Journal of Nature and Science, Vol.1, No.2, e46, 2015


Medical Sciences

 

Renal and Gastrointestinal Considerations in Joint Replacement Surgery

 

Benjamin Voss1, Alexander Kurdi1, Alexander Skopec2, Jasmine Saleh3, Mouhanad M El-Othmani1, Joseph M Lane4, William M Mihalko5, Khaled J Saleh1

 

1Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62794-9679, USA. 2Saint-Louis University School of Medicine, St. Louis, MO 63103 USA. 3National Institute of Health, Bethesda, MD 20892, USA. 4Department of Orthopaedics, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA. Weill Medical College of Cornell University, New York, NY 10065 USA. 5Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 956 Court Ave, Suite E226, Memphis, TN 38163, USA


Renal and gastrointestinal diseases affect a significant portion of the general population. The process of decision making regarding surgical clearance and pre-operative management of the various complexities and medical conditions associated with these diseases hence becomes crucial. To optimize postoperative outcomes, the considerations for the care of this patient population revolve around effective management of hemostasis and electrolyte status. This subset of conditions is uniquely important with regard to the negative impact of improper administration of medications and perioperative care on patients’ prognoses. A thorough understanding and knowledge of standards of care and treatment guidelines for patients with renal dysfunction and gastrointestinal disease assures comprehensive preoperative planning and surgical clearance. This may ultimately lead to improvement of surgical outcomes and potential decrease in postoperative morbidity and mortality. Journal of Nature and Science, 1(1):e46, 2015.

 

Renal disease | gastrointestinal disease | preoperative | medical clearance | joint replacement 

 

Introduction

Renal diseases as well as gastro-intestinal disease affect a large portion of orthopedics patients, requiring additional understanding of the intricacies involved in their care.  Chronic kidney disease (CKD) is a progressive disorder that typically results from glomerulonephritis, diabetes mellitus and hypertension, with nearly 75% of CKD diagnoses caused by these conditions1-4. Acute kidney injury (AKI), a milder decrease in renal function, is often linked to iatrogenic causes such as perioperative anesthesia and medications. Estimates of prevalence for AKI suggest that it may affect 1% of all hospitalized patients, and it is a well-documented independent predictor of poor health outcomes5-7. Gastrointestinal diseases encompass a wide spectrum of conditions. Liver cirrhosis affects up to 1% of the U.S. population while annual incidence of irritable bowel disease (IBD) reaches 29/100,000 per year8-10. Consideration and knowledge of the major co-morbidities associated with the disease processes of kidney dysfunction and gastrointestinal disease and their respective medical treatments are key components of pre-operative medical clearance of orthopaedic patients.

An ample knowledge of the disease manifestation and treatment guidelines for patients with gastrointestinal and renal pathologies would yield a substantial decrease in postoperative morbidity and mortality. Both conditions, in particular the renal system, have a preponderance of established literature detailing the disease origins, variations, and modalities of care. Vigilant evaluation of markers for disease management and prudent perioperative management of medication dosing are paramount. In this review we provide recommendations and considerations for the care of patients with renal and gastrointestinal conditions.

 

Renal Considerations

Chronic Conditions

CKD is a progressive disorder defined as a glomerular filtration rate (GFR) <60 mL/min per 1.73 m2, which represents a loss of half or more of the normal adult renal function level. The National Kidney Foundation (NKF) provides thorough recommendations for both proper disease evaluation and classification – details of which exceed the scope of this review 11,12.  Progression of CKD leads to kidney failure and end stage renal disease (ESRD), defined by the NKF as CKD with a GFR of less than 15 mL/min per 1.73 m2 11. Both CKD and ESRD are predictive of prolonged hospital stay and increased all-cause mortality following surgery13-20. This population is predisposed to multiple possible peri- and post-operative complications, due to the disease process itself, its treatment and the associated comorbidities. These include endothelial dysfunction and hypercoagulability, elevated serum homocysteine, microalbuminuria, and accelerated vascular calcification due to deficient mineral metabolism16,18,19.

Advanced stage renal disease is an independent risk factor for increased post-operative cardiovascular mortality and morbidity15. A longstanding correlation exists between patients treated with prolonged renal replacement therapy and cardiovascular complications21,22. Patients with CKD (all stages) with superimposed cardiovascular disease (CVD) are up to 10 times more likely to die before even reaching a classification of ESRD and can expect their CVD to progress at twice the normal rate when compared to patients with CVD only 23.

Several cardiovascular considerations should be highlighted in CKD patients. Atherosclerosis is a common form of arterial vascular disease seen more extensively in patients with renal dysfunction. It may manifest as ischemic heart disease (angina), myocardial infarction, cerebrovascular disease, peripheral vascular disease, or congestive heart failure24. In 2011, the prevalence of CHF reached up to 31.2% among all Medicare CKD patients4.

The prevalence of atrial fibrillation (AFIB) in the CKD population is as high as 25%4. Uremia, by interfering with the autonomic nervous system and affecting baroreceptor function, predisposes to a higher risk for the development of arrhythmias and AFIB 25. This leads eventually to an increased risk of thromboembolic events.

CKD patients are noted to have a high incidence of concomitant hypertension. In 2011, as many as 63% of these patients were receiving angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) and up to 47% received beta blockers, as a pharmacotherapy to control their blood pressure and renal disease progression 26. Many anaesthetic agents induce peripheral vasodilation and cardiac depression. In patients maintained on ACEI or ARB perioperatively, this will accentuate the risks for hypotension and subsequent renal hypoperfusion, leading to a further potential intraoperative renal insult27. Craig et al. indicate that perioperative development of hypotension relative to preoperative levels is a risk for intolerable further renal damage 28. They recommend individualized treatment of hypotension as opposed to the absolute stringent measure of <90 mm Hg 28.


 

 

 

 

 

Figure 1: Pharmacologic management of CKD-mineral bone disorder.

 


The renal system plays a pivotal role in hematopoiesis. Through the synthesis of erythropoietin, the kidneys drive differentiation and proliferation of erythrocyte progenitor cells and thus control erythrocyte concentration 29,30. It is estimated that up to 18% of stage 3 patients (GFR <30 mL/min/1.73 m2) and nearly 60% of those in stages 4-5 (GFR <30 mL/min/1.73 m2) are anemic31. Epoetin alfa, approved in 1989, was the first erythropoiesis-stimulating agent (ESA) developed for the treatment of anemia in CKD patients 32. Anemia is common in the setting of orthopaedic surgery, and the condition confers increased risk of blood transfusion and peri-and postoperative morbidity and mortality 33. Anemia in CKD (but not CKD alone) was associated with a higher risk of blood transfusion, increased length of hospital stay, periprosthetic joint infection, and increased incidence of 30-day readmission in orthopaedic patients 34-37.  A significant risk for infection is associated with blood transfusion38. Of particular interest, more restrictive transfusion strategies in orthopaedic patients had significantly reduced risk ratios for the development of healthcare-associated infections38-44.The Kidney Disease Outcomes Quality Initiative (KDOQI) and Network for Advancement of Transfusion Alternatives (NATA) both recommend treatment of anemia with ESA33. This algorithm proved to reduce the transfusion requirements in CKD patients. However, the safety and efficacy of this medication is being questioned in recent trials. The CHOIR study showed that treatment of anemic non-dialysis CKD patients to Hb of 13.5 g/dL greatly increased the risk of cardiovascular complications and death compared with Hb levels of 11.3 g/dL45. In another study, Pfeffer et al. demonstrated that ESA use significantly raised incidence of stroke46. In addition, a rise in risks of cardiovascular accidents has also been shown in more recent trials47,48. The risks and benefits of administration of these drugs for patients with CKD-associated anemia should be individualized and further investigated32,45-50.

Dialysis and transplantation are the final recourse when renal failure has progressed beyond the point of independent functionality. Dialysis-dependent patients have longer hospital stays, higher surgical and postoperative complications, and mortality rates when compared to those not requiring intervention4,15,51-56.  Dialysis patients with superimposed DM and hypertension are predisposed to even higher risks52. Of particular significance, ESRD patients on dialysis or those who received kidney transplant are at a greater risk for complications following total hip arthroplasty (THA) or total knee arthroplasty (TKA)57-62. Renal impairment is proposed as an independent risk factor for both periprosthetic joint infection (PJI) in TKA and elevated 90-day readmission risk in THA63,64.


 

Table 1:  RIFLE classification stages and criteria for defining AKI75


Stage

GFR and SCr Criteria

Urine Output Criteria

Risk

SCr 1.5x baseline or GFR decrease >25%

<0.5 mL/kg/hr for 6 hours

Injury

SCr 2x baseline or GFR decrease >50%

<0.5 mL/kg/hr for 12 hours

Failure

SCr 3x baseline or GFR decrease >75% or SCr level ≥4 mg/dL

<0.3 mL/kg/hr for 24 hours or anuria for 12 hours

Loss

                  Complete loss of kidney function > 4 weeks

End Stage Renal Disease

                 Complete loss of kidney function > 3 months

 

 

Table 2:  AKIN stages and criteria for defining AKI75

Stage

SCr Criteria

Urine Output Criteria

Stage 1

Increase in SCr >0.3 mg/dL or SCr 1.5-2x baseline

<0.5 mL/kg/hr for 6 hours

Stage 2

SCr 2-3x baseline

<0.5 mL/kg/hr for 12 hours

Stage 3

SCr >3x baseline, or SCr >4 mg/dL with an acute rise of >0.5 mg/dL, or receiving renal replacement therapy

<0.3 mL/kg/hr for 24 hours or anuria for 12 hours

 


Frequent complications are reported among patients on chronic hemodialysis undergoing hip fracture repair. In this patient population, Karaeminogullari et al. reported a significant correlation between length of hemodialysis and postoperative mortality rates54.  The recommended treatment for these patients with intra-trochanteric and non-displaced femoral neck fractures is osteosynthesis, while hemiarthroplasty is indicated for those with displaced femoral neck fracture54. THA for transplant patients and those on dialysis are associated with high mortality rates, and should be reserved for those who demonstrate a considerable potential for positive post-operative outcomes58,65.

The current literature indicates that patients undergoing hemodialysis are at a greater risk for perioperative complications when compared to those receiving peritoneal dialysis.

Patients on hemodialysis have a 31% higher incidence of hip fracture compared to those receiving peritoneal dialysis.56 When comparing bone lesions between these two patients population, it is noted that those on peritoneal dialysis present with low-turnover lesions, while those on hemodialysis regimen have high-turnover lesions 66. This observation can be in part explained by the significantly higher parathyroid hormone (PTH) levels in hemodialysis patients, representing increased risk of bone depletion and resorption66. In addition to osteodystrophy, steroid use in chronic hemodialysis patients may pose a further burden on bone deterioration67.

The management of bone mineral disturbances in these patients involves maintaining physiologic levels of PTH and stimulating vitamin D receptors68. The pharmacologic classes of available treatment options include phosphate binders, vitamin D analogs, and calcimimetics68 (Figure 1).

There is no reliable evidence that agents such as dopamine, diuretics, calcium channel blockers, ACEIs, N-acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants, ESA, and selected hydration fluids exert any renal protective influence during surgery69. Unexplained preoperative decline in renal function merits postponement of the procedure and meticulous investigations towards identification of any possible insult reason and the condition rectified70. Maintaining the patient’s hydration and fluid balance remains the most effective method for preventing further renal damage71-73. The proper adjustment of drug dosages, taking into consideration the patient’s impaired renal function, must be considered in all stages of the surgical process74.

 

The Acute Setting

Acute kidney injury (AKI) is the rapid loss of renal function leading to a decrease in GFR and urine output, and an accompanying derangement of normal serum electrolyte levels. Several methods have been developed to classify acute kidney injury based on serum creatinine (SCr) levels, GFR, and urine output.  The two most commonly used systems are the RIFLE and the Acute Kidney Injury Network (AKIN) classifications75.  The RIFLE classification defines five stages of acute kidney injury (listed in Table 1).  The AKIN criteria define AKI as a rapid (within 48 hours) decline in kidney function, and classify it into three stages (listed in Table 2).

The incidence of AKI reaches up to 5% of all hospitalized patients with approximately 30-40% of all cases occurring in surgical patients5,76.  This incidence varies with the type of surgery, with the highest being associated with cardiac surgery, vascular surgery, and liver transplantation7,27,75,77.  A wide range of values have been reported for the incidence of AKI following orthopedic surgery, from as low as 0.55% following hip and knee arthroplasty, to as high as 16% following hip fracture surgery78,79. The average incidence of developing AKI following all orthopedic procedures has been reported to be approximately 9%7.

The causes of AKI can be classified as pre-renal, intrinsic, or post-renal.  Pre-renal AKI is the result of hypoperfusion of the kidney, intrinsic AKI is the result of direct damage to the renal parenchyma, and post-renal AKI results from kidney outflow obstruction80.  Multiple studies have identified risk factors for the development of AKI following orthopedic surgery, including, but not limited to, pre-existing kidney disease, heart disease, vascular disease, diabetes, and perioperative dehydration7,78,79,81. Another commonly identified risk factor contributing to the development of AKI is the use of nephrotoxic medications, such as non-steroidal anti-inflammatories (NSAIDs), ACEIs, ARBs, aminoglycoside antibiotics, and IV contrast dye7,27,75-77,79,80