Medical management of the dialysis patient undergoing surgery

INTRODUCTION — Patients with end-stage kidney disease (ESKD) who are on dialysis commonly require surgery or other invasive procedures for reasons related to ESKD, including vascular access procedures, parathyroidectomy, or kidney transplantation. Patients may also require elective or emergency procedures for reasons unrelated to their ESKD.

This topic reviews the preoperative and postoperative medical management of patients on dialysis. Anesthetic management of patients on dialysis and issues specific to patients on peritoneal dialysis undergoing surgery are discussed separately. (See "Anesthesia for dialysis patients" and "Issues in patients on peritoneal dialysis undergoing surgery".)

OUTCOMES AFTER SURGERY — Patients on dialysis have a higher perioperative mortality compared with patients without end-stage kidney disease (ESKD) [1-3]. For example, in a study of 1157 patients with ESKD who had repair of abdominal aortic aneurysm, perioperative mortality was 16 percent for open surgical repair and 10 percent for endovascular repair [3]. By contrast, patients without ESKD had lower perioperative mortality after either open surgery (1 to 5 percent) or endovascular repair (approximately 1 percent) [4-6].

Possible causes of increased morbidity and mortality among patients on dialysis include higher likelihood of the following:

●Cardiovascular complications (see 'Cardiovascular disease' below)

●Perioperative fluid and electrolytes disturbances, particularly hyperkalemia [7] (see 'Indications for urgent preoperative dialysis' below)

●Surgical bleeding complications (see 'Bleeding diathesis' below)

●Poor perioperative blood pressure control (both hypertension and hypotension) (see 'Hypertension' below)

Also, patients on dialysis require increased medical support during the perioperative period, including increased need for vasopressors or antihypertensive agents, and increased duration of mechanical ventilation, intensive care, and inpatient hospitalization [8].

PREOPERATIVE EVALUATION — For most planned surgical procedures, preoperative medical evaluation of patients on dialysis includes baseline laboratory testing, determining the adequacy of hemodialysis or peritoneal dialysis access, and assessing comorbidities. Preoperative considerations for patients on peritoneal dialysis, including which patients may need to switch to temporary hemodialysis due to surgery, are discussed elsewhere. (See "Issues in patients on peritoneal dialysis undergoing surgery", section on 'Preoperative considerations'.)

Laboratory testing — The following laboratory tests are obtained after the most recent preoperative dialysis treatment:

●Serum electrolytes, glucose, blood urea nitrogen, creatinine, calcium, magnesium, phosphorus, and albumin.

●Complete blood count.

●Coagulation tests, including prothrombin time, activated partial thromboplastin time, and international normalized ratio. However, 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 [9,10], 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 "The kidney biopsy", section on 'Patient evaluation'.)

Results of these tests guide the dialysis prescription and provide preoperative baseline values. The time interval between the last dialysis treatment and preoperative laboratory testing should also be considered when interpreting the results. Additional laboratory testing should be tailored to the requirements of the individual patient. In particular, drug concentrations of digoxin or other medications with a narrow therapeutic index should be checked.

Assessment of access — The access site for hemodialysis or peritoneal dialysis should be examined to exclude evidence of infection. (See "Physical examination of the arteriovenous graft", section on 'Infected graft' and "Physical examination of the mature hemodialysis arteriovenous fistula", section on 'Infection'.)

The fistula or graft should be assessed for patency by clinical examination. The access site should be clearly marked and staff warned about its location. (See "Physical examination of the arteriovenous graft", section on 'Thrombosed graft' and "Physical examination of the mature hemodialysis arteriovenous fistula", section on 'Thrombosed AV fistula'.)

Assessment of comorbidities — Patients on dialysis commonly have multisystem comorbidities that may impact anesthetic and surgical care.

Cardiovascular disease — Coronary artery disease and myocardial dysfunction are the most common morbidities in patients with end-stage kidney disease (ESKD), causing significant morbidity and mortality even among those not undergoing surgery [11]. In some series, approximately 50 percent of patients on dialysis undergoing surgery have cardiovascular disease [7,12]. (See "Overview of screening and diagnosis of heart disease in patients on dialysis" and "Clinical manifestations and diagnosis of coronary artery disease in end-stage kidney disease (dialysis)".)

Preoperative evaluation and management of cardiac risk for patients on dialysis is similar to those for other patients undergoing noncardiac surgery, as discussed elsewhere. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Management of cardiac risk for noncardiac surgery".)

Aortic stenosis is common and often severe in patients with ESKD. Patients with limited exercise tolerance and a characteristic systolic ejection murmur should be evaluated for the severity of their aortic stenosis prior to undergoing any other anesthetic or surgery [13,14]. (See "Valvular heart disease in patients with end-stage kidney disease", section on 'Aortic stenosis'.)

Hypertension — Hypertension is common among patients on dialysis. Management of chronically administered oral antihypertensive agents is discussed below. (See "Hypertension in patients on dialysis" and 'Medication management' below.)

If blood pressure (BP) is significantly elevated before surgery, initial management includes dialysis to remove fluid and optimize volume status since volume overload is likely to be the cause (see "Anesthesia for dialysis patients", section on 'Management of intravascular volume overload'). However, antihypertensive therapy may be necessary if BP remains significantly elevated after attaining optimal dry weight, or if dialysis cannot be performed in the immediate preoperative period (eg, need for emergency surgery). Typically, intravenous (IV) antihypertensive therapy is used, with selection of an agent such as enalaprilat, labetalol, hydralazine (administered with a beta blocker to minimize the effect of reflex sympathetic activation), diltiazem, and/or nitroglycerin. The choice of agent may be influenced by the patient's baseline vital signs (eg, hydralazine if bradycardia is present, or a beta blocker if tachycardia is present) as well as interactions with other drugs they are receiving. If the patient is monitored in an intensive care unit, IV nicardipine may be selected.

Clevidipine is selected to treat malignant hypertension in some centers. Notably, transdermal rather than IV administration of clevidipine results in slower attainment of adequate blood levels and may not achieve immediate control of BP. However, this route is useful when BP control is less urgent or in the postoperative period.

During the intraoperative period, only short-acting agents are used to control BP due to the potential for rapid blood loss or other fluid shifts and development of hypotension (table 1).

Diabetes — Many patients on dialysis have diabetes. In those without diabetes, glucose intolerance is a feature of uremia that may result in hyperglycemia, particularly in the perioperative period. Administration of glucose-containing solutions such as parenteral hyperalimentation will exacerbate hyperglycemia in these patients. General considerations in the perioperative care of patients with diabetes are discussed separately. (See "Perioperative management of blood glucose in adults with diabetes mellitus".)

Specific considerations for perioperative care of patients on dialysis who have diabetes include the following:

●All patients with diabetes – Issues specific to patients on dialysis who have diabetes include:  

•IV fluids should contain dextrose if the patient is fasting; insulin coverage is adjusted accordingly. A potential advantage of dextrose-containing solutions is reducing the likelihood of hyperkalemia.

•Insulin requirements of patients on peritoneal dialysis may change depending on whether or not exchanges are being performed. Unless contraindicated, patients on peritoneal dialysis should continue exchanges while awaiting surgery; however, their peritoneum should be drained prior to any surgical or endoscopic procedure. In such circumstances, insulin requirements often change since glucose is absorbed from peritoneal fluid during exchanges (and this source of glucose is eliminated when exchanges are stopped).

•Patients with 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 that will be necessary during hospitalization.

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

●Type 1 diabetes – Patients on dialysis who have type 1 diabetes may be more brittle than other patients with type 1 diabetes. Given the effects of surgical stress on glucose metabolism, perioperative management may be challenging.

●Type 2 diabetes – Among patients on dialysis who have type 2 diabetes, the potential for hyperglycemia with surgery is often underestimated. This is because oral hypoglycemic agents are often discontinued in such patients when they start dialysis because insulin requirements decrease with ESKD. Conversely, patients on dialysis who have type 2 diabetes who continue oral hypoglycemic agents may develop profound hypoglycemia if they cannot eat during the perioperative period since the half-life of some oral hypoglycemics is increased in patients with kidney failure. In some cases, administration of IV dextrose for approximately 48 hours may be necessary to maintain blood glucose.

Anemia — Ideally, the preoperative hemoglobin concentration should be at the recommended target for patients with ESKD. (See "Treatment of anemia in patients on dialysis", section on 'Target Hb levels'.)

If a patient on dialysis has a hemoglobin less than the target before planned surgery, an evaluation for causes of blood loss or erythropoiesis-stimulating agent (ESA) resistance should be undertaken. ESAs are typically adjusted preoperatively to bring the baseline hemoglobin closer to goal, if feasible. Iron studies should also be performed since iron deficiency can contribute to anemia and ESA resistance. (See "Treatment of iron deficiency in patients on dialysis" and "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia'.)

Bleeding diathesis — Patients with ESKD may have an increased tendency to bleed during and/or after surgery due to multiple factors such as retention of uremic toxins due in part to inadequate dialysis, anemia, excess parathyroid hormone, residual heparin used during recent hemodialysis, or chronic administration of aspirin [15,16]. However, not all uremic patients have a bleeding diathesis, and some are actually hypercoagulable [15,17-19].

Preoperative measures to minimize uremic bleeding during and after surgery are discussed elsewhere. (See 'Uremic bleeding' below and "Anesthesia for dialysis patients", section on 'Management of bleeding'.)

Causes and treatment of platelet dysfunction in patients with ESKD are discussed in a separate topic. (See "Uremic platelet dysfunction".)

Nutritional status — It is important to identify patients at high risk for protein-energy wasting in the preoperative period [20]. Assessment and management of nutritional status in dialysis patients are discussed in other topics:

●(See "Assessment of nutritional status in patients on hemodialysis".)

●(See "Pathogenesis and treatment of malnutrition in patients on maintenance hemodialysis".)

●(See "Nutritional status and protein intake in patients on peritoneal dialysis".)

PREOPERATIVE MANAGEMENT

Dialysis considerations

Routine dialysis prior to surgery — Our approach to preoperative dialysis differs depending on whether the patient is on hemodialysis or peritoneal dialysis.

●Hemodialysis – For those patients undergoing elective surgery who are on maintenance hemodialysis, a hemodialysis treatment is usually performed when practical, either the day before or on the day of the procedure. This practice is supported by observational data suggesting that longer intervals between dialysis and surgery may increase the risk of postsurgical complications. In a retrospective cohort study of approximately 350,000 patients with end-stage kidney disease (ESKD) on hemodialysis who underwent surgery, day-long intervals between dialysis and surgery of zero (ie, dialysis on the same day of surgery), one, two, and three days were associated with 90-day postoperative mortality risks of 4, 4.2, 4.7, and 5.2 percent, respectively [21]. However, for well-dialyzed patients, we generally do not add hemodialysis treatments prior to surgery, since intensification of hemodialysis has not been shown to improve outcomes, and changes to the routine dialysis regimen can adversely impact continuity of care.

If dialysis is provided the day of surgery, it is important to institute measures that avoid prolonged anticoagulation. (See "Anticoagulation for the hemodialysis procedure".)

The dialysis prescription is generally the same (or as close as possible to) the usual prescription for the individual patient. However, the patient's 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 prescription to ensure that the patient goes 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 – Some UpToDate contributors increase the amount of peritoneal dialysis before surgery to prevent underdialysis postoperatively in the event that resumption of peritoneal dialysis is delayed. Preoperative intensification of peritoneal dialysis is used even when postoperative delays in peritoneal dialysis are not expected, since unanticipated delays (eg, due to an ileus or constipation) are relatively common. However, other UpToDate contributors do not increase the amount of peritoneal dialysis in well-dialyzed patients before surgery. Preoperative intensification of peritoneal dialysis is discussed in detail elsewhere. (See "Issues in patients on peritoneal dialysis undergoing surgery", section on 'Intensification of peritoneal dialysis before surgery'.)

Similar to patients on hemodialysis, those on peritoneal dialysis should be at their dry weight prior to surgery. Patients should go to surgery after draining the peritoneal dialysate from the abdomen. Volume administration (in combination with vasopressors) is typically necessary during the intraoperative period to treat vasodilation and negative inotropy caused by induction and maintenance anesthetic agents and/or surgical bleeding. (See "Anesthesia for dialysis patients", section on 'Fluid management'.)

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

Hyperkalemia — Hyperkalemia is a potential indication for urgent preoperative dialysis. There are no guidelines that specify a maximum safe level of potassium prior to induction of anesthesia. Decisions regarding treatment of hyperkalemia depend in part on the urgency of surgery (ie, whether it is safe to delay surgery for three to four hours to perform dialysis). Other factors include the likely degree of tissue damage that may cause release of potassium during the planned operation, anticipated blood loss and fluid shifts, chronicity of hyperkalemia, and existing or impending acid-base disturbances (eg, metabolic acidosis) that may affect the intraoperative rate of rise of the serum potassium concentration.

●Elective surgery – The serum potassium concentration should be checked on the morning of surgery; if elevated, a 12-lead electrocardiogram (ECG) is obtained; however, hyperkalemic ECG changes are often not evident (figure 1). These are due to alterations in the transcellular potassium gradient rather than the absolute serum potassium value. However, there is neither an orderly progression of ECG abnormalities in hyperkalemic patients as their potassium rises, nor does the absence of ECG changes preclude the possibility of hyperkalemia-associated cardiac arrest [22-25].

•If serum potassium concentration is <5.5 mEq/L and there are no changes on the ECG, urgent dialysis is generally not necessary prior to surgery, particularly in a patient with chronic hyperkalemia. Patients on dialysis often have chronic elevations in both total body and intracellular potassium, but transcellular gradients may not be altered with moderate hyperkalemia, accounting for the absence of hyperkalemia-induced ECG changes until potassium is >6 to 6.5 mEq/L [22,24-27].

•If serum potassium concentration is ≥5.5 mEq/L, we usually dialyze the patient before surgery, particularly if any hyperkalemia-induced changes in the ECG are evident (figure 1). Two to three hours of hemodialysis will typically suffice to prepare a patient for surgery. If the patient is on peritoneal dialysis, rapid exchanges can be performed to decrease the serum potassium if time permits, or the patient can receive urgent hemodialysis via a hemodialysis catheter. Gastrointestinal cation exchangers (eg, patiromer or sodium zirconium cyclosilicate) can also be used if the patient is not nil per os, but they are slower acting and unlikely to be effective if given shortly before surgery.

●Emergency surgery – For emergency surgical procedures, the nephrology service should be consulted when feasible to determine whether urgent preoperative dialysis may be appropriate to treat severe hyperkalemia. Institution of alternative therapies may be necessary if dialysis is not feasible. Emergency management of hyperkalemia during surgery is discussed separately. (See "Anesthesia for dialysis patients", section on 'Emergency surgery considerations'.)

Volume overload — 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:

●Nonurgent surgery – Intravascular volume overload, in particular clinically significant pulmonary edema, is usually an indication for urgent preoperative dialysis. Typically, the goal of preoperative dialysis is to reach the patient's estimated dry weight. Additional factors are considered, such as the amount of volume that will be administered or anticipated blood loss during surgery. A patient who remains in pulmonary edema once their dry weight has been attained should be evaluated for a cardiac cause. (See 'Routine dialysis prior to surgery' above.)

●Urgent or emergency surgery – For urgent or emergency surgery, the risks of mild, moderate, or severe circulatory volume increases are weighed against the risks of delaying surgery. Discussions among the surgeon, anesthesiologist, and nephrologist can avoid the following perioperative scenarios:

•Hypervolemia and pulmonary edema in the immediate postoperative period necessitating dialysis and possibly noninvasive positive pressure ventilation or controlled mechanical ventilation. This may occur if euvolemia or estimated dry weight is not achieved in the preoperative period and/or the patient receives a large volume of fluid during surgery.

•Intraoperative hypotension due to anesthesia-induced systemic vasodilatation in a relatively hypovolemic patient, which may result in significant complications such as thrombosis of the arteriovenous access site. This may occur if too much fluid is removed during preoperative dialysis.

Use of heparin — If dialysis is performed on the day of surgery, we try to minimize or avoid use of heparin during dialysis. Heparin doses can be reduced and often eliminated by using saline flushes during the hemodialysis treatment. If heparin is administered, we wait for the coagulation parameters to normalize prior to beginning surgery if feasible (typically within four hours of heparin termination).

Medication management — Perioperative medication management is similar to that for patients without ESKD, as discussed in detail separately. (See "Perioperative medication management".)

●Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) – In patients on dialysis who are taking ACE inhibitors or ARBs, we individualize the decision to continue or discontinue these agents based upon the indications for the drug, the patient's blood pressure, and the type of surgery and anesthesia planned. Many anesthesiologists may prefer to withhold these medications on the morning of surgery based on concerns about possible hypotension. However, when the indication is for heart failure or poorly controlled hypertension, we continue them to avoid further exacerbation of these conditions and inform the anesthesiologist of our rationale. If ACE inhibitors or ARBs are held, they are typically resumed on the first postoperative day if the patient is stable. (See "Perioperative medication management", section on 'ACE inhibitors and angiotensin II receptor blockers'.)

●Diuretics – In patients on dialysis who are taking chronically administered diuretics, the decision to continue or temporarily hold these agents is influenced by the patient's volume status prior to surgery. Diuretics can generally be continued if the patient is euvolemic or volume overloaded. If the patient appears volume depleted, we discontinue diuretics prior to surgery and restart them on the first postoperative day, if indicated and the patient is stable. (See "Perioperative medication management", section on 'Diuretics'.)

●Beta-blockers – We continue chronically administered beta blockers to prevent withdrawal. Beta blockers are typically resumed on the first postoperative day in stable patients. However, we do not initiate beta blockers prior to surgery in those who are not on beta blockers. (See "Perioperative medication management", section on 'Beta blockers' and "Management of cardiac risk for noncardiac surgery", section on 'Patients without indications for long-term therapy'.)

●Clonidine – We continue chronically administered clonidine to prevent withdrawal. However, we do not initiate alpha 2 agonist drugs in the perioperative period. (See "Perioperative medication management", section on 'Alpha 2 agonists'.)

Intravenous access — Obtaining intravascular access for the intraoperative period is often difficult in patients on dialysis. The hemodialysis catheter should be avoided. Also, meticulous care of an existing fistula is essential. Peripherally inserted central catheter (PICC) lines and midline catheters should be avoided. Details regarding intraoperative intravascular access are discussed separately. (See "Anesthesia for dialysis patients", section on 'Intravenous access'.)

During the preoperative period, displaying a sign at the patient's bedside or use of a special wrist band 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 health care professionals not to use the designated arm and to preserve the superficial veins of the designated arm for future arteriovenous fistulas. (See "Central vein obstruction associated with upper extremity hemodialysis access".)

Uremic bleeding — Unacceptable uremic bleeding may occur in some patients (eg, those with a history of excessive bleeding from the hemodialysis access site or those who are not optimally dialyzed at the time of surgery) (see 'Bleeding diathesis' above). Preventive measures that can be implemented in the preoperative period to minimize or avoid clinically significant bleeding during and after surgery include:

●Raising the hematocrit to an appropriate level by transfusing red blood cells, based on individual patient-specific and procedure-specific factors. (See "Uremic platelet dysfunction", section on 'Invasive procedures'.)

●Desmopressin – Desmopressin may be administered intravenous (IV) at a dose of 0.3 mcg/kg (in 50 mL of saline over 15 to 30 minutes) or subcutaneously at a dose of 0.3 mcg/kg [16]. (See "Uremic platelet dysfunction", section on 'Other measures'.)

●Dialysis before surgery. (See 'Dialysis considerations' above.)

Management of bleeding in patients on dialysis during elective or emergency surgery is discussed in a separate topic. (See "Anesthesia for dialysis patients", section on 'Management of bleeding'.)

Issues specific to peritoneal dialysis — Several preoperative issues are unique to patients on peritoneal dialysis, including the use of antibiotics to prevent peritonitis and preoperative bowel preparation to minimize the effect of postoperative ileus on the resumption of dialysis. These and other issues are discussed separately. (See "Issues in patients on peritoneal dialysis undergoing surgery", section on 'Preoperative management'.)

INTRAOPERATIVE MANAGEMENT — The intraoperative management of patients on dialysis, including anesthetic management, is discussed separately. (See "Anesthesia for dialysis patients", section on 'Intraoperative anesthetic management' and "Issues in patients on peritoneal dialysis undergoing surgery", section on 'Intraoperative management'.)

POSTOPERATIVE MANAGEMENT

Monitoring — Postoperative monitoring should include an assessment of volume status and hemodynamic stability. Laboratory testing is guided by the specific surgery as well as the results of preoperative lab testing. Patients should be closely monitored for the development of hyperkalemia.

Resuming dialysis — In the absence of an acute indication (such as hyperkalemia), dialysis may be resumed according to schedule. However, some patients may require more urgent dialysis to reduce their circulating volume immediately to facilitate weaning from a ventilator and extubation. Patients who undergo general anesthesia typically experience venodilation and arterial vasodilation. The infusion of volume to attain adequate filling pressures and venous return greatly aids in attaining hemodynamic stability, especially during major procedures. Patients appropriately resuscitated in this manner will have an excessive circulating volume after their anesthetic has worn off. If a patient has clinical symptoms, such as pulmonary edema or difficult to control hypertension, it is reasonable to arrange expeditious hemodialysis and ultrafiltration.

Changes to the peritoneal dialysis prescription after abdominal and cardiothoracic surgery, as well as postoperative indications to switch from peritoneal dialysis to another mode of kidney replacement therapy, are discussed elsewhere. (See "Issues in patients on peritoneal dialysis undergoing surgery", section on 'Postoperative management'.)

After major surgery, heparin with hemodialysis should be avoided for the first 24 to 48 postoperative hours, particularly if the site of surgery is not easy to assess for evidence of postoperative bleeding, or if any bleeding would result in catastrophic consequences (eg, intracranial or intraocular bleeding). Alternatives to the administration of heparin are readily available, including no-heparin hemodialysis. Alternatively, if there is no specific indication for dialysis, we may delay a treatment for 24 to 48 hours postoperatively. Discussion with the surgeon concerning these issues is vital. (See "Anticoagulation for the hemodialysis procedure".)

Patients should be followed closely for subsequent dialysis needs. Capillary leak and fluid accumulation often start to occur at 48 to 72 hours postoperatively, causing pulmonary edema and demand ischemia.

Pain management — A multimodal approach to postoperative analgesia is used when feasible. (See "Approach to the management of acute pain in adults", section on 'Use multimodal analgesia' and "Anesthesia for dialysis patients", section on 'Postoperative analgesia'.)

●Pharmacologic agents – Pain relief may be provided by a variety of agents, including opioids and acetaminophen. Some opioids should not be used in patients with end-stage kidney disease (ESKD), and caution must be used in dosing any opioid. This is particularly important in patients on hemodialysis who are at high risk for opioid-related side effects and drug-drug interactions [28,29]. Furthermore, acute alkalinization with hemodialysis may increase distribution of opioids across the blood-brain barrier into cerebrospinal fluid. (See "Management of chronic pain in advanced chronic kidney disease".)

•Opioid use

-Fentanyl is the opioid of choice for postoperative use patients on dialysis (eg, for patient-controlled analgesia) [30]. Fentanyl is well tolerated because of its short redistribution phase, lack of active metabolites, and unchanged free fraction [31].

-Hydromorphone is also commonly used in the postoperative period in patients with ESKD.

•Opioids to avoid

-Meperidine (Demerol, pethidine) is avoided. Meperidine is metabolized in the liver to an active metabolite normeperidine, which has an extremely long half-life in patients on dialysis [32]. Since normeperidine is excreted both by the liver and kidneys, failure of either organ causes elevated levels. In addition, adverse side effects of normeperidine include myoclonic jerks, seizures, as well as respiratory depression [33-35]. The central nervous system excitatory effects are directly related to elevated normeperidine-to-meperidine ratios [36]. Notably, these adverse excitatory effects are not reversed but may actually be enhanced by naloxone.

-Morphine is generally avoided or used cautiously in patients with ESKD since its sedative effects are also prolonged [37]. Morphine is metabolized by hepatic glucuronidase to morphine 3 glucuronide (M3G) and morphine 6 glucuronide (M6G) [38]. In patients with kidney 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 kidney failure [39]. Morphine and M6G are both removed by hemodialysis [40-42]; however, M6G diffuses out of the central nervous system slowly, which may delay the response to dialysis [42]. Data on the dialyzability of M3G are not available. Peritoneal dialysis does not enhance the clearance of the metabolites of morphine [43].

•Nonopioid analgesic agents

-Acetaminophen – Acetaminophen can be used in patients on dialysis without dose modification [32,44].

-Ketamine – Use of ketamine has been described for very painful surgical procedures [44].

-Gabapentinoids – Although gabapentinoids are used in some institutions as a component of multimodal pain management, patients with ESKD are particularly vulnerable to adverse side effects such as excessive sedation and respiratory depression [44,45]. If a gabapentinoid is used, the dose should be decreased.

●Local anesthetic techniques – The anesthesiologist may employ regional analgesia (neuraxial or peripheral nerve block) or the surgeon may employ wound infiltration to reduce or eliminate opioid dosing in the postoperative period. (See "Anesthesia for dialysis patients", section on 'Postoperative analgesia'.)

Anemia management — Despite being at target hemoglobin, patients may require transfusions postoperatively due to substantial intra- or postoperative blood loss. In patients awaiting kidney transplant, it is important to limit the number of blood transfusions, if possible, to minimize the risk of sensitization. (See "Kidney transplantation in adults: Risk factors for graft failure", section on 'Human leukocyte antigen matching'.)

In addition, patients are often resistant to erythropoiesis-stimulating agents (ESAs) in the postoperative period, possibly due to increased inflammation and elevated hepcidin levels [46]. We continue the ESA throughout hospitalization despite the possibility that the patient may be relatively less responsive. If the patient is hyporesponsive to the ESA and their iron stores are adequate, increasing the dose of the ESA may be reasonable. Alternatively, if the patient is only moderately anemic, the prior dose can simply be maintained.  

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)

SUMMARY AND RECOMMENDATIONS

●Preoperative evaluation – For most planned surgical procedures, preoperative medical evaluation of patients on dialysis includes baseline laboratory testing, determining the adequacy of hemodialysis or peritoneal dialysis access, and assessing for comorbidities, including cardiovascular disease, hypertension, diabetes, anemia, bleeding diathesis, and nutritional status. (See 'Preoperative evaluation' above.)

●Preoperative management

•Routine dialysis prior to surgery – For those patients undergoing elective surgery who are on maintenance hemodialysis, a hemodialysis treatment is usually performed when practical, either the day before or on the day of the procedure. For well-dialyzed patients who are on peritoneal dialysis, some but not all experts increase the amount of dialysis before elective surgery. (See 'Routine dialysis prior to surgery' above.)

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

-Patients with a serum potassium ≥5.5 mEq/L generally require preoperative dialysis, particularly if electrocardiographic (ECG) features of hyperkalemia (figure 1) are present. However, if dialysis cannot be performed prior to surgery, we treat with medical management. For patients with a serum potassium <5.5 mEq/L and no ECG changes, urgent dialysis is not necessary prior to surgery. In a true emergency, life-threatening surgical situation, the operation is performed regardless of potassium level. (See 'Hyperkalemia' above.)

-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.)

•Medication management – Perioperative medication management is similar to that for patients without end-stage kidney disease (ESKD). (See 'Medication management' above.)

•Intravenous (IV) access – Obtaining IV access for the intraoperative period is often difficult in patients on dialysis. The hemodialysis catheter is avoided. Also, meticulous care of an existing fistula is essential. Peripherally inserted central catheter (PICC) lines should be avoided. (See 'Intravenous access' above.)

•Uremic bleeding – Uremic bleeding may occur in some patients. Preventive measures that can be implemented in the preoperative period to minimize or avoid clinically significant bleeding during and after surgery include red blood cell transfusion, desmopressin, and dialysis before surgery. (See 'Uremic bleeding' above.)

●Postoperative management

•Resuming dialysis – In the absence of an acute indication (such as hyperkalemia or volume overload), dialysis is usually resumed according to schedule. However, some patients may require more urgent dialysis to treat volume overload immediately after surgery in order to facilitate weaning from a ventilator and extubation. After some surgeries, patients on peritoneal dialysis may require modification to their dialysis prescription, or, less commonly, may need to switch temporarily from peritoneal dialysis to another mode of kidney replacement therapy. (See 'Resuming dialysis' above.)

•Pain management – A multimodal approach to postoperative analgesia is used when feasible. Pain relief may be provided by a variety of agents, including opioids and acetaminophen. Meperidine, propoxyphene, and morphine should generally be avoided. (See 'Pain management' above.)

•Anemia management – Although erythropoiesis-stimulating agents (ESAs) are typically administered preoperatively in patients whose hemoglobin levels are less than the target before surgery, patients may require postoperative transfusions if intra- or postoperative blood loss is substantial. In patients awaiting kidney transplant, it is important to limit the number of blood transfusions, if possible, to minimize the risk of sensitization. Patients may be resistant to ESAs in the postoperative period, but we continue this treatment throughout hospitalization. (See 'Anemia management' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Liza M Weavind, MBBCh, FCCM, MMHC, who contributed to an earlier version of this topic review.