It is well known that disparities exist in chronic kidney disease (CKD) prevalence, progression, treatment, and outcomes based on demographic, socioeconomic, and geographic factors (1–3). Sex- and gender-based disparities exist in CKD care (4), particularly with regard to transplant access (5). Once patients are on dialysis, disparities in outcomes persist (6–11). Kimmel et al. (6) reported that among White patients on dialysis in the U.S., income inequality was associated with increased risk of mortality; among Black patients on dialysis, residence in highly segregated areas was associated with increased mortality. Hall et al. (7) found that a significantly greater proportion of dialysis facilities serving racial and ethnic minority patients had worse than expected survival compared with facilities serving predominately White patients. The death rate for White patients on dialysis (207.4 per 1000 patient-years) exceeds that for Black patients (135.8 per 1000 patient-years), but this may be due to survival bias—the ability of healthier racial and ethnic minority individuals to reach dialysis therapy (8). Studies accounting for kidney transplantation as a competing risk eliminated the survival benefit in younger Black patients (9). Garg et al. (10) reported an association of higher neighborhood income with decreased mortality and increased likelihood of placement on the kidney transplant wait list among 3000 patients on dialysis. A recent scoping review of health inequities in dialysis care noted disparities based on race and ethnicity, sex and gender, underserved rural populations, and income (11).
An association between a 3-day interdialytic interval and mortality among patients receiving three times weekly hemodialysis (HD) was first reported in 2011 by Foley et al. (12) using data from the U.S. Renal Data System. Increased hospitalization rates were reported when surgery was performed on the third interdialytic day (13). Irrespective of the timing of surgery, patients on dialysis experience a marked increase in perioperative mortality compared with patients with normal kidney function, ranging from an odds ratio of death of 4.0 following vascular surgery to 10.8 following orthopedic surgery (14). Given the vulnerability of patients undergoing HD by the third interdialytic day, elective surgery should be scheduled soon after the HD treatment. This could be later in the day of the dialysis procedure or on the following day to optimize the patient's biochemical and fluid status in the perioperative period. Accordingly, several authors, including Palevsky (15), recommend that patients undergoing major surgical procedures receive dialysis the day preceding surgery, which may require adjustment in the patient's dialysis schedule.
In 2022, Fielding-Singh et al. (16) performed a retrospective cohort study of 1,147,846 surgical procedures among 346,828 Medicare beneficiaries undergoing HD. The patients were stratified by 1-, 2-, or 3-day intervals between the most recent HD treatment and the surgical procedure and whether the patient underwent HD on the day of the surgical procedure. Longer intervals between the last HD session and surgery were associated with a higher, 90-day mortality risk in a dose-dependent manner. Undergoing HD on the same day as surgery was associated with a significantly lower risk of mortality vs. not doing so.
In a follow-up July 2023 publication, Fielding-Singh et al. (17) analyzed the same cohort for exposures by age, sex, race and ethnicity, and social deprivation index (SDI). The primary outcome was the proportion of procedures with a 2- or 3-day interval between the last HD session and the surgical procedure. Older age, female sex, non-Hispanic Black race, and each increasing decile of the SDI were significantly associated with longer intervals between HD and surgery and, by implication from their prior study, increased risk of 90-day mortality. The reasons for the disparities are unclear, and further research is clearly needed. Possible explanations include an inflexibility of the patient's home HD facility to reschedule dialysis closer to an elective surgical procedure, transportation issues for the patient to access dialysis treatment if modified from the usual schedule, and poor communication between the hospital in which the surgery is performed and the dialysis center. Given this opportunity to improve perioperative outcomes among patients who are highly vulnerable, practitioners should explore and overcome barriers to dialysis within 1 day of an elective surgical procedure.
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