Medical management of the dialysis patient undergoing surgery
- Neil S Sanghani, MD
Neil S Sanghani, MD
- Assistant Professor of Medicine
- Vanderbilt University Medical Center
- Ramesh Soundararajan, MD, FACP
Ramesh Soundararajan, MD, FACP
- Clinical Assistant Professor of Internal Medicine
- Midwestern University College of Medicine
- Liza M Weavind, MBBCh, FCCM, MMHC
Liza M Weavind, MBBCh, FCCM, MMHC
- Professor of Anesthesiology and Surgery
- Vanderbilt University Medical Center
- Thomas A Golper, MD
Thomas A Golper, MD
- Section Editor — Dialysis
- Professor of Medicine
- Vanderbilt University Medical Center
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 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 . 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
- Kellerman PS. Perioperative care of the renal patient. Arch Intern Med 1994; 154:1674.
- Hansen LS, Hjortdal VE, Andreasen JJ, et al. 30-day mortality after coronary artery bypass grafting and valve surgery has greatly improved over the last decade, but the 1-year mortality remains constant. Ann Card Anaesth 2015; 18:138.
- Yuo TH, Sidaoui J, Marone LK, et al. Limited survival in dialysis patients undergoing intact abdominal aortic aneurysm repair. J Vasc Surg 2014; 60:908.
- Elkouri S, Gloviczki P, McKusick MA, et al. Perioperative complications and early outcome after endovascular and open surgical repair of abdominal aortic aneurysms. J Vasc Surg 2004; 39:497.
- Schermerhorn ML, O'Malley AJ, Jhaveri A, et al. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358:464.
- Anderson PL, Arons RR, Moskowitz AJ, et al. A statewide experience with endovascular abdominal aortic aneurysm repair: rapid diffusion with excellent early results. J Vasc Surg 2004; 39:10.
- Pinson CW, Schuman ES, Gross GF, et al. Surgery in long-term dialysis patients. Experience with more than 300 cases. Am J Surg 1986; 151:567.
- Deutsch E, Bernstein RC, Addonizio P, Kussmaul WG 3rd. Coronary artery bypass surgery in patients on chronic hemodialysis. A case-control study. Ann Intern Med 1989; 110:369.
- Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial 2001; 14:348.
- Esposito C, Bellotti N, Fasoli G, et al. Hyperkalemia-induced ECG abnormalities in patients with reduced renal function. Clin Nephrol 2004; 62:465.
- Aslam S, Friedman EA, Ifudu O. Electrocardiography is unreliable in detecting potentially lethal hyperkalaemia in haemodialysis patients. Nephrol Dial Transplant 2002; 17:1639.
- Weisberg LS. The risk of preoperative hyperkalemia. Semin Dial 2003; 16:78.
- de Mutsert R, Grootendorst DC, Axelsson J, et al. Excess mortality due to interaction between protein-energy wasting, inflammation and cardiovascular disease in chronic dialysis patients. Nephrol Dial Transplant 2008; 23:2957.
- Schreiber S, Korzets A, Powsner E, Wolloch Y. Surgery in chronic dialysis patients. Isr J Med Sci 1995; 31:479.
- Brown JH, Hunt LP, Vites NP, et al. Comparative mortality from cardiovascular disease in patients with chronic renal failure. Nephrol Dial Transplant 1994; 9:1136.
- Remuzzi G. Bleeding in renal failure. Lancet 1988; 1:1205.
- Holden RM, Harman GJ, Wang M, et al. Major bleeding in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3:105.
- Janssen MJ, van der Meulen J. The bleeding risk in chronic haemodialysis: preventive strategies in high-risk patients. Neth J Med 1996; 48:198.
- Sohal AS, Gangji AS, Crowther MA, Treleaven D. Uremic bleeding: pathophysiology and clinical risk factors. Thromb Res 2006; 118:417.
- Pivalizza EG, Abramson DC, Harvey A. Perioperative hypercoagulability in uremic patients: a viscoelastic study. J Clin Anesth 1997; 9:442.
- Pawlak K, Mysliwiec M, Pawlak D. Hypercoagulability is independently associated with kynurenine pathway activation in dialysed uraemic patients. Thromb Haemost 2009; 102:49.
- Bonomini M, Sirolli V, Merciaro G, et al. Red blood cells may contribute to hypercoagulability in uraemia via enhanced surface exposure of phosphatidylserine. Nephrol Dial Transplant 2005; 20:361.
- Steiner RW, Coggins C, Carvalho AC. Bleeding time in uremia: a useful test to assess clinical bleeding. Am J Hematol 1979; 7:107.
- Liu YK, Goldstein DM, Arora K, et al. Thigh bleeding time as a valid indicator of hemostatic competency during surgical treatment of patients with advanced renal disease. Surg Gynecol Obstet 1991; 172:269.
- Livio M, Gotti E, Marchesi D, et al. Uraemic bleeding: role of anaemia and beneficial effect of red cell transfusions. Lancet 1982; 2:1013.
- Janson PA, Jubelirer SJ, Weinstein MJ, Deykin D. Treatment of the bleeding tendency in uremia with cryoprecipitate. N Engl J Med 1980; 303:1318.
- Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage 2004; 28:497.
- Sear JW. Kidney transplants: induction and analgesic agents. Int Anesthesiol Clin 1995; 33:45.
- Miller's Anesthesiology, 6th ed., Miller RD. (Ed), Churchill Livingston, Philadelphia 2005. p.2183.
- Kurella M, Bennett WM, Chertow GM. Analgesia in patients with ESRD: a review of available evidence. Am J Kidney Dis 2003; 42:217.
- Geller RJ. Meperidine in patient-controlled analgesia: a near-fatal mishap. Anesth Analg 1993; 76:655.
- Gillman AG, Rall TW, Nies AS, et al. Goodman and Gillman's the Pharmacologic Basis of Therapeutics, 8th ed., Pergamon Press, New York 1990. p.504.
- Szeto HH, Inturrisi CE, Houde R, et al. Accumulation of normeperidine, an active metabolite of meperidine, in patients with renal failure of cancer. Ann Intern Med 1977; 86:738.
- Kaiko RF, Foley KM, Grabinski PY, et al. Central nervous system excitatory effects of meperidine in cancer patients. Ann Neurol 1983; 13:180.
- Bansal VK, Vertuno LL. Handbook of Dialysis, 2nd ed., Daugirdas JR, Ing TS (Eds), Little Brown and Co, 1994 p.551.
- Peterson GM, Randall CT, Paterson J. Plasma levels of morphine and morphine glucuronides in the treatment of cancer pain: relationship to renal function and route of administration. Eur J Clin Pharmacol 1990; 38:121.
- Chauvin M, Sandouk P, Scherrmann JM, et al. Morphine pharmacokinetics in renal failure. Anesthesiology 1987; 66:327.
- Hanna MH, D'Costa F, Peat SJ, et al. Morphine-6-glucuronide disposition in renal impairment. Br J Anaesth 1993; 70:511.
- Bayer O, Schwarzkopf D, Doenst T, et al. Perioperative fluid therapy with tetrastarch and gelatin in cardiac surgery--a prospective sequential analysis*. Crit Care Med 2013; 41:2532.
- Serpa Neto A, Veelo DP, Peireira VG, et al. Fluid resuscitation with hydroxyethyl starches in patients with sepsis is associated with an increased incidence of acute kidney injury and use of renal replacement therapy: a systematic review and meta-analysis of the literature. J Crit Care 2014; 29:185.e1.
- Hung M, Ortmann E, Besser M, et al. A prospective observational cohort study to identify the causes of anaemia and association with outcome in cardiac surgical patients. Heart 2015; 101:107.
- SURGICAL MORBIDITY AND MORTALITY
- ROUTINE DIALYSIS PRIOR TO SURGERY
- MEASURES TO PRESERVE RESIDUAL RENAL FUNCTION PRIOR TO SURGERY
- PREOPERATIVE EVALUATION
- Laboratory testing
- Assessment of access
- Indications for dialysis
- - Hyperkalemia
- Elective surgery
- Nonelective surgery
- - Volume overload
- Anemia status
- Cardiovascular evaluation
- - Beta blockers
- Bleeding diathesis
- - Heparin
- Glycemic control
- Intravenous access
- GENERAL ANESTHESIA
- POSTOPERATIVE MANAGEMENT
- - Opiates
- - Acetaminophen
- - Tramadol
- Preservation of residual renal function
- SUMMARY AND RECOMMENDATIONS