From Clinic to Recovery · First Edition
Chapter 26 — Liver Disease, Kidney Disease, Sickle Cell Disease, and Biologic Therapy
Dr. Tamer Rushdy Elalfy · 8 min read
In this chapter
Several other conditions change the counseling, preparation, and risk of surgery enough to deserve their own sections. This chapter covers four of the most common encountered in general surgical practice: chronic liver disease and cirrhosis, chronic kidney disease and dialysis, sickle cell disease, and biologic or disease-modifying medicines for rheumatic and bowel disease. Each is covered separately below, with its own evidence and its own counseling points, because the right advice for one does not transfer to another.
Learning objectives After reading this chapter you should be able to:
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26.1 Chronic liver disease and cirrhosis
Cirrhosis substantially increases surgical risk, through impaired clotting, fluid shifts, infection risk, and poor wound healing. Risk is assessed with the Child-Pugh score (based on bilirubin, albumin, prothrombin time or INR, ascites, and encephalopathy) or the Model for End-Stage Liver Disease (MELD) score (based on bilirubin, creatinine, and INR) [1, 2]. Table 26.1 gives approximate mortality by class; these are illustrative figures from published series and vary by procedure and center.
Table 26.1. Perioperative risk in cirrhosis by Child-Pugh class or MELD score. Figures are approximate and vary by procedure; consult hepatology for individual patients.
| Severity | Approximate 30-day mortality for elective surgery | Usual advice |
|---|---|---|
| Child-Pugh A (score 5 to 6), or MELD below about 10 | Low, often under 10 percent | Elective surgery usually tolerated; optimize nutrition and clotting first |
| Child-Pugh B (score 7 to 9), or MELD about 10 to 15 | Substantially higher | Proceed with caution; involve hepatology; consider converting ascites or encephalopathy to better control first |
| Child-Pugh C (score 10 to 15), or MELD above about 15 to 20 | Very high, reported as high as 30 to 80 percent depending on surgery | Elective and non-urgent surgery is not advised; consider transplant evaluation and non-surgical alternatives first [2] |
Caution: contraindications to elective surgery in liver disease
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When elective surgery is appropriate, optimize nutrition, correct clotting factors and platelets as needed, control ascites, and involve hepatology and anesthesia in planning. Minimally invasive techniques are generally preferred where feasible, and abdominal wall and biliary operations carry higher risk in this group.
26.2 Chronic kidney disease and dialysis
Chronic kidney disease affects fluid balance, electrolytes, bleeding tendency, drug clearance, and infection risk. Staging follows estimated glomerular filtration rate and albuminuria [3]. For patients on hemodialysis, elective surgery is best scheduled the day after a dialysis session, when fluid and electrolytes are best controlled, and the dialysis access (fistula, graft, or catheter) must be protected from pressure, blood pressure cuffs, and needles. For patients on peritoneal dialysis, the surgical team should coordinate with nephrology about pausing exchanges and protecting the catheter.
- Medicines. Many medicines, including some antibiotics and pain medicines, need dose adjustment or avoidance in kidney disease; avoid nephrotoxic anti-inflammatory medicines.
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Potassium. Check potassium before surgery, as both high and low levels affect heart rhythm.
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Anemia. Chronic kidney disease commonly causes anemia; correct it before elective major surgery where possible.
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Fluid balance. Careful intraoperative fluid management avoids both dehydration and fluid overload.
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Contrast. Discuss the need for contrast imaging with the team, because of the risk to remaining kidney function in non-dialysis patients.
26.3 Sickle cell disease
Patients with sickle cell disease are at risk of vaso-occlusive crisis, acute chest syndrome, and infection around surgery. Preoperative blood transfusion to reduce this risk is tailored to the type of surgery: a randomized trial found that a simple top-up transfusion before surgery was as effective as, and safer than, an exchange transfusion at preventing perioperative complications in patients with sickle cell anemia having low- to medium-risk surgery [4]. Transfusion is generally recommended before major or high-risk operations (for example, major abdominal surgery, thoracotomy), while straightforward low-risk procedures (for example, minor surgery under local anesthesia) may not require it; the hematology team should guide the decision for each patient [4, 5].
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Avoid triggers. Keep the patient warm, well hydrated, well oxygenated, and with pain well controlled, to reduce the risk of a sickle crisis.
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Hydration. Give intravenous fluids during any period of fasting; avoid unnecessarily long fasting.
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Oxygen. Avoid hypoxia; use supplemental oxygen as needed and monitor saturation closely.
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Pain. Plan multimodal analgesia; a crisis in the perioperative period can be difficult to distinguish from surgical pain, so close hematology involvement helps.
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Infection. Patients with sickle cell disease may have reduced spleen function; see Chapter 17 for infection prevention principles, which apply here as well.
26.4 Biologic and disease-modifying medicines
Patients taking biologic therapies (for example, for inflammatory bowel disease or rheumatoid arthritis) or disease-modifying antirheumatic drugs such as methotrexate need an individual plan made with the prescribing specialist [6]. In general: methotrexate at low doses used for rheumatic disease is usually continued around surgery; many biologic agents are paused for one dosing interval before major elective surgery, to allow their effect to wane, and restarted once the wound is healing well and there is no infection; and transplant immunosuppressive medicines are never stopped without the transplant team. The exact medicine, dose, indication, and type of surgery all affect the decision, so a blanket rule should not be applied.
Script: biologic and disease-modifying medicines “Please tell us the exact name of your biologic or arthritis medicine and when your next dose is due. We will plan this together with your specialist, because stopping it incorrectly can either increase infection risk or cause your condition to flare.” |
STEP 2 Preparation and the plan for each condition
Table 26.2. Preoperative planning for each condition.
| Condition | Before surgery | Who to involve |
|---|---|---|
| Cirrhosis | Child-Pugh or MELD score; correct nutrition, clotting, and ascites | Hepatology, anesthesia |
| Dialysis | Schedule after a dialysis session; protect access; check potassium | Nephrology, dialysis unit |
| Sickle cell disease | Consider transfusion per surgery risk; plan hydration, warmth, and oxygen | Hematology |
| Biologics and DMARDs | Individual pause-and-restart plan | Rheumatology, gastroenterology, or transplant team |
STEP 3 Questions patients ask
“Is my liver disease too severe for this operation?”
We will score your liver disease and discuss this with our liver specialists. For more severe disease, we may recommend treating the liver first, or an alternative to surgery.
“Can I have my operation on a dialysis day?”
We usually plan surgery for the day after dialysis, when your fluid and salts are best controlled.
“Will I need a blood transfusion because of my sickle cell disease?”
For some operations, yes, to reduce the risk of a sickle crisis. For smaller procedures, it may not be needed. Our hematology team will advise.
“Should I stop my biologic injection before surgery?”
Possibly, but this depends on the exact medicine and your surgery. We will plan this with your specialist; please do not stop it yourself.
STEP 4 Risks, warning signs, and consent
Table 26.3. Additional risks by condition. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Less common to common (varies by severity) | Bleeding, infection, and fluid problems in cirrhosis | Depends on Child-Pugh class [unit data] | “Your liver disease increases the risk of bleeding and fluid problems.” |
| Less common | Electrolyte problems or access complications in dialysis patients | [unit data] | “We watch your salts and protect your dialysis access closely.” |
| Less common | Sickle cell crisis or acute chest syndrome around surgery | [unit data] | “We take steps to reduce the risk of a sickle crisis.” |
| Less common | Infection risk with biologic or immunosuppressive medicines | [unit data] | “These medicines can increase infection risk around surgery.” |
26.5 Checklist
Before surgery ☐ Liver disease severity scored (Child-Pugh or MELD) where relevant; hepatology involved for Child-Pugh B or C. ☐ Dialysis patients scheduled after a session; access protected; nephrology informed. ☐ Sickle cell transfusion decision made with hematology, based on surgical risk. ☐ Biologic and disease-modifying medicines planned with the prescribing specialist. ☐ Teach-back done; patient guide given. |
Key points
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References
1. Friedman LS. Surgery in the patient with liver disease. Trans Am Clin Climatol Assoc. 2010;121:192-205.
2. Northup PG, Friedman LS, Kamath PS. AGA clinical practice update: surgical risk assessment and perioperative management in cirrhosis. Clin Gastroenterol Hepatol. 2019;17(4):595-606.
3. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1-150.
4. Howard J, Malfroy M, Llewelyn C, et al. The Transfusion Alternatives Preoperatively in Sickle Cell Disease (TAPS) study: a randomised, controlled, multicentre clinical trial. Lancet. 2013;381(9870):930-938.
5. National Heart, Lung, and Blood Institute. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014.
6. Goodman SM, Cronstein BN, Bass AR. Preoperative evaluation and management of patients receiving biologics and DMARDs. Curr Opin Rheumatol. 2017;29(3):325-331.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.