In Practice

Preoperative Risk Assessment and

Management in Adults Receiving
Maintenance Dialysis and Those With
Earlier Stages of CKD
Jehan Z. Bahrainwala, Samantha L. Gelfand, Ankur Shah, Blaise Abramovitz,
Brenda Hoffman, and Amanda K. Leonberg-Yoo

With an increasingly aging population and improved mortality in individuals with end-stage kidney Complete author and article
disease, more surgeries are being performed on patients with all stages of chronic kidney disease information provided before
references.
(CKD). This high-risk population carries unique risk factors that have been associated with increased
adverse perioperative outcomes, including acute kidney injury, cardiovascular events, and mortality. In Am J Kidney Dis. XX(XX):1-
this article, we review the literature describing absolute risks associated with common surgeries 11. Published online Month
X, XXXX.
performed in patients with CKD and patients receiving maintenance dialysis. We also review peri-
operative optimization with special risk assessment including evaluation of cardiovascular and bleeding doi: 10.1053/
risk evaluation, hypertension management, and timing of dialysis. Predictive model scores are reviewed j.ajkd.2019.07.008
as a method to stratify risk for acute kidney injury, major adverse cardiac events, or other serious © 2019 by the National
complications with elective surgeries. A multidisciplinary approach with individualized counseling is Kidney Foundation, Inc.
necessary to counsel the patient with advanced CKD or patients treated with maintenance dialysis
considering elective surgery.

Clinical Vignette
A 56-year-old man with diabetes mellitus type
2 (for which he used insulin), hypertension,
dyslipidemia, and kidney failure treated by
maintenance hemodialysis is referred to an
orthopedic surgeon for persistent left hip pain.
Tricompartmental osteoarthritis of the left
knee was diagnosed 10 years ago. Unable to
use nonsteroidal anti-inflammatory drugs, he
has been using topical analgesic agents
without relief. He has become more sedentary
due to chronic pain. The orthopedic surgeon
recommends a total knee arthroplasty. The
patient asks about his ability to safely undergo
this procedure, and the surgeon informs the
patient that these procedures are commonly
performed in patients undergoing dialysis.
Before deciding, the patient wishes to discuss
the surgery with his nephrologist.
Introduction
Elective surgeries, or operations planned in
advance, as opposed to an urgent or emergent
procedure, can range from minor low-risk
procedures such as cataract surgery to
high-risk cardiovascular operations such as
coronary artery bypass grafting (CABG). It is
known that patients treated with dialysis
have increased mortality and higher risk for
perioperative complications than those
not receiving dialysis, in part due to a higher
prevalence of cardiovascular comorbid
conditions (Table 1).1 Even patients with FEATURE EDITOR:
earlier stages of chronic kidney disease (CKD) Holly Kramer
than kidney failure are at increased risk for
postoperative cardiac events and mortality.2 ADVISORY BOARD:
Information on the incidence of elective Linda Fried
Ana Ricardo
surgery in a population with CKD remains
Roger Rodby
limited and we lack research-informed guid- Robert Toto
ance for appropriate preoperative testing for
these patients. Nephrologists are likely to be In Practice is a
asked to assist both patients and surgeons to focused review
assess and minimize the risks associated with providing in-depth
guidance on a clinical
elective operations. Doing so requires not only
topic that nephrolo-
an understanding of the absolute risks related gists commonly
to a surgical procedure, but also specific risk encounter. Using
factors related to the patient with kidney clinical vignettes,
disease. these articles illus-
trate a complex prob-
In this In Practice, we aim to review sur-
lem for which optimal
gical risks related to elective surgeries in in- diagnostic and/or
dividuals with CKD, including special therapeutic ap-
consideration for patients treated with main- proaches are
tenance dialysis. We also summarize recom- uncertain.
mendations for preoperative testing and other
surgical considerations that should be
reviewed in a preoperative visit.
Surgical Morbidity in Patients With
CKD
To understand surgical risk in an elective
surgery, it is important to assess the absolute
risks of surgery for individuals with CKD,
including postoperative complications and
mortality risk (Table 2).

AJKD Vol XX | Iss XX | Month 2019 1


Table 1. Comorbid Cardiovascular Conditions in Prevalent
Hemodialysis Patients
Comorbid Conditions Percentage
Atherosclerotic coronary artery disease 42.3%
Acute myocardial infarction 14.0%
Congestive heart failure 40.4%
Valvular heart disease 14.1%
Cerebrovascular accident/transient 16.3%
ischemic attack
Peripheral artery disease 37.4%
Venous thromboembolism and 6.2%
pulmonary embolism
Based on data in Saran et al.1
Cardiac Surgeries
Aortic Valve Replacement
Calcified aortic stenosis is a common valvular disease
requiring surgical intervention in patients treated with
dialysis. Surgical aortic valve replacement (SAVR) is asso-
ciated with increased morbidity and mortality among pa-
tients receiving maintenance dialysis. Recent data from the
US Nationwide Inpatient Sample show that patients
receiving maintenance dialysis who undergo SAVR have
higher inpatient mortality, as well as hospitalization costs
and lengths of stay, compared with those undergoing
transcatheter aortic valve replacement (TAVR; 13.7% vs
6.1%; P < 0.02).3 Similar results were found when
studying patients with non–kidney failure CKD.4
Although TAVR may have improved outcomes
compared with SAVR, this procedure is also not without
adverse outcomes in patients with CKD. Among patients
who undergo TAVR, those with CKD have higher odds of
in-hospital mortality than those without CKD (odds ratios
[ORs] of 1.39 [95% CI, 1.24-1.55] and 2.58 [95% CI,
2.09-3.13] for non–kidney failure CKD and maintenance
dialysis, respectively).5 One study of patients who un-
derwent TAVR reported higher mortality at 30 days and
after 1 year among those with CKD stages 4 to 5 compared
with those without CKD.6 However, both groups noted
symptom improvement with TAVR. Thus, in patients with
CKD who require aortic valve replacement, TAVR should
be considered over SAVR due to lower mortality risk in this
population.
Controversy exists regarding the preferred valve mate-
rial for patients receiving maintenance dialysis. A bio-
prosthetic valve may be problematic due to accelerated
calcification of an already time-limited valve, whereas a
mechanical valve requires systemic anticoagulation in a
population already at risk for bleeding.7 In both a retro-
spective review and a meta-analysis of data pooled from
patients receiving maintenance dialysis who underwent
aortic valve replacement, there was no difference in sur-
vival with either a bioprosthetic valve or mechanical
valve.8,9 Thus, surgeons may consider other factors when
selecting valve material, such as valve-related complica-
tions and patient bleeding risk.
2 AJKD Vol XX | Iss XX | Month 2019
In Practice
Coronary Artery Bypass Grafting
The incidence of CABG in patients receiving maintenance
dialysis has increased from 2.5 to 5 per 1,000 patient-years
during the past 15 years.10 Surgical mortality remains
higher compared with patients not receiving dialysis.
Studies have shown both non–kidney failure CKD and
maintenance dialysis to be independent risk factors for
surgical and in-hospital mortality in patients undergoing
CABG.11 In a Japanese cohort of patients undergoing iso-
lated CABG, 30-day surgical mortality (7.8% vs 2.1%; P <
0.001) and 30-day mortality (4.8% vs 1.4%; P < 0.001)
were significantly higher among the 1,300 patients
receiving maintenance dialysis compared with the 18,000
patients without CKD.12 Differences in mortality were
largely driven by higher baseline comorbid conditions in
patients receiving maintenance dialysis.13
Alternative revascularization using percutaneous coro-
nary intervention (PCI) is available for the treatment of
multivessel disease. A recent meta-analysis compared
outcomes in patients with CKD undergoing CABG versus
PCI with a drug-eluting stent. The PCI group had higher
rates of all-cause and cardiac mortality, myocardial in-
farctions, revascularization procedures, and major adverse
cardiac and cerebrovascular events.14 PCIs can involve a
staged approach for multivessel interventions to minimize
contrast exposure, although guidelines do not provide
specific recommendations for use in individuals with
CKD.15,16 A retrospective study of patients undergoing
nonemergent multivessel PCI by either staged or ad hoc
(same session) procedures showed increased cumulative
radiocontrast with staged procedures.
In a subgroup analysis evaluating only individuals with
CKD ascertained as an estimated glomerular filtration rate
(eGFR) < 60 mL/min/1.73 m2, patients had a significant
decline in eGFR at 4 to 12 weeks after staged PCI
compared with those who underwent ad hoc PCI.17
There are no randomized controlled trials comparing
CABG to PCI in patients with advanced CKD or receiving
maintenance dialysis. In patients with advanced CKD or
receiving maintenance dialysis who have multivessel
cardiac disease, joint decision making should proceed
between cardiologists, nephrologists, and cardiac sur-
geons to determine optimal treatment strategies for the
individual patient.
Vascular Surgery
It is well known that there is a high burden of vascular
disease in patients with CKD, and this population repre-
sents a group with reduced longevity and also higher
surgical risk. Elective vascular surgery in this group is
usually not without risk. Perioperative morbidity and
mortality risks after elective vascular surgeries for
abdominal aortic aneurysm, carotid artery stenosis, and
peripheral vascular disease are available in the National
Surgical Quality Improvement Program (NSQIP) data-
base. Risk for 30-day postoperative complications (16.5%
In Practice

Table 2. Surgical Morbidity Data in Patients With CKDa

Surgery Mortality Data Predictor of Poor Outcome Postoperative Complicationsb
Cardiac Surgery
TAVR5 In-hospital mortalityc Age MACE (9%-11.8%)
• No CKD: 3.8% HLD Major bleeding complication (16.8%-
• CKD: 4.5% Prior PCI 21.6%)
• Dialysis: 8.3% Coagulopathy Requirement for PPM (13.2%-15.2%)
Transapical TAVR Longer LOS
Nonhome discharge
AKI on CKD (34%)
AKI needing dialysis (2.4%)
CABG11,12 In-hospital mortalityc,11 Patient-specific characteristics: Sepsis (2.1%-4.9%)
• No CKD: 1.4% • Age Respiratory complications (4.4%-13.1%)
• CKD: 9.8% Surgery-specific characteristics: GI complication (1%-4.9%)
• Dialysis: 7.3% • Urgent vs nonurgent Longer LOS
30-d mortalityc,12 • Preoperative inotropy Nonhome discharge
• No CKD: 1.4% Comorbid conditions:
• Dialysis: 4.8% • COPD
Surgical mortalityc,12 • Heart disease (CHF, EF < 30%)
• No CKD: 2.1% • Arrhythmias
• Dialysis: 7.8% • Valvular heart disease
• PAD
Elective Vascular Surgery18
AAA repair, CEA, 30-d mortalityc Age > 65 y STI (8%)
PVD repair • No CKD: 1.4% Respiratory complications (1.7%-4.8%)
• Dialysis: 7.2% Return to OR (23.8%)
Joint Arthroplasty25,26
Total knee arthroplasty25 In-hospital mortalityc Liver disease SSTI (1.0%-1.2%)
• No CKD: 0.1% CHF Wound hematoma (2.0%-3.8%)
• Dialysis: 0.92% Cardiac arrythmias Transfusion (36.7%-43.7%)
Total hip arthroplasty26 In-hospital mortalityc PVD Cardiac complication (1.9%-2.1%)
• No CKD: 0.13% Respiratory complication (1.8%-2.3%)
• Dialysis: 1.88% Urinary complication (1.9%-5.2%)
Longer LOS
Elective General Surgery31
Abdominal (94%), 30-d mortalityc Age > 65 y STI (10%)
thoracic, skin, node • No CKD: 1.5% Respiratory complications (7.4%-21.6%)
dissections, • Dialysis: 12.7% Return to OR (18.5%)
head & neck MACCE (0.6%-1.3%)
Longer LOS
Abbreviations: AAA, abdominal aortic aneurysm; AKI, acute kidney injury; CABG, coronary artery bypass grafting; CEA, carotid endarterectomy; CHF, congestive heart
failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; EF, ejection fraction; HLD, hyperlipidemia; GI, gastrointestinal; LOS, length of stay;
MACE, major adverse cardiovascular events; MACCE, major adverse cardiovascular and cerebrovascular events; OR, operating room; PAD, peripheral arterial disease;
PCI, percutaneous coronary intervention; PPM, permanent pacemaker; PVD, peripheral vascular disease; SSTI, skin and soft-tissue infection; STI, soft-tissue infection;
TAVR, transcatheter aortic valve replacement.
a
Excluding kidney transplant recipients.
b
Complications are listed only for significant complications in non–kidney failure CKD and/or maintenance dialysis patients, compared with patients without CKD.
c
P < 0.001.

vs 8.4%; P < 0.001) and 30-day mortality (7.2% vs 1.4%;
P < 0.001) are significantly higher among patients
receiving maintenance dialysis compared with all other
patients.18 Differences in postoperative complications are
more pronounced with dialysis dependence in patients
older than 65 years regardless of procedure type. Among
patients receiving maintenance dialysis who undergo
surgery for peripheral vascular disease, the presence of
preoperative pain at rest and gangrene were both asso-
ciated with higher mortality risk and postoperative
complications.18 Thus, offering elective surgery for
asymptomatic vascular disease in a high-risk older pop-
ulation receiving maintenance dialysis requires multidis-
ciplinary discussion of postoperative complication risks,
including mortality.
Hemodialysis Access Surgery
Information for hemodialysis patient outcomes following
vascular access surgery remains very limited. In a retro-
spective single-center study, 30-day mortality was 1.1% in
a cohort of nearly 1,400 patients undergoing vascular ac-
cess surgeries. Risk for 30-day mortality was significantly
higher with graft versus fistula in the upper arm (2.9% vs
0.8%; P < 0.005) and with lower-limb access versus
upper-arm fistula (3.9% vs 0.8%; P < 0.007). There was
also 6-fold higher risk for 30-day mortality (95% CI, 2.09-
18.8) when using general versus local anesthesia.19
Other studies have evaluated temporal trends of out-
comes following fistula surgeries. A large study using the
NSQIP database found that arteriovenous fistula surgeries
occurred more frequently in the outpatient setting during

AJKD Vol XX | Iss XX | Month 2019 3


the study interval (2005-2008).20 Comparing surgeries
performed in an inpatient versus outpatient setting,
there was higher postoperative morbidity (adjusted OR,
1.93; 95% CI, 1.41-2.60) and higher 30-day mortality
(adjusted OR, 3.32; 95% CI, 1.70-6.49) for inpatient
compared with outpatient arteriovenous fistula creation.
Importantly, the group that received surgery as inpatients
had a higher burden of comorbid conditions and lower
functional status compared with patients with outpatient
access creation.
We recommend timely referral to vascular surgery to
facilitate access placement in the outpatient setting when
patients are clinically stable. Inpatient access surgeries
should be reserved for patients who need urgent inpatient
hemodialysis initiation or have demonstrated poor
outpatient follow-up.
Total Joint Arthroplasty
The cumulative incidence of total hip arthroplasty is high
in the dialysis-dependent population (35 episodes/
100,000 person-years) compared to 5.3 episodes/10,000
person-years in the general population.21 In the National
Inpatient Sample, patients with CKD who underwent total
joint arthroplasty (TJA) had significantly higher in-
hospital mortality, longer lengths of stay, and higher
complication rates overall compared with patients
without CKD.22-23 Advanced CKD is associated with 2-
fold higher risk for inpatient mortality after TJA as
compared with patients without CKD who undergo TJA.
However, TJA in patients receiving maintenance dialysis
is associated with 10-fold higher risk for inpatient mor-
tality compared with patients without CKD.23 Thus,
complication rates after TJA increase with advancing
stages of CKD. Because complication rates after TJA are
lower among kidney transplant recipients as compared
with patients treated by dialysis,22-24 delaying total hip
arthroplasty until after kidney transplantation may be
prudent when possible. Despite the higher rate of com-
plications with TJA among patients with CKD, reported
survival rates are as high as 98% at 5 to 10 years and 64%
at 20 years.25-27
Abdominal Surgery
Few studies have assessed surgical risks in patients
receiving maintenance dialysis after noncardiovascular
procedures. In one study, risk for perioperative morbidity
and mortality in patients receiving maintenance dialysis
who undergo undergoing elective general surgeries
(abdominal surgery in 94%) was compared with risk
among patients with non–kidney failure CKD using the
NSQIP database.28 Patients receiving maintenance dialysis
had higher odds of soft-tissue infections (OR, 1.55; 95%
CI, 1.37-1.75), death (OR, 2.57; 95% CI, 2.15-3.08), and
need for reoperation (OR, 1.94; 95% CI, 1.68-2.25)
compared with those with earlier stages of CKD. Among
patients receiving maintenance dialysis, gastric, small-
bowel, and colorectal procedures were associated with
4 AJKD Vol XX | Iss XX | Month 2019
In Practice
worse outcomes than hepatobiliary, splenic, and hernia
procedures.
Considerations for Preoperative Testing
No formal guidelines specifically address preoperative
evaluation for individuals with advanced CKD, and existing
risk prediction tools are not tailored toward this popula-
tion. We recommend a preoperative assessment that in-
cludes GFR, cardiopulmonary fitness, hypertension and
anemia management, and bleeding risk for patients with
CKD (Box 1).
Acute Kidney Injury Risk Assessment
Postoperative acute kidney injury (AKI) is a common
complication, ranging from 10% after orthopedic pro-
cedures to up to 28% following cardiovascular sur-
geries.29-30 In one study in a heterogeneous cohort of
patients who underwent surgery at Veterans Affairs (VA)
hospitals, 11.8% of cases had incident postoperative AKI.30
Risk factors for AKI included older age, male sex, African
American race, and body mass index > 25 kg/m2. In pa-
tients with CKD (ascertained as eGFR < 60 mL/min/1.73
m2), each 10–mL/min/1.73 m2 greater eGFR was asso-
ciated with a 20% reduction in risk for AKI incidence.
Although this study was limited to a VA population un-
dergoing major surgery, the data demonstrate the magni-
tude of AKI seen postsurgically, as well as the risk
associated with a lower eGFR preoperatively.
To identify those at risk for postsurgical AKI, several risk
prediction tools have been developed for perioperative use
(Table 3). These risk scores share 4 common variables:
preoperative kidney function, diabetes mellitus, cardiac
surgery characteristics, and preoperative hemodynamic
status. Model performance comparison found that the
Cleveland Clinic Score and the Society of Thoracic Sur-
geons score were consistently better at predicting severe
postoperative AKI and the need for kidney replacement
therapy, although bedside clinical usability decreases with
an increased number of variables included.31 Although
both serum creatinine level and eGFR are strong predictors
of postoperative AKI, risk models that use GFR estimators
demonstrate superior predictive power than models using
serum creatinine level as a dichotomous single-dimension
surrogate of kidney function.32-33 Depending on baseline
CKD status, the risk for AKI requiring kidney replacement
therapy and CKD progression should be discussed with
patients.30,34
Cardiopulmonary Risk Assessment
CKD is an independent risk factor for adverse cardiovas-
cular events in the general population.35 However, it is
challenging to assess cardiovascular fitness in a population
with CKD, and risk stratification may differ compared with
a general population. Variables to consider include sur-
gery- and patient-specific risk factors. The American
In Practice

Box 1. Summary of Pre- and Perioperative Evaluation Recommendations

Preoperative Evaluation
Acute Kidney Injury Risk
• Assess baseline kidney function using eGFR within 1 mo of surgery
• Consider use of risk prediction tools (Cleveland Clinic Score vs STS score)74,75
Cardiopulmonary Risk
• Suggest baseline electrocardiogram and Doppler echocardiogram
• Assess functional capacity using METs criteria
• For maintenance dialysis patients, consider noninvasive cardiac testing, such as dobutamine stress echocardiography
• If considered high risk or noninvasive testing is not adequate, consult cardiology expert
Hypertension Management
• Recommend adequate BP and volume control
• Ideal BP < 140/90 mm Hg
Anemia Management
• Recommend optimizing hemoglobin to KDIGO target (10-11.5 g/dL)
• Discuss risk of transfusion for transplantation-eligible patients
Dialysis Management
• Ensure adequate dialysis using national target Kt/V of 1.2 for thrice-weekly dialysis
• Avoid elective surgery if active infection
• Optimize nutritional status using oral nutritional supplementation

Perioperative Evaluation
Hypertension Management
• Recommend antihypertensive therapies to be continued up to the morning of surgery
• Elective surgery can proceed if BP is <180/110 mm Hg, unless end-organ damage is present
• Consider holding renin-angiotensin-aldosterone system blockade agents and diuretics
Bleeding Risk
• Use desmopressin (intravenous or subcutaneous) if history of excessive bleeding
• Hold anticoagulation based on medication, bleeding risk, procedural risk, baseline eGFR69
• Check INR (warfarin), thrombin time (dabigatran), or anti-Xa levels (Xa inhibitors) if high risk
eGFR 30-60 eGFR < 30 Maintenance Dialysis
Warfarin Hold 3-5 d before surgery; check INR 24 h preoperatively
Dabigatran 2-4 d 3-5 d Not recommended
Factor Xa inhibitora 24-48 h 36-72 h 48-72 h
Dialysis Management
• Avoid scheduling surgeries over long interdialytic period
• Avoid hyperkalemia by ensuring adequate dialysis or evaluating perioperative electrolytes
Abbreviations: BP, blood pressure; eGFR, estimated glomerular filtration rate (in mL/min/1.73 m2); INR, international normalized ratio; KDIGO, Kidney Disease:
Improving Global Outcomes; MET, metabolic equialent; STS, Society of Thoracic Surgeons.
a
Apixaban, edoxaban, or rivaroxaban.

College of Surgeons NSQIP Surgical Risk Calculator in-
cludes a specific Current Procedural Terminology code to allow
for procedure-specific risk assessment to be included in an
individual’s surgical risk assessment.36,37
The American College of Cardiology/American Heart
Association (ACC/AHA) joint guidelines identify clinical
risk for major adverse cardiac events in the general pop-
ulation as unstable coronary syndrome, decompensated
heart failure, significant arrhythmia, and severe valvular
heart disease.38,39 If these clinical risks are not present, risk
stratification should be performed on the basis of func-
tional capacity, estimated using metabolic equivalents
(METs; Table 4). If functional capacity is ≥4 METs, no
further testing is recommended; if unknown or <4 METs,
this is considered indeterminate cardiac risk.
Depending on risk markers, these individuals are strat-
ified to determine whether further testing is indicated. Risk
markers for coronary artery disease include ischemic heart
disease compensated or prior heart failure, diabetes mel-
litus, “renal insufficiency,” and cerebrovascular disease.
Using these risk markers, one can increase the pretest
probability and thus improve the diagnostic yield of
noninvasive testing. However, these guidelines have been
designed for a general population and do not specifically
consider CKD or dialysis dependence. It is difficult to assess
functional status in patients receiving maintenance dialysis.

AJKD Vol XX | Iss XX | Month 2019 5

 In Practice

Table 3. Risk Prediction Tools Evaluating Risk for Kidney Injury Postoperatively
Model Prediction and Performance36 Variables
Name of Model Surgery/Procedure Postop AKI Postop KRT Kidney Nonkidney
Cleveland Clinic Open-heart surgery AUROC = 0.81 AUROC = 0.86 Preop Scr (<1.2, 1.2- Female sex
Foundation Risk Score74 (95% CI, 0.79- (95% CI, 0.84- <2.1, or ≥2.1 mg/dL) Heart failurea
0.83) 0.88) COPD
DM
Cardiac surgery
characteristicsb
Society of Thoracic CABG, valvular surgery, AUROC = 0.81 AUROC = 0.76 Preop Scr Age
Surgeons (STS) Risk CABG + valve (95% CI, 0.78- (95% CI, 0.73- Nonwhite race
Model75 0.86) 0.80) DM
Prior CV surgery
Hemodynamic
stabilityc
COPD
Simplified Renal Index Cardiac surgery with AUROC = 0.79 AUROC = 0.75 Preop eGFR (>60, DM
Score76 cardiopulmonary (95% CI, 0.77- (95% CI, 0.72- 30-60, or ≤30 Heart failurea
bypass 0.82) 0.77) mL/min) Cardiac surgery
characteristicsb
General Surgery AKI Noncardiovascular C statistic = 0.80 Preop Scr > 1.2 Age
Risk Index77 surgeries mg/dL Sex
DM
Surgical
urgency
CHF
HTN
Note: Utility of model defines AKI severity. Validation by an external cohort for discrimination between scores.
Abbreviations: AKI, acute kidney injury; AUROC, area under receiver operator characteristic curve; CABG, coronary artery bypass grafting; CHF, congestive heart failure;
CI, confidence interval; COPD, chronic obstructive pulmonary disease; CV, cardiovascular; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate; HTN, hy-
pertension; KRT, kidney replacement therapy; LVEF, left ventricular ejection fraction; Preop, preoperative; Scr, serum creatinine.
a
Heart failure defined as LVEF < 35%, preoperative intra-aortic balloon pump use. In the Simplified Renal Index Score, LVEF cutoff was < 40%.
b
Prior cardiac surgery, urgency of surgery, type of surgery, defined as valve only vs CABG vs CABG + valve vs other.
c
Hemodynamic stability assessed by cardiogenic shock, New York Heart Association class IV symptoms, recent myocardial infarction.

This, coupled with higher baseline risk for cardiac disease, name a few, and diagnostic capabilities may differ based
suggests that noninvasive methods for cardiovascular on the noninvasive test.41,42 In these cases, engagement of
fitness be used more judiciously in this population. In a cardiologist for risk assessment may be preferred.
transplantation-eligible individuals, guidelines have rec- Pulmonary hypertension is also highly prevalent in
ommended noninvasive stress testing regardless of func- patients with CKD, ranging from 10% to 25% in stage 5
tional status, given the presence of cardiovascular disease CKD to 8% to 68% among maintenance dialysis patients.43
risk factors.40 Noninvasive imaging in individuals with Pulmonary hypertension is associated with significantly
CKD can be less accurate due to limited exercise tolerance, increased risk for death and cardiovascular events in pa-
arrhythmias, and abnormal baseline electrocardiograms, to tients with CKD regardless of dialysis dependence.44 Pul-
monary hypertension is also associated with increased
Table 4. Estimates of Metabolic Expenditure of Common perioperative mortality and morbidity, including hemo-
Activities dynamic instability, hypoxia, and respiratory fail-
Metabolic Expenditure
ure.38,45,46 Given the increased prevalence of pulmonary
(METs)a Activity hypertension among patients with CKD, it is reasonable to
1 MET Self-care assess using noninvasive means in a preoperative setting.
Dressing This may influence intraoperative management, including
Walking indoors optimizing fluid balance and use of intraoperative hemo-
Walking 1 block on level ground at dynamic monitoring.
2-3 mph
4 METs Climbing a flight of stairs
Although no specific guidelines exist for perioperative
Walking up a hill cardiovascular risk assessment before an elective surgery in
Walking on level ground at 4 mph a kidney disease population, the NKF-KDOQI (National
Golf (without a cart) Kidney Foundation–Kidney Disease Outcomes Quality
Dancing
Running a short distance Initiative) guideline suggests “stress imaging is appropriate
>10 METs Strenuous sports (baseball, football, (at the discretion of the patient’s physician) in selected
skiing) high-risk dialysis for risk stratification even in patients who
Abbreviation: MET, metabolic equivalent. are not renal transplant candidates.”47(p S18) Combination
a
One MET is defined as the basal oxygen consumption of a 40-year-old 70-kg man. of both the ACC/AHA and KDOQI recommendations

6 AJKD Vol XX | Iss XX | Month 2019

In Practice
should be individualized based on surgical and patient risk.
Additional research in this area is encouraged to provide
more accurate risk assessment for this high-risk group.
Management of Hypertension
Hypertension is associated with increased risk for adverse
outcomes in a perioperative setting, including AKI, car-
diovascular outcomes, and end-organ damage.30 Key fac-
tors to consider in hypertensive patients in the
perioperative setting include the degree of hypertension
that is considered safe for an elective surgery, blood
pressure lability in an surgical setting, and optimal blood
pressure medical treatment. Attention to blood pressure
management in populations with advanced CKD and
dialysis-dependent CKD is necessary due to risks for AKI,
CKD progression, and loss of residual kidney function.
In a general population, the risk for perioperative
complications in individuals with hypertension is higher
than that in normotensive individuals. In a meta-analysis,
the pooled OR of risk for perioperative cardiovascular
complications in a pre-existing hypertensive population
was found to be 1.35 (95% CI, 1.17-1.56), although
methodological limitations, including heterogeneity in
patient populations and definitions of pre-existing hyper-
tension, make these risk estimates less reliable.48 Another
study found that severely uncontrolled hypertension
(blood pressure > 180/110 mm Hg) has been associated
with increased risk for cardiovascular and kidney adverse
outcomes.49 It has been suggested that surgery may be
deferred or delayed for individuals with severely uncon-
trolled hypertension, especially if there is evidence of end-
organ damage (eg, electrocardiogram changes concerning
for ischemia or CKD). There is a paucity of data regarding
perioperative blood pressure control in individuals with
CKD.
The presence of hypertension can also influence
response to anesthesia.49 Prior studies have shown that
anesthesia-induced vasodilation is associated with a
decrease in arterial pressure to a similar degree in both
hypertensive and normotensive individuals. However, the
absolute reduction in blood pressure in the hypertensive
subgroup was found to be greater given the higher pre-
anesthesia blood pressure.49,50 Although not directly
studied, it may be inferred that individuals with impair-
ment in renal autoregulation may be more susceptible to
changes in blood pressure in an anesthesia setting.51 For
individuals with hypertension, aggressive reduction in
preoperative blood pressure may be more harmful.
It is recommended that elective surgery can proceed if
blood pressure is <180/110 mm Hg unless evidence of
end-organ damage is present. Ideally, blood pressure
should be controlled before surgery to a goal of <140/90
mm Hg. However, the risk for abrupt reduction in blood
pressure to achieve this target immediately preoperatively
may confer additional risk.52 We recommend that anti-
hypertensive therapies be continued up to the morning of
surgery.53 There is insufficient evidence to guide either
AJKD Vol XX | Iss XX | Month 2019
continuation or withdrawal of renin-angiotensin-
aldosterone system blockade, although hemodynamic
instability with anesthesia exposure and risk for hyper-
kalemia should be considered if continuing.54
Management of Anemia and Bleeding Risk
Assessment
Patients with advanced CKD or who are receiving main-
tenance dialysis are at increased risk for perioperative
bleeding.55 Perioperative bleeding contributes to both
mortality and morbidity, including the need for blood
transfusion and reoperations.56 In a population that may
be eligible for transplantation, risk for sensitization with
blood transfusions becomes an important consideration in
preoperative risk assessment.
Anemia and platelet dysfunction contribute to periop-
erative bleeding and transfusion needs in patients with
CKD. Anemia is common in CKD due to relative erythro-
poietin deficiency and iron deficiency anemia.57 Relative
platelet dysfunction results from defects in activation, ag-
gregation, and adhesion caused by uremic toxins. Addi-
tionally, anemia may disrupt usual blood rheology; under
normal conditions, red blood cells usually flow through
the center of the vessel lumen while platelets tend to travel
along the periphery. In anemic conditions, laminar platelet
flow is disrupted, further impairing their function in pri-
mary hemostasis following endovascular injury.58
There are several ways to mitigate perioperative
bleeding risk. First, optimization of anemia preoperatively
with the use of recombinant human erythropoietin and
treatment of iron deficiency anemia may minimize the risk
for postoperative transfusions. The use of erythropoiesis-
stimulating agents can also help reduce bleeding time
and enhance platelet aggregation independent of anemia
treatment.59
Second, it is essential that patients receiving mainte-
nance dialysis are dialyzed adequately before surgery. It
has been shown that adequate dialysis improves functional
platelet abnormalities.60 It is unknown whether increasing
preoperative dialysis dose reduces bleeding events or im-
proves surgical outcomes.
Third, the knowledge of increased bleeding risk in
maintenance dialysis patients can be taken into account by
the surgical team to reduce the risk for symptomatic
postoperative bleeding (eg, selection of surgical approach,
placement of drains, and more vigilant postoperative
monitoring).
For patients maintained on anticoagulation therapy,
temporary interruption of the anticoagulant is usually
required before elective surgery to mitigate bleeding risk.
Contemporary use of direct oral anticoagulants (DOACs)
has increased among patients with CKD despite the
exclusion of patients with advanced CKD (estimated
creatinine clearance less than 25-30 mL/min) in safety and
efficacy trials.61-63 All DOACs undergo renal clearance, but
these agents vary distinctly in their pharmacokinetics
and therefore have different requirements for dose
7

adjustment in CKD. For patients using a DOAC who
require treatment interruption before surgery, the with-
holding duration will depend on procedural bleeding risk,
the specific DOAC agent, and kidney function (Box 1).64
Few data exist for the perioperative management of
DOACs in patients receiving maintenance dialysis, and
monitoring of coagulation parameters is a consideration in
these and other high-risk patients. All DOACs carry a black
box warning to avoid use in patients undergoing spinal/
epidural anesthesia.
Additional Risk Assessment in the Dialysis
Population
An important consideration for elective surgery is the
timing of hemodialysis preoperatively. In a retrospective
analysis using Dialysis Outcomes and Practice Patterns
Study (DOPPS) data, Zhang et al showed increased all-
cause mortality following the longest interval without
dialysis (hazard ratios of 1.40 [United States], 1.30
[Europe], and 1.34 [Japan]; all P < 0.05).65 Risk for
sudden cardiac death and arrhythmias is also greatest
during the prolonged interdialytic period.66,67 Proposed
mechanisms include alterations in volume status and blood
pressure, electrolyte imbalances, and changes in arterial
wall parameters.68 Avoidance of the long interdialytic
period for elective surgeries should be recommended
when appropriate.
In the perioperative setting, both hypo- and hyper-
kalemia contribute to arrhythmias and major adverse car-
diac events.69,70 In a large cohort study using a VA
population undergoing surgical procedures, individuals
with a serum potassium level > 5.5 mmol/L had increased
hazard of major adverse cardiac events (hazard ratio, 2.17;
95% CI, 1.75-2.70) compared with those with normoka-
lemia (defined as serum potassium of 4-5.5 mmol/L).69
Serious hyperkalemia (defined as serum potassium > 6.0
mmol/L) has been described in 10% of maintenance
dialysis patients, even if adequate dialysis is being per-
formed.71,72 In a prospective study evaluating preproce-
dural whole-blood potassium levels before vascular access
procedures in hemodialysis patients, 14.3% had moderate
or severe hyperkalemia (defined as venous blood gas po-
tassium > 5.7 mEq/L).73 These findings overestimate
hyperkalemia due to malfunctioning dialysis access or
inadequate dialysis. However, the collective literature
showing increased adverse outcomes with higher potas-
sium levels, alongside the higher prevalence of hyper-
kalemia in this population, should prompt routine
assessment of perioperative electrolytes as close to the time
of surgery as possible, unless proof of adequate dialysis is
established preoperatively.
Additional preoperative characteristics in patients
receiving maintenance dialysis may influence adverse
outcomes, including infectious complications and malnu-
trition. There are numerous risk factors that predispose
individuals receiving dialysis to infection, including a
high burden of comorbid conditions, uremia, and
8 AJKD Vol XX | Iss XX | Month 2019
In Practice
protein-energy wasting. Little can be done to affect these
conditions in an acute setting, although if an elective
surgery can be postponed to improve these comorbid
conditions, there may be a theoretical benefit.
Case Review and Conclusions
The clinical vignette involves a patient with a perioperative
risk for a serious complication of 2.8% using the NSQIP
Surgical Risk Calculator.37 Because pain was limiting his
exertion, his metabolic capacity cannot be evaluated, so we
recommended that he undergo noninvasive testing for
coronary artery disease. Before surgery, anemia and hy-
pertension management were optimized. Surgery was
scheduled for a midweek nondialysis day to avoid
increased morbidity and mortality from the long dialysis-
free interval.
Despite the limited data and retrospective study designs,
elective surgery in CKD is associated with significant
morbidity and mortality that is higher than in the non-
CKD population. We describe a clinical scenario in
which a patient receiving maintenance dialysis is consid-
ering an elective surgery. By reviewing surgery-specific
risk factors, including risk estimates of mortality, as well
as perioperative risk factors, nephrologists should counsel
a patient on his or her individual risk for postsurgical
complications.
Article Information
Authors’ Full Names and Academic Degrees: Jehan Z.
Bahrainwala, MD, Samantha L. Gelfand, MD, Ankur Shah, MD,
Blaise Abramovitz, DO, Brenda Hoffman, MD, and Amanda K.
Leonberg-Yoo, MD, MS.
Authors’ Affiliations: Renal-Electrolyte and Hypertension Division,
Department of Medicine, University of Pennsylvania, Philadelphia,
PA (JZB, SLG, BH, AKL-Y); Division of Kidney Disease &
Hypertension, Department of Medicine, Brown University (AS);
Division of Nephrology, Medical Service, Providence Veterans
Affairs Medical Center Providence, RI (AS); and Division of Renal-
Electrolyte, Department of Medicine, University of Pittsburgh,
Pittsburgh, PA (BA).
Address for Correspondence: Jehan Z. Bahrainwala, MD, Renal
Electrolyte and Hypertension Division, Penn Presbyterian Medical
Center, 240 Medical Office Bldg, 51 N 39th St, Philadelphia, PA
19104. E-mail: jehan.bahrainwala@uphs.upenn.edu
Authors’ Contributions: All authors contributed equally to the
writing of this article.
Support: None.
Financial Disclosure: The authors declare that they have no
relevant financial interests.
Other Disclosures: Dr Gelfand was a member of the 2018 class of
AJKD Editorial Interns; she was fully recused from any involvement
in the manuscript consideration process.
Disclaimer: The case presentation, although based on a typical
dialysis patient, is not based on a specific patient case.
Peer Review: Received November 12, 2018, in response to an
invitation from the journal. Evaluated by 3 external peer reviewers
and a member of the Feature Advisory Board, with direct editorial
input from the Feature Editor and a Deputy Editor. Accepted in
revised form July 1, 2019.
In Practice
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