Perioperative Management of Patients Receiving Renal Replacement Therapy Undergoing Major Cardiac Surgery: A Narrative Review

The perioperative management of patients with end-stage renal disease on renal replacement therapy undergoing cardiac surgery presents significant clinical challenges and is associated with high morbidity and mortality. These patients frequently exhibit multiple comorbidities, including electrolyte disturbances, anemia, bleeding tendency, and cardiovascular instability, all of which complicate surgical management and postoperative recovery. Renal dysfunction markedly increases the risk of adverse postoperative events, even at mild stages, and is incorporated into established risk stratification models, including EuroSCORE II and the Society of Thoracic Surgeons score. Intraoperative renal injury may result from hypoperfusion, ischemia-reperfusion injury, systemic inflammation, hemolysis, and exposure to nephrotoxic agents. Preoperative optimization includes appropriate timing of dialysis—preferably within 24 hours before surgery—correction of electrolyte imbalances, optimization of hemoglobin levels, and careful assessment of bleeding risk. Intraoperatively, goal-directed fluid therapy guided by dynamic hemodynamic parameters and venous oxygen saturation monitoring is recommended. Integration of hemofiltration into the cardiopulmonary bypass circuit enables effective control of volume status and electrolyte levels. Postoperatively, early resumption of renal replacement therapy, ideally within 24 hours, is advised, with continuous modalities favored in hemodynamically unstable patients. Vasoplegic syndrome represents a frequent and severe complication requiring prompt recognition and targeted management. This review underscores the importance of a multidisciplinary, individualized perioperative approach involving cardiologists, nephrologists, anesthesiologists, and cardiac surgeons to reduce complications and improve outcomes in patients with end-stage renal disease undergoing cardiac surgery.