Are there instances when you recommend initiation of dialysis in patients with advanced chronic kidney disease who are scheduled for a major surgery but do not currently have any indications for renal replacement therapy?

There is this very annoying (annoying because I don't want to believe it) literature regarding CV surgery patients with CKD stages 4-5, but not on RRT, doing better post-op if dialyzed pre-op. It rarely rears its ugly head. Maybe there is something there despite my denial, or better yet my skepticis...

I don't think so. I would like to not do dialysis if possible. If after surgery patient requires dialysis then that can be arranged expeditiously.

I don’t recommend that.

If there is no indication for dialysis and volume and electrolytes are controlled and acceptable GFR, I do not recommend it.

I recommend DDAVP if the bleeding time is prolonged, but not dialysis. If volume overload or hyperkalemia forces me to dialyze, I initiate it postoperatively.

Confirming my practice with my peers!