Surgery in the patient with renal disease

Introduction Kidney disease encompasses a wide spectrum of disorders, ranging from those with normal glomerular filtration rates (GFR) but with urinary abnormalities (nephrotic syndrome or nephritic syndrome), to those with GFR impairments. Patients with a long-standing history (months to years) of renal disease are deemed to have chronic kidney disease (CKD). A staging system has been developed by the National Kidney Foundation to categorize CKD by GFR levels: Stage 1 (GFR ≥ 90 mL/min, but with persistent urinary abnormalities such as proteinuria); Stage 2, mild CKD (GFR 60–89 mL/min); Stage 3, moderate CKD (GFR 30–59 mL/min); Stage 4, severe CKD (GFR 15–29 mL/min); and finally Stage 5, kidney failure or end-stage renal disease (ESRD) (GFR < 15 mL/min or on some form of renal replacement therapy). There is clinical rationale in dividing CKD into these stages; patients with more advanced stages, especially those at stage 3 or higher, have higher rates of death, cardiovascular events, and hospitalizations [1]. In contrast to established kidney disease, acute kidney injury (AKI), previously termed “acute renal failure,” reflects renal dysfunction that arises in the span of hours to days. AKI can develop in those with previously normal kidney function or can be superimposed upon existing CKD. More advanced CKD stages 3 through 5 and AKI are most commonly associated with perioperative complications, and these patients will be the focus of this chapter.