The patient with kidney disease
- Patient and surgery
Weak kidneys clear many anaesthetic drugs slowly and struggle with potassium and fluid, so drugs, fluids and timing of dialysis are planned around them.
What it is
Chronic kidney disease is a lasting loss of kidney function or structure, staged by the glomerular filtration rate and the amount of albumin in the urine. For the anaesthetist it changes almost every system. Drugs and active metabolites that leave the body through the kidneys accumulate, so their effect lasts longer; a low albumin raises the free fraction of protein-bound drugs. The patient may have high potassium, metabolic acidosis, fluid overload or, after dialysis, too little volume. Anaemia is common, and uraemia makes platelets work poorly, so bleeding can be greater than the platelet count suggests. Cardiovascular disease is the main cause of death in these patients: hypertension, coronary disease, left ventricular hypertrophy and heart failure are frequent, often together with diabetes and its delayed gastric emptying. Patients on dialysis have an arteriovenous fistula or a catheter that must be protected, and their surgery is timed after a session. The plan in principle is simple: choose drugs that do not depend on the kidney, avoid anything that harms what kidney function remains, measure potassium and volume before starting, and watch for acute kidney injury, hyperkalaemia and fluid overload afterwards.
What changes in this patient
- Drug clearance: renally excreted drugs and metabolites accumulate, so effects of relaxants, opioids and some antibiotics last longer.
- Potassium and acid: hyperkalaemia and metabolic acidosis are common and worsen with tissue injury, transfusion and suxamethonium.
- Volume: overload with hypertension and pulmonary oedema before dialysis, or hypovolaemia and hypotension just after it.
- Blood: chronic anaemia is often well tolerated; uraemic platelet dysfunction increases bleeding despite a normal count.
- Heart and vessels: high rates of coronary disease, left ventricular hypertrophy, heart failure and calcified arteries.
- Other: diabetes with gastroparesis and aspiration risk, low albumin, poor wound healing and a higher risk of infection.
Anaesthetic plan (and why)
- Find out the stage, cause and dialysis schedule, and the residual urine output — this predicts how drugs and fluids will behave.
- Time surgery the day after dialysis and recheck potassium, haemoglobin and weight afterwards — volume and potassium are best then.
- Postpone elective surgery if potassium is clearly high or the patient is overloaded — both can cause arrhythmias and hypoxaemia under anaesthesia.
- Mark and protect the fistula arm: no cuff, cannula or tight strapping, and pad it well — a clotted fistula costs the patient their dialysis access.
- Use rapid-sequence induction if gastric emptying is slow, with rocuronium rather than suxamethonium when potassium is high — less aspiration, no potassium rise.
- Prefer atracurium or cisatracurium, and fentanyl or remifentanil; monitor neuromuscular block — these do not depend on the kidney, and residual block is common.
- Consider regional anaesthesia, such as a brachial plexus block for fistula creation, after checking clotting and uraemic bleeding — avoids systemic drugs.
- Give fluids in small boluses guided by goals, using balanced crystalloid with care if potassium is borderline — overload is easy and harmful.
- Avoid NSAIDs, contrast and other nephrotoxins, and keep blood pressure near the patient's usual level — protects the remaining nephrons.
Common anaesthetic drugs in kidney failure (principles, no doses)
| Group | Usually preferred | Use with care or avoid | Why |
|---|---|---|---|
| Neuromuscular blockers | Atracurium, cisatracurium | Rocuronium (prolonged); suxamethonium if potassium is high | Organ-independent breakdown versus renal clearance and potassium release |
| Reversal | Neostigmine with an anticholinergic | Sugammadex in severe kidney failure | The sugammadex–rocuronium complex is cleared by the kidney |
| Opioids | Fentanyl, remifentanil | Morphine, pethidine | Active metabolites accumulate and cause sedation, respiratory depression or seizures |
| Simple analgesics | Paracetamol | NSAIDs | NSAIDs reduce renal blood flow and harm remaining function |
| Induction agents | Propofol, titrated slowly | Large boluses in a hypovolaemic patient | Low albumin and post-dialysis hypovolaemia exaggerate hypotension |
Risks and complications
- Hyperkalaemia with peaked T waves, arrhythmia or cardiac arrest, especially after suxamethonium, transfusion or a missed dialysis.
- Prolonged weakness or sedation from accumulated relaxants, opioids or their metabolites; residual block causing hypoxaemia in recovery.
- Pulmonary oedema from fluid overload, or hypotension from post-dialysis hypovolaemia and antihypertensive drugs.
- Bleeding from uraemic platelet dysfunction and heparin given during dialysis.
- Acute kidney injury on chronic disease from hypotension, nephrotoxins or sepsis; loss of a clotted arteriovenous fistula.
- Perioperative myocardial ischaemia, often silent in patients who also have diabetes.
Next step
- In recovery, check potassium, glucose and a blood gas when the surgery was long or bloody, and watch the ECG for signs of hyperkalaemia.
- Confirm the fistula still has a thrill and bruit before the patient leaves recovery.
- Call a senior or the nephrology team for potassium that is rising, overload with hypoxaemia, or need for urgent dialysis.
- Agree the next dialysis session with nephrology, and note any heparin timing against regional catheters and bleeding.
- Adjust the doses and intervals of renally cleared drugs, such as antibiotics and anticoagulants, with the pharmacist and avoid nephrotoxins.
- Track urine output, weight and creatinine daily in patients not on dialysis, since acute kidney injury may appear in the first days.
Test yourself
Think of the answer, then tap the question to see it.
Why are atracurium and cisatracurium preferred relaxants in kidney failure?
They break down spontaneously in the blood (Hofmann elimination) independently of the kidney and liver, so their effect does not build up when kidney function is poor.
Why is surgery for a dialysis patient usually scheduled the day after a session?
Potassium, acid–base balance and volume are best corrected then; potassium and weight are rechecked after dialysis to confirm it was effective and not too dry.
Why is morphine avoided in patients with severe kidney disease?
Its active metabolites are cleared by the kidney and accumulate, causing prolonged sedation and respiratory depression; fentanyl or remifentanil are safer choices.
What precautions protect an arteriovenous fistula during anaesthesia?
No blood pressure cuff, cannula, arterial line or tight strapping on that arm, careful padding and positioning, and checking for a thrill and bruit before discharge from recovery.
Elsewhere in DurgiPedia
Connections
Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.
Sources: Chronic Kidney Disease (StatPearls (NCBI Bookshelf), 2024).
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Representative model, for educational purposes only.