The preoperative evaluation of a patient with end-stage renal disease must include a detailed medical history and physical examination, with special attention to the cause of renal failure, the presence of comorbid conditions, and the patient's current renal replacement therapy. Patients may be receiving either hemodialysis (HD) or peritoneal dialysis (PD), and their fluid and electrolyte status can vary depending on the timing and adequacy of their dialysis treatments. In some cases, patients may still produce urine, though at a reduced volume, while others may be completely anuric.
Key aspects of the preoperative evaluation include:
Fluid and Electrolyte Balance: Fluid management is critical in patients with end-stage renal disease, who may easily shift between states of hypovolemia and hypervolemia. A comprehensive review of dialysis records helps assess whether the patient is adequately dialyzed or if there is fluid overload. Electrolyte imbalances, especially hyperkalemia, are common and should be corrected before surgery. It is crucial to check serum potassium levels within 24 hours of surgery, particularly if the patient is receiving dialysis.
Acid-Base Status: End-stage renal disease patients typically have chronic metabolic acidosis due to the accumulation of sulfates and phosphates. Although dialysis helps correct acidosis, patients have a diminished buffer capacity. Acute changes in ventilation or the development of respiratory acidosis intraoperatively can exacerbate acidemia and lead to dangerous elevations in potassium levels.
Cardiovascular Health: Cardiovascular complications, including hypertension, left ventricular hypertrophy, coronary artery disease, and congestive heart failure, are common in ESRD patients. Careful cardiovascular evaluation is essential, including electrocardiography (ECG) to assess for arrhythmias, left ventricular hypertrophy, and ischemia. Given the high risk of atherosclerosis and cardiovascular disease in ESRD patients, an echocardiogram may be warranted to evaluate left ventricular function, valvular abnormalities, and the presence of pericardial effusion.
Coagulation and Bleeding Risk: Uremic platelet dysfunction is a significant concern in ESRD patients, even if standard coagulation tests such as prothrombin time (PT), partial thromboplastin time (PTT), and platelet counts are normal. The bleeding time may be prolonged due to platelet dysfunction, increasing the risk of perioperative bleeding. Treatment options to improve platelet function include desmopressin (DDAVP), cryoprecipitate, or conjugated estrogens, depending on the severity of the coagulopathy and the planned surgery.
Medication Review: Many drugs commonly used in anesthesia practice undergo renal excretion, and their pharmacokinetics may be significantly altered in ESRD. A detailed review of the patient’s medications is necessary, particularly for drugs that depend on renal elimination. Drugs such as digoxin, certain antibiotics, and neuromuscular blocking agents may require dosage adjustments or should be avoided. Additionally, patients taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for hypertension may experience intraoperative hypotension due to impaired renal compensatory mechanisms.
| Domain | What to establish before surgery |
|---|---|
| Dialysis modality and urine output | Document hemodialysis versus peritoneal dialysis; residual output ranges from reduced volume to complete anuria |
| Fluid and electrolyte balance | Review dialysis records for adequacy or overload; correct hyperkalemia and check serum potassium within 24 hours of surgery |
| Acid-base status | Expect chronic metabolic acidosis with diminished buffer capacity; intraoperative respiratory acidosis can worsen acidemia and raise potassium dangerously |
| Cardiovascular health | ECG for arrhythmias, left ventricular hypertrophy and ischemia; echocardiogram may be warranted for ventricular function, valvular disease and pericardial effusion |
| Coagulation and bleeding risk | Uremic platelet dysfunction can prolong bleeding time despite normal PT, PTT and platelet count; desmopressin, cryoprecipitate or conjugated estrogens may improve platelet function |
| Medication review | Adjust or avoid renally eliminated drugs such as digoxin, certain antibiotics and neuromuscular blockers; ACE inhibitors and ARBs predispose to intraoperative hypotension |
