Anaesthesia for renal failure and dialysis

[1]

Why this is examined / the one-line answer

CKD and dialysis patients appear on every list: vascular access surgery, transplant, orthopaedics, emergency laparotomy. Examiners want a practical plan: potassium, volume, drugs, fistula, and when to dialyse — not a lecture on nephron segments.[1][2]

One-liner: I define residual function vs dialysis dependence, check recent K+ and volume status, time dialysis appropriately, protect AV access, adjust drug choice and doses, avoid further kidney hits when residual function matters, and plan post-op monitoring and dialysis. [1]

Preoperative assessment and risk stratification

Classify the problem

KDIGO-style CKD staging by eGFR/albumin is useful language; for theatre the actionable split is residual function vs dialysis-dependent.[1][4]

Systems review that changes the plan

Cardiovascular: hypertension, LVH, IHD, heart failure, pulmonary hypertension, autonomic dysfunction — higher cardiovascular event risk. [1]

Volume status: interdialytic weight gain, dry weight, oedema, orthopnoea, last dialysis ultrafiltration volume. Overload → desaturation, difficult ventilation; underfilled post-dialysis → induction hypotension.[2]

Electrolytes: K+, Na+, Ca2+, phosphate, bicarbonate. Potassium is the gatekeeper for elective lists.[3][4]

Haematology: chronic anaemia (usually tolerated if chronic), uraemic platelet dysfunction (normal platelet count ≠ normal haemostasis), anticoagulation around dialysis (heparin). [1]

Access: AV fistula/graft arm, tunnelled catheter, PD catheter — document and label the arm. [1]

Glucose: many are diabetic; adjust hypoglycaemics; avoid glucose-free long starvation without plan. [1]

Preoperative tests (exam list)

U&E (including K+ day of surgery for dialysis patients when feasible), FBC, coagulation if bleeding risk/regional planned, ECG, CXR if volume unclear, blood gas if acidotic/hyperkalaemic suspicion, crossmatch if major surgery. Echo if structural disease/poor functional capacity.[4]

Dialysis timing

Elective major surgery (classic teaching): haemodialysis within 24 hours before surgery, ideally the day before or morning of, coordinated so the patient is neither fluid-overloaded nor profoundly hypovolaemic/hypokalaemic. Confirm post-dialysis K+ when possible.[2][4]

Emergency: do not delay life-saving surgery solely for dialysis if hyperkalaemia can be temporised medically and monitored; involve nephrology early for intraoperative/early post-op CRRT/HD pathway. [1]

Post-op dialysis: plan access to HD/CRRT if major fluid shifts, rising K+, or overload expected. [1]

Applied physiology / pharmacology that changes the plan

Potassium

Hyperkalaemia risk rises with missed dialysis, suxamethonium, acidosis, rhabdomyolysis, transfusion, ACEI/ARB/spironolactone, and tissue trauma.[3]

Practical theatre thresholds (local policies vary — state principles): [1]

• Elective: many units postpone if K+ significantly elevated (commonly concern around ≥5.5–6.0 mmol/L depending on chronicity and ECG) until dialysis/medical control
• ECG changes (peaked T, flattened P, wide QRS, sine wave) → treat immediately, do not wait for elective ideals
• Chronic dialysis patients may tolerate higher K+ than AKI patients — still treat dangerous ECG changes and coordinate dialysis [1]

Emergency hyperkalaemia treatment stack (say doses): [1]

1. Calcium (e.g. calcium gluconate 10 mL of 10% IV over 5–10 min) — membrane stabilisation if ECG changes (repeat if needed)
2. Insulin–glucose (e.g. 10 units actrapid in 25–50 mL of 50% glucose or local protocol) — shifts K+ in
3. Salbutamol nebulised high-dose — adjunct shift
4. Sodium bicarbonate — if metabolic acidosis; not sole therapy for hyperkalaemia without acidosis
5. Remove K+ — dialysis is definitive in ESKD; resins limited acute role
6. Stop ongoing loads; hyperventilate carefully if ventilated (pH effect) [1]

[1]

Fluid and acid–base

Zero urine output means every millilitre counts. Use blood products and crystalloid deliberately; avoid “keep-up” liberal fluid. Balanced crystalloids preferred over large 0.9% saline loads when possible (chloride/acidosis issues), but follow local dialysis unit practice for sodium/potassium content of fluids.[1][2]

Drug dosing — viva gold table

Anaesthetic goals

1. Safe K+ and volume for induction and recovery.
2. Protect dialysis access.
3. Right drugs, right doses, full neuromuscular recovery.
4. Haemodynamic stability — coronary and residual renal perfusion (if any).
5. Bleeding awareness — uraemic platelet dysfunction, heparin from dialysis.
6. Clear post-op dialysis and monitoring plan. [1]

Technique options and decision matrix

Fistula / graft precautions (non-negotiable)

• No BP cuff, tourniquet, arterial line, or IV on access arm
• Pad and expose access for inspection; thrill check pre and post
• Prefer contralateral arm or foot IVs; ultrasound for difficult access
• Central venous access: avoid subclavian if possible (stenosis risk for future access); femoral/IJ per local transplant/vascular advice
• Document access site on consent and WHO checklist [1]

Monitoring

Standard + consider arterial line for major surgery/labile BP (on non-fistula arm). Quantitative NMM if NMBA used. Temperature, glucose. CVP rarely helpful alone for volume — use clinical + echo if needed. [1]

Intraoperative management

Induction: expect hypotension if recently ultrafiltered — have vasopressors drawn (metaraminol/phenylephrine; noradrenaline infusion ready for major cases). Reduce induction doses; titrate. [1]

Ventilation: avoid excessive hypercapnia/acidosis (shifts K+ out). Lung-protective settings; many have fluid-related poor compliance. [1]

Maintenance fluids: restrictive, goal-directed only with clear endpoints; replace losses, not “maintenance for anuria.” [1]

Transfusion: chronic anaemia — transfuse to clinical need, not normal Hb; coordinate with dialysis (volume, K+ in stored blood). [1]

Analgesia: paracetamol safe; avoid NSAIDs if residual function; regional where possible; fentanyl/oxycodone reduced rather than morphine PCA defaults. [1]

Crisis pivots

Hyperkalaemia with ECG changes on table

Calcium → insulin–glucose → salbutamol → correct acidosis → emergency dialysis/CRRT pathway → stop K+ sources → ALS if arrhythmia.[3]

Pulmonary oedema / desaturation

Sit up, FiO2, PEEP, diuretics only if residual urine and overloaded; ultrafiltration/dialysis; consider cardiogenic vs fluid. [1]

Fistula thrombosis suspected post-op

Urgent vascular/nephrology review — loss of access is catastrophic for the patient. [1]

Unexplained bleeding

Uraemic platelet dysfunction: optimise haematocrit, consider desmopressin in selected uraemic bleeding (specialist advice), correct fibrinogen/platelets as indicated, dialysis may improve uraemic bleeding over time. [1]

Rising creatinine in CKD not on dialysis

Treat as PO-AKI prevention/management: haemodynamics, avoid nephrotoxins, glucose control, monitor; ADQI/POQI principles.[5]

Postoperative / HDU criteria

• Monitored bed if major surgery, unstable K+/volume, significant comorbidity, or difficult pain control
• Early nephrology review for dialysis timing
• Fluid balance chart; daily weights when feasible
• Watch for delayed respiratory depression from opioids
• VTE prophylaxis: renally adjusted anticoagulants; mechanical methods important [1]

Special populations

PD patients: drain abdomen before laparoscopy; plan temporary HD if PD interrupted. [1]

Transplant recipients: protect graft perfusion pressure; continue immunosuppression with pharmacy; infection precautions; avoid nephrotoxins. [1]

Diabetic ESKD: gastroparesis, silent ischaemia, autonomic neuropathy — RSI thinking when indicated; careful glucose. [1]

Emergency hyperkalaemic arrest: calcium early in ALS algorithm context for suspected hyperkalaemic PEA/wide-complex. [1]

SAQ answer scaffold

A 58-year-old on thrice-weekly HD with a left radiocephalic fistula needs emergency laparotomy. K+ 5.8 mmol/L post last night’s dialysis. Outline anaesthetic management. [1]

1. Assess (3): volume status, ECG for hyperkalaemia, access arm, comorbidities, coagulation/heparin timing.
2. K+ plan (3): ECG-guided treatment thresholds; calcium/insulin–glucose if indicated; nephrology for post-op HD; avoid sux.[3]
3. Access & lines (2): right arm/foot IVs; arterial line opposite fistula; no cuff on left.
4. Drugs (3): titrated induction; cisatracurium or reduced rocuronium + NMM; fentanyl not morphine; vasopressors ready.[1]
5. Post-op (2): HDU, early dialysis plan, fluid restriction, adjusted VTE prophylaxis.[2]

Viva stem bank and model phrases

Stem 1: “Which arm for the BP cuff?”
Model: “Never the fistula arm — contralateral arm or alternative site, and I document that on the checklist.” [1]

Stem 2: “Morphine PCA?”
Model: “I avoid morphine because morphine-6-glucuronide accumulates in renal failure; I prefer fentanyl-based regimens with reduced dosing.” [1]

Stem 3: “When do you dialyse before elective THR?”
Model: “I coordinate HD within about a day pre-op so potassium and volume are optimised without rendering the patient intravascularly empty at induction.”[2]

Stem 4: “K+ 6.3 with peaked T waves.”
Model: “Immediate membrane stabilisation with IV calcium, shift with insulin–glucose and salbutamol, address acidosis, and arrange urgent dialysis — I do not proceed with elective care until safe.”[3]

Stem 5: “RSI agent if K+ 5.9?”
Model: “I avoid suxamethonium; I use rocuronium with sugammadex available and ensure full monitoring of the airway plan.” [1]

Stem 6: “Why is cisatracurium popular in ESKD?”
Model: “Hofmann elimination and ester hydrolysis reduce reliance on renal clearance, giving more predictable recovery than steroidal NMBAs in anuria.” [1]

Stem 7: “Residual urine 400 mL/day — any change?”
Model: “Yes — I treat residual function as precious: avoid NSAIDs and hypotension, renally adjust drugs, and involve nephrology early if oliguria worsens.”[5]

Common traps

• BP cuff on fistula arm
• Morphine default PCA
• Suxamethonium despite high K+
• Liberal fluid in anuria
• Proceeding electively with unchecked dangerous K+
• Forgetting heparin from recent dialysis before neuraxial
• No post-op dialysis plan after major surgery [1]

[1] [1] [1] [1]

Examiner mental map

1. K+ and ECG.
2. Volume vs dry weight.
3. Dialysis timing.
4. Fistula protection.
5. Drug table.
6. Post-op dialysis destination.
   Cover those six and you pass. [1]

References

1. [1]Chowdhury SR, McLure HA Chronic kidney disease and anaesthesia BJA Educ, 2022.PMID 36097571
2. [2]Fielding-Singh V, Vanneman MW, et al. Perioperative Management of the Patient Receiving Maintenance Hemodialysis Anesthesiology, 2025.PMID 40923826
3. [3]Ayach T, Nappo RW, Paugh-Miller JL, Ross EA Postoperative hyperkalemia Eur J Intern Med, 2015.PMID 25698564
4. [4]Nasr R, Abdel Mageed H Preoperative Evaluation in Patients With End-Stage Renal Disease and Chronic Kidney Disease Health Serv Insights, 2017.PMID 35185335
5. [5]Prowle JR, Forni LG, Bell M, et al. Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative Nat Rev Nephrol, 2021.PMID 33976395