What are the risks of surgery in patients with Chronic Kidney Disease (CKD) stage 3?

Risks of Surgery with CKD Stage 3

Patients with CKD stage 3 undergoing surgery face significantly increased risks of acute kidney injury (AKI), cardiovascular events, and mortality compared to those with normal renal function. 1, 2

Specific Risks

Renal Complications

• Increased risk of acute kidney injury (AKI), with CKD stage 3 representing a major inflection point for serious complications 3
• Temporary or persistent worsening of renal function, with even temporary worsening associated with increased long-term mortality 1
• Potential progression to higher CKD stages or end-stage renal disease requiring dialysis 2

Cardiovascular Complications

• Higher incidence of major adverse cardiovascular events (MACE), particularly in patients with CKD stage 3a/3b 3, 1
• Increased risk of perioperative hypertension and hypotension 4
• Greater likelihood of cardiac complications due to the strong association between CKD and cardiovascular disease 1

Other Surgical Complications

• Prolonged hospital length of stay (>5 days) 3
• Higher rates of infection and serious complications 3
• Increased risk of bleeding due to uremic platelet dysfunction 4
• Higher overall perioperative mortality 2, 5

Risk Factors That Compound Surgical Risk

• Emergency surgery (vs. elective) 1
• Prolonged surgical procedures 1
• Extensive blood loss 2
• Preoperative hypoalbuminemia (≤3.5 g/dL) 1
• Preoperative sepsis 1
• Concomitant cardiovascular disease 1
• Diabetes mellitus 1
• Advanced age 2

Risk Mitigation Strategies

Preoperative Assessment

• Thorough evaluation of renal function with estimation of glomerular filtration rate (GFR) 6
• Assessment of cardiovascular risk factors 1, 5
• Optimization of blood pressure control 6
• Correction of electrolyte abnormalities, particularly hyperkalemia 4

Perioperative Management

• Maintain adequate renal perfusion with mean arterial pressure between 60-70 mmHg (or >70 mmHg in hypertensive patients) 6
• Implement goal-directed fluid therapy to optimize renal perfusion 6, 2
• Avoid hypovolemia and maintain hemodynamic stability 6, 2
• Avoid nephrotoxic medications, including NSAIDs 6, 1
• Consider off-pump techniques for coronary artery bypass grafting in patients with CKD 1
• Use norepinephrine rather than dopamine as first-line vasopressor if needed 1

Specific Considerations for Different Surgeries

• For cardiac surgery: Consider off-pump bypass for patients with CKD, as it's associated with decreased risk of postoperative renal replacement therapy 1
• For renal cell carcinoma: Partial nephrectomy should be considered when feasible to preserve renal function 1
• For digestive tract surgery: Be aware of higher risk of complications and mortality 1
• For metabolic/bariatric surgery: CKD stage 3 represents a significant inflection point for increased complications 3

Postoperative Care

• Close monitoring of renal function with regular assessment of urine output and serum creatinine 6
• Early detection of AKI using biomarkers to guide intervention strategies 6
• Maintenance of adequate hydration 6
• Continued avoidance of nephrotoxic medications 6
• Early mobilization when appropriate 6

Common Pitfalls to Avoid

• Using starch-containing intravenous fluids, which should be avoided in patients with renal dysfunction 1
• Administering multiple doses of aminoglycosides when single daily dosing is safer 1
• Failing to adjust medication dosages according to GFR 6, 2
• Neglecting to monitor for and correct electrolyte abnormalities 4
• Overlooking the need for perioperative glycemic control 2

The most critical approach to managing CKD stage 3 patients undergoing surgery is prevention of AKI, as this has been proven to improve outcomes and prevent further deterioration of renal function 2, 7.