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Anaesthesia in the patient with kidney disease
In a dialysis patient potassium and volume are checked before surgery, drugs that do not accumulate are chosen (fentanyl, cisatracurium) and the fistula is protected; in every patient blood pressure is maintained and nephrotoxic drugs are avoided to prevent AKI.
Why it matters in the exam
The exam asks when dialysis should be done before surgery, which potassium level requires postponement, whether succinylcholine is allowed, which opioids and relaxants accumulate (morphine, pethidine, rocuronium, vecuronium), and what to do for uraemic bleeding (desmopressin). It also asks about the definition of AKI and its prevention around surgery.
In a dialysis patient dialysis is done on the day before surgery, to correct volume and potassium without causing hypovolaemia on the day of surgery. Potassium above 5.5–6 mmol/L must be corrected before elective surgery; succinylcholine raises potassium by about 0.5 mmol/L and is allowed only when potassium is normal. Uraemia impairs platelet function — desmopressin at 0.3 mcg/kg improves it for hours. Chronic anaemia is usually well tolerated.
AKI is defined as a creatinine rise of 0.3 mg/dL within 48 hours, a rise to 1.5 times baseline over 7 days, or a urine output under 0.5 mL/kg/h lasting 6 hours. The perioperative risk factors are hypotension, sepsis, hypovolaemia, contrast media, NSAIDs and aminoglycosides, and cardiac and aortic surgery. The best protection is a MAP of at least 65, adequate volume, a balanced crystalloid and avoidance of toxins — no drug protects the kidney. In a kidney transplant recipient the graft's perfusion is guarded with the same care, and drugs are chosen by the graft's function rather than by the old disease. In a dialysis patient fluid balance and dry weight are also checked, because excess volume shows as pulmonary oedema early in the anaesthetic.
Key points
- Dialysis on the day before surgery.
- Potassium above 5.5–6 — correct before elective surgery.
- Fentanyl and cisatracurium; avoid morphine and pethidine.
- Desmopressin for uraemic bleeding.
- AKI: a rise of 0.3 mg/dL within 48 hours; prevention — blood pressure and no toxins.
Summary table
| Issue | What is done | Exam point |
|---|---|---|
| Dialysis | On the day before surgery | Not on the day of surgery itself — hypovolaemia |
| Potassium | Correct above 5.5–6 mmol/L before elective surgery | Succinylcholine only with normal potassium |
| Opioids | Fentanyl, remifentanil; hydromorphone with care | Morphine and pethidine accumulate |
| Relaxants and reversal | Cisatracurium | Sugammadex not recommended with clearance below 30 mL/min |
| Uraemic bleeding | Desmopressin 0.3 mcg/kg; dialysis | A problem of platelet function, not number |
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Sources
- KDIGO Clinical Practice Guideline for Acute Kidney Injury, 2012 — Definition and prevention
- Miller's Anesthesia, 9th edition (2020) — Anesthesia for Patients with Renal Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.