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INTRODUCTION

Chronic Kidney Disease in the Surgical Population

Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function, present for ≥ 3 months. Approximately 14% of the American population has chronic kidney disease (CKD), but this may be an underestimation as CKD is usually asymptomatic.1

The 2002 Kidney Disease Improving Global Outcomes (KDIGO) criteria are now the commonly accepted criteria for defining CKD, specifying six stages based on increasing severity of estimated glomerular filtration rate (eGFR) (Table 24-1).2 Additional data regarding the presence and severity of albuminuria can provide prognostic information about the likelihood of CKD progression in the general medical population.2 In recent studies examining the effect of CKD on perioperative outcomes, the reported prevalence of stage 3 and higher CKD in cardiac surgery patients was up to 45%3,4 and in noncardiac surgery patients (including vascular surgery), it was > 20%.5–7

TABLE 24-1Criteria for Defining Chronic Kidney Disease

CKD and Perioperative Outcomes

CKD is one of the most significant risk factors for postoperative acute kidney injury (AKI) and is associated with several adverse outcomes. Risks of kidney injury in cardiac and noncardiac surgery patients are different not only because of surgical risk factors such as cardiopulmonary bypass, but also due to differences in underlying patient demographics. In addition to the risk for AKI on CKD, presence of CKD by itself is associated with adverse perioperative outcomes. In cardiac surgery patients, CKD is correlated with postoperative mortality. In a retrospective database study of over 1300 CABG patients, Hedley et al. demonstrated that there was an approximately 40% increased risk of death for every decrease in eGFR by 10 ml/min/1.73 m2 from baseline.4 Noncardiac surgery patients with preoperative CKD also have higher rates of postoperative mortality than those with normal renal function, with the odds ratio (OR) for mortality also increasing by CKD stage.5,7 For example, compared with patients with an eGFR > 90 ml/min/1.73 m2, the ORs for mortality are 2.8 in patients with eGFRs of >30–<45 and 5.8 for patients with eGFR <15.5 Besides mortality, CKD is also associated with other adverse perioperative outcomes. Preoperative CKD in cardiac surgery is associated with infection,3 prolonged length of stay, return to the operating room, prolonged ventilation, sepsis, and need for renal replacement therapy.4 CKD is also associated with adverse outcomes in noncardiac surgery, although most studies are in specific surgical populations. For example, in a meta-analysis of 19 studies that included over 2 million total joint arthroplasty patients, preoperative CKD was associated with elevated rates of readmission, blood transfusion, and surgical ...

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