Researchers identify disparities in timing of dialysis performed pre-surgery

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Fielding-Singh reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

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Key takeaways:

• U.S. Renal Data System data show patients did not receive a timely dialysis treatment prior to surgery.
• Longer intervals between dialysis and surgery led to higher mortality than shown in a previous study.

Researchers tied disparities related to age, sex, race and ethnicity, along with social deprivation, to the timing of hemodialysis for patients preparing for surgery, according to a study.

Previous research conducted and published in 2022 by Vikram Fielding-Singh, MD, JD, and colleagues identified an association between longer intervals of preoperative hemodialysis and surgery and postoperative mortality. But little is known, they wrote in a research letter in JAMA Network Open, “about whether minoritized or otherwise socially vulnerable patients with [end-stage kidney disease] ESKD experience longer preoperative intervals between hemodialysis and surgery.”

The authors used the U.S. Renal Data System to identify adults with prevalent ESKD receiving hemodialysis who were undergoing surgical procedures from Jan. 1, 2011, to Sept. 30, 2018. Fielding-Singh and colleagues identified 1,120,763 surgical procedures among 338,391 patients. Of this group, 18.1% of the procedures had a longer (2- or 3-day) interval between the last outpatient hemodialysis treatment and the surgery.

Timing of dialysis

“The primary outcome was the proportion of procedures with a 2- or 3-day interval between the last outpatient hemodialysis session and the surgical procedure. A 2- or 3-day interval is associated with higher postoperative mortality compared with a 0- or 1-day interval,” the researchers wrote.

Fielding-Singh, a clinical assistant professor in the department of anesthesiology, perioperative and pain medicine at Stanford University, told Healio that the timing of the last preoperative dialysis session can be determined by different members of the care team.

“As this is a retrospective study, we don’t know who is deciding the preoperative hemodialysis schedule,” Fielding-Singh said. “Typically, the perioperative team weighing in on this issue consists of the patient’s nephrologist, surgeon, their internist and an anesthesia team (either the patient’s anesthesiologist for the procedure or a preoperative clinic).

“In terms of when to time hemodialysis before surgery, there are no prospective randomized data on this, but our prior study found that longer intervals were associated with higher risk of postoperative mortality,” Fielding-Singh said, “so we suspect that shorter intervals are better for patients.”

Social deprivation

In the analysis, the researchers found that older patients had longer hemodialysis-to-surgery intervals (aged 60 to 79 years old) compared with patients aged 18 to 39 years old.

In addition, more women (vs. men), “non-Hispanic Black” individuals (vs. “non-Hispanic white” individuals) and “each increasing decile of social deprivation index on a scale from [one] (lowest area deprivation) to 10 (highest area deprivation) were all significantly associated with longer intervals between hemodialysis and surgery,” the authors wrote.

Fielding-Singh told Healio: “Even accounting for social deprivation, older, female and non-Hispanic black patients still experienced longer intervals between hemodialysis and surgery. In our previous study, we showed that those longer intervals were associated with a higher risk of dying after surgery … Of course, even this measure of social deprivation may not fully account for things like the walkability of a neighborhood or a patient’s exposure to social stressors,” Fielding-Singh said. “But social deprivation index incorporates a lot of information about the community and context that a patient experiences, so I think our models suggest that it isn’t just sociodemographic factors alone that drive the disparities we observed.”

Fielding-Singh and colleagues concluded that the study findings support the need for more research on access to care and surgical outcomes.

“Given that a longer interval between preoperative hemodialysis and surgical procedures is associated with higher postoperative mortality, these findings are concerning and identify a possible avenue to improve equity in surgical outcomes for patients with ESKD,” the authors wrote. “Our study highlights the need for equitable access to perioperative care coordination for persons with ESKD.”