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Kidney disease is a growing problem worldwide. The prevalence of end-stage renal disease has increased by 20% since 2000 1. In addition, more than 10% of the general population globally suffers from chronic kidney disease, affecting a total of over 800 million individuals 2. Of these, over 2 million people require dialysis or a kidney transplant to remain healthy, although likely many more require additional treatment in order to even stay alive 3. Dialysis patients require special considerations when receiving anesthesia; this may occur for a variety of reasons, including dialysis procedures themselves.
Patients on dialysis require local anesthesia during catheter insertion. They may also need to undergo a number of other invasive procedures, such as parathyroidectomy, vascular access, or a kidney transplant 4. Specific anesthesia considerations must be kept in mind. Patients with end-stage kidney disease may also have impaired function in other organs. In addition to assessing patients’ clinical data and history, a preoperative assessment is needed to identify and help optimize the patient’s organ function prior to the stresses caused by surgery and/or anesthesia. Patients at risk of poor outcomes, in terms of functional capacity, cardiovascular dysfunction, or oxygen delivery, should be identified and flagged at this stage.
Local or regional anesthesia is safer than general anesthesia and is thus usually the modality of choice for access creation 5. Patients on chronic hemodialysis can receive a topical anesthetic application prior to using needles for an arteriovenous fistula cannulation for dialysis 6. It is important to keep in mind that local anesthetics may have a delayed onset and prolonged duration of action due to low levels of bicarbonate in patients with kidney disease.
The clearance rates of local anesthetics with hemodialysis are not very thoroughly described. Some data have shown that the disposition kinetics of lidocaine were the same between healthy individuals and those on hemodialysis 7. A subsequent study, however, revealed the removal of lidocaine with hemodialysis to be rather negligible 8. In other words, hemodialysis did not help remove lidocaine from the blood. There remains thus no clear role for dialysis in the treatment of local anesthetic toxicities.
Post-anesthetic hypotension within 48 hours has been found to be more common in individuals with less than a 7-hour interval between dialysis and anesthesia. As such, if feasible, a delay of 7 or more hours should be respected in order to limit postoperative hypotension 9. However, more precise associations remain to be obtained through prospective research studies.
If general anesthesia has to be induced, several drugs can be used. Each has different benefits and drawbacks. Propofol is safe but might induce hypotension. Midazolam is partially dialyzable and could also induce hypotension. Sevoflurane is likely to be safe since no nephrotoxicity has been seen in vivo. Finally, nitrous oxide, ketamine, desflurane, and isoflurane are all safe 10.
Anesthesia considerations for dialysis patients are complex and need to be thoroughly respected by clinicians. Meanwhile, they will likely continue to be honed through clinical research efforts into the near future.
References
1. Trainor, D., Borthwick, E. & Ferguson, A. Perioperative Management of the Hemodialysis Patient. Seminars in Dialysis (2011). doi:10.1111/j.1525-139X.2011.00856.x
2. Kovesdy, C. P. Epidemiology of chronic kidney disease: an update 2022. Kidney International Supplements (2022). doi:10.1016/j.kisu.2021.11.003
3. Couser, W. G., Remuzzi, G., Mendis, S. & Tonelli, M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. (2011). doi:10.1038/ki.2011.368
4. Anesthesia for dialysis patients – UpToDate. Available at: https://www.uptodate.com/contents/anesthesia-for-dialysis-patients. (Accessed: 17th December 2022)
5. Shemesh, D., Raikhinstein, Y., Goldin, I. & Olsha, O. General, regional or local anesthesia for successful radial cephalic arteriovenous fistula. Journal of Vascular Access (2017). doi:10.5301/jva.5000676
6. Uppal, N. N. et al. Local anesthetics for the Nephrologist. Clin. Kidney J. (2022). doi:10.1093/ckj/sfab121
7. Thomson, P. D. et al. Lidocaine pharmacokinetics in advanced heart failure, liver disease, and renal failure in humans. Ann. Intern. Med. (1973). doi:10.7326/0003-4819-78-4-499
8. Dabir Vaziri, N., Saiki, J. K. & Hughes, W. Clearance of lidocaine by hemodialysis. South. Med. J. (1979). doi:10.1097/00007611-197912000-00023
9. Deng, J., Lenart, J. & Applegate, R. L. General anesthesia soon after dialysis may increase postoperative hypotension – A pilot study. Hear. lung Vessel. (2014).
10. Helvaci, Ö. & Derici, Ü. Perioperative management of patients on hemodialysis: A practical guide. Turkish J. Nephrol. (2020). doi:10.5152/turkjnephrol.2020.4288
