Cleveland Clinic journal of medicine
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Patients with an elevated serum creatinine or whose serum creatinine levels increase postoperatively, regardless of baseline levels, are at increased risk for elevated mortality. Women have a higher risk from acute renal failure than men at every level of serum creatinine. Acute renal failure confers an increased risk of mortality, chronic renal insufficiency, and postoperative infection independent of other postoperative complications. Preoperative measures to reduce risk of acute renal failure include optimizing volume and solute status, ensuring adequate urine flow, avoiding high doses of diuretics, optimizing hematocrit levels, and avoiding contrast agents.
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Most patients with chronic kidney disease eventually become anemic. We should view the management of anemia in these patients as part of the overall management of the many clinically relevant manifestations of chronic kidney disease. Erythropoiesis-stimulating agents (ESAs) are safe and should be used, as treating anemia may forestall some of the target-organ damage of chronic kidney disease.
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Tumor necrosis factor (TNF) inhibitors have proven highly effective against a number of autoimmune diseases but have been disappointing in treating others. An increase in the risk of Mycobacterium tuberculosis and other opportunistic infections has been noted in patients treated with these agents. If we use these drugs, we need to weigh their beneficial and adverse effects.
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The history and the physical examination remain the most important elements in cardiac risk stratification of patients prior to noncardiac surgery. Indications for further cardiac tests and interventions are usually the same as in the nonsurgical setting. No test should be performed unless the results will affect patient management. In many cases, noninvasive testing is being replaced by prophylactic medical therapy, a topic explored in the next article in this supplement.