Hyperbilirubinemia and Liver Disorders Overview
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Questions and Answers

What is the primary cause of conjugated (direct) hyperbilirubinemia?

  • Biliary obstruction causing direct bilirubin reflux into the blood (correct)
  • Excessive hemolysis of red blood cells
  • Inherited disorders leading to bilirubin buildup
  • Reperfusion injury after liver transplantation

    • Which hepatitis virus is primarily associated with chronic disease and often leads to the need for hepatic transplantation?

  • Hepatitis C (correct)
  • Hepatitis E
  • Hepatitis A
  • Hepatitis B

    • What condition is characterized by severe jaundice and can result in brain damage if untreated?

  • Alcohol-related liver disease
  • Gilbert Syndrome
  • Benign Postoperative Intrahepatic Cholestasis
  • Crigler-Najjar Syndrome (correct)

    • What is a common physical examination finding in patients with advanced alcohol-related liver disease?

    <p>Peripheral edema and jaundice</p> Signup and view all the answers

    Which of the following describes the bilirubin type associated with Gilbert Syndrome?

    <p>Unconjugated (indirect) hyperbilirubinemia</p> Signup and view all the answers

    What is the primary definitive treatment for Nonalcoholic Fatty Liver Disease (NAFLD)?

    <p>Liver transplant</p> Signup and view all the answers

    Which condition is characterized by autoantibodies and hypergammaglobulinemia?

    <p>Autoimmune hepatitis</p> Signup and view all the answers

    What is the most common cause of drug-induced liver injury?

    <p>Acetaminophen</p> Signup and view all the answers

    Which liver disease results from a failure of copper metabolism and can present with psychiatric symptoms?

    <p>Wilson Disease</p> Signup and view all the answers

    What is a common consequence of both ischemic hepatitis and congestive hepatopathy?

    <p>Jaundice</p> Signup and view all the answers

    What is a typical outcome of Autoimmune Hepatitis treatment?

    <p>Remission rate of 60-80%</p> Signup and view all the answers

    Which condition can lead to cirrhosis and is associated with COPD/emphysema?

    <p>A1-antitrypsin deficiency</p> Signup and view all the answers

    In cases of acute liver failure, which of the following occurs within less than 26 weeks?

    <p>Hepatocyte necrosis</p> Signup and view all the answers

    What is the prevalent symptom associated with cholelithiasis, even though most cases are asymptomatic?

    <p>Right shoulder referred pain</p> Signup and view all the answers

    Which of the following represents a significant complication of choledocholithiasis?

    <p>Cholangitis</p> Signup and view all the answers

    Which risk factor is NOT typically associated with the development of cholelithiasis?

    <p>Low cholesterol diet</p> Signup and view all the answers

    What is the AST:ALT ratio indicative of acute liver dysfunction?

    <p>2:1</p> Signup and view all the answers

    In which form of hepatic dysfunction would you expect normal alkaline phosphatase levels?

    <p>Prehepatic</p> Signup and view all the answers

    Which of the following is NOT a typical consequence of alcohol-related liver disease?

    <p>Hemolysis</p> Signup and view all the answers

    What is a common laboratory finding in posthepatic (cholestatic) dysfunction?

    <p>Markedly increased alkaline phosphatase</p> Signup and view all the answers

    What is the primary cause of hyperbilirubinemia in prehepatic dysfunction?

    <p>Hemolysis</p> Signup and view all the answers

    Which type of hepatitis is typically transmitted through contaminated food and water?

    <p>Hepatitis A</p> Signup and view all the answers

    What factor contributes to increased risks for bleeding in patients with liver dysfunction?

    <p>Decreased production of Vitamin K dependent factors</p> Signup and view all the answers

    What is the key reason for avoiding neuromuscular blockade in patients with chronic kidney disease during anesthesia?

    <p>Reduced clearance of certain agents</p> Signup and view all the answers

    Which statement about regional anesthesia in patients with chronic kidney disease is most accurate?

    <p>A sympathetic block can potentially improve renal function.</p> Signup and view all the answers

    In the context of anesthetic management for patients with chronic kidney disease, which volatile anesthetic is particularly advised to avoid?

    <p>Sevoflurane</p> Signup and view all the answers

    Which muscle relaxant is considered safe for use in patients with chronic kidney disease who have a creatinine clearance greater than 30 mL/min?

    <p>Sugammadex</p> Signup and view all the answers

    What should be prioritized in anesthetic management of patients with chronic kidney disease to ensure hemodynamic stability?

    <p>Maintaining a stable fluid balance</p> Signup and view all the answers

    What is the primary function of erythropoietin in the renal system?

    <p>Stimulation of red blood cell production</p> Signup and view all the answers

    In assessing renal function, which measurement is considered the best overall indicator?

    <p>Glomerular filtration rate (GFR)</p> Signup and view all the answers

    What does a fractional excretion of sodium (FENa) greater than 2% suggest?

    <p>Renal tubular dysfunction</p> Signup and view all the answers

    Which anatomical feature differentiates the kidneys' location?

    <p>Right kidney is slightly lower than the left kidney</p> Signup and view all the answers

    What typically happens to GFR after the age of 30?

    <p>Decreases by 8 mL/year</p> Signup and view all the answers

    Which renal function is primarily involved in maintaining extracellular fluid (ECF) composition?

    <p>Regulation of ionic composition and osmolality</p> Signup and view all the answers

    What is an early symptom commonly associated with acute kidney injury?

    <p>Asymptomatic presentation</p> Signup and view all the answers

    Which physiological process is affected by chronic renal disease, leading to anemia?

    <p>Inadequate erythropoietin production</p> Signup and view all the answers

    What is the primary cause of edema in patients with chronic kidney disease?

    <p>Inadequate waste excretion and fluid homeostasis</p> Signup and view all the answers

    What urinary finding suggests prerenal failure rather than renal tubular dysfunction?

    <p>FENa &lt; 1%</p> Signup and view all the answers

    What is the leading cause of chronic kidney disease?

    <p>Diabetes mellitus</p> Signup and view all the answers

    Which stage of chronic kidney disease has a GFR of 45-59 mL/min?

    <p>Stage 3a</p> Signup and view all the answers

    What complication is most serious in peritoneal dialysis?

    <p>Peritonitis</p> Signup and view all the answers

    What should be avoided when managing a patient with CKD who is hyperkalemic?

    <p>Succinylcholine</p> Signup and view all the answers

    How is chronic kidney disease primarily diagnosed?

    <p>GFR &lt; 60 mL/min for over 3 months</p> Signup and view all the answers

    Which electrolyte imbalance is typical in Stage 4 chronic kidney disease?

    <p>Hypocalcemia</p> Signup and view all the answers

    What is a characteristic of hemodialysis compared to peritoneal dialysis?

    <p>More commonly performed and tailored regularly</p> Signup and view all the answers

    Which molecule is involved in enhancing platelet function during higher-risk procedures?

    <p>DDAVP</p> Signup and view all the answers

    What should the blood sugar level be maintained at prior to elective surgery in CKD patients?

    <p>&lt; 180 mg/dL</p> Signup and view all the answers

    What is a common cardiovascular effect of chronic kidney disease?

    <p>Left ventricular hypertrophy</p> Signup and view all the answers

    What type of anesthesia induction is most often recommended for ESRD patients to prevent hemodynamic fluctuation?

    <p>Rapid sequence induction (RSI)</p> Signup and view all the answers

    What vascular access method is recommended to minimize infection risk in CKD patients?

    <p>Femoral artery access</p> Signup and view all the answers

    What complication is associated with stage 5 chronic kidney disease?

    <p>Anemia</p> Signup and view all the answers

    What should be monitored closely in patients with chronic kidney disease during intraoperative management?

    <p>Blood pressure and volume status</p> Signup and view all the answers

    What defines a prerenal cause of acute kidney injury (AKI)?

    <p>Inadequate renal perfusion usually due to systemic conditions</p> Signup and view all the answers

    Which of the following is NOT a typical characteristic of postrenal AKI?

    <p>Associated with elevated creatinine levels due to renal perfusion</p> Signup and view all the answers

    What treatment approach is indicated to manage fluid overload in AKI?

    <p>Fluid resuscitation with balanced salt solutions</p> Signup and view all the answers

    What laboratory finding is consistent with nephrotoxic acute kidney injury?

    <p>Increased protein in the urine</p> Signup and view all the answers

    Which of the following is an expected complication associated with AKI?

    <p>Neuro complications such as confusion</p> Signup and view all the answers

    In which condition would the use of aminoglycosides be contraindicated?

    <p>Acute kidney injury</p> Signup and view all the answers

    Which class of drugs can potentially exacerbate renal perfusion issues?

    <p>Diuretics</p> Signup and view all the answers

    What is the primary goal in the management of patients with AKI?

    <p>Limit further renal injury while correcting imbalances</p> Signup and view all the answers

    Which of the following is a primary pharmacological intervention for patients with AKI?

    <p>Selection of drugs not reliant on renal excretion when possible</p> Signup and view all the answers

    What is the expected effect of norepinephrine in the treatment of AKI?

    <p>Maintained mean arterial pressure (MAP)</p> Signup and view all the answers

    What is a common electrolyte disturbance that occurs in AKI?

    <p>Hyperkalemia resulting in peaked T waves</p> Signup and view all the answers

    In AKI caused by sepsis, which factor primarily influences renal perfusion?

    <p>Cardiac output and systemic vascular resistance</p> Signup and view all the answers

    Which patient population is at highest risk for developing AKI?

    <p>Those undergoing high-risk surgical procedures</p> Signup and view all the answers

    What is a hallmark sign of acute kidney injury related to urine output?

    <p>Oliguria defined as urine output less than 0.5 mL/kg/hr</p> Signup and view all the answers

    Study Notes

    Unconjugated (indirect) hyperbilirubinemia

    • Results from imbalance between synthesis and breakdown of bilirubin

    Conjugated (direct) hyperbilirubinemia

    • Results from reflex of direct or conjugated bilirubin into the blood following a biliary obstruction

    Gilbert Syndrome

    • Inherited disorder that results in unconjugated hyperbilirubinemia
    • Jaundice, fatigue, pain with dehydration, stress, fasting, or exercise

    Crigler-Naijjar Syndrome

    • Severe, very rare inherited disorder that can result in brain damage if untreated
    • Treated with transfusions and phototherapy.
    • Symptoms include severe jaundice, fever, and vomiting.

    Benign Postoperative Intrahepatic Cholestasis

    • Multifactorial problem associated with hypotension, large blood loss, transfusions, or hypoxemia

    Viral Hepatitis

    • Most often caused by hepatitis A, B, C, D, and E, abbreviated as HXV
    • Each causes an acute infection that can result in significant morbidity.
    • HBV and HCV are associated with chronic disease states, both of which commonly result in a need for hepatic transplantation. HCV is the most common viral agent that leads to hepatic transplantation in the US.
    • New therapies result in a clearance of up to 99% of viral loads for certain types of HCV
    • Harvoni: combination drug made by Gilead Pharmaceuticals
    • #1 indication for liver transplantation in the US and world.
    • Patients often asymptomatic with ALD and with early/compensated cirrhosis.
    • Associated with malnutrition, muscle wasting, and parotid gland hypertrophy.
    • Physical exam with advanced disease will reveal jaundice, ascites, hepatosplenomegaly, and peripheral edema.

    Epidemiology

    • 4.5 million Americans live with liver disease.
    • 40,000 deaths/year due to liver disease in the US.
    • Viral infectious hepatic disease has decreased with modern therapy.
    • Both alcohol and nonalcohol-related liver disease have increased.

    Liver functions

    • Central to numerous metabolic and physiologic processes.
    • Patients with liver dysfunction are at an increased risk for perioperative morbidity and/or mortality due to failure of one of the liver's essential functions.

    Liver Blood flow

    • 25% of cardiac output when portal and hepatic flow are considered.
    • Portal vein: confluence of splenic vein and SMV → 75% of flow, with 50% of O2 supply
    • Hepatic artery: only 25% of blood flow, but supplies 50% of O2.
    • Regulated by intrinsic and extrinsic mediators.
    • If portal flow decreases, hepatic artery flow increases only works one direction
    • Portal vein flow will not change if hepatic artery flow decreases.
    • With elevated portal pressure, portosystemic shunts form, which lead to the development of varices.

    Liver Anatomy

    • Lobe: portion of the liver.
    • Right | Quadrate | Caudate | Left
    • Segment: a further subdivision of the lobe.

    Liver Assessment

    • History/Physical: RF for liver disease, severity of findings, and comorbidities.
      • Risk Factors: family history, alcohol use, DM obesity, IV drug use, tattoos (2/2 HepC risk), transfusions, hepatotoxic drugs.
      • Assess for fatigue, pruritis, bleeding/bruising, volume overload, weight change (esp weight gain), dark urine.
    • Lab Data:
      • Comparison will result in identifying the type of dysfunction present.
      • Liver Chemistry:
        • Aspartate aminotransferase (AST): Alanine aminotransferase (ALT): Acute liver dysfunction will have an AST:ALT ratio of at least 2:1, while it is 1:1 with nonalcoholic steatohepatitis.
        • Alkaline Phosphatase, gamma-glutamyltransferase (GGT), and bilirubin levels are useful to determine cholestasis.
      • CBC & Coagulation studies.

    Causes of Hepatic Dysfunction Based on Liver Chemistry Test

    Hepatic Dysfxn Bilirubin Aminotransfera se Enzymes Alkaline Phosphatase Causes
    Prehepatic Increased unconjugated fraction Normal Normal Hemolysis, Hematoma resorption, Bilirubin overload from transfusion
    Intrahepatic (hepatocellular) Increased conjugated fraction Markedly increased Normal to slightly increased Viral infection, Drugs, Alcohol, Sepsis, Hypoxemia, Cirrhosis
    Posthepatic (cholestatic) Increased conjugated fraction Normal to slightly increased Markedly increased Biliary stones/tumors, Sepsis

    Cholelithiasis

    • Occurs when substances in bile become hardened within the gallbladder, due to oversecretion of cholesterol, excess bilirubin, or hypomotility of GB.
    • Risk factors: obesity, hypercholesterolemia, family history, diabetes, pregnancy, female gender.
    • 80% are asymptomatic → common symptoms are pain, nausea, vomiting, and indigestion.
    • Can have right shoulder referred pain.
    • Can develop sepsis.
    • Anesthetic Implications:
      • Consider opioid use within context of the Sphincter of Oddi → can antagonize a spasm with naloxone, glucagon, or a nitrate.
      • Will likely be a laparoscopic case.
      • Consider aspiration risk secondary to N/V

    Choledocholithiasis

    • Complication of cholelithiasis where a stone blocks the common bile duct.
    • Presentation is often as biliary colic → pain in RUQ with intermittent nausea and vomiting.
    • Can lead to cholangitis, with associated fever, rigors, and jaundice in addition to previously identified symptoms.
    • Treatment: ERCP with endoscopic sphincterotomy; exploratory laparoscopy/LC, with or without IOC.

    Steatohepatitis

    • Chronic: greatly increases MAC requirements → increased risk for recall.
    • Acute intoxication: decreased MAC requirements.
    • AKA Nonalcoholic Fatty Liver Disease.
    • Excessive accumulation of fat in the liver without a clear cause, like alcohol.
    • Associated with obesity, DM, insulin resistance, and metabolic syndrome.
    • Outcomes include hepatic fibrosis, cirrhosis, and hepatocellular carcinoma.
    • Diagnosis: Liver biopsy is required for definitive diagnosis.
    • Treatment: Lifestyle changes can decrease the severity, but there is no medication to treat this.
    • Transplant is the definitive therapy.

    Autoimmune Hepatitis

    • Inflammatory disease that is characterized by autoantibodies and hypergammaglobulinemia.
    • Affects both genders, but favors women.
    • Can range from asymptomatic to fulminant liver failure.
    • ALT and AST may surpass 10-20X normal values.
    • Treatment: therapy includes prednisone and azathioprine.
    • Remission rate is 60-80%.
    • May require immunosuppression → maintain sterile technique (esp with SAB).
    • May require transplantation.
    • Results in:
      • Ischemic hepatitis - often results from shock, appears after 2-24h latency
        • Asymptomatic or resembles viral hepatitis.
      • Congestive hepatopathy - results from impaired venous outflow secondary to right ventricular failure.
        • Typically subclinical, but can have jaundice, malaise, and intermittent RUQ pain.

    Miscellaneous

    • COVID-19: 14-53% have acute liver injury → could be related to cytokine storm.
      • Appears to affect prognosis.
    • Drug-induced Liver Injury: can require transplantation.
    • Acetaminophen is #1 cause of drug induced liver injury.
      • Symptoms are similar to other liver disease with exception of rash, fever, and eosinophilia.
    • Wilson Disease: impaired copper metabolism.
      • Can include psychiatric symptoms.
    • A1-antitrysin Deficiency: leads to cirrhosis, but also will cause COPD/emphysema.
      • Only treatment is transplantation.
    • Hemochromatosis - excessive systemic iron.

    Acute Liver Failure

    • Critical illness characterized by severe hepatocyte injury that occurs in less than 26 weeks.
    • Massive hepatocyte necrosis.

    Renal Anatomy

    • Kidneys are retroperitoneal structures located between T12 and L4, with the right kidney slightly lower than the left.
    • The functional unit of the kidney is the nephron, a complex tubule system that interacts with the vascular system.
    • The kidneys are innervated by the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS).
      • SNS preganglionics originate from T8-L1.
      • PSNS innervation is via the vagus nerve (CN X) to the kidney and the pudendal nerve (S2, S3, S4) to the ureters.
    • Nociception is via afferent SNS fibers from T10-L1, making a T10 epidural or ESP necessary for a nephrectomy.

    Renal Functions

    • The kidneys maintain extracellular fluid (ECF) composition by regulating ionic composition and osmolality, which refers to the sodium concentration.
      • They also conserve non-ionic components like glucose and amino acids.
    • The kidneys excrete waste products and regulate arterial blood pressure.
    • The kidneys have endocrine functions, producing renin-angiotensin-aldosterone system (RAAS) components, erythropoietin, and vitamin D.
      • Vitamin D activation increases calcium absorption from the gastrointestinal tract.
      • Erythropoietin stimulates red blood cell production.
      • Chronic renal disease leads to anemia due to erythropoietin deficiency and hypocalcemia due to impaired calcium absorption.

    Assessment of Renal Function: Diagnostic Data

    Glomerular Filtration Rate (GFR)

    • GFR is the best overall measure of renal function.
    • GFR is calculated using the following formula: GFR = Kf × (ΔP – ΔΠ)
      • Kf represents the surface area for filtration.
      • ΔP is the difference in hydrostatic pressures across the membrane.
      • ΔΠ is the difference in osmotic pressures across the membrane.
    • In pre-renal failure, progression of the disease causes a decrease in Kf, the surface area for filtration.
    • In pre-renal failure, hypovolemia causes a decrease in AP, the hydrostatic force differential.
    • GFR typically mirrors cardiac output.
    • Normal GFR is between 125-140mL/min, decreasing by 8mL/yr after age 30.
    • A GFR less than 60mL/min indicates chronic kidney disease (CKD).
    • GFR is assessed by evaluating creatinine, creatinine clearance, blood urea nitrogen, and protein levels.
      • Creatinine levels are typically 0.6-1.3mg/dL and are freely filtered.
      • Creatinine clearance is the most reliable measure of GFR, with normal values between 110-140 mL/min.
        • A creatinine clearance value less than 30mL/min indicates that drugs relying on renal clearance (e.g., sugammadex) should be avoided.
      • Blood urea nitrogen levels are typically 10-20mg/dL.
      • Protein levels should be less than 150mg/day.

    Renal Tubular Function

    • Specific gravity of urine (the concentration of urine compared to water) should be less than 1.018 in the absence of diuretics, glycosuria, or proteinuria.
    • Fractional excretion of sodium (FENa) is a measure of the percentage of filtered sodium excreted in urine.
      • FENa levels less than 1% are suggestive of pre-renal disease, indicating normally functioning tubules are conserving sodium.
      • FENa levels greater than 2% are consistent with tubular dysfunction, as the tubules are unable to conserve sodium.
    • Urinalysis is used to assess urine pH, specific gravity, and microscopy.
      • The presence of protein, blood, glucose, hemoglobin, leukocytes, and toxins in the urine can indicate a pathological state.

    Acute Kidney Injury (AKI)

    • AKI is characterized by deterioration of renal function over hours to days, resulting in the kidneys' failure to excrete wastes and maintain fluid homeostasis.
    • Affects up to 20% of hospitalized patients and 50% of ICU patients.
    • Most common cause is hypotension and hypovolemia.
    • Symptoms can range from asymptomatic to malaise, weight loss, orthostatic hypotension, volume overload (in cases of cirrhosis), and dyspnea.
    • AKI can be diagnosed by:
      • An increase in creatinine of 0.3mg/dL within 48 hours, or 1.5 times baseline within 7 days.
      • An abrupt decrease in urine output to less than 0.5mL/kg/hr or less than 500mL/day.
    • AKI can be oliguric (low urine output) or nonoliguric.

    Etiology of AKI

    Prerenal Disease

    • Pre-renal disease is caused by inadequate renal perfusion, often due to congestive heart failure (CHF), liver dysfunction, or sepsis.
    • It is the most common form of AKI and is rapidly reversible.
    • Induction of anesthesia or poor hemodialysis (HD) management during anesthesia can lead to pre-renal disease.
    • Urine indices are often normal in pre-renal disease.
    • Blood and urine specimens must be analyzed to determine the cause before treatment.

    Intra/Intrinsic Renal Disease

    • Intra/intrinsic renal disease is caused by injury to the anatomical parts of the kidney, including the glomerulus, tubules, interstitium, or renal vasculature.
    • It can be caused by toxic drug effects, particularly antibiotics (most often aminoglycosides or vancomycin) and NSAIDs.
    • It can have a nephritic pattern (hematuria) or nephrotic pattern (proteinuria).

    Postrenal Disease

    • Postrenal disease is caused by obstruction of the urinary flow tract, often due to prostatic hypertrophy, stones, or tumor bulk.
    • Although less common, it is the most easily reversible type of AKI.
    • The potential for recovery is inversely related to the duration of obstruction.
    • Diagnosis is often made with ultrasound.

    Complications of AKI

    • Many complications of AKI result from impaired fluid balance and electrolyte homeostasis.
    • Volume overload is common.
    • Neurological complications can include confusion, somnolence, and seizures.

    Treatment of AKI

    • The goal of AKI treatment is to limit further renal injury while correcting fluid, electrolyte, and acid-base imbalances.
    • Fluid resuscitation and vasopressor therapy are universal treatments for prevention and management of AKI. Balanced salt solutions and lactated Ringer's (LR) are preferred, as 0.9% NS is associated with hyperchloremic metabolic acidosis and hyperkalemia.
    • Norepinephrine and vasopressin are used to maintain a mean arterial pressure (MAP) between 65-70mmHg.
    • Dopamine use is not supported by the literature to treat or prevent AKI, as it can also lead to tachycardia.
    • Fenoldopam, a D1 agonist that increases renal perfusion/blood flow, has not shown true benefit in the treatment of AKI in clinical trials.
    • Loop diuretics can be used for hypervolemic, non-anuric AKI.
    • N-acetylcysteine and mannitol can decrease injury related to radiopaque dyes.
    • Blood glucose levels should be managed.
    • Continuous renal replacement therapy (CRRT) is a valuable treatment option.

    Pharmacology in AKI

    • Drug selection should favor agents that do not rely on kidney excretion; however, this is not always possible.
    • Loading doses typically do not require alteration unless the patient's volume of distribution (VD) has changed due to fluid overload, which can affect water-soluble agents.
    • Dosing intervals are likely to increase in patients with AKI.
    • Drugs with toxic and/or active metabolites should be avoided altogether.
    • Nephrotoxic drugs (NSAIDS, some antibiotics like aminoglycosides and vancomycin, and contrast dyes) should be avoided.
    • Avoid drugs that decrease renal perfusion, including ACEIs, ARBs, NSAIDs, and diuretics.

    Anesthetic Management of AKI

    • Only lifesaving surgery should be performed in patients with AKI, due to high mortality and morbidity.
    • Goals of anesthetic management of AKI include maintaining adequate systemic blood pressure and cardiac output, and avoiding further renal insults such as drug injury, hypovolemia, and hypoxia.
    • Preoperative evaluation should include EKG, blood chemistries, CBC, coagulation assessments, and urine indices.
    • Patients with respiratory issues require chest radiographs.
    • Preoperative dialysis should be considered for high-risk patients.
    • Desmopressin (DDAVP) should be considered for platelet dysfunction in high-risk procedures.
    • Intraoperative management involves using large bore IVs (≥18g), avoiding succinylcholine in hyperkalemia, correcting anemia, maintaining intravascular volume, and avoiding morphine, tramadol, and meperidine (due to reduced GFR and toxic metabolites).

    Chronic Kidney Disease (CKD)

    • CKD is a progressive, irreversible deterioration of renal function caused by a wide variety of diseases.
    • Diabetes mellitus is the leading cause, followed closely by hypertension.
    • There is a significant racial disparity in CKD prevalence, with ESRD rate in African American patients 3.6 times that of Caucasians, and Native American rate 1.8 times that of Caucasians.
      • This disparity is often due to untreated hypertension.
    • Approximately 15% of the American population has CKD, with half developing CKD in their lifetime.
    • CKD is diagnosed when the GFR is less than 60mL/min for more than 3 months.
    • A decrease in GFR to less than 25mL/min will progress to ESRD requiring dialysis and transplantation.

    Cardiovascular Effects of Chronic Kidney Disease

    • Systemic hypertension increases the risk of left ventricular hypertrophy, CHF, coronary artery disease (CAD), and cerebrovascular disease.
    • CKD also accelerates the development of ESRD.

    Peritoneal vs Hemodialysis

    • Peritoneal dialysis is used by about 10% of patients with ESRD, whereas hemodialysis is more common.
    • Peritoneal dialysis involves placing an anchored catheter in the peritoneal cavity for infusion of dialysate that remains for several hours, with solute transport via diffusion until fresh fluid is exchanged for the old fluid.
    • Hemodialysis involves diffusion of solutes between the blood and dialysate, achieved by passing heparinized blood through a dialyzer that establishes a countercurrent within a semipermeable membrane.
    • Peritoneal dialysis is best for patients who cannot tolerate rapid fluid shifting, such as those with angina or CHF.
    • Hemodialysis parameters are changed regularly by the physician and tailored to each patient's needs.
    • Peritoneal dialysis has few absolute contraindications, while hemodialysis mortality rates are approximately 16% (down from 30% 20 years ago), likely due to cardiovascular disease, arrhythmia, and sudden cardiac arrest.
    • Peritoneal dialysis can lead to scarring that might interfere with certain surgeries, while hemodialysis limits vascular access site availability.
    • Peritonitis is the most serious complication of peritoneal dialysis.
    • Hospitalization rates are slightly higher with peritoneal dialysis than with hemodialysis.

    Anesthetic Mgt of CKD: Preop

    • The general approach for anesthetic management of CKD is similar to that of AKI, with a focus on optimizing modifiable risk factors, minimizing other risk factors, and preventing further kidney injury.
    • Preoperative evaluation should assess patients' oxygen delivery capacity, with a Lees Index (CRI) of 2 or greater with less than 4 METs requiring additional workup.
    • Blood pressure should be controlled prior to elective surgery, with antihypertensives continued; there is a trend to hold ACEIs and/or ARBs on the day of surgery, particularly when potential for blood loss is high or neuraxial anesthesia is used.
    • Blood sugar should be less than 180mg/dL and potassium levels should be less than 5.5mEq/dL.
    • Interventions to improve blood quality, such as DDAVP, EPO, and iron supplementation, may be required.
    • IV access and blood pressure monitoring should be tailored to each patient's needs and the surgical procedure.
      • Arterial monitoring is helpful for predicting fluid responsiveness in paralyzed, mechanically ventilated patients in sinus rhythm.
      • Femoral artery monitoring is associated with the lowest infection risks.
    • Central venous catheterization and pulmonary artery catheterization may be valuable for high-risk patients.
    • Transesophageal echocardiography (TEE) is an alternative for evaluating hemodynamic status.
    • Vascular access placement should avoid the extremity with an arteriovenous fistula, and consideration should be given to future access placement, typically avoiding the nondominant arm.
    • Temporary access can be used if necessary, but is not the ideal option.

    Anesthetic Management of CKD: Induction

    • ESRD patients often respond to induction of anesthesia as if they are hypovolemic or "volume contracted."
    • Hypotension is common, especially in patients with uremia or on antihypertensive medications.
    • Induction drugs should be titrated to effect to prevent hemodynamic fluctuations.
    • Rapid sequence intubation (RSI) is often necessary.
    • Succinylcholine can be used even with potassium levels less than 5.5mEq/dL, as its response is not exaggerated in patients with CKD.
    • Rocuronium is often the best option for neuromuscular blockade, and sugammadex may also be a possibility.
      • Because SNS activity is impaired in patients with CKD, decreased ability to compensate means even small changes in management can lead to a significant decrease in systemic blood pressure.

    Anesthetic Management of CKD: Maintenance

    • General anesthesia with a balanced technique is a safe and effective plan.
    • Volatile anesthetics do not depend on renal function.
    • Sevoflurane might be avoided due to its potential for causing fluoride toxicity and/or production of compound A, which can increase the risk of dysfunction in ESRD patients.
    • Total intravenous anesthesia (TIVA) is an alternative, with electroencephalogram (EEG) monitoring helping to titrate medications.
    • Cerebral oximetry can be helpful in high-risk patients.
    • Hemodynamics are expected to be labile, so a defibrillator must be readily available.
    • Neuromuscular blockade should be avoided whenever possible.
      • Rocuronium and vecuronium have reduced clearance, and laudasine has potential to cause seizures.
    • Neostigmine and edrophonium have reduced clearance, making the risk of re-curarization low. Sugammadex appears safe and effective in CKD with creatinine clearance greater than 30mL/min.
    • Opioids are preferred over volatile agents, as they have minimal cardiac depressant effects and can reduce the need for inhaled anesthetics.
    • M6G can accumulate in patients with CKD.

    Anesthetic Management of CKD: Regional & Positioning

    • Brachial plexus block (supraclavicular, infraclavicular, and axillary approaches are all appropriate) is useful for placing vascular access for chronic hemodialysis.
    • The presence of uremic neuropathies should be assessed and documented prior to regional anesthesia administration.
      • A T4-T10 sympathetic block can improve renal function by attenuating vasoconstriction and suppressing surgical stress.
    • All types of regional anesthesia are possible, but the placement of vascular access and future access placement must be considered.

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    Description

    This quiz covers topics related to hyperbilirubinemia, including unconjugated and conjugated types, and syndromes such as Gilbert and Crigler-Naijjar. It also addresses benign postoperative intrahepatic cholestasis and viral hepatitis. Test your knowledge on these liver-related conditions and their implications.

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