Do you switch a patient from peritoneal dialysis (PD) to hemodialysis (HD) before undergoing coronary artery bypass grafting (CABG)?

Switching from Peritoneal Dialysis to Hemodialysis Before CABG

You do not need to routinely switch a patient from peritoneal dialysis (PD) to hemodialysis (HD) before coronary artery bypass grafting (CABG), as PD can be safely continued perioperatively with appropriate management. 1, 2, 3

Evidence Supporting Continuation of PD

The available evidence demonstrates that dialysis-dependent patients can safely undergo CABG on either modality:

• PD offers specific cardiovascular advantages that may actually benefit patients undergoing cardiac surgery, including better hemodynamic control, less acute electrolyte shifts that could trigger arrhythmias, and avoidance of rapid volume changes that occur with HD 1

• Successful perioperative outcomes have been documented in patients maintained on PD through the CABG perioperative period, with one case series reporting successful continuation of peritoneal dialysis starting just 10 hours after surgery 2

• Mixed dialysis cohorts (predominantly HD but including PD patients) undergoing cardiac surgery show acceptable mortality rates (7.1% 30-day mortality) without evidence that PD patients fared worse 3

Perioperative Dialysis Management Strategy

Timing of Dialysis Sessions

• Perform dialysis within 24 hours before surgery to optimize volume status, electrolytes, and uremia control 2, 4

• Resume dialysis the day after surgery for HD patients, or as early as 10 hours postoperatively for PD patients if clinically appropriate 2

Key Perioperative Considerations

Bleeding risk management is critical, as dialysis-dependent patients have greater tendency to bleed perioperatively 4:

• Optimize coagulation parameters before surgery
• Consider timing of heparin exposure relative to surgery

Volume status optimization before CABG 1:

• Achieve dry weight prior to surgery to enhance cardiac assessment
• Maintain mean arterial pressure >60 mmHg during on-pump CABG 1
• Maintain hematocrit >19% during cardiopulmonary bypass 1

Off-pump CABG may be reasonable in dialysis patients to reduce acute kidney injury risk, though this applies more to patients with residual renal function 1

When to Consider Switching to HD

The only situations requiring a switch from PD to HD would be PD-specific contraindications that develop perioperatively 1, 5:

• Abdominal surgical complications requiring laparotomy that would compromise peritoneal membrane function
• Peritonitis occurring in the immediate preoperative period
• Inadequate ultrafiltration or fluid removal that cannot meet postoperative volume management needs
• Technical/mechanical catheter problems preventing effective PD 1, 5

Common Pitfalls to Avoid

• Do not assume PD must be discontinued simply because the patient is undergoing major cardiac surgery—this is not supported by guidelines or evidence 1, 2, 3

• Do not delay necessary CABG to establish HD access if the patient is functioning well on PD 1

• Avoid inadequate preoperative dialysis—ensure the patient is optimally dialyzed within 24 hours of surgery regardless of modality 2, 4

• Do not ignore the hemodynamic advantages of PD in patients with severe cardiac disease, as PD avoids the rapid fluid and electrolyte shifts of HD that can be poorly tolerated 1

The 2011 ACCF/AHA CABG guidelines address renal dysfunction management but do not mandate switching dialysis modalities 1. The decision should be based on the adequacy of the current dialysis modality and patient-specific factors, not on the surgery itself.