The complications of chronic kidney disease (CKD) present the anaesthetist with a number of clinical challenges related in part to altered drug handling and to difficulties with vascular access and fluid balance. Safe anaesthetic management requires an understanding of CKD pathophysiology to prevent aggravation of pre-existing disease. This review will consider some recent changes in the management of adult patients with CKD as they affect the anaesthetist. It will consider medical problems associated with CKD together with new developments in perioperative management.