Patient with chronic renal failure undergoing surgery.

PURPOSE OF REVIEW: Chronic kidney disease (CKD) is an increasing health problem worldwide and is associated with a number of clinical challenges. In this paper, we review recent studies that deal with strategies for the management of patients with CKD undergoing surgery.

RECENT FINDINGS: Effective strategies for nephroprotection are crucial for the handling of patients with CKD in the perioperative setting to prevent complications and to avoid the progression of CKD. Due to the lack of perioperative studies with CKD patients there are only level 2 recommendations. First of all, this requires the identification of CKD patients through risk assessment and preoperative laboratory tests. In this regard, biomarkers, such as cystatin C may facilitate the detection of chronically impaired renal function. Secondly, particular attention should be paid to the maintenance of hemodynamic stability, including an adequate blood pressure and cardiac index and the preservation of intravascular volume. There is clear evidence that an unimpaired renal perfusion, guaranteed through hemodynamic stability, and an undisturbed fluid balance both reduce the incidence of acute kidney injury (AKI) and consequently the further deterioration of renal function. Thirdly, several studies demonstrate that tight glycemic control is associated with less renal impairment and better survival for patients with CKD. Lastly, the highest priority for the patient with CKD should be assigned to the prevention of AKI, which is an action of proven efficacy.

SUMMARY: Identification and risk stratification is crucial for the perioperative management of patients with CKD. To improve clinical outcomes, nonemergent procedures should be postponed, renal function optimized, nephrotoxic drugs avoided, and AKI prevented.