Anaesthesia management in Chronic Kidney Disease (CKD) patient undergo repair pseudoaneurysms surgery: a case report

Introduction: Chronic kidney disease (CKD) is marked by the presence of kidney damage (usually defined as estimated GFR < 60 mL/ min/1.73 m2) for 3 or more months, and it may be caused by a multitude of disease processes. Management of patients with CKD includes aggressive treatment of the underlying cause, pharmacologic therapy to delay disease progression and prevent complications, and preparation for hemodialysis as ESRD ensues. Case presentation: In this case report, a 48-year-old man with a pseudoaneurysms due to the insertion of a vascular access for hemodialysis, undergo repair pseudoaneurysms surgery under general anesthesia, at the Sanglah General Hospital, October 2020. The patient came with fully awareness, blood pressure 145/95 mmHg, heart rate 85 times per minute regular and oxygen saturation 97% with room air. Conclusion: General anesthesia in patients with CKD requires an understanding of the pathologic changes that accompany renal disease, co-existing medical conditions, and the impact of reduced renal function on drug pharmacokinetics.

Carboplatin Dosing in Children Using Estimated Glomerular Filtration Rate: Equation Matters

Renal function-based carboplatin dosing using measured glomerular filtration rate (GFR) results in more consistent drug exposure than anthropometric dosing. We aimed to validate the Newell dosing equation using estimated GFR (eGFR) and study which equation most accurately predicts carboplatin clearance in children with retinoblastoma. In 13 children with retinoblastoma 38 carboplatin clearance values were obtained from individual fits using MWPharm++. Carboplatin exposure (AUC) was calculated from administered dose and observed carboplatin clearance and compared to predicted AUC calculated with a carboplatin dosing equation (Newell) using different GFR estimates. Different dosing regimens were compared in terms of accuracy, bias and precision. All patients had normal eGFR. Carboplatin exposure using cystatin C-based eGFR equations tended to be more accurate compared to creatinine-based eGFR (30% accuracy 76.3–89.5% versus 76.3–78.9%, respectively), which led to significant overexposure, especially in younger (aged ≤ 2 years) children. Of all equations, the Schwartz cystatin C-based equation had the highest accuracy and lowest bias. Although anthropometric dosing performed comparably to many of the eGFR equations overall, we observed a weight-dependent change in bias leading to underdosing in the smallest patients. Using cystatin C-based eGFR equations for carboplatin dosing in children leads to more accurate carboplatin-exposure in patients with normal renal function compared to anthropometric dosing. In children with impaired kidney function, this trend might be more pronounced. Anthropometric dosing is hampered by a weight-dependent bias.

The Glomerular Filtration Rate: From the Diagnosis of Kidney Function to a Public Health Tool

The prevalence of chronic kidney disease (CKD) continues to increase worldwide, as well as the associated morbidity and mortality and the consequences on the patients' quality of life and countries' economies. CKD often evolves without being recognized by patients and physicians, although the diagnosis is based on two simple laboratory data: the estimated glomerular filtration rate (eGFR) and urine analysis. To measure GFR, the knowledge about the physiologic processes at the nephron level, the concept of clearance, and the identification of creatinine as a suitable endogenous marker for measuring the creatinine clearance (CrCl) had to be previously developed. On those bases, different equations to calculate CrCl (Cockcroft and Gault, 1976), or estimated GFR (four variables MDRD, 1999; CKD-Epi, 2009, among others) were generated. They all include creatinine and some demographic data, such as sex and age. However, to compare results throughout life or among laboratories, the creatinine determination must be standardized. In addition, the accuracy of these equations remains controversial in certain subgroups of patients. For these reasons, other mathematical models to improve CrCl estimation have been developed, such as when urine cannot be collected, in debilitated elderly patients and patients with trauma, diabetes, or obesity. Currently, eGFR in adults can be measured and reported immediately, using isotope dilution mass spectrometry traceable creatinine-based equations. In conclusion, based on knowledge obtained from renal physiology, eGFR can be used in the clinic for the diagnosis and early treatment of CKD, as well as a public instrument to estimate the prevalence.

Tailoring the sampling time of single-sample GFR measurement according to expected renal function: a multisite audit

BackgroundThe 2018 BNMS Glomerular Filtration Rate (GFR) guidelines recommend a single-sample technique with the sampling time dictated by the expected renal function, but this is not known with any accuracy before the test. We aimed to assess whether the sampling regime suggested in the guidelines is optimal, and determine the expected error in GFR result if the sample time is chosen incorrectly. We can then infer the degree of flexibility in the sampling regime.Methods Data from 8946 patients referred for GFR assessment at 6 different hospitals for a variety of indications were reviewed. The difference between the single-sample (Fleming) GFR result at each sample time and the slope-intercept GFR result at each hospital was calculated. A second dataset of 775 studies from one hospital with nine samples collected from 5 minutes to 8 hours post injection was analysed to provide a reference GFR to which the single sample results were compared.Results Recommended single-sample times have been revised: for estimated GFR above 80 ml/min/1.73m2 a 2 hour sample is recommended, giving mean difference from slope-intercept GFR of -2.08 ml/min/1.73m2 (1333 GFR tests included). Between 30 and 80 ml/min/1.73m2 a 4 hour sample is recommended, giving a 1.95 ml/min/1.73m2 mean difference (2057 GFR tests included). The standard deviation of the differences is 3.50 ml/min/1.73m2 at 2 hours and 2.56 ml/min/1.73m2 at 4 hours for GFR results in the recommended range. It is 5.81 ml/min/1.73m2 at 2 hours and 5.70 ml/min/1.73m2 at 4 hours for GFR results outside the recommended range. ConclusionThe results of this multisite study demonstrate a reassuringly wide range of sample times for an acceptably accurate single-sample GFR result. Modified recommended single-sample times have been proposed in line with the results, and the reported errors for both sample times can be used for error analysis of a mistimed sample.