Dr. Fang advises a DOCS Education member on a patient with chronic kidney disease

A DOCS Education member seeks the faculty’s assistance:

I have a patient who has a GFR of 31. I understand that the normal GFR is 131 to 140 and that the minimum acceptable level is 60.

The patient's nephrologist said he considers the patient stable and that she could under-go anesthesia. However, he acknowledged he did not understand which type of anesthesia we would be using.

He also said that any medications utilized should be dose adjusted for her GFR. Should I stay away from treating her totally? Or, with him considering her stable is there a way that I can treat her with local anesthesia and sedation safely?

Dr. Leslie Fang, DOCS Education faculty, responds:

CKD 4

This will be a difficult patient to manage.
Here are the things you need to know:

1. Cause of renal disease
2. Adequacy of control of her underlying renal disease
3. Adequacy of control of her diabetes or hypertension, common causes of chronic kidney disease
4. She will probably be anemic
5. She will have thrombocytopathy with poorly functional platelets and will be a bleeding risk
6. She is more likely to go into congestive heart failure
7. Many of her medications may interact with planned sedation
8. You will have to limit vasoconstrictor use
9. You have to have a good grip of any cardiac concerns

In short, it is not that you cannot sedate - but you need a lot more information and will need to be comfortable with tidying up all of these loose ends.

The DOCS Education member responds:

Thank you for your reply. Her physician states that she has "chronic kidney disease" and patient states it was due to "multiple kidney stones causing a filtration problem." The patient’s medications are only lisinopril and vit D.

Her blood pressure at our appointment was 136/93. No cardiac concerns noted by her or physician. He states to "dose adjust any medications including antibiotics." Should I ask him for more information to make a correct judgement? Am I assuming too much in thinking there not other concerns because he has not stated any in the consult letter?

I was making those assumptions based on her lack of medications. Would you advise a CBC, etc. so I don't assume too much?

Thanks.

Dr. Leslie Fang replies:

This is enough information.

Get last set of blood chemistries and CBC to gauge extent of involvement.

1. Is she anemic?
2. Is BUN higher than 50? (Thrombocytopathy)

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