As the burden of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) continues to rise globally, so too does the number of patients requiring maintenance hemodialysis. These patients are living longer due to improved access to kidney replacement therapies; however, this longevity comes with increased exposure to the healthcare system, including the operating room. Surgical interventions in patients receiving hemodialysis are increasingly common and associated with significant perioperative risk.

This news post explores evidence-based, multidisciplinary approaches to managing patients on maintenance hemodialysis throughout the perioperative period. We highlight clinical strategies, risk mitigation, and future directions aimed at improving safety and outcomes for this high-risk yet increasingly prevalent population.

The epidemiological landscape: why surgical risk is rising in dialysis patients

ESKD affects over 800,000 people in the United States alone, with a growing global footprint due to increased rates of diabetes, hypertension, and obesity. According to recent data:

• Mortality from CKD is projected to become the fifth leading cause of years of life lost by 2040.
• The age-standardized prevalence of CKD globally is 10.4% in men and 11.8% in women.
• Patients with ESKD are 13 times more likely to undergo surgery than those with normal renal function.

Higher stakes, higher risks

The perioperative landscape for patients receiving hemodialysis is uniquely challenging:

• Cardiovascular complications are the most common cause of perioperative mortality.
• Infection, stroke, and bleeding rates are significantly elevated.
• Postoperative hospital readmission and length of stay are longer in patients with ESKD compared to those without ESKD.

Preoperative evaluation

Multidisciplinary coordination is key

Successful perioperative care starts with collaboration between:

• Nephrologists
• Anesthesiologists
• Surgeons
• Internists
• Pharmacists
• Cardiology or pulmonary hypertension specialists, when indicated

Cardiovascular risk stratification

Cardiovascular disease affects up to 77% of patients undergoing hemodialysis. Common pathologies include:

• Coronary artery disease
• Heart failure
• Peripheral arterial disease
• Valvular heart disease

Despite high prevalence, symptoms in dialysis patients are often atypical or masked. Hence:

• Baseline electrocardiogram (ECG) and transthoracic echocardiogram (TTE) are recommended—even in asymptomatic patients.
• Patients on dialysis for more than 2 years should undergo routine echocardiographic surveillance for aortic stenosis.
• Consider cardiac MRI or CT for inconclusive TTEs, especially in the presence of an AV fistula that may distort flow assessments.

Addressing aortic stenosis and pulmonary hypertension

• Aortic stenosis progresses rapidly in dialysis patients and may require surgical correction before noncardiac procedures.
• Pulmonary hypertension, with an estimated prevalence of 16–47%, necessitates early specialist involvement for optimization and stratification of surgical risk.

Hematologic management

Anemia in ESKD is multifactorial

• Diminished erythropoietin production
• Iron deficiency
• ESA resistance due to inflammation

Preoperative strategies

• Optimize iron stores with IV iron infusions.
• Consider increasing ESA doses weeks before surgery.
• Aim for hemoglobin levels between 10–11 g/dL—lower than the general population but safer for this group.

Bleeding risks

Dialysis patients exhibit platelet dysfunction, often termed uremic thrombocytopathy. Strategies to reduce bleeding include:

• Holding antiplatelet/anticoagulants unless critical for cardiovascular risk mitigation.
• Using desmopressin or tranexamic acid perioperatively (with caution in cardiac surgery due to seizure risk).
• Avoiding unnecessary transfusions, particularly for transplant candidates, to prevent alloimmunization.

Dialysis-specific considerations

Hemodialysis dose

• Preoperative reductions in dialysis dose (lower Kt/V) have been linked to higher postoperative mortality.
• While causality is unclear, maintaining or optimizing dose pre-surgery is advisable.

Fluid management

Volume overload worsens outcomes:

• Assess for interdialytic weight gain, dyspnea, JVD, and pulmonary edema.
• Nephrology input is crucial for determining dry weight and optimizing ultrafiltration before surgery.

Ideal timing of dialysis

• Day-before-surgery hemodialysis is associated with improved outcomes.
• Same-day dialysis may raise the risk of intraoperative hypotension, especially if performed within 7 hours of anesthesia.

Anticoagulation during dialysis

• Heparin (either low-molecular-weight or unfractionated) is the standard.
• Discuss anticoagulation strategy with the nephrology team if surgery follows dialysis closely.
• Heparin-free or saline flushes may be appropriate when bleeding risk is high.

Vascular access

Preoperative access inspection

• Check the AV fistula for patency using the look, listen, feel technique.
• Avoid pressure, kinking, or trauma intraoperatively.
• Frequent post-op checks ensure early detection of thrombosis or access loss.

Central line placement guidelines

• Avoid subclavian vein access—associated with central vein stenosis.
• Use aseptic technique when manipulating tunneled catheters.
• Never access dialysis catheters unless necessary.

Intraoperative strategies

Anesthetic technique

• Regional anesthesia improves AV fistula patency and may reduce hemodynamic variability.
• No definitive survival advantage of general vs. regional anesthesia; decision should be patient-specific.
• Use guidelines for anticoagulated patients from the American Society of Regional Anesthesia and Pain Medicine (ASRA).

Electrolyte management

Hyperkalemia

• Extremely common perioperatively.
• Watch for: succinylcholine use, tissue necrosis, acidemia.
• Treatments include calcium, insulin, beta-agonists, bicarbonate, and dialysis.

Hyponatremia

• Common due to free water intake and fluid retention.
• Avoid rapid correction, which can cause osmotic demyelination.

Pharmacologic considerations

Neuromuscular blockade

• Cisatracurium is preferred due to organ-independent clearance.
• Rocuronium + sugammadex is increasingly used, but:
  • Sugammadex has unclear safety in ESKD.
  • Recurarization is a concern.
  • Dialyzable if needed.

Antimicrobials

• Vancomycin, cefepime, and piperacillin-tazobactam require dose adjustments for renal function.
• Monitor trough levels when using nephrotoxic agents.

Postoperative care: monitoring, recovery, and dialysis resumption

Pain management

• Avoid renally cleared opioids like tramadol and oxycodone.
• Favor fentanyl, hydromorphone (with dose adjustment).
• Minimize use of gabapentinoids due to risk of encephalopathy.
• Baclofen is contraindicated.

Dialysis after surgery

• Tailor frequency and modality to:
  • Fluid balance
  • Electrolyte status
  • Hemodynamic stability
• Early nephrology consultation is critical for dialysis planning and ICU or step-down disposition.

Quantifying surgical risk

Despite higher relative risks, absolute risks remain manageable:

• Intra-abdominal surgeries: ~11.7% 30-day mortality
• Vascular surgeries: ~12.6%
• Orthopedic/musculoskeletal: ~12.2%

The key takeaway: dialysis patients can and should undergo necessary surgery, provided risks are addressed proactively through optimized perioperative care.

Future directions

1. Standardize perioperative dialysis protocols.
2. Develop tailored guidelines for neuromuscular reversal, antimicrobial dosing, and transfusion targets.
3. Expand research on intraoperative dialysis and pharmacologic safety in ESKD.
4. Promote widespread adoption of multidisciplinary perioperative teams.

Conclusion

Patients on maintenance hemodialysis represent one of the most complex surgical populations in modern medicine. Yet, with careful planning, collaborative team efforts, and evidence-based adjustments across the perioperative continuum, these patients can achieve excellent surgical outcomes. The challenge is no longer whether these patients can safely undergo surgery—but how we, as care teams, will evolve to meet their needs safely and effectively.

For more information, refer to the full article in Anesthesiology. 

Fielding-Singh V, Roshanov PS, Morris AM, Chertow GM. Perioperative Management of the Patient Receiving Maintenance Hemodialysis. Anesthesiology. 2025 Oct 1;143(4):1030-1048.

Read more about kidney injury in our Anesthesiology Module on NYSORA 360—a complete training resource designed for residents, with practical, up-to-date guidance on perioperative and critical care management.