Case 4: When to do hemodialysis before surgery in patients with ESRD?

Preoperative Care of Patients with Kidney Disease
Author: V. Dimov, M.D., Department of General Internal Medicine, Cleveland Clinic

67 yo female with DM2, HTN, HPL, CAD, ESRD on hemodialysis on Tue/Thu/Sat is scheduled for total knee replacement (TKR) on Tuesday.

When to do hemodialysis before surgery?

Hemodialysis should be done the day before the surgery.

Uremia causes platelet dysfunction which can result in increased perioperative bleeding. Patients with ESRD should undergo dialysis on the day before surgery to minimize uremic complications.

Some drugs have only minor platelet effects in patients without uremia but can have exaggerated effects in ESRD: diphenhydramine (Benadryl), NSAIDs, chlordiazepoxide (Librium), and cimetidine (Tagamet).

Heparin is used during hemodialysis (HD) with a residual anticoagulant effect lasting for 2-3 hours after the procedure. It is recommended to wait 12 hours after the last HD before surgery is performed.


Patients with ESRD should undergo dialysis on the day before surgery to correct hyperkalemia, fluid overload and to minimize uremic complications.

Studies failed to document a significant improvement in mortality with daily dialysis for a few days prior to surgery or intraoperative hemodialysis, and therefore this modality of intensive dialysis cannot be recommended.


Preoperative Care of Patients with Kidney Disease. Mahesh Krishnan, M.D., M.P.H. Am Fam Physician 2002;66:1471-6.
Perioperative Management of the Patient With Chronic Renal Failure. Kenneth E Otah, MD, MSc, Moro O Salifu, MD, MPH, Eseroghene Otah, MD., last accessed 3/7/06,
Medical management of the dialysis patient undergoing surgery. Ramesh Soundararajan, MD, FACP, Thomas A Golper, MD. UpToDate 14.1, 2006 (subscription required).

Image source: National Institutes of Health, public domain.

Created: 5/31/06
Updated: 8/06/06

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