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Medical management of the dialysis patient undergoing surgery
Authors
Neil S Sanghani, MD
Ramesh Soundararajan, MD, FACP
Liza M Weavind, MBBCh, FCCM
Thomas A Golper, MD
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD

Disclosures: Neil S Sanghani, MD Nothing to disclose. Ramesh Soundararajan,

MD, FACP Nothing to disclose. Liza M Weavind, MBBCh, FCCM Nothing to
disclose. Thomas A Golper, MD Nothing to disclose. Jeffrey S Berns, MD
Consultant/Advisory Boards: Amgen [Anemia (Darbepoetin alfa)]; Bayer [Anemia
(Investigational product)]. Alice M Sheridan, MD Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group.
When found, these are addressed by vetting through a multi-level review process, and
through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards
of evidence.

Conflict of interest policy

All topics are updated as new evidence becomes available and our peer review process
is complete.
Literature review current through: Sep 2015. | This topic last updated: Aug 06, 2015.

INTRODUCTION There are limited published data concerning the optimum medical
management of the dialysis patient undergoing surgery. This topic reviews the
preoperative evaluation and postoperative management (including pain control).

Issues relating to acute kidney injury after surgery, including renal replacement therapy,
are discussed elsewhere. (See "Renal replacement therapy (dialysis) in acute kidney
injury (acute renal failure) in adults: Indications, timing, and dialysis dose" and
"Overview of the management of acute kidney injury (acute renal failure)" and "Acute
hemodialysis prescription".)

SURGICAL MORBIDITY AND MORTALITY Dialysis patients have a higher

perioperative mortality compared with the non-end-stage renal disease (ESRD)
population [1-3]. As an example, in a study of 1157 ESRD patients who underwent
repair of abdominal aortic aneurysm, the perioperative mortality was 16 percent for
those undergoing open repair and 10 percent for those undergoing endoscopic repair [3].
By contrast, the reported perioperative mortality in the general population is 1 to 5
percent for open repair and approximately 1 percent for endoscopic repair [4-6].

The cause of the increased morbidity and mortality with dialysis may be attributed to a
number of factors:

A high incidence of coronary artery disease and myocardial dysfunction

A high rate of perioperative fluid and electrolytes disturbances in the perioperative

period, particularly hyperkalemia [7]

Increased bleeding complications

Poor blood pressure control, including hypertension and hypotension

Dialysis patients require increased medical support, including an increased need for
vasopressors and antihypertensive agents, increased time on mechanical ventilators, and
an increased number of days in intensive care and the hospital [8].

ROUTINE DIALYSIS PRIOR TO SURGERY Our approach to preoperative dialysis

differs depending on whether the patient is on hemodialysis or peritoneal dialysis.

Hemodialysis - Hemodialysis patients should be dialyzed the day before surgery, if

possible. Thus elective surgery should not be scheduled to occur on a Monday for a
patient who receives maintenance dialysis on Tuesdays, Thursdays, and Saturdays.
However, we do not add hemodialysis treatments prior to surgery, since intensive
hemodialysis has not been shown to improve outcomes.

If dialysis is provided the day of surgery, it is important to institute measures that avoid
prolonged anticoagulation. Heparin should not be used during hemodialysis. (See
"Hemodialysis anticoagulation".)

The dialysis prescription is generally the same (or as close as possible to) the usual
prescription for the individual patient. However, the patients laboratory values (ie,
serum potassium, calcium, and phosphorus) and the dialysate calcium and potassium
concentration should be carefully reviewed and adjusted in order to use the dialysate
potassium, calcium, and bicarbonate that will allow the patient to go to the operating
room with normal or near-normal plasma concentrations.

The amount of ultrafiltration should be carefully adjusted to ensure that the patient is at
or close to dry weight prior to surgery.

Peritoneal dialysis - For peritoneal dialysis patients, we increase the amount of

dialysis approximately a week before surgery. The dialysis time is increased in order to
prevent underdialysis postoperatively in the event that resumption of peritoneal dialysis
is delayed (due to an ileus or constipation, for example). Patients who are on continuous
ambulatory peritoneal dialysis (CAPD) add an additional exchange each day. Patients
who are on automated peritoneal dialysis add one or two hours per day on the cycler.

However, there are no published data to support this approach, and some nephrologists
do not increase the dialysis time preoperatively for peritoneal dialysis patients.

As for hemodialysis patients, peritoneal dialysis patients should be at their dry weight
prior to surgery. Hypotension secondary to vasodilation and negative inotropy with the
use of induction and maintenance agents utilized for anesthesia frequently results in
perioperative fluid loading to maintain hemodynamic stability. (See 'Volume overload'
below.)

MEASURES TO PRESERVE RESIDUAL RENAL FUNCTION PRIOR TO

SURGERY The preservation of native renal function is extremely important. Many
dialysis patients, particularly in the first 6 to 12 months after starting dialysis, rely on
residual renal function for fluid balance and solute clearance. Residual renal function
has also been associated with increased survival. (See "Urine output and residual kidney
function in kidney failure", section on 'Clinical importance of residual kidney function'.)

We generally discontinue angiotensin-converting enzyme (ACE) inhibitors and

angiotensin receptor blockers (ARBs) in dialysis patients prior to surgery. We also
generally stop diuretics in dialysis patients, if prescribed preoperatively. Stopping these
agents prior to surgery may reduce the hemodynamic instability associated with
hypovolemia and vasodilation from anesthetic agents.

Among patients who are stable, ACE inhibitors and ARBs as well as diuretics may be
resumed on the first postoperative day as clinically indicated.

PREOPERATIVE EVALUATION For all dialysis patients who are undergoing

surgery, evaluation should include the following:

Physical examination and general laboratory evaluation

Assessment of hemodialysis or peritoneal dialysis access

Assessment for possible indications for dialysis (hyperkalemia, volume overload)

Assessment of anemia status

Assessment of nutritional status

Evaluation for cardiovascular disease

Evaluation and possible correction of bleeding diathesis

In addition, among diabetic patients, there should be a careful review of glucose control
and hyperglycemic medical regimen. These issues are individually discussed below.

Laboratory testing A baseline set of electrolyte values, serum concentrations of

glucose, blood urea nitrogen (BUN), creatinine, calcium, phosphorus, magnesium, and
albumin, as well as a complete blood count and coagulation profile, should be
performed prior to surgery in all patients. This will help to guide the dialysis
prescription and provide preoperative baseline values. As an example, phosphorous
levels may decrease postoperatively due to decreased oral intake before and after
surgery. It is important to monitor phosphorous levels so that medications can be
adjusted. Continuing outpatient phosphorous-binding medications can result in
dangerously low phosphorous levels.

Additional laboratory testing should be tailored to the requirements of the individual

patient. Patients who are on digoxin or other medications with a narrow therapeutic
index should have drug concentrations checked.

Blood glucose levels should be reviewed and monitored closely in diabetic patients,
prior to, during, and after surgery, particularly when the patient cannot ingest food. (See
'Glycemic control' below.)

Assessment of access As part of the physical examination, the dialysis access (ie, for
hemodialysis or peritoneal dialysis) should be examined to exclude evidence of
infection. (See "Tunnel and peritoneal catheter exit site infections in continuous
peritoneal dialysis", section on 'Evaluation of the exit site and diagnosis of infection'
and "Physical examination of the arteriovenous graft", section on 'Infected graft' and
"Examination of the mature hemodialysis arteriovenous fistula", section on 'Infected
fistula'.)

The fistula or graft should be assessed by clinical examination for patency. (See
"Examination of the mature hemodialysis arteriovenous fistula", section on
'Thrombosed fistula' and "Physical examination of the arteriovenous graft", section on
'Thrombosed graft'.)

Indications for dialysis The major indications for urgent preoperative dialysis are
hyperkalemia and volume overload.

Hyperkalemia The potassium concentration that is acceptable for surgery depends on

the urgency of the surgery. There are no guidelines that definitively state a maximum
safe level of potassium prior to induction of anesthesia.

Elective surgery For elective surgery, most anesthesiologists are prepared to induce a
patient with a serum potassium level <5.5 mEq/L. The potassium concentration that is
deemed acceptable for induction of individual patients may vary depending on
chronicity of hyperkalemia, location of surgery (freestanding surgery center versus
hospital operating room), and type of surgery. The type of surgery varies with respect to
blood loss, fluid shifts, and acid-base disturbances, all which affect the rate of rise of the
serum potassium concentration.

We generally dialyze patients who are undergoing elective surgery and have a serum
potassium >5.5 mEq/L. Hemodialysis can remove 25 to 50 mEq of potassium per hour,
with variability based upon the initial serum potassium concentration, the dialyzer, the
blood flood rate, and the potassium concentration of the bath [9]. In general, two hours
of hemodialysis will suffice to prepare a patient for surgery under most circumstances.
Nonelective surgery In general, the approach to hyperkalemic patients who require
nonelective surgery is based upon the clinical setting. Important considerations include
the anticipated degree of tissue damage and release of potassium during the operation,
the urgency for surgery, and determination of whether it is safe to delay surgery for
three to four hours while the patient is dialyzed.

All patients with an elevated serum potassium concentration should have a 12-lead
electrocardiogram (ECG). Surgery with anesthesia in the face of chronic hyperkalemia
(K <6) and no ECG changes is usually well tolerated by the majority of patients.
Chronic dialysis patients often have an increased tolerance for hyperkalemia as ECG
changes are frequently not seen until the serum potassium concentration exceeds 6.0 to
6.5 mEq/L [9]. Changes in the ECG with hyperkalemia are thought to result from
alterations in the transcellular potassium gradient rather than the absolute value of the
serum potassium. Dialysis patients often have elevations in total body and intracellular
potassium; as a result, the transcellular gradient may not be altered with moderate
hyperkalemia, resulting in the absence of hyperkalemic changes on the ECG [10,11].

If there are no ECG changes and the patient is otherwise stable, an individual with a
serum potassium of 6.0 to 6.2 mEq/L should be able to safely undergo emergency
surgery with close intraoperative monitoring by anesthesiologists [12].

If ECG features of hyperkalemia are present, we dialyze the patient. As noted above,
two hours of hemodialysis is sufficient to reduce potassium. If dialysis cannot be
performed prior to surgery, medical management should be initiated (see "Treatment
and prevention of hyperkalemia in adults"). However, even a short hemodialysis session
would be preferred, if at all possible.

In a true emergency, life-threatening surgical situation, the operation is performed

regardless of potassium level. Anesthesiologists will temporize with medical
management of the hyperkalemia until a more definitive solution for electrolyte control
can be initiated. (See "Treatment and prevention of hyperkalemia in adults".)

Volume overload The optimal volume status prior to surgery is based in part upon
estimates of anticipated fluid to be administered and/or lost during surgery. As a result, a
discussion with the surgeon and anesthesiologist regarding perioperative volume status
goals is desirable:

If euvolemia or estimated dry weight is not achieved and/or the patient receives a large
volume of fluid during surgery, hypervolemia and possibly pulmonary edema can occur
in the immediate postoperative period, thereby necessitating dialysis.

If too much fluid is removed, there is the risk of hypotension during anesthesia-
induced systemic vasodilatation; this can cause many significant complications,
including but not limited to thrombosis of the arteriovenous access.

Standard practice in anesthesia is to utilize 500 mL infusion bags of normal saline with
a micro-dripper to minimize electrolyte and volume loading with end-stage renal
disease (ESRD) patients (depending on the surgical intervention).
Anemia status Ideally, the preoperative hemoglobin concentration should be at the
recommended target for ESRD patients. (See "Anemia of chronic kidney disease: Target
hemoglobin/hematocrit for patients treated with erythropoietic agents", section on
'Target levels'.)

For patients undergoing elective surgery, if the patient has a hemoglobin less than target,
erythropoietin-stimulating agents (ESAs) may be administered preoperatively to bring
the baseline hemoglobin closer to goal. Iron studies should also be performed since iron
deficiency can contribute to anemia and ESA resistance. (See "Use of iron preparations
in hemodialysis patients".)

Nutrition Protein-energy wasting, inflammation, and cardiovascular disease may

increase mortality in the dialysis population [13]. It is important to identify patients at
high risk and work to reduce these risk factors prior to undergoing surgery [13].

The assessment of the nutritional status of ESRD patients is discussed elsewhere. (See
"Assessment of nutritional status in end-stage renal disease".)

Hypertension Since hypertension is common in the dialysis population, significantly

elevated blood pressure levels measured prior to surgery may require immediate
therapy. With dialysis patients, initial therapy of hypertension should aim to optimize
volume status via the fluid removal with dialysis since volume overload is likely to be
causative. (See "Hypertension in dialysis patients".)

Antihypertensive therapy may be necessary if the blood pressure remains high despite
the attainment of optimal dry weight, or if dialysis cannot be performed in the
immediate preoperative period because the surgery is emergent or access related. In this
setting, parenteral antihypertensive therapy is commonly used. Agents most commonly
used include intravenous (IV) enalaprilat, labetalol, hydralazine (which should be given
with beta blockers to minimize the effect of reflex sympathetic activation), diltiazem,
and/or nitroglycerine. If the patient is monitored in the intensive care unit, IV
nitroprusside (or nicardipine, and some institutions have access to clevidipine for
malignant hypertension) may also be utilized. The use of parenteral medications in
dialysis patients is discussed elsewhere (see "Seizures in patients undergoing
hemodialysis", section on 'Hypertensive encephalopathy'). The benefits of using beta
blockers in this setting are discussed below. (See 'Cardiovascular evaluation' below.)

Transdermal clonidine requires a longer time to achieve adequate blood levels and may
not immediately control blood pressure. Transdermal clonidine may be more useful
postoperatively or when blood pressure control is less urgent. Anesthesiologists avoid
long-acting antihypertensives in the perioperative period as they render the patients
more hemodynamically unstable, with increased risk of intraoperative hypotension and
postoperative fluid shifts.

We do not initiate beta blockers or clonidine preoperatively, but we do continue these

agents in patients who are already on them in order to avoid withdrawal syndromes.

Once oral intake is tolerated, the normal antihypertensive regimen may be reinstituted
(see "Hypertension in dialysis patients"). In some settings, these medications may have
to be gradually introduced and/or staggered; precise blood pressure limits for
withholding and/or giving medications or doses may be needed as the patient's
requirements for antihypertensive therapy may differ in the acute postoperative setting.

Cardiovascular evaluation Coronary artery disease and myocardial dysfunction are

the most common comorbidities in patients with renal failure. In some series,
approximately 50 percent of dialysis patients undergoing surgery are thought to have
cardiovascular disease [7,14].

Heart disease results in significant morbidity and mortality in patients with ESRD, even
among those not undergoing surgery. As an example, in one prospective study of 305
dialysis patients followed for a four-year period, 114 cardiovascular events and 89
deaths were reported [15]. The mortality was 10 times that of the general population,
including 44 times higher in diabetic patients with renal disease. (See "Clinical
manifestations and diagnosis of coronary heart disease in end-stage renal disease
(dialysis)".)

The optimal preoperative cardiac evaluation for dialysis patients is not well defined, but
generally depends upon the level of risk. The risk stratification and screening for
cardiovascular disease and myocardial dysfunction in ESRD patients is discussed
elsewhere. (See "Clinical manifestations and diagnosis of coronary heart disease in end-
stage renal disease (dialysis)", section on 'Screening and evaluation' and "Myocardial
dysfunction in end-stage renal disease", section on 'Screening'.)

Beta blockers We do not initiate beta blockers prior to surgery in patients who are
not on beta blockers. This is consistent with the preoperative approach to the non-CKD
general population. (See "Management of cardiac risk for noncardiac surgery", section
on 'Patients not taking beta blockers'.)

Among patients who are already on beta blockers, we continue them in order to prevent
withdrawal. In addition, for all patients, we use beta blockers for rate control in the
setting of demand ischemia. The requirement for rate control in the setting of demand
ischemia is uncommonly observed intraoperatively, but may be observed
postoperatively in the setting of high catecholamine levels, exacerbated by pain and
fluid shifts.

Bleeding diathesis An increased tendency to bleeding may be present in dialysis

patients [16-19]. This is frequently manifested by bleeding at sites of surgery or trauma.
However, not all uremic patients have a bleeding diathesis, and some are actually
hypercoagulable [20-22]. (See "Management of thromboembolic risk in patients with
atrial fibrillation and chronic kidney disease", section on 'Thromboembolic risk'.)

A bleeding time is not recommended as a preoperative screening test. Although some

studies have found a good correlation between uremic bleeding and the bleeding time
[23,24], a normal bleeding time does not predict the safety of surgical procedures, nor
does a prolonged bleeding time predict excessive bleeding. Assessment of the bleeding
time is subject to considerable variation due to technical factors in executing the test.
(See "Approach to the adult patient with a bleeding diathesis", section on 'Bleeding
time' and "Indications for and complications of renal biopsy", section on 'Pre-biopsy
evaluation'.)
It is likely that multiple factors are responsible for the platelet dysfunction in uremia.
These include retention of uremic toxins due in part to inadequate dialysis, anemia,
excess parathyroid hormone, and the use of aspirin [16]. (See "Platelet dysfunction in
uremia".)

Steps may be empirically taken to limit uremic bleeding, as, for example, in patients
with a history of excessive bleeding from the hemodialysis access or who may not be
optimally dialyzed at the time of surgery. These steps include the following:

Raising the hematocrit by blood transfusion The target value is not clear. We target a
hemoglobin of 10 g/dL [25].

Desmopressin Desmopressin may be given intravenously or subcutaneously at a

dose of 0.3 mcg/kg (in 50 mL of saline over 15 to 30 minutes, if intravenously), or 3
mcg/kg can be given intranasally [16]. (See "Platelet dysfunction in uremia", section on
'Desmopressin (dDAVP)'.)

Cryoprecipitate Ten units intravenously may be given every 12 to 24 hours. The

effect lasts 8 to 24 hours [26].

Dialysis.

The efficacy and use of these modalities is discussed in detail elsewhere. (See "Platelet
dysfunction in uremia".)

Among such patients who have a history of excessive bleeding, we initiate therapy by
increasing the hematocrit (if low) and administering desmopressin. If there is no
response, we give cryoprecipitate. Estrogen, which has a more prolonged effect, is given
to patients who require chronic control of the bleeding time, such as those with
angiodysplasia.

Heparin We do not use heparin during dialysis, if dialysis is performed on the day of
surgery. Heparin doses can be reduced and often eliminated with use of saline flushes
during the hemodialysis treatment. If heparin is administered, the coagulation profile
should return to normal within four hours of heparin termination. Thus, if time permits,
we wait for the coagulation parameters to normalize prior to beginning surgery. If more
emergent surgery is required, the effect of heparin can be reversed by administering
protamine. (See "Therapeutic use of unfractionated heparin and low molecular weight
heparin".)

After major surgery, heparin with dialysis should be avoided for 24 to 48 hours,
particularly if the site of surgery is not easy to assess for evidence of postoperative
bleeding, or if bleeding would result in catastrophic consequences. Discussion with the
surgeon concerning these issues is vital. Alternatives to the administration of heparin are
readily available, including no-heparin hemodialysis. (See "Hemodialysis
anticoagulation".)

Glycemic control Many dialysis patients have diabetes. Patients usually have better
control of blood glucose levels at home than in the hospital because of multiple factors.
These include the following:
Change in physical activity.

Acute comorbid conditions for which they have been hospitalized, such as infections,
vomiting, and diarrhea.

Inability to ingest food.

Changes in oral intake and medical regimen based on the surgical schedule, which
often changes. As an example, surgery is scheduled at 8 AM, but finally takes place at 4
PM.

Many issues regarding the perioperative care of dialysis patients with diabetes are the
same as for diabetic patients without ESRD. (See "Perioperative management of blood
glucose in adults with diabetes mellitus".)

However, there are important considerations that are specific to diabetic patients who
are on dialysis.

Dialysis patients with type 1 diabetes may be more brittle than patients with type 1
diabetes who do not have ESRD. In some patients, for example, a single unit of insulin
can make a difference between a blood glucose level of 120 mg/dL and one of 20
mg/dL. Given the wide variations in glucose metabolism with surgery, the management
of these patients may therefore be extremely difficult.

Among dialysis patients with type 2 diabetes, the potential for hyperglycemia with
surgery is often underestimated. This is because glycemic control medications have
often been discontinued in such patients when they start dialysis. Oral hypoglycemic
agents are discontinued in such patients because insulin requirements decrease with
ESRD.

Among type 2 diabetic patients who are treated with oral hypoglycemic agents,
profound hypoglycemia may result in patients who cannot eat because of the increased
half-life of some oral hypoglycemics with renal failure. In this setting, the
administration of IV dextrose for 48 hours may be necessary to maintain blood glucose.

General recommendations regarding the care of diabetic patients undergoing surgery are
discussed elsewhere. (See "Perioperative management of blood glucose in adults with
diabetes mellitus".)

Issues specific to all diabetic dialysis patients are as follow:

IV fluids should contain dextrose if the patient is fasting; insulin coverage is adjusted
accordingly. The use of dextrose-containing solutions will also help to prevent
hyperkalemia.

Insulin requirements of peritoneal dialysis patients may change depending on whether

or not they are performing exchanges. Unless contraindicated, peritoneal dialysis
patients should continue exchanges while awaiting surgery; however, their peritoneum
should be drained prior to surgery, computed tomography (CT) scan of the abdomen, or
any endoscopic procedures. In these settings, insulin requirements often change since
glucose is absorbed from peritoneal fluid during exchanges (and this source of glucose
goes away when exchanges are stopped).

Patients who have had years of experience in determining the particular dose of insulin
required for their glucose control in different settings should be consulted to help
determine the dose of insulin in the hospital.

Among patients in whom diabetic ketoacidosis is suspected, urine ketones are not
useful; serum ketones must be measured.

Glucose intolerance is also a feature of uremia. As a result, nondiabetic dialysis patients

may exhibit hyperglycemia in the perioperative period, especially when given glucose-
containing solutions such as parenteral hyperalimentation.

Intravenous access All patients require intravenous access. Among ESRD patients,
we use small caliber IV catheters that are placed in hands or feet. If peripheral access is
not available, we place an internal jugular central venous catheter. Placement of
catheters in the subclavian vein should be avoided, if at all possible, because of the risk
of central stenosis, which could imperil the fistula or graft. (See "Central vein stenosis
associated with hemodialysis access", section on 'Central venous catheters'.)

Central lines should also not be placed on the same side as the arteriovenous access.

Knowledge of the patients' vascular anatomy, such as an occluded internal jugular,

subclavian, or femoral vein, may help the anesthesiologist establish central venous
access. The use of small, portable ultrasound machines to identify patent veins has
decreased complications, including accidental arterial punctures and pneumothorax in
high-risk patients with multiple stenotic veins.

Displaying a sign at the patient's bedside to save the designated arm for proposed or
existing accesses (avoiding needle sticks or blood pressure measurements in the arm) is
important. Patients need to be taught to remind healthcare professionals not to use the
designated arm. Peripherally inserted central catheter (PICC) lines should be avoided in
dialysis patients, unless patients have a short life expectancy, so as to preserve the
superficial veins for future arteriovenous fistulas. Tunneled PICC lines placed in the
internal jugular vein are preferred to peripherally inserted lines. (See "Central vein
stenosis associated with hemodialysis access".)

GENERAL ANESTHESIA The metabolism of different anesthetic agents utilized in

general anesthesia varies in patients with renal failure. The optimal choice of the
anesthetic agent varies based upon underlying metabolism, concurrent comorbid
conditions, and the surgical procedure. Anesthesia for dialysis patients is discussed
elsewhere. (See "Anesthesia for the patient on dialysis".)

POSTOPERATIVE MANAGEMENT

Pain Pain relief may be provided by a variety of agents, including opiates,

acetaminophen, and tramadol. Some opiates should not be used among end-stage renal
disease (ESRD) patients, and caution must be used in dosing of all opiates, particularly
among hemodialysis patients. Acute alkalinization with hemodialysis may increase
distribution of opiates across the blood-brain barrier into cerebrospinal fluid (CSF). (See
"Management of chronic pain in chronic kidney disease".)

Opiates Fentanyl is the opiate of choice for postoperative dialysis patients [27]; it is
well tolerated because of its short redistribution phase, the lack of active metabolites,
and unchanged free fraction [28]. Remifentanyl has also been used without
complication in ESRD patients [29].

By comparison, meperidine (Demerol, pethidine), morphine, and propoxyphene should

be avoided, if possible [30]. These agents are metabolized by the liver to their
metabolites, normeperidine and norpropoxyphene, both of which have extremely long
half-lives in dialysis patients:

Since normeperidine is excreted both by the liver and kidneys, the failure of either
organ may cause elevated levels. Normeperidine causes myoclonic jerks, seizures, and
respiratory depression [31-33], with central nervous system excitation directly related to
elevated normeperidine-to-meperidine ratios [34]. These excitatory effects are not
reversed, but may actually be enhanced by naloxone.

Norpropoxyphene is a cardiotoxin.

Morphine should also be used cautiously in patients with renal failure since its sedative
effects are also prolonged [35]. Morphine is metabolized by hepatic glucuronidase to
morphine 3 glucuronide (M3G) and morphine 6 glucuronide (M6G) [36]. In patients
with renal failure, the half-life is unchanged for morphine, but it is prolonged for both
M3G and M6G; these last two agents are both pharmacologically active, thereby
explaining the prolonged effect of the drug in renal failure [37]. Peritoneal dialysis does
not enhance the clearance of the metabolites of morphine [38].

Hydromorphone is also commonly used postoperatively in ESRD patients.

Acetaminophen Acetaminophen can be used in dialysis patients without dose

modification [30].

Tramadol Tramadol may be used in dialysis patients.

Preservation of residual renal function The preservation of native renal function is

extremely important. Many dialysis patients, particularly in the first 6 to 12 months after
starting dialysis, rely on residual renal function for fluid balance and solute clearance.
Residual renal function has also been associated with increased survival. (See "Urine
output and residual kidney function in kidney failure", section on 'Clinical importance
of residual kidney function'.)

This should be taken into consideration when evaluating the need for intravenous (IV)
contrast, nonsteroidal anti-inflammatory drugs (NSAIDs), and other nephrotoxins in the
postoperative period (see "Etiology and diagnosis of prerenal disease and acute tubular
necrosis in acute kidney injury (acute renal failure)", section on 'Nephrotoxins').
Hetastarch used intraoperatively has also been shown to cause acute kidney injury and
should be avoided in this population [39,40]. (See "Treatment of severe hypovolemia or
hypovolemic shock in adults", section on 'Hyperoncotic starch'.)
Dialysis In the absence of an acute indication (such as hyperkalemia or volume
overload), dialysis may be resumed according to schedule. However, some patients may
require dialysis to treat volume overload immediately after surgery in order to facilitate
weaning from a ventilator and extubation. Volume overload may occur as a result of a
requirement for volume administration and blood transfusion intraoperatively. Patients
should be followed closely for subsequent dialysis needs. Capillary leak and fluid often
start to occur at 48 to 72 hours postoperatively, causing pulmonary edema and demand
ischemia.

Anemia Despite being at target hemoglobin, patients often require transfusions

postoperatively due to substantial intra- or postoperative blood loss. In addition, patients
are often resistant to erythropoietin-stimulating agents (ESAs) postoperatively, possibly
due to increased inflammation and elevated hepcidin levels [41]. We continue the ESA
throughout hospitalization despite the possibility that the patient may be relatively less
ESA responsive.

It is important to limit the amount of blood transfusions, if possible, in patients awaiting

kidney transplant in order to minimize the risk of sensitization. (See "Risk factors for
graft failure in kidney transplantation", section on 'Human leukocyte antigen matching'.)

SUMMARY AND RECOMMENDATIONS

Dialysis patients have a higher perioperative mortality compared with the non-end-
stage renal disease (ESRD) population. This is related to a high incidence of heart
disease, perioperative fluid and electrolyte disturbances, increased bleeding
complications, and hemodynamic instability. (See 'Surgical morbidity and mortality'
above.)

Patients should be well dialyzed prior to surgery. Hemodialysis patients should be

dialyzed the day before surgery, if possible. If dialysis is provided the day of surgery, it
is important to institute measures that avoid prolonged anticoagulation.

We increase the dialysis of peritoneal dialysis patients approximately a week before

surgery. (See 'Routine dialysis prior to surgery' above.)

We discontinue angiotensin-converting enzyme (ACE) inhibitors and angiotensin

receptor blockers (ARBs) and diuretics in most dialysis patients two days prior to
surgery. Stopping these agents prior to surgery may reduce the hemodynamic instability
associated with hypovolemia and vasodilation from anesthetic agents. (See 'Measures to
preserve residual renal function prior to surgery' above.)

A baseline set of electrolyte values, serum concentrations of glucose, blood urea

nitrogen (BUN), creatinine, calcium, phosphorus, magnesium, and albumin, as well as a
complete blood count and coagulation profile, should be performed prior to surgery in
all patients. (See 'Laboratory testing' above.)

The preoperative physical exam should include careful evaluation of the dialysis
access (ie, for hemodialysis or peritoneal dialysis). (See 'Assessment of access' above.)
The major indications for urgent preoperative dialysis are hyperkalemia and volume
overload. The potassium concentration that is acceptable for surgery depends on the
urgency of the surgery.

We generally dialyze patients who have a serum potassium >5.5 mEq/L prior to
elective surgery.

If there are no electrocardiographic (ECG) changes and the patient is otherwise stable,
an individual with a serum potassium of 6.0 to 6.2 mEq/L should be able to safely
undergo emergency surgery.

If ECG features of hyperkalemia are present, we dialyze the patient prior to surgery.
However, if dialysis cannot be performed prior to surgery, we treat with medical
management.

In a true emergency, life-threatening surgical situation, the operation is performed

regardless of potassium level.

Patients should be at or close to dry weight prior to surgery. The optimal volume status
prior to surgery depends on estimations of the amount of fluid to be administered and/or
lost during surgery. A discussion with the surgeon and anesthesiologist regarding
perioperative volume status goals is desirable. (See 'Volume overload' above.)

The preoperative hemoglobin concentration should be at the recommended target for

ESRD patients. (See 'Anemia status' above.)

Significant hypertension prior to surgery should be treated with fluid removal with
dialysis. If the blood pressure remains high despite dialysis, or if dialysis cannot be
performed in the immediate preoperative period, hypertension may be treated with
parenteral medications. Long-acting antihypertensives should be avoided in the
perioperative period as they render the patients more hemodynamically unstable. (See
'Hypertension' above.)

The preoperative cardiac evaluation depends upon the level of risk. We stratify
patients for cardiac risk according to clinical criteria and according to the nature and
risk of the surgical procedure. (See 'Cardiovascular evaluation' above.)

An increased tendency to bleeding may be, but is not always, present in dialysis
patients. We do not perform bleeding time prior to surgery, because it is not predictive
of safety during the surgical procedure, and the test is subject to technical variability.
(See 'Bleeding diathesis' above.)

Among all diabetic dialysis patients, intravenous (IV) fluids should contain dextrose,
particularly in fasting patients. Peritoneal dialysis patients should continue exchanges
while waiting for surgery. If exchanges are stopped, insulin requirement may change
since peritoneal dialysate absorption is a source of glucose for such patients. (See
'Glycemic control' above.)
Postoperative issues that are specific to ESRD patients include pain management, safe
resumption of dialysis, and continued protection of residual renal function. (See
'Postoperative management' above.)