the role of endocrine system regulation in managing fluid balance during surgery for CKD patients.
Main Methods:
- Review of recent studies on fluid therapy in surgical patients with CKD.
- Analysis of the consequences of fluid overload and forced diuresis.
- Examination of the endocrine regulation of renal function (renin-angiotensin-aldosterone, vasopressin) and potential therapeutic targets.
Main Results:
- Fluid overload offers no renoprotective effects and increases postoperative complications in CKD patients.
- A "zero-fluid balance policy" may be beneficial, shifting focus from fluid quantity to hemodynamic control.
- Hydroxyethylstarch use requires careful consideration in CKD, particularly with increased vascular permeability.
Conclusions:
- Fluid therapy in surgical CKD patients should prioritize rational, endocrine-focused interventions over simple volume management.
- Targeting the renin-angiotensin-aldosterone and vasopressin systems may offer a novel approach to correcting fluid imbalances.
- Avoiding fluid overload is crucial for improving surgical outcomes in patients with chronic kidney disease.
Abstract:
Chronic kidney disease (CKD) often accompanies cardiovascular complications, causing postoperative morbidity and even mortality. Since fluid and electrolyte homeostasis is deregulated in CKD patients, fluid therapy itself may cause postoperative morbidity. Recent studies have shown that forced diuresis through fluid overload offers no renoprotective effect and instead has harmful consequences. Fluid overload should be avoided, and the volume load should be used as the rationale for controlling hemodynamics. The emerging concept of a "zero-fluid balance policy" may be beneficial even for CKD patients. Hydroxyethylstarch might not be preferentially used for CKD patients. Hydroxyethylstarch is not contraindicated for CKD patients except in cases with long-term accumulation caused by increased vascular permeability, such as cases with sepsis, as long as an efficient volume expansion is beneficial to the patient. The regulation of renal function through the endocrine system (i.e., renin-angiotensin-aldosterone and vasopressin) is a key target for protecting the kidney in CKD. The recent development of a receptor blocker targeting these endocrine systems may be beneficial for correcting the fluid balance caused by excess intraoperative fluid therapy. The main issue for fluid therapy in surgical CKD patients may not be the quantity of fluid, but rational intervention affecting the endocrine system.
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