Perioperative Management of the Patient Receiving Maintenance Hemodialysis

The global prevalence of end-stage kidney disease (ESKD) is rising due to an aging population; increases in risk factors for kidney disease such as hypertension, obesity, and diabetes; improved survival among patients with kidney disease; and broadened access to kidney replacement therapy around the world.¹ Patients with ESKD are also more likely to require surgical procedures than patients with normal or near normal kidney function and are at high risk for perioperative complications. With growing numbers, a high incidence of surgical procedures, and an elevated risk profile, providing high-quality and coordinated care for patients with ESKD represents an increasingly common challenge for perioperative teams.

In this Clinical Focus Review, we review current challenges in the perioperative management of patients receiving maintenance hemodialysis, with an emphasis on evidence-based and multidisciplinary approaches to caring for this high-risk surgical population (fig. 1). Of note, patients with ESKD include those receiving hemodialysis or peritoneal dialysis and kidney transplant recipients. While much of the pathophysiology is shared by all patients with ESKD, we focus on patients receiving hemodialysis because of the unique management considerations in this population.

Fig. 1.

Perioperative management considerations for the patient receiving maintenance hemodialysis.

Epidemiology and Risks of Surgery

In contrast to other common noncommunicable diseases such as cardiovascular disease, stroke, and respiratory disease, mortality attributable to chronic kidney disease (CKD) is rising and is projected to be the fifth leading cause of years of life lost globally by 2040,² with an age-standardized prevalence of CKD of 10.4% among adult men and 11.8% among adult women.³ Mortality associated with kidney failure, or ESKD, is particularly high. For example, in the United States in 2021, persons aged 40 to 44 treated with hemodialysis had a life expectancy of approximately 9 yr, an estimate just above persons aged 80 to 84 yr in the general population.

In addition to experiencing a heightened risk of mortality, patients with ESKD are more likely than those without ESKD to undergo surgical procedures and to have perioperative complications. In a population-based cohort study of greater than 1.4 million patients in Alberta, Canada, adult males under 65 yr old with ESKD had an adjusted incidence of surgical procedures approximately 13 times higher than patients with normal or near-normal kidney function.⁵ The same pattern has been observed in Australia and New Zealand,⁶ as well as in the United States for cardiac surgical procedures.⁷ Several studies have also shown substantially higher risk of perioperative mortality, myocardial infarction, bleeding, stroke, and infection.^8–12

Preoperative Approach to Patients Receiving Hemodialysis

Patient receiving hemodialysis who present for surgical procedures have numerous preoperative considerations involving the expertise of multiple specialties (table 1). If possible, nephrology and anesthesia teams should ideally be consulted, and surgical procedures should be scheduled with adequate lead time to optimize the patient.

Table 1.

Selected Comorbid Conditions and Preoperative Management Considerations

Comorbid Condition	Management Considerations
Cardiovascular
Coronary artery disease, congestive heart failure	Symptoms and signs perform poorly to identify disease Consider screening electrocardiogram and echocardiography, as well as a baseline troponin in high-risk patients to help distinguish chronic abnormalities from acute myocardial injury
Pulmonary hypertension	Pulmonary hypertension is common in patients receiving hemodialysis, in part related to chronic volume overload Consider consultation with the pulmonary hypertension team
Aortic stenosis	Typical symptoms of aortic stenosis may overlap with symptoms related to ESKD Consider screening echocardiography, particularly in patients with known aortic stenosis as the rate of progression can be rapid Consider alternative modalities such as computed tomography and cardiac magnetic resonance imaging if there are questions regarding disease severity due to the high flow state that may result from arteriovenous fistulae
Peripheral vascular disease	Peripheral vascular disease is common and may complicate perioperative vascular access
Endocrine
Diabetes	Hemoglobin A1c levels may be artificially low because patients with ESKD often have a higher proportion of young erythrocytes Because of a high risk of hypoglycemia in patients with ESKD, blood sugar should be monitored frequently in the perioperative period, particularly with exogenous insulin administration
Hematologic
Preoperative anemia	Anemia is common in patients with ESKD Consider iron infusion or temporary increases in the dose of erythrocyte-stimulating agents before surgery
Bleeding risk	Anemia is an independent risk factor for perioperative bleeding Temporary cessation of anticoagulant and antiplatelet medications should be strongly considered, with special attention to altered pharmacokinetics in ESKD Consider preoperative use of anti-Xa, thromboelastography, or platelet function assays
Electrolytes and toxins
Hyperkalemia	While there are no data on “safe” preoperative potassium levels for patients receiving hemodialysis, preoperative hyperkalemia is associated with increased mortality for surgical patients in general Consider preoperative hemodialysis or medical management if a patient presents with hyperkalemia
Hyponatremia	Hyponatremia is common among patients with ESKD Avoid excess oral intake of electrolyte-free water and infusions of hypotonic solutions (e.g., 5% dextrose or 0.45% saline) Avoid rapid correction of sodium and consider use of agents to reduce serum sodium after inadvertent excessive correction

ESKD, end-stage kidney disease.

Cardiovascular Disease

The prevalence of cardiovascular disease in patients with ESKD is high, most recently estimated at 77.3% of patients treated with hemodialysis.⁴ Specifically, heart failure, coronary artery disease, and peripheral arterial disease each have a 40 to 45% prevalence in patients with ESKD receiving maintenance dialysis.⁴ It was recognized more than a half a century ago that patients with ESKD experience accelerated atherosclerosis.¹³ Moreover, vascular stiffness associated with medial arterial calcification contributes to exceptionally high rates of left ventricular hypertrophy, heart failure, valvular disease, stroke, and arrhythmia, including sudden cardiac death.^14,15

While there are numerous approaches to preoperative evaluation, there are no specific guidelines for preoperative evaluation for all patients with ESKD. A common recommendation is to follow general guidelines on cardiovascular evaluation for noncardiac surgery such as the 2024 American Heart Association/American College of Cardiology Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery and the 2022 European Society of Cardiology Guidelines on Cardiovascular Assessment and Management of Patients Undergoing Non-Cardiac Surgery.^16,17 Neither guideline describes a specific preoperative workup for evaluation of patients with ESKD, instead relying on age, symptoms and physical examination findings, risk factors, calculated risk of major adverse cardiac event, and assessments of functional status to guide the need for additional cardiovascular workup or management.

We suggest that approaches to preoperative evaluation for kidney transplantation are important to consider in the approach to the patient with ESKD receiving maintenance dialysis undergoing other major surgical procedures. A 2022 scientific statement from the American Heart Association (Dallas, Texas) on coronary disease screening for kidney transplant candidates outlines an approach that at a minimum includes screening transthoracic echocardiography and electrocardiogram.¹⁸ Reasons for proposing this approach included the poor performance of symptoms and signs for distinguishing patients with and without coronary artery disease^19,20 and the contribution of conditions such as heart failure and arrhythmias to mortality in this high-risk population.¹⁸ Similarly, the 2020 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline on the evaluation and management of candidates for kidney transplantation recommends a screening electrocardiogram in all patients and a transthoracic echocardiogram in asymptomatic patients who have been on dialysis for at least 2 yr.²¹ These recommendations exceed what might be recommended by the most recent United States–based and European guidelines for noncardiac surgery for unselected populations with ESKD, but given the prevalence of cardiovascular comorbidities in this population and the current state of the evidence, a more comprehensive baseline workup is often indicated.

Pulmonary Hypertension.

Pulmonary hypertension is common in patients receiving maintenance dialysis, with a pooled prevalence estimated at 16 to 47%.²² Although the presence of pulmonary hypertension is associated with mortality in this population, there are no specific data to guide perioperative management. Available data from right heart catheterization studies suggest a mix of pre- and postcapillary etiologies.^23,24 In patients receiving hemodialysis, assessment of pulmonary hypertension typically varies depending on the timing of the assessment and the most recent hemodialysis session—precapillary pulmonary hypertension can be unmasked after hemodialysis.²⁴ While a discussion of perioperative management of pulmonary hypertension is beyond the scope of this review, perioperative clinicians caring for patients receiving maintenance hemodialysis should be aware of the high prevalence in this population and consider consultation with a pulmonary hypertension team for preoperative optimization.

Aortic Stenosis.

Patients with advanced chronic and end-stage kidney disease experience accelerated calcific aortic stenosis, potentially as a result of disorders of bone and mineral metabolism including secondary hyperpara-thyroidism, hyperphosphatemia, and hypercalcemia.^25,26 Aortic stenosis in patients receiving maintenance dialysis may progress at twice the rate of patients with normal or near normal kidney function.²⁷ Typical symptoms of aortic stenosis, including dyspnea, chest pain, and presyncope, may overlap with symptoms related to ESKD and associated complications (e.g., pericarditis), making clinical diagnosis and detection of progression challenging. The most recent American Heart Association scientific statement on evaluation and management of aortic stenosis in chronic kidney disease suggests monitoring with transthoracic echocardiography every 6 months for patients with ESKD and rapidly progressive or severe aortic stenosis.²⁸

In addition, the diagnosis of aortic stenosis in patients with ESKD is complicated by risk factors for both low- and high-flow states that can influence calculations commonly employed in the classification of aortic stenosis by echocardiography. Left ventricular hypertrophy and dysfunction, right ventricular dysfunction, tricuspid or mitral regurgitation, and atrial fibrillation—alone or in combination—can contribute to reduced transvalvular flow. Moreover, patients with ESKD typically have limited flow reserve and may not normalize flow with dobutamine stress echocardiography.²⁸ The presence of an arteriovenous fistula can increase left ventricular preload and cardiac output, leading to a high-flow state with elevated transvalvular flow, although the clinical significance of this phenomenon remains unclear.²⁹ Additional imaging modalities including computed tomography and cardiac magnetic resonance imaging can help to resolve questions of severity and determine whether preoperative correction of aortic stenosis is required before planned noncardiac surgery.²⁸

Management of Common Cardiovascular Medications.

Patients with ESKD are frequently prescribed multiple medications, with a median of approximately seven medications per patient in the United States.³⁰ Many of these medications treat type 2 diabetes, hypertension, and cardiovascular disease.^30,31 Beta blockers and calcium channel blockers are often continued through the perioperative period. Although United States–based and European guidelines differ on perioperative cessation of renin–angiotensin system inhibitors, the recent Stop-or-Not trial randomized 2,222 participants to either continuation or discontinuation of renin–angiotensin system inhibitors for 3 days before surgery and found no difference in postoperative complications.³² However, patients with kidney failure were not included in the Stop-or-Not trial, so the applicability of these findings to patients receiving maintenance dialysis is unknown. Autonomic dysfunction is also a common challenge for patients with ESKD and is thought to contribute to intradialytic hypotension.³³ It may be helpful for perioperative teams to discuss whether hypotension during hemodialysis has been an issue for the patient preoperatively and to consider holding some antihypertensive agents in anticipation of the acute reduction in systemic vascular resistance and cardiac function caused by medications commonly used during the induction and maintenance of anesthesia.

Diabetes

Because diabetic nephropathy is a leading cause of ESKD, diabetes is an extremely common comorbidity for patients with ESKD.³⁴ While perioperative management of patients with diabetes has been reviewed elsewhere,³⁵ there are a few special considerations for patients with ESKD and diabetes presenting for surgical procedures.

Compared to patients without ESKD, the proportion of young erythrocytes in patients receiving hemodialysis is likely increased due to use of erythropoietin-stimulating agents, circuit-related hemolysis, frequent phlebotomy, and chronic inflammation.³⁶ Higher percentages of young erythrocytes have been hypothesized to artificially lower hemoglobin A1c levels. Indeed, studies using continuous glucose-monitoring systems show poor correlation of glycated hemoglobin and mean serum glucose concentrations in patients receiving hemodialysis.³⁷ As consideration of the hemoglobin A1c is often part of a preoperative evaluation for patients with diabetes, perioperative care teams should consider that this value may not be accurate in patients receiving hemodialysis. In addition, because of a high risk of hypoglycemia in patients with ESKD, blood sugar should be monitored frequently in the perioperative period, particularly with exogenous insulin administration.³⁸

Anemia and Risk of Bleeding

Patients with ESKD receiving maintenance hemodialysis are at risk of clinically significant perioperative bleeding,¹² likely due to a combination of defective platelet adhesion and baseline anemia. Although often referred to as uremic thrombocytopathy, disordered platelet function in patients with kidney disease is caused by accumulation of toxins other than urea.³⁹ Although these toxins are at least partly dialyzable, there are few data to inform how perioperative hemodialysis practices influence bleeding risk.

Anemia is itself an independent predictor of perioperative bleeding.⁴⁰ The association between anemia and clinically significant bleeding (often defined using blood transfusions) may be due either to starting closer to the transfusion threshold or to impaired coagulation from reduced red cell mass.⁴¹ Anemia is common among patients with ESKD, often the result of diminished iron absorption associated with upregulation of hepcidin, erythropoietin deficiency, or diminished responsiveness to erythropoiesis-stimulating agents (ESAs) associated with chronic inflammation. Observational studies have demonstrated a strong association between baseline anemia and risk of mortality for patients with ESKD.⁴² However, in view of complications associated with overzealous long-term use of ESAs,⁴³ the target hemoglobin concentration for stable patients receiving dialysis—previously in the range of 11 to 13 g/dl—is typically lower, in the range of 9 or 10 to 11 g/dl.⁴⁴

Perioperative providers should interface with nephrologists in advance of elective surgical procedures so that patients and their outpatient physicians understand the anticipated blood loss; in some instances, nephrologists may consider increasing the ESA dose in the weeks before planned surgery to accommodate blood loss and hyporesponsiveness to ESAs that can be caused by postoperative inflammation. Although not specifically studied in patients receiving maintenance dialysis, short-term preoperative use of ESAs (as part of perioperative blood management programs) has been associated with reduced transfusion needs without a significant increase in risk.⁴⁵ Most patients treated with hemodialysis also receive maintenance iron infusions, and nephrology teams can ensure that patients are iron replete in anticipation of major surgery. Finally, perioperative healthcare teams may notice increasing use of a new class of anemia treatment medications called hypoxia-inducible factor prolyl hydroxylase inhibitors. Several of these medications have been evaluated in phase 3 trials and have been found to be noninferior to ESAs with regard to cardiovascular safety and hematological efficacy. There are currently no known perioperative implications for their use in terms of side effects or significant drug interactions.

It remains unclear whether correction of preoperative anemia (via medical treatments or transfusion) reduces perioperative complications or facilitates postoperative recovery. While there is no recommended perioperative hemoglobin target for patients with ESKD, results from the recent Myocardial Ischemia and Transfusion (MINT) and Restrictive and Liberal Transfusion Strategies in Patients with Acute Myocardial Infarction (REALITY) trials suggest that, unlike many other previously studied populations, patients with myocardial infarction and anemia may benefit from more permissive transfusion strategies.^46,47 Of note, both of these trials included patients with ESKD. With the high prevalence of cardiovascular disease in this patient population, familiarity with these trials and their implications may be helpful for teams that care for patients with ESKD who are at elevated risk of perioperative myocardial ischemia.

For management of bleeding risk, temporary cessation of antiplatelet or anticoagulant medications, which are commonly used by patients with ESKD given the high prevalence of cardiovascular disease,⁴ should be carefully considered. Unless the patient was recently treated with percutaneous coronary intervention, antiplatelet medications should be temporarily stopped. The Perioperative Ischemic Evaluation-2 (POISE-2) trial demonstrated that continuation of aspirin through the perioperative period was associated with higher risk of major bleeding without a reduction in mortality or nonfatal myocardial infarction in patients without a history of percutaneous coronary intervention.⁴⁸ Although very few patients receiving dialysis were enrolled in this study, it reasonable to hold antiplatelet medications perioperatively in patients with ESKD without previous percutaneous coronary intervention.

For the management of anticoagulation, special consideration should be given to the indication for anticoagulation and the anticipated pharmacokinetics of the medication in the context of kidney failure. Current guidelines for the management of atrial fibrillation recommend direct oral anticoagulants for patients with kidney disease,⁴⁹ and use of these medications has been increasing despite the fact that patients with significant kidney disease were excluded from most pivotal trials.⁵⁰ Apixaban and rivaroxaban are currently the only two direct oral anticoagulants approved by the U.S. Food and Drug Administration (Silver Spring, Maryland) for use in patients receiving dialysis.⁵¹ The most recent American College of Chest Physicians (Glenview, Illinois) clinical practice guideline categorizes surgical procedures by bleeding risk and generally recommends holding apixaban and rivaroxaban for 1 to 2 days before a surgical procedure.⁵² However, for patients with impaired kidney function, the authors note that a longer hold period may be indicated. Based on known delayed clearance, some sources have suggested 48 to 72 h or more for agents such as apixaban and rivaroxaban in patients receiving maintenance dialysis.⁵³ Assessment using anti-Xa levels, thromboelastography, or platelet function assays may be helpful, in addition to more routine laboratory studies (e.g., platelet count, prothrombin time).

Common Electrolyte Abnormalities

Because the kidneys play a critical role in maintaining acid–base and electrolyte homeostasis, patients with ESKD frequently present with abnormalities on preoperative laboratory evaluations. Two common abnormalities are hyperkalemia and hyponatremia.

Hyperkalemia.

Hyperkalemia (defined as a serum concentration greater than 5.5 mEq/l) is common among patients receiving hemodialysis, with an estimated prevalence of approximately 16.5 events per 100 patient-months.⁵⁴ Hyperkalemia is 2 to 2.4 times more common on the day after the long interval between hemodialysis sessions compared to the day after the short interval. Hyperkalemia in patients with kidney disease is associated with increased mortality.⁵⁵

Although preoperative hyperkalemia is associated with an increased risk of 30-day mortality and adverse cardiovascular events in an undifferentiated veteran population,⁵⁶ there are few recent data regarding the incidence or implications of preoperative hyperkalemia in patients with ESKD. Older data suggest the incidence is 19 to 38%.⁵⁷ Even with hemodialysis within 24 h of surgery, at least 5% of patients may be hyperkalemic on preoperative testing.⁵⁸ For these reasons, we suggest checking serum potassium before surgery, with the caveat that the postdialysis serum potassium will remain below the equilibrated concentration for several hours after a hemodialysis session (and should not necessarily be supplemented if low).

Similarly, there are no data to guide whether to proceed with surgery with medical management of preoperative hyperkalemia versus delaying surgery to treat with hemodialysis. An individualized choice must be made incorporating the urgency of the surgical procedure and the patient’s medical history, degree of hyperkalemia, and other clinical factors such as presence of arrhythmias or electrocardiogram changes.

Hyponatremia.

Hyponatremia is also common among patients with ESKD. Approximately 6 to 29% of patients treated with hemodialysis have a serum sodium less than 135 mEq/l. This is due to excessive intake of free water and in outpatients is a marker of poor adherence to fluid restriction. There are myriad data linking hyponatremia to increased risk of mortality in patients with ESKD.⁵⁹ In the perioperative arena, hyponatremia has been shown to be an independent risk factor for 30-day postoperative morbidity and mortality.⁶⁰ However, while hyponatremia may serve as an indicator of elevated risk, there is no evidence that preoperative correction of hyponatremia alters postoperative outcomes.

Myocardial Injury after Noncardiac Surgery

Based on the prognostic value of postoperative cardiac biomarkers, use of a new clinical diagnosis referred to as “myocardial injury after noncardiac surgery” has been on the rise.⁶¹ Myocardial injury after noncardiac surgery is currently defined by at least one cardiac troponin level that exceeds the 99th percentile upper reference limit for the assay as a result of a presumed ischemic insult. The elevation should be identified within 30 days postoperatively, although most elevations are identified within days of a surgical procedure. Symptoms and electrocardiographic findings are not required. Myocardial injury after noncardiac surgery includes myocardial infarction and ischemic myocardial injury that do not fulfill the Universal Definition of Myocardial Infarction.⁶² Patients with ESKD are at high risk of myocardial injury after noncardiac surgery; unfortunately there are currently no known effective preventative interventions supported by high-quality evidence. However, the diagnosis can inform intraoperative and postoperative management by triggering specific hemodynamic approaches, initiation of antithrombotic or statin therapy, recommending behavioral interventions, or considering cardiac intervention.⁶²

One important factor when considering a diagnosis of myocardial injury after noncardiac surgery in a patient with ESKD is the presence of persistent troponin elevations in patients with kidney disease.⁶³ Although associated with mortality, the reasons behind these elevations remain unclear. However, persistent troponin elevations are believed to represent some component of chronic myocardial injury rather than inadequate clearance of troponin. The most recent scientific statement on myocardial injury after noncardiac surgery from the American Heart Association and the Fourth Universal Definition of Myocardial Infarction suggest that, in the absence of symptoms and electrocardiographic findings, serial biomarker measurements may be particularly helpful in determining whether clinically significant ischemia is present in patients with kidney disease.^62,64 A preoperative baseline troponin measurement may help ascertain the significance of an elevated postoperative troponin.

Assessment of Residual Kidney Function

In 2022, 88.2% of patients initiating dialysis had an estimated glomerular filtration rate greater than or equal to 5 ml · min⁻¹ · 1.73 m⁻², suggesting that many patients who present “on dialysis” have residual kidney function.⁶⁵ Perioperative teams should be aware of residual kidney function and make every effort to preserve it, as the loss of residual kidney function in patients receiving hemodialysis is associated with all-cause mortality.^66,67 Clinical indications of residual kidney function may include patient-reported urine output, diuretic use, or hemodialysis sessions scheduled less frequently than three times per week.^68,69 Previous studies suggest that patients with chronic kidney disease are at higher risk of acute kidney injury and that acute kidney injury may lead to further declines in kidney function.⁷⁰ While there is currently no single evidence-based strategy to prevent or treat perioperative acute kidney injury,⁷¹ KDIGO guidelines recommend use of a care bundle that involves optimization of hemodynamics, prevention of hyperglycemia, avoidance of nephrotoxic agents, and close monitoring of renal function.⁷² At least in cardiac surgical patients, implementation of bundle elements has been associated with a reduced rate of acute kidney injury.⁷³

Evaluation before Emergency Surgery

There may not be time to optimize a patient with ESKD presenting for emergency surgery. In this case, we suggest checking preoperative labs as soon as feasible. Given the nature of many emergency procedures, the team should be prepared to manage electrolyte abnormalities, volume overload, and bleeding risk. The nephrology team should be urgently consulted to consider rapid postoperative hemodialysis or even intraoperative dialysis, if available.

Preoperative Approach to Hemodialysis

Dialysis is a treatment modality designed to restore (to the greatest extent possible) the essence of the extracellular fluid environment maintained in the setting of normal kidney function. While many of the typically measured parameters of electrolyte and acid–base balance can be corrected to within their population reference ranges, dialysis does not restore the health of organ systems or the fluids that perfuse them, particularly with respect to the inflammatory state and immune function.⁷⁴

In 2021, 58% of patients with ESKD in the United States were treated with in-center hemodialysis. This number represents a slight decline over the past two decades as the prevalent transplant (approximately 32%) and peritoneal dialysis (approximately 8%) populations have gradually increased.⁴ In this review, we focus on hemodialysis because it is the most common dialysis modality and has the best evidence regarding perioperative management and implications.

Dialysis serves two main functions: (1) removal of injurious solutes (clearance) and (2) removal of excess fluid (ultrafiltration). For most patients treated with maintenance hemodialysis, these functions are performed 3 times per week, with intervals between treatments of 1 or 2 days. Thus, when planning a surgical procedure, perioperative teams should consider clearance, ultrafiltration, and the timing of when these functions are performed relative to the surgical procedure (table 2).

Table 2.

Perioperative Hemodialysis-related Considerations

Aspect	Management Considerations
Preoperative hemodialysis
Clearance and dose	Hemodialysis dose is estimated using measurements of urea before and after hemodialysis and is most affected by dialysis session duration and the blood pump speed Reduced hemodialysis dose before a surgical procedure is associated with increased perioperative risk, but there is no evidence that this relationship is causal or that preoperative hemodialysis dose should be modified to improve postoperative outcomes
Volume removal	Significant weight gain between hemodialysis treatments is associated with risk of mortality Consider symptoms of volume overload relative to the timing of hemodialysis and whether symptoms are relieved by hemodialysis Target dry weight, but consider a preoperative discussion with the nephrology team to understand the patient’s overall trajectory or any challenges related to volume status before surgery
Timing	Longer intervals between hemodialysis and surgery are associated with mortality Consider hemodialysis on the day before surgery if possible
Anticoagulation	Systemic low-molecular-weight or unfractionated heparins are often used to maintain the integrity of the hemodialysis circuit; however, saline can be used if there is reason to avoid anticoagulants If the surgical procedure is planned immediately after hemodialysis, consider discussing the approach to anticoagulation with the nephrology team
Intraoperative and postoperative considerations
Management of existing vascular access for hemodialysis	Perioperative vascular access choices may affect patients’ long-term dialysis vascular access strategy Examine any arteriovenous fistula preoperatively and postoperatively to ensure patency has not been lost during the surgery Position carefully intraoperatively to avoid pressure and check for thrill regularly if possible Avoid accessing indwelling hemodialysis catheters; if necessary, use aseptic nontouch technique with chlorhexidine to “scrub the hub”; aspirate contents before use; catheters should be locked with a local anticoagulant solution after use
Obtaining perioperative vascular access	Subclavian vein placement of central venous access should be avoided if possible Consider avoiding arterial cannulation and using noninvasive monitoring of arterial blood pressure if appropriate
Risk of bleeding and anemia	Avoiding blood transfusion and resultant immune sensitization is an important goal for patients who are kidney transplant candidates Consider use of desmopressin and tranexamic acid as adjuncts to reduce bleeding
Pain management	Consider use of regional anesthesia, particularly for arteriovenous fistulae creation Use the American Society of Regional Anesthesia and Pain Medicine guidelines to guide the use of regional anesthesia in patients receiving antithrombotic or thrombolytic therapy

Although dialysis removes many other solutes, dialysis dose is most commonly described in terms of small molecule (urea) clearance using the urea reduction ratio and urea clearance × time product (Kt/V). For patients receiving hemodialysis, clearance is measured using blood (serum) urea nitrogen concentrations before and after hemodialysis approximately every 4 to 6 weeks.

In the ambulatory setting, once a minimum degree of solute clearance is achieved, targeting higher dialysis dose does not appear to be of significant benefit. The Hemodialysis (HEMO) trial, a randomized controlled trial of 1,846 patients with kidney failure managed with thrice weekly hemodialysis, compared standard (equilibrated Kt/V_urea 1.05) versus higher (equilibrated Kt/V_urea 1.45) clearance targets over a mean of about 4.5 yr and found no evidence of benefit from higher doses of dialysis.⁷⁵ The Kidney Disease Outcomes Quality Initiative currently recommends a minimum clearance for patients treated with hemodialysis but does not recommend targeting higher clearance.⁷⁶

However, patients undergoing preoperative evaluation may have global impairment of systolic cardiac function related to inadequate clearance (i.e., uremic cardiomyopathy) and/or persistent volume overload. Preoperative intensification of dialysis and associated ultrafiltration may be considered in an attempt to enhance cardiac function if surgery can be reasonably delayed for several weeks.

Whether we should modify the approach to dialysis dosing in the perioperative setting is unknown. Surgical procedures are associated with logistical changes to the dialysis schedule, fluid shifts, medication administration, and an inflammatory response that may alter the risk calculus. It is biologically plausible that strict attention to the dialysis prescription before the perioperative period of high stress might prevent adverse outcomes by reducing cardiovascular events due to electrolyte disturbances or arrhythmias. However, there are limited data to guide decision-making.

Dosing.

We recently published results from an observational cohort study examining preoperative hemodialysis dose before 151,240 procedures in 103,618 Medicare beneficiaries receiving maintenance hemodialysis and found that preoperative decreases in hemodialysis dose (compared to, and controlling for, baseline hemodialysis dose) were significantly associated with postoperative mortality. However, this study and other retrospective studies examining dialysis dose are subject to dose-targeting bias, a form of confounding in which the inability to achieve a target dialysis dose (due to acute illness, for example) may be associated with poor outcomes.⁷⁷ Thus, while it may be informative for perioperative care teams to include a discussion of recent changes to hemodialysis dosing as part of perioperative risk assessment, there is currently no evidence to support modifying preoperative hemodialysis dose to improve postoperative outcomes.

Volume Management.

Volume removal, or ultrafiltration, is the second major function of hemodialysis with perioperative implications. Most patients treated with hemodialysis have an “estimated dry weight,” defined as the postdialysis target weight, aimed to optimize the balance between control of hypertension and the ability to tolerate ultrafiltration during the relatively short hemodialysis session length. One of the goals of hemodialysis is to remove interdialytic (i.e., in between sessions) fluid gains and abrogate or at least ameliorate volume overload. However, volume removal in many patients is limited by hypotension or even myocardial ischemia (“stunning”) during hemodialysis.⁷⁸ Significant interdialytic weight gains (and the higher rates of ultrafiltration required to remove them) have been associated with risk of mortality in patients treated with hemodialysis.⁷⁹ However, how these observations might apply to perioperative care is currently unknown.

Patients on maintenance hemodialysis presenting for surgical procedures should be evaluated for signs and symptoms of volume overload, including dyspnea, rales, orthopnea, jugular venous distension, or weight significantly above the estimated dry weight. It is important to assess symptoms that might occur between hemodialysis sessions, as the accumulation of extracellular fluid during this period may lead to symptoms consistent with heart failure, even in patients without a history of heart failure or other ischemic heart disease. For patients with concomitant heart failure, a modification to the New York Heart Association classification system has been proposed by the Acute Dialysis Quality Initiative (table 3).⁸⁰ The Acute Dialysis Quality Initiative classification system considers whether a patient’s symptoms are relieved by hemodialysis.⁸⁰ While not specifically targeted to the perioperative environment, this framework is useful for the perioperative clinician when evaluating a patients treated with maintenance hemodialysis. Finally, a discussion with the nephrology team regarding recent challenges achieving dry weight or intradialytic hypotension can be informative, as the overall trajectory and reasons behind ultrafiltration challenges may provide a more nuanced assessment of the patient’s individual risk and management.

Table 3.

Acute Dialysis Quality Initiative Heart Failure in ESKD Classification System

Class	Description
Class 1	Patients with echocardiographic evidence of heart disease and are asymptomatic
Class 2R	Dyspnea on exertion that is relieved with KRT/UF to a NYHA class 1 level
Class 2NR	Dyspnea on exertion that CANNOT be relieved with KRT/UF to a NYHA class 1 level
Class 3R	Dyspnea with activities of daily life that is relieved by KRT/UF to a NYHA class 2 level
Class 3NR	Dyspnea with activities of daily life that CANNOT be relieved by KRT/UF to a NYHA class 2 level
Class 4R	Dyspnea at rest that is relieved by KRT/UF to a NYHA class 3 level
Class 4NR	Dyspnea at rest that CANNOT be relieved by KRT/UF to a NYHA class 3 level

Adapted from Chawla et al.⁸⁰ This proposed system incorporates symptoms of dyspnea before and after volume removal to assign a heart failure class. ESKD, end-stage kidney disease; KRT, kidney replacement therapy; NYHA, New York Heart Association; UF, ultrafiltration.

Timing.

Finally, in addition to dialysis dose and ultrafiltration, perioperative providers should consider the timing of preoperative hemodialysis. Nephrologists have long been aware that, in patients treated with thrice weekly hemodialysis, the long interdialytic interval (the 2 days without dialysis, often over the weekend) is associated with risk of mortality.⁸¹ The hypothesized mechanism for this signal has been cardiovascular events, possibly resulting from solute and volume accrual over 2 days instead of 1 day with contribution from their rapid correction with the subsequent dialysis session.

However, few studies have examined this phenomenon in the perioperative context. Hemodialysis performed within 24 h of surgery lowers preoperative serum potassium,⁵⁸ but there is evidence of higher rates of postoperative hypotension when hemodialysis is performed within 7 h before general anesthesia.⁸² There was no effect on graft function in an open-label single-center randomized trial that compared preoperative hemodialysis in the hours before surgery to no preoperative hemodialysis in 100 patients undergoing deceased donor kidney transplantation.⁸³ We recently reported results of a retrospective cohort study of 1,147,846 surgical procedures performed in approximately 350,000 Medicare beneficiaries treated with maintenance hemodialysis. Longer intervals between hemodialysis and subsequent surgical procedures were significantly associated with higher risks of postoperative 90-day mortality in a “dose-dependent” manner. The strength of this association was significantly reduced in patients who had hemodialysis on the same day as the surgical procedure. When incorporating this study with previous literature suggesting elevated risk of mortality with long interdialytic intervals, we believe the safest and most defensible practice is likely to perform hemodialysis on the day before surgical procedures. If this is not possible (or has not occurred), we suggest a multidisciplinary and patient-centered discussion about whether to proceed incorporating the patient’s clinical history, laboratory values, and the risks, benefits, and urgency of the surgical procedure.

Anticoagulation Used in Hemodialysis.

Prophylactic doses of low-molecular-weight or unfractionated heparins are infused during hemodialysis to maintain the integrity of the hemodialysis circuit. Common low-molecular-weight heparins have longer half-lives (on the order of several hours) with known delayed clearance in patients with kidney failure but a similar safety profile. It is noteworthy that reversal of low-molecular-weight heparins with protamine is incomplete. Regional citrate anticoagulation and anticoagulant-free hemodialysis are rarely used in the outpatient setting but can be considered for perioperative hemodialysis. Despite frequent exposure to heparin (typically thrice weekly for the duration of a patient’s outpatient hemodialysis experience), the risk of heparin-induced thrombocytopenia in patients receiving maintenance hemodialysis is thought to be extremely low.⁸⁴ While most surgical procedures are performed long enough after hemodialysis that the effects of heparin have dissipated, perioperative clinicians contemplating a surgical procedure within hours after hemodialysis should discuss anticoagulation with the nephrology team.

Preoperative Considerations for Vascular Access

Patients on maintenance hemodialysis access the circulation via either an arteriovenous fistula, arteriovenous graft, or an indwelling tunneled catheter. Over the past two decades, there has been a push to increase the proportion of patients with arteriovenous fistulae based on data demonstrating fewer infections, hospitalizations, interventions, and lower mortality associated with arteriovenous fistula use.⁸⁵ More recently, emphasis has been placed on each patient’s “ESKD life plan,” an holistic approach to planning for life with ESKD that aims to optimize care including modality and access choices for a specific patient’s foreseeable lifespan and preferences.⁸⁶ It emphasizes not just immediate vascular access needs but anticipation of future needs and planning for those needs. Understanding vascular access considerations and each patient’s ESKD life plan is helpful for perioperative teams caring for these patients as decisions made in this arena can affect patients’ long-term vascular access strategies.

First, for patients with an existing arteriovenous fistulae, an examination of the site is an essential part of the preoperative evaluation. Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend use of a look, listen, and feel approach to rapid fistula assessment.⁸⁶ The skin overlying an arteriovenous fistula should be devoid of erythema, swelling, or drainage. There should be an audible thrill when examined with a stethoscope and a palpable thrill. Unrecognized or untreated infections can lead to erosion of skin and life-threatening hemorrhage, which might be triggered by the hemodynamic swings commonly observed during surgical procedures. Finally, because arteriovenous fistulae and grafts may be at higher risk of thrombosis due to pressure from patient positioning needs or perioperative hypotension, regular intraoperative or postoperative examination of the site should be part of the anesthetic plan so that prompt vascular intervention to salvage the access can be pursued if a palpable thrill is lost perioperatively.

Second, anesthesiology and nursing staff should carefully consider how perioperative venous access might affect future vascular access. Generally, peripherally inserted central catheters should be avoided. Placement of large bore, inflexible catheters into the subclavian veins can injure the wall of the vessel, resulting in stenosis that may compromise subsequent radiocephalic, brachiocephalic, or brachiobasilic fistulae. Left internal jugular vein placement has also be linked to development of central vein stenosis, possibly due to a smaller diameter and multiple anatomic turns leading to higher wall contact and increased endothelial injury.⁸⁷ Even short-term central venous catheters have been linked to thrombus, perivascular sleeve formation, and vein stenoses.^88–90 Because these studies have largely focused on placement of temporary hemodialysis catheters, it is unknown whether placement of smaller central venous catheters would demonstrate the same association. However, while line placement remains a highly individualized choice, subclavian vein placement of central lines should be avoided by perioperative teams whenever possible.

Thought should also be given to the locations of other peripherally inserted catheters, such as intravenous catheters and arterial lines. Peripheral intravenous catheters should preferentially be placed on the dorsal surface of the hand, away from possible sites for future arteriovenous fistulae. While there are no data to specifically guide radial arterial line placement in patients with ESKD, KDOQI guidelines recommend avoiding radial access for cardiac catheterization due to published rates of radial artery occlusion in 5.5% of patients at follow-up longer than 1 week after catheterization.^86,91 Occlusion rates after radial artery catheterization for hemodynamic monitoring are similar⁹²; alternative noninvasive monitoring approaches should be carefully considered for these patients.

Because temporary or “permanent” (tunneled) hemodialysis catheters are associated with a 2to 3-fold higher risk of infection-related hospitalizations compared to arteriovenous grafts or fistulas, perioperative central venous catheter manipulation for purposes other than hemodialysis should be minimized. Kidney Disease Outcomes Quality Initiative guidelines recommend chlorhexidine for “scrubbing the hub” and exit site cleansing, which may be required if a dressing change is performed due to the need to “prep and drape” for surgery. Aseptic nontouch techniques are recommended. If a catheter must be accessed, perioperative teams should be aware that these catheters are often locked with heparin, citrate, or rarely tissue-plasminogen activator. The contents of the catheter should be aspirated before its use.

Intraoperative Management

Choice of Anesthetic Technique

Regional anesthetic techniques have been associated with higher patency rates after arteriovenous fistulae creation compared to local anesthetic techniques.^93,94 When compared to general anesthesia, the possible benefit of regional anesthesia is less clear.^95,96 Theorized mechanisms include the sympathectomy and reduced hemodynamic lability from the use of a regional block. However, available evidence suggests that the majority of arteriovenous fistulae surgeries are done without regional anesthesia,⁹⁷ possibly due to other contraindications to regional blocks commonly present in patients with ESKD such as coagulopathy or use of anticoagulant medications. Although further evidence is needed, it is reasonable to consider regional anesthesia for arteriovenous fistula creation in patients receiving hemodialysis.

For other procedures, there are limited data to guide the choice of anesthetic technique in patients with ESKD. The largest trial to date, the Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults (REGAIN) trial, randomized approximately 1,600 older adults having hip fracture surgery to spinal versus general anesthesia and did not find a significant difference in survival and recovery of ambulation at 60 days.⁹⁸ In a subsequent analysis, spinal anesthesia was associated with more postoperative pain and prescription analgesic use.⁹⁹ Patients with kidney disease were included in the trial but constituted only about 5% of participants.

The choice of regional versus general anesthesia (or a combination of techniques) remains an individualized choice. Local anesthetics are well tolerated by patients receiving hemodialysis with low risk of toxicity. Medications and coagulation laboratory results should be reviewed preoperatively, and American Society of Regional Anesthesia and Pain Medicine guidelines to guide the use of regional anesthesia in patients receiving antithrombotic or thrombolytic therapy should be followed.¹⁰⁰

Management of Bleeding

Avoiding transfusion is an important goal for patients on dialysis—particularly those who are transplant candidates—to avoid potential immune sensitization.¹⁰¹ For medical management of perioperative bleeding, teams can consider prescribing desmopressin, a vasopressin analog known to promote hemostasis in the presence of uremic platelet dysfunction.^102,103 However, while a small number of trials—mostly in cardiac surgery—have suggested a reduction in blood transfusion,¹⁰⁴ evidence that desmopressin limits perioperative bleeding in patients receiving maintenance dialysis is mixed, and recommendations are based largely on experience after percutaneous kidney biopsy.¹⁰⁵ Moreover, administration of desmopressin in patients with kidney disease has been associated with hypotension,¹⁰⁴ suggesting that close monitoring and a longer infusion time (e.g., 30 min) should govern its use. Hyponatremia has also been associated with perioperative administration in patients with kidney disease,¹⁰⁵ although we would not anticipate a major effect of desmopressin on water handling in patients with minimal or no residual kidney function.¹⁰⁶

The use of tranexamic acid, an antifibrinolytic agent, should also be considered in patients with impaired kidney function who experience excessive perioperative bleeding. However, while an argument can be made for its use in patients with non–dialysis-requiring CKD, the risk of seizures and complete dependence on renal elimination calls for caution and potentially dose reduction, especially in cardiac surgery, for which doses tend to be higher.^107,108 Topical tranexamic acid has been considered as an alternative because it causes lower systemic concentrations than intravenous tranexamic acid but, at least in cardiac surgery, is much less effective.¹⁰⁹ The safety of perioperative tranexamic acid should not be inferred in the absence of direct data in this population because patients with ESKD are also at high risk of thrombotic events and have been shown to have impaired fibrinolysis.¹¹⁰ Finally, estrogens have been suggested as a possible therapy for bleeding, but limited data support their use.¹¹¹

Intraoperative Electrolyte Abnormalities

Patients with ESKD are theoretically at elevated risk of intraoperative hyperkalemia because of impaired potassium excretion. Intraoperative hyperkalemia may be caused by tissue damage, compensatory mechanisms for acidosis, malignant hyperthermia, diabetic ketoacidosis, reperfusion injuries, or infusion of high potassium treatments such as blood products. Parathyroidectomy, a relatively common surgical procedure for patients treated with dialysis,¹¹² is specifically associated with an incidence of intra- and postoperative hyperkalemia ranging from 25 to 80%, likely due to potassium shifts caused by changes in parathyroid hormone levels.¹¹³ Treatment algorithms for hyperkalemia have been described and typically include interventions such as calcium, β-agonists, insulin and glucose, potassium binders, diuretics (if the patient makes urine), management of acidosis using sodium bicarbonate and changes to mechanical ventilation, or dialysis.¹¹⁴

Hyponatremia is also common among patients receiving hemodialysis. Perioperative teams should pay close attention to inadvertent corrections to serum sodium that can be caused by use of iso- or hypertonic intravenous fluids, blood transfusions, or medications that may lead to hypernatremia such as sodium bicarbonate or mannitol. Excess oral intake of electrolyte-free water and infusions of hypotonic solutions (e.g., 5% dextrose or 0.45% saline) should be avoided. Inadvertent rapid correction of hyponatremia may lead to osmotic demyelination syndrome, a syndrome associated with progressive and debilitating neurologic findings such as seizures, movement disorders, and paralysis. While the “safe” rate of correction for hyponatremia depends on the risk of osmotic demyelination syndrome and remains a topic of debate,¹¹⁵ a correction limit of 6 to 10 mEq/l per day implies that during most shorter surgical cases, the treatment team should try to maintain intraoperative serum sodium close to preoperative levels with only slight correction, unless there is a compelling clinical reason for more rapid correction. In addition, current guidelines endorse reducing serum sodium after inadvertent excessive correction, although there is no documented benefit from doing so.^116,117

Intraoperative Dialysis

There are extremely limited data to guide use of dialysis. Most studies address its use during liver transplantation. In liver transplantation, while it appears to be safe and feasible, there is no clear benefit conferred from its routine use.^118,119 Other published experience is generally limited to case reports.¹²⁰ Similarly, there are very few studies that address the intraoperative continuation of dialysis for patients who need it preoperatively.¹²¹

Intraoperative indications include hyperkalemia, metabolic acidosis refractory to medical therapy, volume overload, or cerebral edema and increased intracranial pressure, but there are no widely accepted thresholds to trigger treatment. Given the significant resource utilization involved with deployment of intraoperative kidney replacement therapy, the intraoperative use of kidney replacement therapy remains a choice tailored to each patient.

Intraoperative Pharmacology

Several commonly prescribed intraoperative medications require special consideration in patients with ESKD, including neuromuscular blockade and reversal and antimicrobial medications (table 4).

Table 4.

Perioperative Management of Medications for the Patient Receiving Maintenance Hemodialysis

Aspect	Management Considerations
Preoperative
β blockers	Typically continued in the perioperative period
CCB	Typically continued in the perioperative period
ACE/ARB	Recent trial data suggest no difference in postoperative complications with continuation or stoppage, although patients with ESKD were not included in the trial Consider discussing incidence of recent hypotension during hemodialysis to help inform whether these medications should be continued or stopped perioperatively
Anticoagulation and antiplatelet agents	Temporary cessation of antiplatelet medications and anticoagulation should be strongly considered to reduce risk of bleeding Consider a longer hold period for direct oral anticoagulants such as apixaban and rivaroxaban
Intraoperative
Neuromuscular blockade and reversal	Use of rocuronium in patients with impaired kidney function is increasing Sugammadex appears to be an effective reversal agent, although safety concerns regarding recurrent blockade have not been fully resolved with high-quality data
Bleeding risk	Consider the use of desmopressin or tranexamic acid to reduce intraoperative bleeding.
Antimicrobial medications	Vancomycin, cefepime, and piperacillin—tazobactam are commonly used broad spectrum antibacterial agents that may require dose adjustment for patients with ESKD
Postoperative
Acetaminophen	Preferred nonnarcotic analgesic in patients with ESKD
Opioids	Patients with ESKD have altered clearance of several commonly used opioids Fentanyl and hydromorphone are generally considered safe Care should be taken with oxycodone and tramadol, which are both renally cleared
Gabapentinoids	Gabapentinoids are renally cleared and have been associated with altered mental status and falls
Muscle relaxants	Baclofen should be avoided in patients with ESKD Cyclobenzaprine should be used with caution
Nonsteroidal anti-inflammatory medications	Although commonly avoided, time-limited trials of nonsteroidal anti-inflammatory medications have been reported in patients on dialysis
Serotonin-modulating medications	Duloxetine should be avoided in patients with kidney disease

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; ESKD, end-stage kidney disease.

Neuromuscular Blockade and Reversal.

Historically, neuromuscular blockade with atracurium or cisatracurium was recommended, as clearance of these medications is independent of kidney function. However, in part due to the reduced availability of these medications¹²² and the wide availability of an effective reversal agent in sugammadex, the use of rocuronium in patients with impaired kidney function has increased. However, the safety of sugammadex in patients with impaired kidney function remains in question, and in the United States, the current Food and Drug Administration label does not endorse use of sugammadex in patients with an estimated creatinine clearance of less than 30 ml/min. Despite the labeled recommendations, it appears that use of sugammadex in patients with impaired kidney function is also on the rise.¹²³

Although initial evidence suggested that sugammadex could be used safely for these patients,¹²⁴ current safety concerns center around the ability to detect rocuronium–sugammadex compounds in the blood in patients with poor kidney function, sometimes days after administration of the reversal agent.^125,126 The clinical implications of these complexes are unclear, with limited data on whether these compounds have any association with clinical consequences of incomplete reversal. If used, the possibility of residual or recurrent neuromuscular blockade should be raised in patients with respiratory complications postoperatively, as this is a known and feared complication of incomplete reversal of neuromuscular blockade.¹²⁷ Rocuronium–sugammadex complexes appear to be dialyzable, if needed.¹²⁸ Finally, although there were initial concerns regarding an exaggerated risk of hyperkalemia in patients with kidney failure,¹²⁹ succinylcholine use is generally regarded as safe in this population as long as potassium is within normal range and there are no other contraindications.¹³⁰

Antimicrobial Medications.

Antimicrobial dosing must often be adjusted for patients with ESKD due to reduced clearance and risk of toxicity. Vancomycin, cefepime, and piperacillin–tazobactam are commonly used broad spectrum antibacterial agents that require careful attention to perioperative dosing to avoid complications. The most recent Infectious Disease Society of America clinical practice guidelines for antimicrobial prophylaxis in surgery mention that dose adjustments may be required based on kidney function but do not recommend specific dosing for patients with ESKD undergoing surgical procedures.¹³¹

Postoperative Management

Pain Management

Perioperative pain management is another area that should be carefully considered in patients with ESKD. Chronic pain is common in this population, with a prevalence greater than 50%.¹³² Acetaminophen is a preferred nonnarcotic analgesic in patients with ESKD; regional anesthetic techniques should be considered due to impaired clearance of commonly used analgesic agents. Patients with ESKD are frequently prescribed opioids, benzodiazepines, antispasmodic and muscle relaxants, gabapentinoids, and nonsteroidal anti-inflammatory medications.³⁰

While toxicities associated with opioids are well documented, the perioperative period is marked by wide variability in acute pain and opioid prescribing patterns.¹³³ These practice patterns may be particularly relevant for patients with ESKD, who have altered clearance of several commonly used classes of opioids and may be taking other medications that can contribute to nausea, vomiting, respiratory depression, or altered mental status. Opioids such as fentanyl and hydromorphone are generally considered safe in patients with ESKD,¹³⁴ although some sources recommend dose reduction of hydromorphone.¹³⁵ In contrast, oxycodone and tramadol are both renally cleared, so providers should remain vigilant for a longer-than-anticipated duration of effect with these medications.^136,137 In addition, tramadol may have a reduced volume of distribution, which can lead to elevated plasma concentrations and increased risk of seizures without dose reduction.^137,138

Gabapentinoids, which have been used as perioperative analgesic adjuncts,¹³⁹ are eliminated by the kidneys and have be associated with altered mental status (including marked hypnotic effects, depression, and suicidal ideation) and falls.¹⁴⁰ Selective serotonin and serotonin and norepinephrine uptake inhibitors are generally well tolerated in patients with advanced CKD and ESKD, although duloxetine should be avoided in patients with kidney failure. While nonsteroidal anti-inflammatory drugs are commonly avoided in patients with kidney disease, time-limited trials in patients on dialysis have been reported in association with close monitoring for side effects, the most worrisome of which is gastrointestinal bleeding.¹³² Muscle relaxants are commonly used to treat the muscle pain and cramping experienced by patients with ESKD.¹⁴¹ Baclofen should be avoided in patients with ESKD;¹⁴² even cyclobenzaprine has been associated with altered mental status and falls¹⁴¹ and should be used with caution in the perioperative period.

Postoperative Kidney Replacement Therapy and Disposition

Unfortunately, there are no data to guide the use of kidney replacement therapy after a surgical procedure for patients with ESKD. Considerations such as the patient’s volume status, electrolyte derangements, hemodynamic stability, and the resources and institutional practice of the healthcare system will inform when and how kidney replacement therapy is deployed postoperatively. Early consultation with the nephrology team is strongly recommended, as the choice of kidney replacement therapy modality after surgery will likely affect the disposition of the patient after surgery.

Balancing Risks and Potential Benefits

While perioperative risks in ESKD are higher than the general population, absolute event rates support proceeding with surgery when clinically indicated. For many common major surgeries, the 30-day risk of acute myocardial infarction or death in patients receiving maintenance dialysis is less than 10%, likely in a range acceptable to patients who truly need a given surgical procedure.¹⁴³ Even for procedures with higher event rates, including intra-abdominal (11.7%), musculoskeletal (12.2%), and vascular surgeries (12.6%), the large majority of patients undergo these operations without experiencing major adverse events. When surgery is indicated, the path to better outcomes is likely through optimal perioperative care rather than denying the procedure on the basis of “high risk.”

Conclusions and Future Directions

Patients with ESKD frequently require surgical procedures. Their risk of perioperative complications is higher than average but not prohibitive. They should not be denied surgery when surgery is indicated. Patients with ESKD receiving maintenance hemodialysis require a specialized approach to preoperative evaluation, optimization (when time allows), intraoperative management, and postoperative care. Addressing these elements requires careful care coordination by surgeons, nephrologists, anesthesiologists, and internists, emphasizing that a multidisciplinary team approach is essential to providing high-quality perioperative care for this high-risk surgical population.

Abbreviations:

CKD

chronic kidney disease

ESA

erythropoiesis-stimulating agent

ESKD

end-stage kidney disease

KDIGO

Kidney Disease Improving Global Outcomes

KDOQI

Kidney Disease Outcomes Quality Initiative