What is your approach to perioperative risk stratification and optimization of patients with ESRD on HD?

When evaluating a patient with end-stage renal disease (ESRD) on maintenance hemodialysis for surgery, my approach to perioperative risk stratification centers on three major areas: cardiovascular risk assessment, optimization of dialysis-related factors, and careful perioperative medication and metabolic management. Patients receiving hemodialysis are among the highest-risk surgical populations because they have a markedly increased prevalence of coronary artery disease, heart failure, arrhythmias, peripheral vascular disease, electrolyte disturbances, anemia, bleeding complications related to uremic platelet dysfunction, and postoperative infectious complications. I generally begin by assessing overall surgical risk using standard periope...