Improving Peri-operative Surgical Care in Kidney Failure Patients

Abstract

Chapter 1: Introduction

Peri-operative surgical care in patients with kidney failure has conflicting evidence supporting increased bleeding risk and/or thrombotic risk.

This thesis aims to assess the role of intra-operative intravenous (IV) unfractionated heparin (UFH) bolus in impacting peri-operative outcomes in bleeding and thrombosis for kidney failure patients.

Chapter 2:

This chapter assessed the impact of intra-operative IV UFH bolus in outcomes for autogenous surgical dialysis access creation. The findings support the role of giving an intra-operative IV UFH in reducing incidence of AVF thrombosis, particularly for radio-cephalic AVF creation (Relative Risk, RR = 0.45, 95% CI 0.25 to 0.80). It also resulted in improved clinical patency in the follow-up period. Whilst bleeding complications were increased in the IV UFH group (RR = 2.7, 95% CI 1.42 to 5.17), these were mostly self-limited to small amount of ooze at the surgical site.

Chapter 3:

This chapter presents a systematic review and meta-analysis assessing the value in intra-operative IV UFH in kidney transplant recipients. The study found three retrospective cohort studies, which included 1989 participants. The use of IV UFH compared to no heparin did not impact the incidence of graft thrombosis. Surprisingly, there was also no difference seen in bleeding complications or in incidence of delayed graft function. Further higher quality prospective studies in this area are required to enhance our understanding.

Chapter 4: Discussion/Conclusion

This thesis investigated the complex haemostatic disturbances observed in patients with renal failure undergoing surgery, with a specific focus on the peri-operative use of intraoperative intravenous (IV) heparin.

Significant gaps in current evidence were identified. Future research priorities include development of a Delphi consensus and a prospective randomized trial.