November 29, 2025
Background: Patients with chronic kidney disease who require maintenance dialysis experience excess morbidity and mortality for reasons that are not fully understood. There are few established targets for intervention to improve outcomes. This study tested the hypothesis that perioperative hypotension is more common in patients receiving maintenance dialysis.
Methodology: A retrospective cohort study was conducted among adult patients who underwent inpatient noncardiac surgery lasting more than 2 hours under general anesthesia between January 2012 and December 2021 at the Cleveland Clinic. Using International Classification of Diseases codes, dialysis documentation in the electronic medical record, age, American Society of Anesthesiologists Physical Status, surgery type, and propensity score (predicting dialysis dependence), three 1:1:1 matched groups were created: (1) patients with dialysis-dependent chronic kidney disease, (2) patients with nondialysis chronic kidney disease, and (3) patients without kidney disease. The primary outcomes were the total area under the curve of mean arterial pressure (MAP) below 65 mmHg during surgery and postoperative MAP below 70 mmHg during the first 48 hours after surgery.
Results: Three matched groups of 1,886 patients each (total 5,658 patients) were derived from an overall cohort of 123,761 patients. Patients with dialysis-dependent kidney disease had a greater intraoperative area under the curve of MAP below 65 mmHg compared with patients who had nondialysis kidney disease (difference in medians, 18.4 mmHg-min; 98.75% CI, 11.3 to 25.6; P < 0.001) and compared with patients without kidney disease (difference in medians, 15.5 mmHg-min; 98.75% CI, 6.6 to 24.4; P < 0.001). Patients receiving preoperative dialysis were also more likely to have postoperative MAP below 70 mmHg than patients with nondialysis kidney disease (rate ratio, 1.52; 98.75% CI, 1.48 to 1.57; P < 0.0001) and patients without kidney disease (rate ratio, 1.43; 98.75% CI, 1.38 to 1.47; P < 0.0001).
Conclusions: Perioperative hypotension is more severe and more common among patients receiving chronic maintenance dialysis than among similar patients without dialysis dependence. Hemodynamic management in this population presents unique challenges that warrant further systematic evaluation.
©2026 OR. All Rights Reserved
