Anaesthetic and Perioperative Management of Adults with Chronic Kidney Disease: A Critical Narrative Review of Risk, Pharmacology, Haemodynamic Strategy and Kidney Protection

Abstract

Chronic kidney disease is common among surgical patients and is associated with higher postoperative mortality, cardiovascular complications, acute kidney injury and loss of independence. Anaesthetic practice for this population has traditionally relied on pharmacokinetic reasoning and expert opinion, yet a substantial body of randomised and large observational evidence published over the past decade now bears directly or indirectly on its care. This critical narrative review examines how that evidence should shape the anaesthetic and perioperative management of adults with non-dialysis chronic kidney disease, those receiving maintenance dialysis and kidney transplant recipients undergoing surgery. Literature was identified through structured searches of PubMed, Europe PMC, Crossref, the Directory of Open Access Journals, Semantic Scholar and Google Scholar, supplemented by citation searching and examination of guideline documents, with emphasis on randomised trials, large cohorts, meta-analyses and consensus statements. The synthesis indicates that postoperative risk rises in a graded manner with declining kidney function and is highest in patients receiving dialysis, and that kidney function measured before surgery carries prognostic information beyond binary thresholds. Evidence is strongest for avoiding restrictive fluid regimens in major abdominal surgery, for preferring balanced crystalloids to saline in kidney transplantation, for brachial plexus block in arteriovenous fistula creation and for recognising that longer intervals between haemodialysis and surgery are associated with higher mortality. Evidence is weaker and more indirect for individualised blood pressure targets, for sugammadex in severe renal impairment, for opioid selection and for pharmacological kidney protection, where the most promising data derive largely from cardiac surgery. Patients with established chronic kidney disease are frequently excluded from, or under-represented in, perioperative trials, and many recommendations therefore extrapolate from mixed populations. Priorities include trials powered for outcomes within chronic kidney disease strata, harmonised definitions of acute kidney injury superimposed on chronic disease, pharmacokinetic studies of newer agents in dialysis, and long-term kidney outcomes after surgery. The current evidence supports a structured, physiology-informed approach while indicating that several widely taught practices remain insufficiently tested.