Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease

Abstract

Importance: For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown.

Objective: To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis.

Design, setting, and participants: Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018.

Exposures: One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure.

Main outcomes and measures: The primary outcome was 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model.

Results: Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6% [95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4% [95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5% [95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P<.001 for interaction).

Conclusions and relevance: Among Medicare beneficiaries with end-stage kidney disease, longer intervals between hemodialysis and surgery were significantly associated with higher risk of postoperative mortality, mainly among those who did not receive hemodialysis on the day of surgery. However, the magnitude of the absolute risk differences was small, and the findings are susceptible to residual confounding.

Figure 1.. Surgical Procedures Reported by the United States Renal Data System by Exclusion or Inclusion in the Analyses

^aMay have met more than 1 exclusion criterion. The individual exclusions under this category do not sum.

Figure 2.. Unadjusted 90-Day and 14-Day Postoperative Mortality

For panel B, the x-axis and y-axis scales differ from the other panels in this Figure. For panels C and D, the unadjusted cumulative incidence of mortality for patients with 1 day between last hemodialysis treatment and surgical procedure is used as the reference category. A sensitivity analysis examining 30-day mortality follow-up appears in eFigure 2 in the Supplement. The unadjusted cumulative incidence of 90-day mortality for patients with 1 day between hemodialysis treatment and surgical procedure was stratified by whether the patient received an additional hemodialysis session on the day of the surgical procedure and this analysis appears in eFigure 3 in the Supplement.

Figure 3.. Association Between Interval From Hemodialysis Treatment to Surgical Procedure and Perioperative Outcomes

All models were adjusted for the covariates in the Table and in eTable 4 in the Supplement and are described in the Methods section. ^aRepresent all predetermined secondary outcomes. Additional secondary outcomes and sensitivity and subgroup analyses appear in Figure 4 and in eTables 8-9 in the Supplement.

Figure 4.. Subgroup Analyses

^aThe estimates use a 1-day interval from hemodialysis treatment to the surgical procedure as a reference category because same-day hemodialysis treatment was received by fewer than 0.5% of the patients. The sensitivity analyses using alternative reference categories appear in eTable 6 in the Supplement. ^bPresented for each subgroup vs the reference group. ^cComparison group for the interaction tests, thus no P values for interaction are displayed for this group. ^dIncludes common bariatric, cardiac, otolaryngological, general, gynecologic, orthopedic, spine, thoracic, urological, and vascular procedures. The full list of procedures appears in eTable 2 in the Supplement and an additional analysis appears in eTable 9 in the Supplement.